– Dr. Adewale Oluseye Adisa
Lecture Delivered at the 60th Birthday Ceremony Of
Mrs. Betty Anyanwu-Akeredolu
On 20th July, 2013
It is a great honor and privilege for me to give this lecture in honor of our amiable mother and friend, Mrs. Betty Anyanwu-Akeredolu who is marking her 60th birthday today. When I got her message asking me to give this lecture, I first posted a query back to her to confirm she is really turning sixty. I know the enormous activities she engages in and one cannot but thank God for granting her good health and the strength and courage to carry on. I have also extracted a promise from her that before the end of today, she will share with those of us much younger than her the secret of looking young at sixty. I wish to join all others here today in wishing her many more happy returns, long life, good health and prosperity.
1.2 Mrs. Betty Anyanwu-Akeredolu
I first met Mrs. Anyanwu-Akeredolu early in 2007. One of her workers attended a symposium in Ile-Ife where I gave a talk on the burden of breast cancer in Nigeria and came to me after the talk to request for my contact details. A few days later, I received a call from Madam. I listened to her vision and mission and had no difficulty identifying with her. She spoke like a passionate football coach aiming to recruit a striker from a rival club. That day, I gave her my word to work with her organization and today I am still keeping that word.
Her remarkable story is encapsulated in the workings of Breast Cancer Association of Nigeria (BRECAN), an organization she established in 1997 shortly after she survived the scourge of breast cancer. In a country like ours, it is a taboo to publicly disclose the medical condition of elite. The ailments that gradually took the life of a sitting president, that which kept the current first Lady outside the country for some months and whatever is afflicting at least 3 sitting Governors who today are almost always outside the country are mere subjects of newspaper speculations. This attitude has deprived us of the unique opportunity for national health education on each of those ailments thereby promoting awareness and behavioral changes which could have led to reduction in the burden of diseases and possible improvement in our health as a nation. Mrs. Anyanwu-Akeredolu did not hide under religion or blame her political opponents for her health condition; she chose to face it headlong. Since 1997, she has continued to devote her time, energy and personal finances to improving awareness about breast cancer. She said
“My experience of shattering loneliness, unavailability of information and group support coupled with “tight-lip” syndrome and indifference surrounding the disease so stirred me that I was inspired to do something that will bring about a positive and lasting change in the attitude of breast cancer victims themselves and the Nigerian society towards breast cancer and sufferers”.
That inspiration has been her driving force over the past 16 years within which she had taken BRECAN and breast cancer awareness all around Nigeria and to the best of gatherings outside the shores of the country.
She has again taken her passion a step further, deciding that on her 60th birthday today we should discuss the topic “It is time to make Breast Cancer a National Priority”.
2.1: The Burden of Cancer
The incidence of cancers is rising worldwide. A steady increase in incidence has been observed in most developed and developing countries. Apart from incidence, cancer related deaths are also increasing. In 2008 alone, up to 7.6 million people died from cancers all over the world with about 70% of these deaths occurring in developing countries. While we do not yet have accurate national data on occurrence of cancers in Nigeria, it is estimated that more than 250,000 new cases of cancers are diagnosed in Nigeria every year and up to 10,000 Nigerians die each year from cancer related causes. These estimates are based largely on hospital generated data without provision for the many cases that do not present in hospitals as well as the many cases of misdiagnosis in our numerous peripheral hospitals.
2.2: Breast Cancer in Nigeria
Breast cancer is now an epidemic, posing a serious threat to the health of women of all races globally. In Nigeria, cervical cancer was the commonest cause of cancer related deaths among women for several decades but breast cancer is now the leading cause of cancer related deaths among Nigerian women. This is not due to a reduction in cervical cancer but an increase in the incidence of breast cancer.
Breast cancer is commonly seen in four stages that represents its progression. In stage I, the disease is confined entirely to the breast. The cancer usually start as a very tiny growth that cannot yet be felt but can be detected with imaging tests such as mammography and ultrasound. At this first stage, treatment is usually curative and more than 95% of those so detected will survive the disease beyond 5 years. Stage II is a cancer that has involved lymph nodes in the armpit of the same side of the breast while stage III disease is one that has involved the muscles under the breast. Stages II and III therefore require very aggressive treatment using different modalities to contain the spread of the disease. It is however difficult to cure a patient in stage IV because the disease has spread to involve other organs in the body such as the lungs, liver, bones, the brain or the spine. The sad story is that reports from many tertiary hospitals in Nigeria indicates that a large percentage of our women present with breast cancers in either stages III or IV. In Ile-Ife for instance, 52% of women presenting with breast cancer between 1991 and 2005 had stage IV diseases. It is therefore not surprising that our people continue to hold the belief that there is no cure for cancer and many will because of this continuously pursue unorthodox treatments in the early stages, giving a lengthy time for the cancer to spread before presenting in the specialist hospitals. The poor awareness of breast cancer symptoms also contribute to this late presentation. In most instances, breast cancers starts as a painless lump. A number of Nigeria women who detect such lumps in their breasts however disregarded it because it is not painful and many will seek treatment only when the lump has grown so big to cause discomfort.
Another major challenge with breast cancer in Nigeria is the increasing detection of advanced disease in young women. In most Western countries, breast cancer is more frequently diagnosed in older women with the peak age being in the sixth and seventh decades of life. The disease however occurs at least a decade earlier among Nigerian women. The majority of reports from Nigerian hospitals confirm the late 40s as the mean age at initial diagnosis. It is also not uncommon to find many women younger than 40 with the disease in our setting. Over the past one year, 4 ladies younger than 30years have presented with histologically confirmed breast cancer at the Obafemi Awolowo University Teaching Hospital, Ile-Ife with one of them undergoing the National Youth Service Scheme in Osun State.
This presents us as a nation with many challenges. We cannot strictly follow the timing and modalities of screening for early detection set by recommending bodies of Western societies as this will lead to non-detection of the disease in our younger women. The psychological, social and financial implications of treatment of breast cancer in a young Nigerian woman are enormous and should be a source of concern to us all.
The treatment of breast cancer involves a combination of different modalities including operations on the affected breast, use of anti-cancer drugs, other drugs that target the biological type of cancer being treated as well as treatment with radiation. The challenges of these for a Nigerian woman can be imagined based on the resources available. A particular country in Europe with a population of about 8 million has more than a dozen centers for radiation therapy and about a hundred specialists in radiation therapy. For the more than 150 million residents of Nigeria, only 6 centers have facilities for radiation therapy and most of the times only 3 or 4 are functional leading to overcrowding of such centers. There are only a handful of radiation oncologists across the country. As expected, this presents opportunities for corruption in accessing the service. Regarding anti-cancer drugs, the cheapest effective combination that may be administered on a patient in a 3weekly cycle cannot be purchased by anyone earning the national minimum wage of N18,000 monthly not to consider the several millions earning below the minimum. Ongoing research efforts are leading to production of new drugs, many of which are very costly and beyond the reach of the average working class citizens. A new drug for those with a particular type of receptor may cost close to 2million Naira for a complete dose. We can all imagine how a female teacher in a state owned primary school will react to such treatment advice.
We once conducted a study among women who were receiving treatment with cyclical injections of anti-cancer drugs and found that up to 80% may miss their treatment schedule; nearly half of this non-adherence being due to financial difficulties. A number of these women, some of who may be presenting with locally advanced breast cancers that require urgent treatment, may then stop receiving treatment due to lack of funds only to return to the hospital in terminal stages. This group of women need not die if some financial help is available to them.
I believe every well-meaning Nigerian will agree with Mrs. Anyanwu-Akeredolu that “It’s time to make Breast Cancer a National Health Priority”.
3.0: Breast Cancer as Health Priority in Nigeria
Breast cancer is an established health priority in many developed countries. This has shown many dividends in reduction of the incidence of the disease improvement of early detection, increase in disease free survival among those diagnosed with breast cancer as well as reduction in breast cancer related mortality. In many developing countries like Nigeria more attention is paid to communicable diseases. Our overdependence on foreign aids to run many health programs compels us to align our priorities to that of the donors. That is why today in Nigeria HIV/AIDS attracts funding and attention more than other conditions that have been with us for ages such as malaria and sickle cell anemia. On many occasions we may hear awareness campaign regarding “Autism” on Nigerian media without similar opportunities for more perilous conditions like cancers.
The National Strategic Health Development Plan, initiated by the Federal Ministry of Health and endorsed by the President as well as all 36 states Governors, identified nine key indicators and targets for healthcare development. These include laudable high impact interventions regarding maternal and child health issues as well as malaria and HIV/AID control. I believe it is high time we include targeting the reduction of cancer related deaths as the 10th issue on the list of targets.
A study was conducted in Ibadan in 2005 in which the investigators set out to assess the level of knowledge of breast cancer among women in the community. 65% of the women were adjudged to have poor knowledge of the symptoms that may indicate cancer of the breast. I have found similar deficiencies when interacting with women in our out-patient clinics. The majority who noticed a lump in their breasts delay for up to 3-6months before seeking medical attention “because it is not painful”. Sadly, breast cancer usually starts as a painless lump and pain usually occurs when the disease is advanced or when infection is associated. Our women should therefore learn not to disregard a painless breast lump. The fact is, a lump in the breast that starts out being very painful may not be a cancer but will equally require further examination and tests.
Several reports from low and middle income countries similar to Nigeria have indicated that women who practice regular Self Breast Examination (SBE) can detect lumps at relatively early stages and seek intervention thereby reducing the disabilities and deaths commonly associated with late presentations of the disease. Sadly, the practice of SBE is very low among Nigerian women. Some studies have reported that only 35-50% of our women, including professionals; know of the benefits of SBE and only a smaller percentage practice SBE. We therefore need to educate the populace on the benefits of this simple practice on the health of women in the nation. Women in the reproductive age and beyond are equally encouraged to present to a healthcare provider for a clinical breast examination since a trained personnel may be able to detect lumps in the breast or point out suspicious areas that may require further investigations. A woman of 40 years or older in our country should endeavor to have such a check-up at least twice a year. On the other hand, Mammography, a form of X-ray of the breast, is able to detect growth or changes in the breast that are still very tiny as not to be felt by hand examination of even the expert. If abnormal findings are seen on the films, attention can then be directed to the area for further tests. Any cancer detected and treated at such an early stage when it is not yet large enough to be felt has a very high chance of total cure.
The common belief among Nigerians is that breast cancer is only a disease of women and it cannot affect men. The disease however affects men and1-2% of breast cancers may occur in the rudimentary breasts in men. In most instances, the affected men do not seek treatment for the swelling early due to poor knowledge. I have treated a number of elderly men with breast cancer and it is often difficult to convince the relations of the need for treatment since they commonly believe it is a “boil” that is persisting.
I believe we urgently need a National Breast Cancer Awareness Campaign Committee. This Committee would fashion out culturally acceptable modalities of delivering health communication to girls, women and men using existing health programs and facilities. For instance, integration of these teachings into the curriculum of training of primary health care providers including community health extension workers, midwives and nurses could be helpful. The training model advocated by the late Professor Olikoye Ransome-Kuti for producing Nigerian doctors who will immediately serve as front-line health workers in primary health centers and general hospitals across the country is gradually being replaced by the model producing a typical Western doctor. We need to review the incorporation of health communication skills in our medical education so that young doctors on National Youth Service in rural areas can effectively educate our community dwelling women. The National Breast Cancer Awareness Campaign Committee will need to work with Non-Governmental Organizations like BRECAN and Mrs Anyanwu-Akeredolu to implement an integrated response that will incorporate socio-cultural considerations to reach the different segments of our population, involve other interest groups that may not be directly linked with breast cancer to provide information and build awareness and to build pressure groups for lobbying government.
3.2: Early Detection
When we improve awareness, there will be a change in attitude towards early detection. Along with Self Breast Examination, the demand for mammography will increase and we currently do not have enough of this facility across the country. The few centers where mammography can be performed are in the busy radiology units of tertiary hospital or in a few private establishments. A community screening facility of great importance like mammography should be available in our General Hospitals as well as the Federal Medical Centers. We may not need to employ a lot of specialists in such peripheral hospitals. With Information Technology facilities, the images taken from patients in such centers can be sent to Specialists in Designated centers for review. This will go a long way in improving access to the service, particularly in our semi-urban centers.
It is imperative that we develop an effective and efficient healthcare system in Nigeria where access to healthcare is guaranteed for every citizen irrespective of their financial status. Currently, 69% of our healthcare is financed “out-of-pocket” by households through unplanned catastrophic spending. This is unsustainable and certainly cannot suffice for adequate treatment of cancers among our large population of poor patients.
In a radio interview in Ibadan a few years ago, Mrs Anyanwu-Akeredolu said “Awareness without access to treatment and care is a wasted effort” This is a fundamental issue that we must all consider. The cost of drugs for treatment of breast cancer is high and beyond the reach of the average citizen. It is the commonest reason for non-adherence to treatment schedule thereby contributing to a dismal outcome of treatment in many patients. I believe strongly that this is an area that we should look into as a nation. The amount of money spent in a year by public officers and Nigerian elites on medical tourism abroad is enough to equip a Tertiary Hospital with all the latest state of the art facilities for detection and treatment of cancers. On the other hand, records of patients treated in our hospital in the early 1970’s shows that the bill of all patients treated for cancer was forwarded to the Western Regional Government under the great leadership of Chief Obafemi Awolowo and the hospital is refunded within a month. Unfortunately today, when as a nation we budget in trillions of naira, there is not enough to pay for the bill of a citizen who develops a cancer of unknown cause! Certainly we can all collectively appeal to our consciences on this matter. It is bad enough to have to tell a patient the news of cancer but it is worse to tell them they need to source for an amount they don’t earn in a year to purchase drugs every 3 weeks to earn a right to live. The National Health Insurance Scheme has not been helpful in this regards due to limited coverage. The majority of those enrolled on the Scheme are Government workers and a few private establishments with the majority of Nigerians in the informal sector having no health insurance. Statistics from the Federal Ministry of Health shows that it contributed only 2% of the financing of health needs of the nation between 2003 and 2005. The scheme does not generally cover for the disbursement of the drugs required for cancer treatment by most healthcare providers. This is another area that requires a comprehensive review. There is no reason whatsoever why an HIV positive Nigerian will have access to free treatment and another suffering an equally perilous condition like cancer will die without care due to lack of funds.
Another area of need is radiation therapy. Radiotherapy machines should be provided in most Tertiary Hospitals in Nigeria to aid the treatment of patients with cancer. With the rising incidence of cancers in Nigeria the need for this facility will continue to grow. For our population, at least one radiation center should be available in each state of the federation, while a congested place like Lagos should have several of this facility. I have had to refer patients from Ife to Lagos, Zaria and Sokoto at different times for radiotherapy. We are all familiar with the challenges such referrals would pose to ailing persons on our roads.
As an academic staff, I am trained to ask questions. Unfortunately many of the questions there are about breast cancer in Nigeria today remain largely unanswered. For instance “What is the true incidence and prevalence of breast cancer in Nigeria? Why do women in Nigeria present with breast cancer at very young age compared to women in other climes? Why do they present with very huge tumors in the breast with ulcers? Are there specific genetic and biological changes responsible for the disease in our patients? Should we be using the recommended drugs and other treatments and schedules developed in Western countries where the presentation is different from ours? Is our adoption of foreign diets and lifestyles responsible for the increasing incidence of cancers in our nation?
We can choose to ignore these questions. We can, in our typical way, take each cancer death as “an act of God”. Or we can choose to look into these questions. We can, as a nation, decide to take these questions seriously and commit ourselves to finding answers. I believe the future of cancer care in Nigeria lies in finding answers to our specific questions through research. Our priority should be to commission research at the national level to generate data on the aforementioned questions. This will help us to formulate policies on how best to screen for the disease in our population and to develop specific guidelines for treatment that we can use to educate and audit our caregivers. We need to strengthen existing research infrastructures in our tertiary institutions and provide funds for multicenter collaborative research that will address specific questions. We must build capacity and infrastructure to locally sustain research in cancers generally.
On a final note, I wish to remind us all that cancers are on the rise globally. The World Health Organization estimates that at least one-third of all cancer cases are preventable. As we say, prevention is better than cure. Individuals need to make healthy lifestyle choices. With globalization, we are constantly embracing dietary and lifestyle practices that are alien to our African culture. The extent to which this has contributed to the advent of new diseases that used to be uncommon in Africa and the rising incidence of cancers in our environment remain a source of academic debate. Each one of us must however remember to add exercises to our daily routine and maintain a healthy weight. Tobacco use, estimated to cause 22% of the total annual cancer related deaths worldwide, must be avoided in both the active and the passive forms. We are also encouraged to limit alcohol intake and consume diets rich in natural fruits and vegetables. Women of reproductive age are encouraged to breastfeed their babies and those in the postmenopausal age should avoid the use of hormone replacement drugs as much as possible.
Current evidence shows that breast cancer is a key health challenge for Nigerian women and the country at large. To meet the challenge, we need to deploy all resources at our disposal towards improving awareness of the disease, promoting early detection and enhance access to treatment by offering support to those who are diagnosed with the condition. Those of us who are blessed with good health should endeavor to spare a little effort to contribute to the wellbeing of others. The disease do not show respect for persons.
Once again, I congratulate the celebrant and join all present here today to pray for long life, good health and prosperity for you. I thank you all for your attention.