By Dr Evelyn Ho
Challenges to beating breast cancer exists at many levels from health habits, financial resources, education level, social support, pluralistic health systems/beliefs, communication skills of the health professional, medical facilities and more.
Middle and low income countries do not report the kind of survival rates from breast cancer as advanced or higher income nations do. Living with or living long after a diagnosis of breast cancer is closely dependent on how early the person presents at the doctor’s. Ethnicity in South East Asia may also be an independent factor for survival. It was found that Malay ethnicity has poorer survival which may be due to variations in tumour biology and other factors. University of Malaya reports women in Malaysia still come in advanced stages of the disease.
Access to diagnosis, then to treatment and having adequate treatment facilities and relevant healthcare professionals are crucial to persons detected with breast cancer, even if the detection is early. This is not just the surgeon. A whole team, multidisciplinary in nature, to offer optimum treatment is preferred but not always possible. This include the surgeon, radiologist, pathologist, oncologist, psycho-oncologist/psychologist, palliative medical specialist, breast care nurses and of course the patient herself/himself! Remember that breast cancer, sometimes can only be controlled, especially if it has spread to parts of the body beyond the breasts. However, more and more patients are living longer even with metastatic breast cancer and palliative care is needed to ensure they are not suffering unnecessarily.
In terms of widespread availability of these multidisciplinary facilities, Malaysia still has some way to go, before it reaches the level of high income countries. There are controversies with population based screening programmes but the one of the arguments for screening mammograms in women above 40 or 50 years old is the fact that it can detect breast cancer before the woman is aware
of it, before it can be felt. On the other hand, by the time Malaysia becomes a developed country with high income, the breast cancer incidence may rise to the pattern seen in developed countries. This may have to do with delayed age of 1st pregnancy (marriage at a later age); shortened breast feeding duration; dietary changes resulting in earlier menarche (age at which periods/menses begins); number of children (if any) and other factors. However, these are just risk factors. The biggest risk factors are being female and getting older!
Many men are not even aware they may also get breast cancer, although rarely. Therefore screening tests in males for breast cancer are not necessary (as it is rare in them). With less breast tissue, it is easier to be physically aware of breast changes or growths in their breasts. Therefore screening mammograms will not be promoted for males, but self-breast awareness is still essential.
There are many misconceptions about breast cancer. They associate their misfortune with deeds/misdeeds, dietary concerns, work/family stress. Some will immediately say, what wrong did they do? Their friends will laugh or make fun of them or say, what a terrible life she must have led to have become afflicted with breast cancer. Or they may ask themselves, “how can I get it? I eat a very healthy diet, only organic food, exercise, breastfed…how?” After treatment and diagnosis, they may not want others to know, not even outside their immediate family. They are concerned about the “marriageability” of their daughters! These are all gleaned from comments from patients – all true stories (even if they may sound unbelievable to some, but I am sure some will identify with these statements!).
Malaysians have choices when it comes to seeking a diagnosis or treatment because of the pluralistic nature of the Malaysian health care system. It is commonly seen in those who try to “make” their breast “mass/lump” go away with alternative traditional or multilevel marketing health products. Then there are those who don’t have money and therefore are unable to see a doctor about their problem to get tests. Lack of social support, psychosocial included and human resources to help with seeing to their children, when the mother goes for tests or treatment is a real problem for some.
Then even after diagnosis, they may delay “conventional” treatment to get alternative treatments. Some may be fatalistic, especially after seeing someone they know die from cancer after going through treatment. Some need money; some are prevented by the spouse or family member from getting treated.
The quality of communications between patient and doctor is crucial to enabling the woman to make the right choices for herself. The paternalistic nature of some consultations also results in delays. Skills in breaking bad news may be lacking in some health professionals. Shared decision making is deemed best but requires time, empathy and skill on the health professional’s part. Language barriers (as Malaysians may be from various ethnic backgrounds), cultural barriers, poor breast health literacy, fatalistic fears, lack of psychosocial support professionals (to address the emotional turmoil and pressures in a woman just told she has breast cancer), lack of financial resources and her social support system at home – all serve to delay the presentation of women to their doctors at the earliest stage of the disease.
If you are interested to read more:
1. Taib NA, Yip CH, Low WY. A Grounded Explanation of Why Women Present with Advanced Breast Cancer. World J Surg. 2014 Jul;38(7):1676-84. doi: 10.1007/s00268-013-2339-4
2. Cheng-Har Yip & Nur Aishah Taib. 2012. Challenges in the management of breast cancer in low- and middle-income countries. Future Oncology.
3. Bhoo-Pathy N, Hartman M, Yip C-H, Szena N, Taib NA, et al. 2012. Ethnic Differences in Survival after Breast Cancer in South East Asia. PLoS ONE 7(2): e30995. Doi:10.1371/journal.pone.0030995