Emerging breast cancer epidemic: impact on palliative care

Abstract

Imagine that you are poor and living in Africa, you develop breast cancer, your country has no oncology service, no prevention, early detection or treatment, and the strongest analgesic is paracetamol. You are lucky just to be found under these circumstances. Th is is the plight of thousands of women and some men in Africa today. And yet to control their pain and symptoms and bring them to peace before the end of life would cost so little. Th e West today sees the breast as a fashion symbol. In my lifetime it has gone from needing to be hidden from all to being fl aunted, pumped up and pumped down according to fashion. A treatise could be written on fashions for breasts in the generations in the developed world. But deep inside, the breast to an African woman is much more than a sexual organ. In Africa it is the life bringing organ that allows a child to survive above 1 year of age. To the woman it makes her attractive to her man. To the man it is sexual and brings the relationship between his wife and his mother into stark reality. But the breast is attached to a woman. A woman with feelings and, in Africa, a need to survive in the world of men. Losing a breast may make her unacceptable to her husband. She may be sent back to her family without her children. And the age for onset of breast cancer is much younger than in the developed world. So, breast cancer in Africa is a huge tragedy. In women it also sometimes occurs during pregnancy, and if the woman is among the 5% who are lucky enough to reach treatment, then they can only have it in the last trimester, when it may be too late (Fig. 1). Uganda In 1993, Uganda was chosen by Hospice Africa as the country in which to place a model hospice, Hospice Africa would reach out to all Africa at a time when only 3 of the 56 countries in Africa had any palliative care. Even today, many in the west still remember the atrocities carried out during the Amin and Obote eras in Uganda’s history. But since 1986, Uganda has developed and grown under the leadership of President Yoweri Museveni. Since 1993, the population has grown from 23 million to 33 million and the prevalence of HIV has been reduced from 30% to 6.7% of the population. HIV has aff ected the incidence and prevalence of cancer. Today, 50% of cancer patients at Hospice Africa Uganda are HIV-positive. Although cancer of the breast is not directly linked with HIV, the rates of all cancers have doubled with the advent of HIV. Although it is diffi cult to get statistics in most African countries for any disease, Uganda has boasted a cancer registry for many years and Hospice Africa Uganda keeps its own statistics. Based in Kampala, the cancer registry is confi ned to one district, Kyandondo, and only records those who reach hospital and have a confi rmed biopsy. Given that 57% of a population never see a health worker and 30% live on less than $2 per day, it is apparent that not only are most cancer cases not recorded but they also never reach any form of health care, so the cancers grow and patients die in severe pain and displaying obvious symptoms witnessed by their grieving families.