A month of Breast Cancer Aware­ness

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Pink­to­ber: A month of Breast Cancer Aware­ness

On a beau­ti­ful Satur­day morn­ing, 35-year-old Nina was busy look­ing af­ter her one year old son. She had been so busy for the past few months that she hadn’t had any time for her­self. While in the shower on this par­tic­u­lar morn­ing, Nina felt that there was slight thick­en­ing of the skin on the up­per, outer part of her right breast. On Mon­day morn­ing she went to her doc­tor, who or­gan­ised an ul­tra­sound scan and breast mam­mo­gram. There was some con­cern re­gard­ing the pos­si­bil­ity of cancer and she was re­ferred to the hospi­tal where a biopsy was done. The biopsy proved that she did have breast cancer and re­quired fur­ther scans and tests. She was di­ag­nosed with Stage 1 breast cancer. Nina had surgery – a mas­tec­tomy (re­moval of the breast). Be­cause ra­di­a­tion ther­apy is not avail­able in Fiji, the op­tion of lumpec­tomy (re­mov­ing only the lump in the breast) to­gether with ra­dio­ther­apy was not an op­tion. Nina did well af­ter the surgery and con­tin­ued with her usual ac­tiv­i­ties. When 45-year-old Manju woke up at dawn on a rainy Mon­day morn­ing she no­ticed a blood­stained dis­charge on her bra. She also had a pain in her left breast and could feel a lump. She was shocked; this was the first time some­thing like this had hap­pened to her. Manju had a real fear of doc­tors and the hospi­tal be­cause her mother had died of breast cancer. So Manju didn’t go to see a doc­tor, she was in de­nial that any­thing was re­ally wrong. It wasn’t un­til she de­vel­oped a rapidly grow­ing mass over her breast that she went to the doc­tor and was sent to hospi­tal. By this stage Manju’s cancer had spread from the breast tis­sue to the sur­round­ing lymph nodes. The sur­geon per­formed a mas­tec­tomy and re­moved the lymph nodes. Manju sur­vived for a year but her cancer spread to her liver and lungs and she passed away. In a nearby vil­lage lived Mere­oni, aged 60. For the past six months she had been feel­ing more tired, los­ing weight and had a lump on her right breast. Mere­oni had been us­ing some tra­di­tional medicine to re­lieve her pain. She did not be­lieve in mod­ern medicine and re­fused to see a doc­tor. Within four weeks she be­came more short of breath, had ab­dom­i­nal swelling and passed away. It ap­peared that she died of metastatic breast cancer, cancer that had spread to other or­gans. Th­ese sort of cases are not un­com­mon when it comes to aware­ness and man­age­ment of breast cancer in the de­vel­op­ing world. The Amer­i­can Cancer So­ci­ety and the phar­ma­ceu­ti­cal com­pany As­trazeneca founded Breast Cancer Aware­ness Month in 1985. Its cam­paign pink rib­bon is syn­ony­mous with Oc­to­ber and many peo­ple re­fer to the month as “Pink­to­ber.” The ac­tiv­i­ties of the month help to in­crease at­ten­tion and sup­port for the aware­ness, early de­tec­tion and treat­ment as well as pal­lia­tive care of this dis­ease. There are about 1.38 mil­lion new cases and 458 000 deaths from breast cancer each year (IARC Globo­can, 2008). Breast cancer is by far the most com­mon cancer in women world­wide, both in de­vel­oped and de­vel­op­ing coun­tries. In low- and mid­dle-in­come coun­tries the in­ci­dence has been ris­ing up steadily in the past few years due to in­creased life ex­pectancy, in­creased ur­ban­i­sa­tion and adop­tion of western life­styles. (World Health Or­ga­ni­za­tion) Cur­rently there is not suf­fi­cient knowl­edge on the causes of breast cancer. Early de­tec­tion of the dis­ease re­mains the cor­ner­stone of breast cancer con­trol. When breast cancer is de­tected early, and if ad­e­quate di­ag­no­sis and treat­ment are avail­able, there is a good chance that breast cancer can be cured. If de­tected late, how­ever, cu­ra­tive treat­ment is of­ten no longer an op­tion. In such cases, pal­lia­tive care to re­lief the suf­fer­ing of pa­tients and their fam­i­lies is needed. The ma­jor­ity of deaths (269 000) oc­cur in low- and mid­dlein­come coun­tries, where most women with breast cancer are di­ag­nosed in late stages due mainly to lack of aware­ness on early de­tec­tion and bar­ri­ers to health ser­vices. Ac­cord­ing to the lat­est World Health Or­ga­ni­za­tion data pub­lished in May 2014, Breast Cancer Deaths in Fiji reached 114 or 2.13%of to­tal deaths. The age ad­justed Death Rate is 31.38 per 100,000 of pop­u­la­tion. Fiji ranks num­ber two in the world with re­gard to death rate from breast cancer. The World Health Or­ga­ni­za­tion (WHO) pro­moted early de­tec­tion strate­gies for low- and mid­dle-in­come coun­tries are aware­ness of early signs and symp­toms and screen­ing by clin­i­cal breast ex­am­i­na­tion. Mam­mog­ra­phy screen­ing is costly and is fea­si­ble only in coun­tries with good health in­fra­struc­ture that can af­ford a long-term pro­gram. So what ad­vice can we give women in de­vel­op­ing coun­tries? Well, if we can min­imise the fac­tors that in­crease our risk of de­vel­op­ing breast cancer then we may have some hope. Th­ese risks in­clude obe­sity, lack of phys­i­cal ac­tiv­ity, drink­ing more than one stan­dard drink of al­co­hol daily, hor­mone re­place­ment ther­apy dur­ing menopause, early age of first men­stru­a­tion, not hav­ing any chil­dren or hav­ing chil­dren late in life. Breast­feed­ing may re­duce the risk of breast cancer slightly. Although some risks might be re­duced by preven­tion strate­gies, such as more ex­er­cise and los­ing weight, they can’t stop the ma­jor­ity of breast can­cers in low- and mid­dlein­come coun­tries. So find­ing out as early as pos­si­ble is the most im­por­tant way to im­prove the chances of con­trol­ling and sur­viv­ing breast cancer. (An­der­son et al., 2008). There are two ways to de­tect cancer in the early stages: di­ag­no­sis or aware­ness of early signs in symp­to­matic

pop­u­la­tions, peo­ple most at risk, so they can get early treat­ment, and screen­ing, which is the sys­tem­atic ap­pli­ca­tion of a test in groups of peo­ple con­sid­ered to be most at risk. The test aims to iden­tify in­di­vid­u­als with an ab­nor­mal­ity that sug­gests it could be cancer. It is im­por­tant that women are aware of the symp­toms and signs of breast cancer. The most com­mon symp­tom is a new lump. A pain­less, hard mass that has ir­reg­u­lar edges is more likely to be cancer, but breast can­cers can also be ten­der, soft, or rounded. They can even be painful. For this rea­son, it is im­por­tant to have any new breast mass, lump, or breast change checked by a health care pro­fes­sional ex­pe­ri­enced in di­ag­nos­ing breast dis­eases. Other pos­si­ble symp­toms of breast cancer in­clude: Swelling of all or part of a breast (even if no dis­tinct lump is felt) Skin ir­ri­ta­tion or dim­pling (some­times look­ing like an or­ange peel) Breast or nip­ple pain Nip­ple re­trac­tion (turn­ing in­ward) Red­ness, sca­li­ness, or thick­en­ing of the nip­ple or breast skin Nip­ple dis­charge (other than breast milk) Some­times a breast cancer can spread to lymph nodes un­der the arm or around the col­lar bone and cause a lump or swelling there, even be­fore the orig­i­nal tu­mor in the breast is large enough to be felt. Swollen lymph nodes should also be checked by a health care provider. Although any of th­ese symp­toms can be caused by things other than breast cancer, if you have them, they should be re­ported to a health care pro­fes­sional so that the cause can be found. With re­gard to screen­ing tests, many de­vel­oped coun­tries such as Aus­tralia of­fer rou­tine screen­ing mam­mo­grams for women aged 50 and over ev­ery two years to pick up any early changes in the breasts. This is not fea­si­ble in de­vel­op­ing coun­tries due to the cost. How­ever women who can af­ford to pay for a mam­mo­gram can have mam­mo­grams ev­ery two years af­ter the age of 50. Self breast ex­am­i­na­tion monthly by the women her­self can make the wo­man more aware of her breasts and if there are any con­cerns, then a health care provider should be con­sulted. Clin­i­cal breast ex­am­i­na­tion by a health care provider ev­ery year af­ter the age of 20 can also act as a screen­ing test. It is im­por­tant to note how­ever, that this may pick up more ad­vanced stage can­cers as op­posed to early breast cancer. Women who have a strong fam­ily his­tory of breast cancer may need to be screened more of­ten. This Oc­to­ber truly un­der­stand what the pink rib­bon sig­ni­fies. Pink is only a colour and cure is an il­lu­sion. We des­per­ately need more re­search to turn breast cancer into a man­age­able dis­ease for all women, not just some. To this day about 30% of all breast cancer pa­tients will go on to de­velop in­cur­able dis­ease. So to all you breast cancer sur­vivors- tell your story and cel­e­brate strength and sur­vival. To those women who have suc­cumbed to breast cancer, it is a time to hon­our them. Beau­ti­ful words by Jim Val­vano: “Cancer can take away all of my phys­i­cal abil­i­ties. It can­not touch my mind, it can­not touch my heart, and it can­not touch my soul.”

“Cancer can take away all of my phys­i­cal abil­i­ties. It can­not touch my mind, it can­not touch my heart, and it can­not touch my soul.”

DR. KRUPALI RATHOD TAPPOO is an Aus­tralian qual­i­fied Gen­eral Prac­ti­tioner, a Fel­low of the Royal Aus­tralian Col­lege of Gen­eral Prac­ti­tion­ers and the Med­i­cal Co­or­di­na­tor for Fiji-based NGO Sai Prema Foun­da­tion. Dr. Krupali is based at Mitchells Clinic...

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