CLOSING THE CARE GAP ON BREAST CANCER IN JAMAICA AND THE CARIBBEAN

BREAST CANCER continues to be the topic of discussion as we are in the month of October, where awareness is being made to the public about this highly prevalent disease in our society. Chances are that if you are reading this article, you are familiar with someone in your family, workplace, neighbourhood, church, etc. who is or has been affected by this disease. There is also a high probability that you are familiar with some of the information that is shared below. This year is different as we are fully navigating life affect the COVID-19 pandemic, which severely affected the medical profession and caused many elective operations to come to a halt after a two-year period from March 2020 until the end of 2021/beginning of 2022. This unfortunately led to delays in treatment, as we continue the fight against this disease.

Breast cancer is a disease that affects women and men, but women are approximately a hundred times more likely to be affected than men. Unfortunately, when men do develop the disease, it appears to be more aggressive. Women in Jamaica have a 1-in-8-12 chance of developing breast cancer during their lifetime. Raw data from other English-speaking Caribbean islands also suggests that the incidence (number of new cases that develop each year) may be similar to the one quoted above. Noticeably, the incidence of breast cancer in Jamaica over the past 20 years has shown a slight increase and this figure is expected to rise even further. When compared to North America, we can also see some differences in our breast cancer patient population:

1) The median age that women develop breast cancer in the United States of America (USA) is about 60, while in Jamaica our reported median age is around 52 (approximately eight years younger).

2) Approximately 60 per centof our females affected with the disease are between the ages of 25 and 59 years.

3) Another disheartening statistic is that approximately 20 per cent of our patients present with advanced breast cancer when compared to 6 per cent in North America, which represents more than three times the number of patients presenting at an advanced stage or beyond. In the Breast Oncology Clinic conducted at the Kingston Public Hospital (KPH), which has been functioning for the past three years, the proportion of advanced cases seen among all breast cancer patients is even higher with more than 40 per cent patients presenting with stage III disease or beyond. What is also alarming is that patients under the age of 50 years tend to present at a more advanced stage when compared to our North American neighbours, and the cancer tends to be more aggressive (as emphasised by higher histological grades).

These figures result in a poorer prognosis (outcome) for patients, and the treatment that patients must undergo with stage III compared to stages I or II (early disease) is not only more intense, but the financial, emotional and psychological journey that these patients endure is more taxing. Because of this, significant emphasis has been placed on screening. But what is this term that is being thrown around so often in the medical fraternity and the public.

“Screening is the ability to detect any disease that has a significant impact on a society (or part thereof ), by subjecting that population to test(s) or investigation(s), before they display any symptoms or signs of the disease.”

Hence, we are carrying out investigations in people who are asymptomatic (have no symptoms) who are at risk for development of the disease. The general goal of screening is to either detect i) the disease at an early stage, or ii) a lesion that will go on to develop into the disease, also known as a “precursor lesion”, so that (in either circumstance) some form of treatment can be implemented to improve the patient’s outcome (and live longer).

With regard to breast cancer, we do not know of any precursor lesions, and thus the goal with screening is to detect the disease at an earlier stage. The expectation is that detecting the disease at an early stage gives patients a better prognosis and outcome, as well as in some clinical scenarios, less treatment required to eradicate the disease. Most people agree that screening for breast cancer is beneficial, and there are clear examples of other cancers where screening has had a significant impact to reduce the ill- effects of the disease and improve survival (prevention of patient demise). One such example that many people are familiar with is cervical cancer, where screening with a PAP smear has shown a reduction in the number of cases by detecting the disease at an earlier stage, as well as detecting (and then eradicating) precursor lesions.

The controversies related to breast cancer screening more so lie in trying to determine i) WHEN the appropriate time to commence screening is, and ii) the TIME INTERVAL between each screening test once screening has started. Worldwide the radiological investigation that has been approved and used for screening is the MAMMOGRAM. In the United Kingdom (UK) screening for averagerisk females begins at age 50 and is conducted every three years. In the USA most protocols recommend screening for average-risk individuals to commence at age 40 on an annual basis, but there are a few associations that suggest and recommend that screening commences at age 50, and the mammogram be performed every two years instead of annually. In the USA, there is no consensus among these different groups, and this is why you may see variations in screening protocols for breast cancer depending on what medical group or information one reads. Unfortunately, this can make it confusing for physicians and even more so for the public. What we should also be aware of is that there is evidence to suggest that breast cancer among certain ethnic groups, AfricanAmerican and Hispanics, tends to be more aggressive and can also develop at an earlier age. That information has been identified locally and regionally (as mentioned above).

In April 2019, the University of the West Indies published guidelines (in the West Indian Medical Journal) for the treatment (and screening) of some common surgical diseases, including screening protocols for patients with breast cancer. It was concluded that screening should occur on an annual basis with the mammogram, which can commence at age 40, BUT WOMEN SHOULD COMMENCE SCREENING NO LATER THAN AGE 50, and this can continue up to

age 74. This should also be coupled with clinical breast examinations by your doctor on an annual basis as well.

It is imperative that women know their individual risk for the development of breast cancer. The majority of women will fall into the average risk group, and thus the abovementioned guidelines for screening may apply to them. For higher-risk patients, such as those who have a strong family history of breast cancer, screening protocols must be individualised, and this most likely will include the commencement of screening at an earlier age and/or more frequent intervals between screening tests.

So, what do you need to do? Below is a list of what you should be aware of: i) Know your risk profile. ii) Be aware of what you breast feel like (breast awareness)

iii) Talk to you physician (whether you family doctor (GP), gynaecologist or surgeon) or occupational health nurse; and have your clinical breast examination done by the above or a nurse trained in breast examinations.

iv) Consider screening mammography at age 40, AND NO LATER THAN age 50 (if older than age 40, and you have not commenced mammographic screening as yet).

The one problem with everything mentioned above is that we only have approximately twenty (20) mammogram machines across the island. And out of the afore-mentioned number, only two (2) are the newer and improved 3-D machines of which one is housed at the University Hospital of the West Indies. Up to two months before this article was written, there were no mammography machines in the public sector. Recently a (mammography) unit was installed at the Kingston Public Hospital (KPH) and another at Cornwall Regional Hospital (CRH) where service to the public commenced in September 2023. While this is a start, we are still behind the eight ball and no machines are currently available in the public sector at any of the remaining major hospitals or health centers islandwide. So, while we promote and spread awareness about a disease that

Throughout the world the management of breast cancer has shifted more towards pharmacological management (drugs), which is decided and administered by the haemonocologist. These advances are seen in the development of newer chemotherapeutic drugs, as well as drugs targeted to destroy proteins and other substances associated with the growth of breast cancer cells (immunotherapy). While these newer treatment modalities have showed significantly promising results, they are extremely expensive.

is the number one cancer amongst women in our population, we are still moving slowly to address the real problem, which is creating (easy) access for all women to have a mammogram performed throughout the island. The Jamaica Cancer Society (JCS) provides discounted prices for mammograms at their head office. In addition, the JCS, as well as the Ministry of Health and Wellness (MOHW) have independently forged public/ private partnerships with some radiological centres across the island, which allows public patients to access these machines in the private sector. Despite the above solution, the long-term fix to the shortage of machines in the public sector, is to provide more access with more machines being available islandwide.

While the physical resources (mammography units) contribute to the problem of breast cancer management, we cannot overlook i) the human resource factor, ii) the cost of medications and iii) the time interval from diagnosis to treatment, especially as it relates to surgery.

While we recognise that there is a shortage of medical staff in most specialties involved in the management of breast cancer, there is certainly a significant shortage in radiology, heamoncology and radiotherapy, as well as nurses specialized in oncology treatment. Increasing staffing in these areas may help to decrease the time interval from diagnosis to treatment but diminishing the time interval to acceptable standards will still be problematic. This is mainly due to the lack of operating time. Operating time can only be solved by providing more operating theatres (for surgeons) and again, this will also require more human resources in the field of anaesthesiology and nursing in order to manage the increased patient load.

Throughout the world the management of breast cancer has shifted more towards pharmacological management (drugs), which is decided and administered by the haemonocologist. These advances are seen in the development of newer chemotherapeutic drugs, as well as drugs targeted to destroy proteins and other substances associated with the growth of breast cancer cells (immunotherapy). While these newer treatment modalities have showed significantly promising results, they are extremely expensive. Some medications can cost well over $300,000 per dose, and in some instances as many ten doses or more are required for a course of treatment.

The information above is not meant to scare or deter anyone diagnosed with breast cancer, but it to make individuals aware of the realities faced. With discussions with your physician or medical personnel involved with your management you will find avenues to reduce costs. Programmes and subsidies have been provided by government entities such as the JCS, MOHW and the National Health Fund (NHF), and some private companies also involved in the field. We recognize that the cost associated with cancer treatment anywhere in the world, including the Caribbean is expensive; and while screening cannot prevent the development of breast cancer, it can help with early detection, which may improve your chance of a better outcome, and in many instances, less money spent by the individual diagnosed.