Breast Cancer in Nigeria: Diagnosis, Management and Challenges

By Erhabor Osaro

Worldwide, breast cancer is the commonest cancer in women and it is characterized by regional variations and late clinical presentation and poor access in low and middle income countries including Nigeria. It is disproportionately responsible for mortality among women in developing countries compared to those in developed countries. There are several challenges associated with the effective management of breast cancer in Nigeria; financial barriers limit womens access to screening and treatment services, late-stage presentation, high incidence of triple negative breast cancers and failure in stewardship by government in their inability to provide the best possible cancer care like their counterparts in the West. There is an urgent need to step up activities through governmental and non-governmental agencies to promote advocacy, national policy on training of personnel for diagnosis, clinical and self-breast examination and nationwide screening program (mammography) in order to enhance early detection, control the upward trends and reduce the mortality rate associated with breast cancer. Routine age appropriate and specific breast screening should become an integral part of healthcare system in Nigeria allowing for early detection and intervention; aggressive awareness campaign on the advantages of early diagnosis and the dangers of late presentation, need to offer universal and affordable treatment, implementation of a strategy to offer annual mammogram to women above the age threshold for breast cancer, increased budgetary allocation for the diagnosis and management of cancer, more investment in the training of healthcare workers involved in the diagnosis and management of breast cancer, provision of Health Education encouraging women to conduct routine Breast Self Examination (BSE). BSE could become a simple, low-priced, secure, effective, appropriate and feasible screening tool in Nigeria. There is need to re-emphasize the importance of prompt reporting of any new breast symptoms to a health professional. Clinical Breast Examination (CBE) should become part of a periodic health examination, preferably at least every three years. Asymptomatic women aged 40 and over should be offered a CBE as part of a periodic health examination, preferably annually. Objective implementation of these steps can help reduce the incidence of breast cancer-related mortality in Nigeria.

• Language: English
• Publisher: AuthorHouse UK
• Release date: Mar 9, 2016
• ISBN: 9781504996778

Erhabor Osaro

Dr Erhabor Osaro is a chartered scientist and fellow of the Institute of Biomedical Science of London. He holds a doctor of philosophy degree in immunohaematology. He completed the University of Greenwich specialist courses in blood transfusion and laboratory quality management system. His teaching experience spans both Nigeria and the United Kingdom. His work experience includes working as a Specialist Biomedical Scientist at the Royal Bolton Hospital-a continuous improvement conscious and a centre of excellence in the implementation of lean principle in the health sector in Europe. He is the recipient of several awards, including the famous British Blood Transfusion Society Young Scientist Award and the Margaret Kenwright Young Scientist Award. He is a registration portfolio verifier/examiner for the Institute of Biomedical Science of London. He is a member of the editorial board as well as an article reviewer for several scientific journals. A well-published contributor in the field of infectious diseases, immunohaematology, and transfusion medicine, he is chairman of the board of directors of Nelson Biomedical Limited, UK and Nigeria. He is married to Angela, and they are blessed with five children – Emmanuel, Majesty, David, Daniel, and Michelle. Dr Adias Teddy Charles is the provost of the Bayelsa State College of Health Technology, Ogbia, Nigeria. He holds a PhD in immunohaematology and is a fellow of the Institute of Biomedical Science (FIBMS), London. His current research interest is focused on transfusion immunology, safety and alternatives, and the haematology of infectious diseases. Recent publications have included articles in journals, such as the Journal of Blood Medicine, Transfusion Clinique et Biologique, Pathology, and Laboratory Medicine International, amongst others. Dr Adias is happy married and blessed with two children.

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Published by AuthorHouse  03/08/2016

ISBN: 978-1-5049-9676-1 (sc)

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Table of Contents

Chapter                            Title

Preface

Acknowledgement

1.   Introduction

2.   Challenge of Suboptimal Access to Mastectomy

3.   Lack of Access to Optimum Mammography and other Diagnostic Services

4.   Challenges associated with access to radiotherapy, chemotherapy and treatment

5.   Challenge Associated with Screening for Breast Cancer in Nigeria

6.   Late stage breast cancer among premenopausal Nigerian women

7.   Challenge of Triple Negative Brest Cancer (TNBC) in Nigeria

8.   Challenges Associated with Carrying out Randomized Clinical Trials on Breast Cancer in Nigeria

9.   Failure in Stewardship in the Management of Breast Cancer by the Nigerian Government

10.   Socioeconomic Factors and Unaffordability of Breast Cancer Treatment in Nigeria.

11.   Challenge of Increasing Incidence of Risk Factors for Breast Cancer in Nigeria

12.   Challenge of Poor Awareness of Breast Self Examination (BSE)

13.   Role of Spirituality in the Delay in Seeking Care among Breast Cancer Patients

14.   Challenge of Increasing Incidence of Breast Cancer among Men

15.   Poor knowledge and awareness- related challenges associated with Breast Cancer

16.   Lack of access to diagnostic test to determine predisposition to Breast Cancer

17.   Poor access to Breast Cancer diagnostic services in rural settings

18.   Pregnancy and breast cancer in Nigeria

Breast Cancer in Nigeria: Diagnosis, Management and Challenges

Erhabor O ¹, Abdulrahaman Y¹, Retsky M ², Forget P ³, Vaidya Jayant ⁴, Bello O ⁵, Adias TC ⁶, Dagana A ⁷, Egenti BN ⁸, Mainasara AS ⁹, Sahabi SM ¹⁰, Rilwanu TI ¹⁰, Ahmed Y ¹¹, Hassan M ¹¹, Ajayi O. Ifedayo ¹², Okara GC ¹³, Lori J ¹⁴, Ibiang L ¹⁵.

Department of Haematology Faculty of Medical Laboratory Science Usmanu Danfodiyo University, Sokoto, Nigeria ¹, Harvard TH Chan School of Public Health Boston MA USA ², Department of Anesthesiology, Universite catholique de Louvain, St-Luc Hospital, Av. Hippocrate 10-1821, 1200 Brussels, Belgium ³, University College Hospital, London ⁴, Faculty of Basic Medical Sciences Usmanu Danfodiyo University Sokoto ⁵, Medical Laboratory Science Department Niger Delta University Amassoma Bayelsa State ⁶, Department of Haematology University of Abuja Teaching Hospital Teaching Hospital ⁷, Department of Community Medicine University of Abuja, Nigeria ⁸, Department of Clinical Biochemistry Faculty of Medical Laboratory Science Usmanu Danfodiyo University, Sokoto, Nigeria ⁹, Department of Histopathology Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria ¹⁰, Department of Obstetrics and Gynaecology Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria ¹¹, Department of Physiology University of Benin ¹², Dr. Hassan’s Hospital & Diagnostic Centre, Abuja, Nigeria ¹³, Bingham University Karu, Abuja, Nigeria ¹⁴, Management Sciences for Health (MSH) Abuja, Nigeria ¹⁵.

Preface

Worldwide, breast cancer is the commonest cancer in women and it is characterized by regional variations and late clinical presentation and poor access in low and middle income countries including Nigeria. It is disproportionately responsible for mortality among women in developing countries compared to those in developed countries. There are several challenges associated with the effective management of breast cancer in Nigeria; financial barriers limit women’s access to screening and treatment services, late-stage presentation, high incidence of triple negative breast cancers and failure in stewardship by government in their inability to provide the best possible cancer care as their counterparts in the West. There is an urgent need to step up activities through governmental and non-governmental agencies to promote advocacy, national policy on training of personnel for diagnosis, clinical and self-breast examination and nationwide screening program (mammography) in order to enhance early detection, control the upward trends and reduce the mortality rate of breast cancer. Routine age appropriate and specific breast screening should become an integral part of healthcare system in Nigeria allowing for early detection and intervention; aggressive awareness campaign on the advantages of early diagnosis and the dangers of late presentation, need to offer universal and affordable treatment, implementation of a strategy to offer annual mammogram to women above the age threshold for breast cancer, increased budgetary allocation for the diagnosis and management of cancer, more investment in the training of healthcare workers involved in the diagnosis and management of breast cancer, provision of health education encouraging women to conduct routine Breast Self Examination (BSE). BSE could become a simple, low-priced, secure, effective, appropriate and feasible screening tool in Nigeria. There is need to re-emphasize the importance of prompt reporting of any new breast symptoms to a health professional. Clinical Breast Examination (CBE) should become part of a periodic health examination, preferably at least every three years. Asymptomatic women aged 40 and over should be offered a CBE as part of a periodic health examination, preferably annually. Objective implementation of these steps can help reduce the incidence of breast cancer-related mortality in Nigeria.

Prof. Erhabor Osaro (PhD.)

Manchester, United Kingdom

Acknowledgement

My sincere thanks goes to AuthorHouse Publishers UK, for their assistance and contribution to the publication of this book; to my Father in the Lord, Bishop David O. Oyedepo for being an inspiration in my life through his teachings; to Pastor Timi Davies for his spiritual oversight; not forgotten my Parents Late Mr Aibangbee and Mrs Rose Erhabor; to my co-labourers in the fight against breast cancer in Nigeria; Retsky Michael, Demicheli Romano, Forget Patrice, Vaidya Jayant, Bello Shaibu, Adias Teddy Charles, Dagana Amos, Egenti Nonye B, Mainasara Abdullah Suleiman, Sahabi SM, Rilwanu TI, Ahmed Yakubu, Hassan Mairo, Bashir Bello and Ifedayo Ajayi. I also wish to thank my wife; Mrs Angela Erhabor and my children; Emmanuel, Majesty, David, Daniel and Michelle. To the source of my life and strength, the Almighty God be all the praise.

Chapter 1

Introduction

Breast Cancer constitutes a major public health issue globally, with over 1 million new cases diagnosed annually; resulting in over 400,000 annual deaths and about 4.4 million women living with the disease. It also affects one in eight women during their lives. It is the commonest site specific malignancy affecting women and the most common cause of cancer mortality in women worldwide. Breast cancer is a malignant (cancerous) growth that begins in the tissues of the breast. Cancer is a disease in which abnormal cells grow in an uncontrolled way. It is the most common cancer in women, but it can also appear in men. 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 and may have involved other organs in the body such as the lungs, liver, bones, the brain or the spine. The five year survival rate for breast cancer patients in the United States exceeds 85%, in Nigeria it is a dismal 10%. Breast cancer is responsible for about 16% of all cancer related deaths in Nigeria ¹.

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Figure 1: WHO statistics on Cancer among women

There are many risk factors that have been associated with breast cancer. Being a female, the risk increases with the age of the woman; the older a woman, the increased chances of getting breast cancer. History of breast cancer in close relatives especially in mothers and siblings has been associated with the risks of getting breast cancer, early onset of menstrual periods before the age of 12 years or reaching menopause after the age of 55 years has both been associated with risks of developing breast cancer, prolonged period of estrogen exposure in females, overweight, using hormone replacement therapy, taking birth control pills, drinking alcohol, not having children or having your first child after age 35 or having dense breasts.

The incidence of cancers is increasing 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, about 7.6 million people died from cancers globally, with about 70% of these deaths occurring in developing countries. In Nigeria, it is estimated that more than 250,000 new cases of cancers are diagnosed every year, and up to 10,000 Nigerians die each year from cancer related causes. These estimates may not be a reflection of the true picture as they are often largely based on hospital generated data without provision for the many cases that do not present in hospitals, those managed by traditional medicine practitioners, as well as the many cases of misdiagnosis in our numerous peripheral hospitals. There are over 230,000 new cases of breast cancer each year in the United States as of 2015. About 40,000 fatalities occur in the U.S. every year from this particular form of cancer². The risk of breast cancer increases with age, and in the U.S. approximately one out of eight women will get breast cancer at some point in their lives. The physical, emotional and financial cost of this disease is staggering.

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Figure 2: WHO statistics on Cancer among both gender (WHO, 2011)

The incidence of cancer continues to rise all over the world, and current projections show that there will be 1.27 million new cases and almost 1