Clement, you are talking here at the conference in Lyon about actually breast cancer in Africa and the impact of breast cancer. How much do we know about this?

Not a whole lot because traditionally there has not been a lot of research on breast cancer incidence in Africa and a substantial part of what is in the literature is derived from small case series, single hospitals, clinicians and pathologists reporting their experiences. It’s only in the last decade or so that we’ve begun to see epidemiological research that’s giving us more robust data about breast cancer in Africa. So those researchers are now beginning to correct some of the issues that were out there in the literature.

And what are we seeing, in fact, epidemiologically?

What we are seeing, basically, is that the pattern in terms of incidence of breast cancer in Africa is similar to what we see in other parts of the world. But because of the peculiar population structure of African countries with a high proportion of young people, we then end up seeing a lot of young women with breast cancer in the hospitals, in contrast to what you see in developed countries where the predominant proportion of people with breast cancer are over the age of 50-60. In Africa you see a lot of 30 year olds and 40 years olds with breast cancer.

And what effect does that have?

That has significant clinical, public health, social, economic and psychological effects. Clinically differential diagnosis of breast cancer in young women is a bit more challenging because we don’t have good screening modalities for that age group; mammography doesn’t work well before the age of 40-45. The breast is denser and there are a couple of other conditions that occur in the breast of young women that may be confused with breast cancer.

Namely?

Benign breast diseases, fibroadenoma, fibrocystic diseases, these are some of the things that are confused.

Now, what you’re saying is that you’re seeing more young patients with breast cancer. It’s not because the overall incidence at a particular age is any higher, or is it?

No, I don’t think it’s any higher, I think it’s a reflection of the epidemiological transition that this population has had the broad base of young people and a very narrow older population.

While we’re on epidemiology, what difference does the ratio of urban to rural living have on the impact of breast cancer in Africa?

Some of the risk factors for breast cancer are differentially distributed when you consider urban and rural populations. For example, number of children that women have, duration of breast feeding, the amount of physical activity that the women in rural populations have compared with the urban population. These have an impact on the incidence of breast cancer so there are fewer, or the incidence of breast cancer in the rural areas in Africa is lower than in the urban areas where people are now engaged in more physical inactivity, they are more obese, they are spacing children, they are having fewer children and they are having their first pregnancies much later in life and increasingly the use of contraceptives is commoner in the urban centres than in the rural areas.

And all of these factors in the urban areas are increasing the incidence of breast cancer?

Yes, compared to the rural areas.

Does your research suggest that something could be done about that to preserve some of the rural lifestyles?

That’s a difficult one because a significant proportion of the risk factors for breast cancer are not modifiable but things like physical activity and obesity represent opportunities that we can respond to. In Africa the cultural attitude to obesity is not a positive one.

In Nigeria it’s quite popular, isn’t it?

So people tend to associate obesity with well-being and having resources so there is no movement towards uptake of recreational physical activity, for example as you have in Western countries. People are not as concerned about obesity as they should be.

But this could change?

It could change, it requires intervention at the public health level and at the messaging level so that the population begins to change their attitude and understand that obesity is not necessarily, as they call it, evidence of good living.

Yes. Now, interventions is an issue now, you’re concerned about interventions, medical interventions to do something about breast cancer. How does that differ from various parts of Africa as compared with Europe, North America and so on?

I think a major problem in terms of interventions in Africa is the difficulties we have in implementing an appropriate healthcare financing model such that patients still have to, to a large extent, spend money out of pocket to take care of themselves. This limits their ability to access high quality modern treatment. A breakdown of the communal pattern of lifestyle, which in the past would have provided some support for individual patients, is also a development that we have not adequately responded to. Many African countries have instituted health insurance schemes but these insurance schemes, by and large, are still limited to communicable diseases and where they cover non-communicable diseases they do not offer robust support for conditions like breast cancer which can require a high level of expenditure within a short period of time.

Clearly these are big challenges but, of course, resources are not unlimited in a number of countries, perhaps less so in Nigeria where, in theory, they could be quite extensive. But what, from your research, have you distilled as the ways forward to actually overcome some of these big challenges in the African situation and, by comparison, other parts of the world?

Yes, I think in Nigeria an important intervention is to increase breast awareness and also to work with the medical community, the government and non-governmental organisations and pharmaceutical industry to develop the business of oncology. Because we’ve got to look at what will work, given all of the parameters within that context. The patients often are poorly served by the healthcare system as it is; there are gross inefficiencies within the system that can be corrected. So we can get more benefit even with the limited resources that are available and improve outcomes significantly.

But how?

Well, by promoting breast awareness patients will present with earlier stage disease and with earlier stage disease the interventions that we have, including surgery and the basic traditional chemotherapy without worrying about some of the new molecular biology based treatments can significantly impact survival.

So tried and trusted treatments are going to work, yes.

Exactly.

Now, what about that special group that you mentioned, the young patients? In absolute numbers quite a lot of young women with breast cancer, what are you doing for them?

I think that they do have several peculiar needs, including issues relating to social and psychological support. Many of them are in the prime of life, professionals, important members of society and in some cases providing leadership in the family and holding the family together. We know from research that households that lose mothers, the outcomes for the children are significantly poorer than households where the father is lost. So the important thing that we’re doing is to educate the community and the healthcare professionals about this pattern of breast cancer that should definitely increase their ability to diagnose the disease earlier and refer the patients. We also think it’s important to promote regional centres of excellence for care.

Now, I can see the priority from an individual point of view, from the people’s point of view, but what about governments in different African countries, and indeed elsewhere, why should breast cancer be a priority when there are a lot of other priorities, pressing ones too?

That’s a good question. I think that traditionally African countries have considered that their major healthcare problems are communicable diseases and it’s only in recent times with the effort of different organisations and individuals that there’s increasing appreciation of the epidemic of non-communicable diseases including cancers but commonly breast and cervical cancer in women which, in many African countries, combined represent over 50% of all the cancers occurring in the population. So relatively low cost interventions, including improving awareness in society, considering clinical breast examinations and all that, can significantly impact outcome.

So in a resource-poor setting your key recommendations, finally, would be about information, is that it?

About information, about breast awareness and about developing systems of care that maximise efficiencies within the limited resources that the hospitals and institutions have.

And the key treatments would be what?

The key treatments in many of these environments remain surgical intervention and the standard chemotherapy regimes that have been available for years and years and have been associated with improved survival. Radiotherapy is another level of intervention but it requires a relatively high capital investment which many countries are not able to implement but it’s an important contribution.

And another modality requiring high capital investment we’ve been hearing quite a bit about here at the conference in Lyon is mammography and screening. Where would you place the priority in, for instance, a country like Nigeria, perhaps other African countries, and elsewhere?

So, in a country like Nigeria, because we have to remember that the populations in all of these countries are heterogeneous. So there are areas of Nigeria, say in Lagos, that with a population of, say, 13 million people and a relatively high GDP per capita where implementation of mammographic screening is an available public health intervention. But there are other parts of the country where the population is more rural and poorer and the infrastructure is not there so we’ve got to look at differential implementation of some of these early detection modalities, taking account of the social economic and age profile.

And viable mammography may be but we have been hearing here that even in rich countries mammography may not be economically justified, or even effective.

Certainly in some. I think that overall we should not have a kind of blanket approach to the use of mammography. It does have a role and that carefully designed and implemented it will contribute to reduction of mortality from breast cancer.

So your brief take-home message from the African situation, what would that be, Clement?

My brief take-home message will be that governments and the population in African countries need to come to an understanding that non-communicable diseases, including breast cancer, are now a major threat, it’s a significant public health challenge for them and they need to invest in both prevention and treatment of these people who have these diseases. And also to be aware that there already exists interventions that can make a significant difference in outcome, morbidity and mortality outcomes.

Thank you for joining us on ecancer.tv.

You’re welcome.