I was asked to give this talk on challenges in managing breast cancer in low and middle income countries. So there are a few main challenges that we face. Even though breast cancer is lower incidence in low and middle income countries compared to the high income countries, the incidence is increasing rapidly and it’s a matter whether the countries are ready to deal with this increasing number of breast cancers. Because in low and middle income countries mortality is high and the mortality from breast cancer, to reduce the mortality you need to get early detection and optimal access to treatment. So in low and middle income countries women present with advanced stages of breast cancer; more than 50% of patients come with stage 3 and 4. The first step is to get the women to come earlier. Because there are no screening programmes for breast cancer in low and middle income countries women come with large tumours. But if we can do early detection programmes, just clinical breast examination or breast self-examination, instead of coming with an average size of about 4-5cm they can come with an average size of 2cm. In stage 1 breast cancer the cure rate can be more than 90%.

So the first problem is late presentation and the second problem is optimum access to treatment. Breast cancer is very expensive to treat, especially when you come with late stages, because you will need chemotherapy, you will need radiotherapy and then you will need a very expensive targeted therapy as well as surgery. We find that because a lot of these countries do not have a universal healthcare system the patients have to pay out of pocket for treatment. Because they do not have enough money, a lot of them will do without treatment. We did a study, it’s a longitudinal study, on the risk of financial catastrophe in eight low and middle income countries in Southeast Asia. This study is called the ACTION study and it’s actually a very important study because it showed that in Southeast Asia in the poorer countries 48% of the patients their family went into financial catastrophe because of treatment. Financial catastrophe was defined as when you spend more than 30% of your household income as out of pocket payment for cancer. And if we look at the individual countries in Southeast Asia, Cambodia and Laos were the poorest countries and in those countries 80-90% of the patients died within a year so the financial catastrophe was actually less because when you die you do not spend money. So that’s why the FC rate was lower in these countries.

But financial catastrophe may not really tell you whether the patients are suffering or not because we have also to look at what we call economic hardship. When we say economic hardship it means not being able to pay for medicines, not being able to pay your rent, not being able to see a doctor, not being able to basically pay for household expenses. So we found that 45% of the women with breast cancer, their family could not afford to pay for the doctor, for them to see the doctor so they stopped medication because of that. Now, why we look at economic hardship is that if you are rich, spending 30% of your income on treatment is not so much a hardship but when you are living hand to mouth spending 30% of your household income on treatment can really be catastrophic for your family because you won’t be able to afford the basic necessities of life. So that’s why we look at it.

Besides looking at financial catastrophe, the other thing about low and middle income countries is that the women present with late stages, they need palliative care. There are not enough palliative care physicians and, in fact, it’s quite hard to get access to morphine as well in low and middle income countries. So that’s a problem with actually palliative care. Access to care is not just money, it’s also the healthcare professionals, there are not enough oncologists and in low and middle income countries the access to radiotherapy is also very limited. There are some countries with no radiotherapy units at all. So these are issues with access to treatment.

The other issue we find is survivorship. We talk about survivorship in Western countries, you have all these breast cancer support groups, breast cancer advocates all fighting for better treatment, but in poor countries you find that there’s not much access to support so survivorship is not really an important issue there, which it should be. There’s also a stigma attached to having breast cancer so you don’t get these breast cancer champions that you would see in the high income countries because if you have breast cancer a lot of women will not tell their friends. I’ve had patients with breast cancer who don’t even tell their sisters or their mother or their daughters; I had one patient who didn’t even tell her husband that she has breast cancer. So there’s a big stigma attached to having breast cancer in some of these countries.

How can this be addressed?

Education. The most important thing we lack is education but then I’ve had women who were educated who still come with advanced breast cancer. The barriers to early detection, why women present late, is fatalism, especially in some of the Muslim communities especially because they think it’s God’s will. So if it’s God’s will for them to die why fight it, so fatalism is a big issue. Another issue, besides fatalism, is belief in alternative therapy. Because alternative therapy, even though we would say it doesn’t work, but to them it is a form of treatment, it’s a form of active treatment. So belief in alternatives. The other one is poor decision making because women do not make autonomous decisions, they depend on their significant others. For example, if they are married they depend on their husbands, if they are not married they depend on their parents or their brothers or their sisters to make the decision for them so there’s no autonomous decision making. In the end they might decide just to go for no treatment so that’s a problem with decision making. Of course in the countries where there’s no universal healthcare system it’s financial. If they are poor they just do not have the resources to seek treatment.