The status of breast health management in South Africa

I recently returned from the 6th European Breast Cancer Conference in Berlin, Germany where I presented a paper on the “Status of Breast Care in South Africa.”

Attended by the “who's who” in world breast cancer, the 5 300 delegates included doctors, surgeons, clinicians, scientists and patients. They discussed not only scientific advances in breast cancer treatment but, equally importantly, they also talked about the ethical, social, political and practical issues associated with breast cancer patients. They looked at the whole woman, not just one part of her.

Some facts about breast cancer in South Africa:

· Currently the country experiences an estimated 8,000 new cases of breast cancer, of which only about 2,000 are catered for in four academic, multidisciplinary centres offering varying degrees of state of the art diagnostics and therapy.

· All women are at risk of developing breast cancer. Urbanisation and a westernised life-style have contributed to increased numbers of breast cancer. In 1997, 140 new cases were registered at Tygerberg Hospital, this year we expect about 350.

·For the majority of these women treatment means the loss of a breast and later, the loss of life.

·From a health administration perspective, the final years of these women's lives will be costly - therapy with expensive drugs, radiation and hospital stays.

Are we doing enough with the limited resources at our disposal?
The apartheid system, which created an extremely efficient, high quality health service for a minority of the population, became untenable by 1990.

Resources were then redirected to primary care at the expense of tertiary care.

Deteriorating working and life circumstances and increasingly inadequate salaries led to emigration of professionals. A third of all South African nurses work abroad and half of all medical graduates emigrate upon graduation.2

In the under-resourced public sector a small minority of medical doctors cater for about 80% of the population. Breast cancer, despite being the most common female cancer, does not appear in the top 10 causes of women life years lost; the first five places are taken by AIDS, homicide, TB, diarrheal diseases and pulmonary infections.3

The incomplete statistics available also generate the perception that breast cancer is largely a “white women's disease” - pushing it further down the list of priorities.4

In a paper for the National Department of Health outlining the background and making a rational, resource based suggestion for a Breast Cancer Screening Policy for South Africa, we argued that mammographic screening was out of reach for our communities, as the infrastructure and expertise was not available. Nothing much has changed in this respect.

It is not that women are unaware of lumps in their breasts - they simply do not enter the health infrastructure for a painless breast mass. This experience is shared with other developing countries. Clinical examination, which is cheap and enforces the importance of self-monitoring, would detect many masses at incidental contact. Therefore community care centres should be required to conduct annual breast examinations when they come into contact with women over 25 years. Attempts at establishing such a program have fizzled out for lack of proper administrative support.

We have offered to support the community health centres in teaching clinical examination skills and speed up referrals for women with problems.

Diagnosis for women with breast masses should be pathology driven - a prerequisite to be seen at the Breast Clinic of Tygerberg Hospital. Although the Department of Pathology at Tygerberg Hospital has been training community centre staff in the technique of Fine Needle Aspiration (FNA) - a simple way of establishing a ;pathologic diagnosis of malignancy - much still needs to be done.

Due to administrative shortcomings and inexperience with the technique of FNA, all too often colleagues still have to take women to theatre to establish a diagnosis by open biopsy.

This is a huge waste of scarce resources on top of the trauma caused to women.

Initial therapy for breast cancer is increasingly taking place at secondary hospitals, without the advanced technical options available at tertiary level.

Research has shown this may result in more than half of women receiving inadequate therapy.

Medical oncology needs to be brought up to date - the Western Cape is stuck with chemotherapy that is outdated by about 10 years and therefore stuck at a "basic" level according to the Breast Health Global Initiative guidelines. In provinces with much less of a breast cancer burden, modern agents such as taxanes are more freely available. Due to their far superior efficacy, even certain biological agents should be made available, even if they are hugely expensive.

Our motivation for these agents has not even received recognition, indicating an administrative problem at drug provision level in our province rather than engagement for the benefit of our women. We are aware that these drugs are expensive; on the other hand, women's lives depend on them.

So where do we go from here?

· The institution of a clinical screening programme is not out of reach in our setting. It deserves proper administrative support.

·Breast cancer management must be restricted to tertiary hospitals.

·Instead of placing mammography machines in secondary hospitals, pathology services at primary and secondary level must be beefed up.

·Administrative frustrations in drug provision must be cleared. Clinicians must primarily be responsible for the choice of drugs and not administrative personnel removed from service provision.

To prevent further deterioration and reverse the trend, where there is still expertise left it must be maximally supported and exploited. Public - private partnerships where private institutions support diagnostic services should be extended, notably in logistics in the public sector.

South2south collaboration is valuable as other middle-income countries, such as Singapore and Malaysia have shown how to organize public health efficiently.

South Africa has a long way to go to improve the status of breast health care, but there is much data available for us to learn how to organise public health efficiently. We just need to pay attention to it.

REFERENCES

2Nduru, Moyiga. “Africa: Emigration of Doctors Causes Health-Care Shortages,” Interpress Service, 25 May 2007.

3Bradshaw D, Groenewald P, Laubscher R, Nannan N, Nojilana B, Norman R, Pieterse D and Schneider M. Initial Burden of Disease Estimates for South Africa, 2000. Cape Town: South African Medical Research Council, 2003, 35.

4 Mqoqi N, Kellett P, Sitas F, Jula M: National Cancer Registry of South Africa, National Health Laboratory Service, Johannesburg Dec. 2004

5This is not published information, it is an exchange of data between the unit heads in Johannesburg (Dr Carol-Ann Benn), Durban (Dr Inez Buccimazza), Cape Town (Dr Elizabeth Murray) and Stellenbosch (Professor Justus Apffelstaedt)