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Breast cancer screening, making a case for aggressive active surveillance
General Surgery

Breast cancer screening, making a case for aggressive active surveillance

Breast cancer has received a lot of publicity in Ghana since it became a public health issue. Much has been done to get people to use simple techniques such as  breast self examination to detect lesions and report to hospital.  A lot of the education has to do with has been carried out on radio,  television and the print media.  Much and almost all that patients know is based on spoken word and imagery. The low literacy rate in Ghana makes it difficult for people to access information about changing modalities for treatment. The ordinary citizen knows two things about breast cancer namely : A positive diagnosis speaks for  total removal of the breast and certain death. Such belief is strongly held by even those who have had the opportunity to travel to western countries where much has been achieved in breast conservation surgery. For  instance a patient who was diagnosed of invasive ductal carcinoma in Holland left for Ghana to seek treatment from a pastor in a remote part of the Northern Ghana . She was later brought to KATH very ill looking , with severe anaemia and cerebral  metastasis and she eventually died.
The main challenges to  early presentation as seen at from the breast clinic at KATH are
Mis- information :
A growing number of patients present with breast lesions which they believed could been managed by topical agents eg over the counter creams and herbal preparation. Much of such information is gathered on radio where individuals especially herbalists  with very little to no formal knowledge are allowed air time ,to misinform such vulnerable women. Eczematous conditions ( which may be difficult to assign a  proper clinical diagnosis even in the clinic until further investigations prove otherwise ), are usually portrayed as disorders that can be easily be treated by application of topical agents. Such claims are strongly linked to the sale of their products  Such patients may  later find out too late that their condition has worsened before presenting to hospital. Two of the most feared signs that gets patients running to hospital is a palpable breast mass and bloody nipple discharge. Diffuse lesions and skin changes ie ulcerations, excoriations,  are usually managed OTC drugs and herbs
There is also an unfortunate yet true fact that some health workers who have not updated themselves on early breast cancer  presentation tend to wrongly reassure patients into thinking that their lesions are benign . Some of these lesions may end up being excised at the insistence of patient or doctor but the sample may not be sent for histopathological analysis. ( a luxury which is not readily available in district hospitals.) Excised samples given to patients to send to histopathology labs may  end up in the nearest dustbin, most patients thinking that the excision  of the bothersome lump equals cure.
Special mention must be made of a facility in one city widely acclaimed for the mangement of breast diseases. A sad trend has been noted in the number of patients put on chemotherapy in this facility without biopsy for histopathology !  Such patients who may clinically show florid signs of breast cancer usually feel better on seeing the effect of the cytotoxic drugs on reducing the size of the tumour and so reaily accept to continue treatment until they run out of cash. They then present to KATH with flare ups , advanced disease and a thus are poor candidates for meaningful management
Social stigma :
Most women fear  losing their husbands after undergoing breast surgeries. Much has to do with the feminine shine which is apparently dulled by such breast operations  in the absence of acceptable reconstructive surgery and so some women are lost to  follow ups on learning of a diagnosis of breast cancer. It is interesting to know that some of these women are have achieved their reproductive goals and are menopausal. It is also interesting to note that these men would reconsider ther marriage whether a part or the whole  of the breast was surgically removed
Recommendation :
1.There must be a quartely or twice yearly active surveillance programmes for breast cancer. Financial support packages must be tagged to early presented cases with positive histological diagnosis. This will generate renewed interest in reporting early disease
2. Effective courrier systems (in the short term) to transport all breast biopsis to reliable histopathology labs for analysis. Patients with positive results must have their data immediately uplinked to  a central database (breast cancer registry ) shared my all major histopathology labs in the country.  Such patients must be  actively tracked by phone or other convenient means of communication to help with early treatment and follow up. This would shift the burden of chasing results  wich is financialy unattractive and laborious to the patient.
3. Establishment of multiple counselling and screening centers equiped with mordern methods of screening eg genetic screening for BRCA1 &2 genes in at risk families. These centers must also be staffed with dedicated caregivers abreast with the latest information that effectively addresses patients needs
Conclusion : Breast cancer cases in Ghana  have unfavorable tumour features such as being Tripple negative ( oestrogen receptor, progesterone receptor , HER/2neu negative ). The tumours are more aggressive, most have micrometastasis  at time of presentation with a palpable mass. It is therefore important to carry out aggressive active surveillance like the Japanese do for gastric cancers.
Credits : Dr Richard Ametih ,  Staff of Breast Clinic , KATH
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