The Observer (Kampala)
Devapriyo Das
2 July 2009
Far from Uganda's celebrity-endorsed war against HIV/Aids, and million-dollar campaigns to combat malaria, a silent struggle is on against a remorseless killer. Breast cancer has emerged as the third commonest cancer to affect Ugandan women, after cervical cancer and Kaposi's sarcoma.
Statistics at the Kampala Cancer Registry show that 11 in every 100,000 Ugandan women suffered from breast cancer in the 1960s. Today, the figure has doubled to 22 in 100,000. Research shows that ethnic, economic and regional factors do not determine the incidence of breast cancer: all Ugandan women are equally vulnerable. However, the incidence is growing among younger women.
Aggressive in Africa
Dr Fred Okuku, a cancer specialist and In-charge, Breast Cancer Screening at Mulago Hospital's Uganda Cancer Institute (UCI) says, "You see professionals, old ladies in the village, young girls; but generally speaking, we are seeing younger populations [being affected].
Most of our patients are below 50 years of age. This is different from what is seen in the western world where breast cancer is common in women above 50." Okuku suggests the lower age bracket reflects particularities in African genes.
"Some studies done among African women have shown that cancers that are common in this part of the world are the aggressive type", he notes. Scientists are now examining cancerous tissue from African women to learn what new therapies can be used to treat them.
"Africa may not benefit so much from drugs developed in the Western world because the genes there are different, the biology of the tumour is different."
Tough cure
Cancer is an uncontrolled division of abnormal cells in any part of the body, which can impair functioning of organs and tissues. Breast cancer usually manifests as a small, painless lump in the breasts, and forms in the ducts that transfer breast milk to the nipples and in the glands where milk is produced.
Men are also susceptible to breast cancer which often proves fatal in their case.
"The time for cancer to go from one cell to the next, takes about 75 days, for some cancers", says Okuku.
"For others, the aggressive ones, half that time." When left untreated, the cancer can spread to lungs, liver, brain and bones. Almost always, surgery is the first line of defence: either a lumpectomy (removal of cancerous lumps) or mastectomy (removal of entire breast in case of aggravated cancer).
UCI treats 30-50 women every week. One of its younger patients is Laviny Daru, a 41 year-old domestic worker from Arua. She discovered a lump in her breast in her late thirties, which proved cancerous and had to undergo a mastectomy.
This was followed by chemotherapy: intravenously administered drugs that kill or limit the spread of cancerous cells in the breast or surrounding tissue. In some women, this includes dosing with hormone-blocking drugs as breast cancer can result from hormonal imbalances.
Radiation therapy was later used to burn-off cancerous cells that eluded the surgeon's knife. As Okuku explains, "For maximum control, you need to involve as many combinations as possible."
While these interventions guarantee a fresh lease of life for the patient, post-operative complications also arise.
Some patients react badly to chemotherapy and might die. Others like Ms Daru (who received four doses of chemotherapy) find their nails turning black and hair falling out. They will also need supplementary drugs to repair damaged tissue and boost blood and bone growth.
Poor access
The funding for research, drug-development, treatment, and post-palliative care of cancer runs into hundreds of millions of dollars; money that Uganda does not have. This means Mulago, along with three referral hospitals in Gulu, Arua and Mbarara, are the only public hospitals that can treat breast cancer; and only Mulago can handle advanced cases.
The time lag between a referral from a district hospital to a patient presenting themselves at UCI can be as long as six months. "And again, more than six months between the time they first saw the lump and when they saw the first health worker", Okuku adds.
Rural health workers do, in fact, play a worrying role in cancer referral. Zainab Kokopchelimo, a 65 year-old peasant farmer from Tegerese parish, Kapchorwa, found a lump in her breast and approached her local health centre for help.
Astonishingly, they treated her with antibiotics, hoping the lump would subside. She finally received appropriate treatment at Mulago, but not before her condition had worsened. Little wonder that many Ugandan women ignore abnormal growths, and up to 90% seek treatment when their cancer has reached the fourth or most aggressive stage; but treatment works best in the first and second stages.
Even when treatment is available, it could last several months, making it financially difficult to complete therapy. Ms Daru, who works as a housekeeper for an expatriate family in an upmarket Kampala enclave, has had to support her family while footing her medical bills: Ush 200,000 for her mastectomy, Ush 270,000 per dose of palliative drugs (each lasting three to four weeks), and Ush 30,000 per mammogram (breast x-ray). She cannot afford to take a break.
Breast aware
Given the environmental factors that make breast cancer so dangerous to Ugandan women, an early detection and response is best. "To date, you cannot die of AIDS unless you choose to, especially if you protect yourself", observes Florence Mugisha, CEO of the National Breast Cancer Care Fund Uganda.
"But for cancer, every time people are told 'you have cancer', it evokes the reality of death." To avert this, the organisation promotes a "Be Breast Aware" campaign that encourages women above 25 years to go for clinical breast examinations and annual mammograms, as well as teaching them how to conduct breast self-examinations on a monthly basis.
Meanwhile, a mobile clinic is being used by Mulago Hospital to bring mammogram facilities to selected urban and rural centres.The struggle, though far from over, is slowly making itself heard.
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