BREAST cancer is the most common cancer occurring in women worldwide and it accounts for the greatest number of cancer-related deaths, morbidity, and economic loss.
While the incidence of breast cancer continues to increase globally, the burden of the disease is disproportionately distributed, with low- to middle-income countries accounting for almost 60 per cent of the global breast cancer deaths despite having much lower incidence rates than high-income countries.
As a region, the Caribbean has the fourth-highest breast cancer death rate in the world and has seen the greatest increase in breast cancer-related death rates over the past three decades. It is expected that, as the populations in low- and middle-income countries continue to age and their lifestyles become more westernised, the incidence and death rates will similarly increase. In many ways, low- or middle-income countries are facing a breast cancer epidemic.
In Jamaica, breast cancer accounts for more than one out of every three cancers that are diagnosed in women, conferring a lifetime risk approaching seven per cent. We had approximately 1,208 new breast cancer cases diagnosed in 2020 according to data from the Global Cancer Observatory, up from 974 cases diagnosed in 2018. This trend of increasing breast cancer incidence is in keeping with the epidemiological transition of diseases, from communicable to non-communicable, as the country becomes more developed and the reproductive patterns of our women change resulting in delay in the age of onset of childbirth, decrease in the number of offspring per woman, and diminished regular breastfeeding habits.
Jamaica's breast cancer death rates have worsened, rising from 56.8 to 66.9 per 100,000 women over the past few years. More significant is our high breast cancer case fatality rate (proportion of women diagnosed with breast cancer who die of the disease), which averages between 41 and 51 per cent. As a result, the average Jamaican woman is approximately three times more likely to die as a result of being diagnosed with invasive breast cancer compared to a woman in the United States. These differences in mortality and case fatality rates result from various issues which may be related to the patient, the health-care delivery systems, and/or national policies regarding breast cancer screening and therapy.
The average age of presentation for breast cancer in Jamaican women is 54 years, much younger than what is reported in the United States (62 years). These younger women are often in their reproductive, family-rearing, or economic prime and suffer significant social, as well as family life disturbances during breast cancer treatment. They are also more likely to suffer from depression, anxiety, body image disturbances, and sexual dysfunction than older women. Breast cancer in our women tend to be diagnosed at more advanced stages and exhibit more aggressive biology — twice the rate of triple negative breast cancer — than the average patient presenting in high-income countries such as the USA. Therefore, our women are intrinsically worse off from the time of their diagnosis and are burdened with higher recurrences and inferior long-term survival.
Our women often suffer delays in accessing and completing therapy for breast cancer. There are significant delays in women presenting to their physicians out of fear, denial, ignorance about breast cancer, the inability to pay for timely diagnostic tests or the common practice of trying non-conventional 'remedies' first.
The fear experienced is complex and is often related not just to the fear of the diagnosis, but also the fear of being ostracised by family members or their partners, the fear of breast cancer surgery due to the incorrect belief that the only surgical treatment is to completely remove the breast (mastectomy), as well as the fear of other therapeutic components such as chemotherapy or radiation therapy. Other areas of delay include accessing clinics, making the diagnosis, initiation of surgery, chemotherapy, and radiation therapy.
Approximately 40 per cent of our women with breast cancer present with locally advanced disease for which the treatment typically involves a combination of major surgery, chemo or immunotherapy, and radiation therapy. These patients suffer some of the greatest cost and morbidity that is associated with breast cancer care. Despite these high rates of advanced stage, up to 50 per cent of our patients present at a stage where breast conversion surgeries (lower cost and treatment morbidity), along with breast radiation therapy would be the preferred treatment option rather than mastectomies.
Jamaica continues to lack a national breast cancer screening programme, which would allow for the detection of breast cancer at an earlier stage, where it is more readily treated, resulting in better outcomes as far as physical morbidity, psychosocial morbidity, and overall survival are concerned. Access to mammographic screening is greatly hampered by the absence of mammography capabilities in any of our public hospitals. With respect to breast cancer treatment, locally, the delivery of care remains fragmented with no sustainable integration of multiple specialists (oncologic surgeon, medical oncologist, radiation oncologist, and reconstructive surgeon) to formulate comprehensive treatment plans from the time of initial breast cancer diagnosis. Currently, the Kingston Public Hospital operates a multidisciplinary breast cancer clinic, but can only see approximately 10 per cent of all breast cancer patients that are diagnosed in the country annually.
The burden of breast cancer in Jamaica is severe and worsening. In order to reverse the trends of increasing breast cancer death rates and morbidity in our population, there has to be a coordinated approach which incorporates early breast cancer detection and screening, rapid breast cancer diagnosis, and local research-guided interdisciplinary therapy by trained specialists in dedicated breast cancer treatment units. This will require the introduction of sustainable policies to improve infrastructure, facilitate specialist training, and improve public awareness regarding breast cancer screening and treatment. Also, there needs to be greater focus on improving the psychosocial well-being and overall quality of life of our patients, which will include greater access to reconstructive surgery, mental health professionals, patient support groups, and options for fertility preservation.
Dr Jason Copeland is a breast surgeon, breast surgical oncologist, and consultant general surgeon. He's clinical director of the Breast Health & Oncology Care Centre at Andrews Memorial Hospital and clinical director of the Kingston Public Hospital Breast Oncology Clinic.