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Our breasts, our cervix and our lives

Sunday, June 05, 2016

LET’S talk about it. Let’s talk about our breasts and our wombs and the disease that is killing us. While we talk about it, let’s realise that this disease is a regional one, that it doesn’t care if you woke up this morning in a palatial bedroom or if you shared a bed with a family of six. It doesn’t care if you stepped into an Audi or if you walked to work. And it doesn’t care whether you are ‘high-colour’ or as black as night. Let’s talk about the fact that among Caribbean women, breast cancer and cervical cancer are taking away our sisters, mothers, daughters, friends, colleagues and loved ones. Then, let’s talk about how we stop it.

The cancer epidemiology in Jamaica is similar to that of a low-middle income country. In the high-income countries, cervical cancer is no longer found in the top five cancers, mainly due to successful screening programmes. The Jamaica Cancer Society is the only organisation with an organised screening programme and with a mobile screening clinic which takes screening to underserved women in their communities across the island. They also own their own cytology lab which offers Pap smear results within 15 working days compared with the Government lab which has a waiting period of eight to 12 months.

No national data on cancer incidence or outcome is available for Jamaica, but data from the Kingston and St Andrew Cancer Registry reveals that the standardised incidence of cancer was 189 per 100,000 for men and 144 per 100,000 for women for the period 2003-2007. These rates were essentially unchanged when compared to the rates 1998-2002

Breast and cervical cancer remain the leading cause of cancer-related deaths in Jamaican women. In a country where almost 50 per cent of households are headed by women, it is imperative to safeguard the health and well-being of our women. More than 30 per cent of cancers could be cured if detected early and treated adequately, and 30 per cent of cancers could be prevented, mainly by not using tobacco, having a healthy diet, being physically active, and preventing infections that may cause cancer.

If these figures are compared with developed nations, we see that breast cancer is remaining stable in Europe, the UK and the US, and cervical cancer incidence and mortality are declining. Two things identified as causing this stability or decline are the use of primary preventative medicine and the use of screening modalities that lead to early interventions and treatment. Primary prevention means that we seek to reduce the incidence of new disease by removing or decreasing risk factors. Screening is a form of secondary prevention whereby we detect disease or cancer, thereby leading to early treatment and improved prognosis.

Both methods of prevention depend on health care workers knowing what is beneficial to patients and then educating them in a way that reaches all members of our society. Health education has to be continuous, culture-sensitive, creative, and must address myths and fears. It should involve all stakeholders and seek to involve the regular and unusual players in society. Screening programmes should be accessible and reasonably priced.

Risk factors for breast cancer are not all preventable — increased age, early age at menarche (first period) and late age at menopause (last period). But some interventions can be made to other risk factors — obesity, alcohol intake, older than 32 years for first child and use of oral contraceptives. Cervical cancer has risk factors that allude to socioeconomic concerns — early intercourse, multiple partners, male promiscuity and infection with Human Papilloma Virus (HPV).

Screening has been shown to reduce the death from both breast and cervical cancer by early detection and prompt intervention with surgery, chemotherapy and radiotherapy. Mammograms are used to detect breast cancers. In the Jamaican public system mammograms are available at quite a few private offices in many parishes. The Jamaica Cancer Society offers mammograms as well. All these must be paid for.

There is no mammography unit available in the public sector — this screening device is not available free of cost. Screening for cervical cancer is opportunistic at best, since there is no comprehensive national screening system in place. Pap smears are done every one to two years from age 21 up to age 70 years, and primary prevention with vaccination is only available in the private sector. Ideally, screening with HPV testing every five years in low-income areas might be more effective than attempting to do Pap smears at a national level in women in the same demographic. Primary prevention with vaccination starting as early as 10 years of age is ideal but significant in reducing the incidence of cervical cancer, which can be achieved by vaccinating all women between ages 10 to 55 years, since the vaccine has been shown to be immunogenic in this age group.

Socio-economic association

Throughout Jamaica, and for most of the Caribbean, the household is a matriarchal one. Children are grown and nurtured by a single female parent. These women are primary breadwinners for their families and if they can no longer function in that manner, then the collapse of that particular unit is almost inevitable. Some women never find time to attend to themselves as they work multiple jobs to keep their households safe. Some women, mothers or not, may not be able to afford the screening modalities. Others are turned off at the response time for publicly done Pap smears and do not see the importance of doing a test promoted as ‘important and necessary’ when results may take months to be returned. And some women are forced into having multiple partners as a profession or by way of short-lived partnerships to support themselves or their families.

In the instances when women become too ill to work, several other factors come into play — reduced income, caregivers employed, or family members who become caregivers sacrificing their own income. In extreme cases, children may be forced to leave school. In all cases savings are reduced or depleted.

Death from cervical and breast cancer is high because of late diagnosis due to lack of access to screening. Children are left behind to be cared for by women already running their own households, thereby initiating a new cycle of impoverishment.

What is to be done?

Health education and promotion is of utmost importance. Can we answer these questions in the affirmative or with confidence?

•What age should breast cancer screening start and why?

•Where can I go for a mammogram and what will it cost me?

•What is a Pap smear?

•How often should a woman have one?

•When was my last Pap smear and what did the results mean?

•Are the other women in my life having their Pap smears?

•What is the HPV vaccine and should I get it?

The list could go on. The fact is, we need to encourage large sections of our society (men and women) into talking about these two cancers. This is not really ‘women’s cancer’; for us in the Caribbean and definitely in Jamaica, it is family cancer. Saving our women is in fact saving our families.

Perhaps instead of asking women to come to us at our meetings, fairs and lectures, we need to go to where our women are and have frank, unstructured discussions with them. They are in our schools, at the markets, in the dancehalls, on certain streets at nights, at their jobs, and in the church. Let’s keep the message sustained and loud until every woman understands the basics about these cancers. Let’s help to lower the incidence of death from breast and cervical cancers.

Let’s talk about it.


Contributed by:
Dr Aleiya Virgo-Herron — The Hope Institute
Yulit Gordon — The Jamaica Cancer Society
Dr Sharmaine Mitchell — The University Hospital of the West Indies