Badejo Olawale, Clinical Director for General Medical and Surgical Services, at the African Medical Centre of Excellence (AMCE) Abuja, discusses the growing concern over breast cancer among younger women, why African patients may require different treatment approaches, and the importance of early detection, accurate diagnosis and locally driven cancer research in improving treatment outcomes in Nigeria in this interview with GODSGIFT ONYEDINEFU: Excerpts:

Generally speaking, what is your assessment of the cancer burden in Nigeria, particularly breast cancer?

Breast cancer is the most common cancer in Nigeria and is now also the leading cause of cancer deaths, followed by colorectal cancer and cervical cancer. In terms of burden, it accounts for about 20 to 25 percent of the cancer cases we see in the country.

Cancer is rising globally, and it is also increasing in Nigeria. We used to think that increased awareness was bringing more patients to hospitals, but statistics and findings now show clearly that the incidence of cancer is rising in Nigeria.

This is happening, especially as we begin to adopt some non-African cultures, particularly in our dietary habits and social habits, such as smoking, alcohol consumption and the consumption of low-residue diets. So, yes, breast cancer is rising in Nigeria.

The other thing about breast cancer in Nigeria and the West African sub-region is that we tend to find cancers in younger age groups. While it is true that breast cancer is a disease of older people, starting from the fifth decade of life, we are beginning to see cancers in the third and fourth decades, mainly the fourth decade. By the fourth decade, I mean patients aged 30, 35 and above, particularly those in the 35 to 45 age group.

Why are we seeing younger patients being diagnosed with cancer? What do you think accounts for this shift in the age profile?

If you look at the age pyramid in developed countries, it is like an inverted pyramid, where you tend to have more older people than younger people. So, naturally, the burden of disease tends to be higher among older people.

In Africa, however, our pyramid stands tall, like a pyramid. We have more young people than older people. So, naturally, the burden of disease will be found among younger people. That is one explanation.

Another explanation is that, as we indulge in and imbibe Caucasian or non-African cultures, including smoking, alcohol consumption and the consumption of low-residue diets, the burden of cancer is generally rising among us.

Another very important factor is that it is becoming increasingly clear that the biology of breast cancer in Africans is completely different. We have seen this at the level of hormone receptors. At the molecular level, our molecular and genetic makeup tends to be somewhat different, and our tumours tend to be more aggressive, even when compared stage for stage and age for age.

We are finding that most treatment modalities and approaches to cancer management, particularly breast cancer, are adapted from research conducted in the developed world. However, some of those research findings and approaches do not really fit our tumour biology because of our genetic makeup.

Our genetic makeup can also contribute to the pattern of incidence and the timing of disease onset. If you look at the developed world, you will find that our disease patterns are somewhat similar to those of non-white populations in Europe and America. For example, among Africans and Hispanics, the pattern and behaviour of breast cancer tend to be similar. In America, for instance, the pattern and behaviour of breast cancer differ somewhat between white and black populations. The pattern of the disease among black people tends to resemble what we see in Africa, even when they are living outside the continent.

We are beginning to see that there is something about our genome or genetic makeup that affects the biology of breast cancer in terms of incidence and disease progression, ultimately going to affect the approach to treatment.

So, the combination of treatments and the approaches used will depend on the type of tumour biology each individual has. It is not a one-size-fits-all approach.

Breast cancer is often perceived as a disease that affects only women, but men can also develop it. Could you explain how breast cancer affects men and the risk factors that make them susceptible to the disease?

I have treated many men with breast cancer, so it is not something new to us.
Generally speaking, without trying to frighten anybody, the most common risk factor for breast cancer is being a woman. Any woman, or indeed anybody who has breast tissue, can develop breast cancer.

In women, it has a lot to do with hormonal balance, especially the hormone oestrogen, which is predominantly a female hormone. This is why breast cancer is more common in women. Men also have oestrogen, but it is expressed at a lower or suppressed level because of the predominance of the male hormone, testosterone.

In most cases, breast cancer may run in families. The vast majority of cancers, however, occur spontaneously, and a family history cannot be established. But when you begin to see patterns of breast cancer running in families, it should prompt even the men in those families to take precautions.

There are also situations in which men experience hormonal imbalances that may lead to increased oestrogen expression. This may also make them more susceptible. Habits such as smoking and chronic alcohol consumption can affect oestrogen metabolism and make a person more prone to developing breast cancer.

However, we must say that, up until now, we cannot point to one specific cause of breast cancer. Research is still ongoing. It is just that a few people, based on their genetic makeup and possibly a combination of other environmental factors, may be more susceptible to developing cancer.

Are all breast lump or tumour cancerous and require immediate surgery?

As we have said, breast cancer tends to be a disease of older people, particularly those in the older age groups. When we use the word “tumour”, we mean a swelling or mass in the breast. Tumours in the breast can be classified into two types. We have benign breast diseases, which are non-cancerous. Some of them are also not pre-cancerous, meaning they do not lead to cancer. The vast majority of breast swellings in younger women tend to be benign, non-cancerous conditions. For instance, when you see a 13- or 15-year-old with a breast lump, or a 25-year-old with a breast lump, the vast majority of such cases are benign.

However, there is a caveat to this. Let me explain why. The youngest patient I have treated for breast cancer was a 16-year-old girl. I also know a few people who have seen breast cancer in children as young as 13. So, that is not to say that every tumour in a young person is non-cancerous.

Every breast lump should therefore be examined in three ways. First, it should be examined clinically by a doctor. Second, it should be examined radiologically, and pathologically.

Sometimes, it may simply be a fluid-filled growth in the breast. At other times, it may be a solid tumour. It could also be an inflammatory or infectious process. Sometimes, it may be a traumatic lesion or a lesion in the skin of the breast that has nothing to do with the underlying breast tissue. So, quite a number of conditions can present this way.

At what age should women and girls begin breast screening or self-examinations, and what warning signs should they look out for that require prompt medical assessment to prevent late presentation?

Self-breast examination should actually begin in every girl or woman from the onset of menstruation. This is because many benign breast lumps begin to develop around this stage.

We are beginning to see quite a number of young girls presenting with benign lumps. Even a 13-year-old girl may have lumps in both breasts. So, self-breast examination should begin from the first menstruation.

Examine yourself in front of a mirror. There are five recommended steps. You examine your breasts in both the lying-down and standing positions. You should do this on the first day of your menstrual cycle to maintain regularity.

You should take note of any lump or swelling. Sometimes, you may also notice skin changes because there are some rare diseases that affect the skin of the breast. You may begin to notice rashes around the nipple, which could be a pointer to an underlying disease. Other warning signs include nipple discharge, unusual breast pain, particularly non-cyclical pain, and sometimes changes in the armpits, such as swellings. All these should prompt you to take action. See a doctor, undergo a proper clinical breast examination and proceed to other necessary diagnostic investigations, which may include imaging and tissue diagnosis.

Another important consideration is a positive family history. If a patient has a family history of breast cancer,  she needs to be very vigilant and take appropriate action. Sometimes, genetic testing may be necessary. But one area where we have a gap in our practice is the absence of genetic testing, which has become very important.  Breast cancer occurring at a younger age, such as 20 or 22, could also point to the possibility of a genetic predisposition. Other members of the family should take note and exercise caution. When cancers are detected early, the prognosis and outcomes, with appropriate treatment, are much better than when they are detected late.

Late presentation of breast cancer cases remains a major challenge in Nigeria. What practical steps should the government and other stakeholders take to encourage early presentation and improve survival rates?

The greatest reason people present late is a lack of education.  I do not mean attending primary school, secondary school or university because we have seen even professors, Doctors presenting with advanced breast disease. Another major factor is fear: the fear that breast cancer is a death sentence and that when you go to the hospital, you may lose your breast.

I am of the opinion that one of the missing links in breast cancer awareness is advocacy for survivors and survivorship. There are many breast cancer survivors and survivorship groups that are unknown. In this part of the world, we have cultural limitations. People are not willing to come out. So, we need to interview people and let them tell their survivorship stories. We need to let people know that if they present early, their chances of a cure and survival are very high. That is what will encourage people to seek treatment early.

Of course, awareness can never be too much. Breast cancer awareness, cancer awareness and cancer screening should also be incorporated into the educational curriculum from primary school. I have just returned from the village, and there are so many unreached people. No matter what you do on Facebook, in newspapers or on television, some people will never receive the information. However, there are schools in these places where children can be taught from an early age about their bodies, the possibility of disease and disease prevention. So, awareness should extend to the grassroots.

Very importantly, many people in this part of the world have deep religious faith, whether in Christianity, Islam or other traditional faiths. Some are made to believe that cancer is a satanic affliction. So, you find many people who notice their lesions very early but do not present at the hospital until the disease has advanced significantly. We therefore need to involve our clergy and traditional rulers. Many cancer patients suffer or experience disease progression in their homes without seeking medical attention, regardless of their religious affiliation.

Another gap is the need for proper training for doctors. Better patient care, information and communication can help people who already have the disease to remain in care and complete their treatment. One of the things that happens with cancer is that it is a highly distressing disease. Even when a patient presents early at the hospital, the attrition rate, meaning the number of patients who are able to follow their treatment from beginning to end, is very high. That is another problem.

We should also advocate for cancer healthcare and treatment support. Because cancer treatment is very expensive many people drop out of treatment or are unable to start at all, even when the disease is detected early.

What role is the African Medical Centre of Excellence (AMCE), Abuja playing in tackling cancer, particularly in improving access to care and treatment?

One of the things that the African Medical Centre of Excellence brings on board is support for awareness campaigns. We have a big unit that is educating people about cancer. We work individually and support learning societies. We support research into cancer and research groups so that we can make people aware of some of the possibilities available for cancer treatment.

Secondly, we also support training and training institutions. The African Medical Centre of Excellence is complementary because of the type of equipment we have. We also carry out advocacy within the medical society. We collaborate for various reasons and to help people know what facilities are available. We also share that information with the learning community on different approaches.

We do a lot of outreaches. The African Medical Centre of Excellence has travelled to many states to support other institutions and help patients obtain a complete and specific diagnosis at the molecular level. We also support other institutions with tissue diagnosis and imaging, including very advanced imaging.

Standardisation is another major contribution that AMC brings. We do not treat patients based on how we feel. We want to standardise treatment so that patients know what comes next in their treatment journey.

The African Medical Centre of Excellence is also a major contributor to research. This hospital has a research directorate that is supported with funds to help us study our own disease patterns and ultimately develop a homegrown, specific treatment model.  You cannot use results from Caucasian populations to treat Africans. The Centre of Excellence is supporting research in Africa to establish genuine disease patterns and understand disease behaviour so that we can provide appropriate solutions for our own types of diseases, including cancer.

Another important issue that we need to address at the African Medical Centre is cost. They say that if a problem is known, it is solved. Many of the problems associated with breast cancer management and cancer generally in Africa stem from incorrect diagnoses or misdiagnosis. If you can obtain a proper diagnosis, you have solved at least 50 percent of the problem. We support patients in obtaining the right diagnosis and ensuring early diagnosis. In most centres,  it may take up to six weeks to two months to obtain the right diagnosis. As a result, a patient’s disease may progress even while they are within the four walls of the hospital. That part of the cancer journey has been addressed seriously at AMCE, where patients can sometimes obtain the right diagnosis within three or four weeks.

Finally, we talk about survivorship. AMCE offers a survivorship class and a survivorship clinic for people who have been treated and survived.

In the short time since AMCE started, we have been able to cure patients who came in with even some forms of advanced disease. Some have achieved a complete pathological response, and we could say that these patients have been cured. They are then enrolled in the survivorship class. A breast cancer survivorship programme is an opportunity to reassure people about the possibility of survival and the possibility of maintaining a good quality of life even after breast cancer. Breast cancer is a potentially curable disease. What is important is that people examine themselves and seek care early so that cure becomes more common than palliation.