The Cancer Mystique There's one belief that still shackles many Filipinas-confounding modern technology and good intentions-and it's getting deadlier by the day
The Philippines now has the highest incidence of breast cancer in Southeast Asia, with 48 out of every 100,000 Filipinas getting afflicted. Despite gross underreporting, Dr. Marietta Sapaula of St. Luke's Medical Center's obstetrics-gynecology department says that the country also has one of the highest death rates in the Asia Pacific from cancer in the cervix uteri, a burden mostly carried by women in the developing world, where as much as 80 percent of cases occur. The 2005 Philippine Cancer Facts and Estimates, a collaborative project of the Department of Health, Philippine Cancer Society Inc. (PCSI), and the University of the Philippines Manila, cites the same sad refrain as the 1992 and 1998 reports, with only the absolute numbers of casualties changing. The breast is by far the leading cancer site and cause of cancer deaths among Filipino women, accounting for more than 25 percent of all female cancer cases. The number of cases is almost equal to the total number of women with cervical cancer (the second-leading site that accounts for more than 13 percent of cancer in Filipinas) and the third- and fourth-leading cancer sites for women: lung and colon/rectum. The report points out that the correlation of economic develop-ment with a fall in birth rates augurs a grim trade-off between better living conditions for Filipinas in general and the rise of breast-cancer incidence, since not having any children or having them after age 30 is a known risk factor for the disease. Cervical cancer claims only half as many lives as cancer of the breast, but appears to be deadlier. For every four Filipinas who survive breast cancer, only two or three will survive cervical cancer, says obstetrician-gynecologist Rebecca Singson of the Makati Medical Center. As a sexually transmitted disease, its incidence will track the progress (or lack thereof) of efforts to promote safe sex and use of contraceptives in the country, issues fraught with their own complicated dynamics. Ovarian cancer, the second-leading malignancy of the female reproductive tract, has become one of the 10 leading cancer sites in 2005 and the ninth most common cause of cancer deaths if all cancer deaths, regardless of sex, were accounted for. But this might be attributed to better diagnosis rather than actual increase in incidence, says Dr. Adriano Laudico, project director of PCSI's Manila cancer registry. From 1998 to 2005, it remains the fifth-leading cancer among Filipino women, accounting for six percent of the female total. Rounding out the 10 leading malignancies among Filipinas are cancers of the thyroid and liver, leukemia, endometrial cancer, and stomach cancer. Historically, female residents in the Philippines have one of the highest thyroid-cancer incidences in the world. It is four times more common among Filipino women than among men and is the only common malignancy normally occurring in both sexes where women have a higher burden than men. Observations among women of Filipino extraction from Hawaii and the US West Coast indicate that the link between thyroid cancer and being Filipina crosses geographic boundaries, as similarly high rates of this slow-growing cancer are observed. No adequate clinical explanation exists why this cancer, the most common form among women aged 15 to 24, is a bigger yoke for Filipinas than other women around the world. And no explanation seems forthcoming, since it appears to be more manageable (highly curable by surgery alone) than the other forms of cancers anyway. Endometrial cancer is slightly more common now than stomach cancer among women, overtaking the latter as the ninth-leading cancer in females, with a 3.2-percent share of total female cancer incidence in the country. It has a common major risk factor with breast cancer: high estrogen exposure. In fact, a history of breast cancer increases the risk for developing it. Like most cancers, it is also associated with other degenerative conditions such as hypertension, obesity, and diabetes mellitus. And as more and more Filipinos fall prey to these degenerative diseases, there is a grim likelihood that more women would end up developing endometrial cancer.
In theory, Filipino women should be having a better handle on the most common cancer situations afflicting them. After all, more than half (53.63 percent) of top malignancies occurring among females can be detected early and cured, compared with less than 22 percent of the common cancers affecting males. Instead, the five- and 10-year local survival rates for breast cancer as of 2005 indicate that most cases are addressed only when the disease has reached a quite advanced stage. The five-year survival rate of 50.1 percent for Filipina breast-cancer patients has a dismaying congruence with US and European data, showing that Western patients diagnosed at stage IIIA of the disease would have a 56 percent five-year survival rate. After that, only 32.38 percent of Filipinas with breast cancer are expected to be alive 10 years from diagnosis. Within a 22-year period (1980-2002), the percentage of local breast-cancer cases detected at stage I-the earliest clinically detectable stage without aid of mammography-remained at 10 percent of the total. This means only 10 percent of Filipinas with the disease can expect to have more than a 90-percent chance of living for another five to 10 years. Between what could be and what actually is the general state of early detection in the Philippines for breast and cervical cancers-the two most common yet preventable malignancies-here is a morass of negative predispositions amplified by shortcomings in the institutional support system. Laudico has a long, sad anecdote to illustrate how big a fight local early detection proponents have in their hands if all they have to go by are Western examples of intervention. In the 1990s, a big cohort of Filipinas aged 30 to 60 was persuaded to go to public-health centers for breast examination as part of a multimillion-dollar study sponsored by the World Health Organization-affiliated International Agency for Research on Cancer (IARC). The intent was to have the screen-positives (women with suspicious mass in their breasts) go to the hospital afterwards for diagnosis and treatment. Only 15 percent of the screen-positive women actually went to the hospital for biopsy. A more aggressive (and more expensive) tack was resorted to: the creation of a home visit team composed of a nurse and a doctor to go after the screen-positives in their homes with a biopsy instrument in tow. They were only slightly more successful as very few consented to the biopsy in their homes. In the end, only about a third of all women found to be screen-positives ever had a biopsy. Explains Laudico: "Some women only went for screening in the hope that they are negative, but when told that they need a biopsy, they won't go because they are afraid. They though it is not curable. If you believe that breast cancer is curable, there's a big chance you would go and get a biopsy. If you did not, you won't. That's one of the study's conclusions." He points out that those pushing for early detection without addressing this perception of incurability may have been putting the cart before the horse as they try to replicate locally the experience with Western women who are not dead-ended by such thinking. The UP Manila Surgery Research Unit cites findings to indicate that this perception can change given the right environment. In another population-based study of predominant breast-cancer stages among ethnic groups in the US, the 36.3 percent of Filipinas at stage I are within close range to other groups, including the whites (44.3 percent) and the Japanese (53 percent), a culture with a strong history of institutional cancer prevention. Filipina-Americans are certainly not detecting it any later than the other minority groups such as the Hispanics (36.3 percent) and the blacks (33.3 percent). Aside from the IARC study, Laudico says there are self-evident signs that Filipinas tend not to believe in the curability of cancer. One of these is the persistently high proportion over the years of women with stage-III cancer as compared to stage I. "No one will be able to believe that the women didn't detect those tumors months or even years before. They knew that they have something there but they waited until they were suffering already and there's blood and pus coming out. If they go only when the mass is ulcerated, common sense will tell you that they think nothing can be done," the Manila Cancer Registry project director says. How Filipino men view cancer is also part of the equation. "Men can persuade their womenfolk to go for screening. None of that is happening because men don't believe in the curability of cancer also. It's the attitude of the entire population that need change," he adds. He says government and nongovernment institutions pushing for early detection should spend advocacy resources by hammering home one point first. "What we need is a genuine, 21st-century promotions campaign saying only four words: Breast cancer is curable." If the message gets across for breast cancer, where facilities for diagnosis and treatment are already in place nationwide, then the attitude shift can benefit patients suffering from other forms of cancer too.
The message about cancer's curability may be basic but it has to make its tortuous path amidst barriers other than cultural resistance. According to DOH program director for cancer control Frank Diza, the government's program covers the whole spectrum from preventive to palliative, but the devolution of the department's functions to local governments since the early 1990s has limited the DOH's role in pushing interventions to the grassroots. They can only advocate for activities promoting primary and secondary cancer prevention-and not to a very receptive audience either. "From our observation, most [local government units] tend to prioritize curative treatment in general, which is more expensive and which we discourage," notes Diza. As many local health providers exit for better opportunities abroad and elsewhere in the country, he says they are relying on a dwindling amount of holdovers from the predevolution era who are personally committed to continue implementing the awareness activities. This patchy approach to primary prevention shades over to the measly adoption of early detection procedures, which comprise secondary prevention, as indicated by poor cancer survival statistics. It is one thing to advocate continually that monthly self breast examination and annual health-worker examination are as effective as one mammogram, it is quite another to convince women to actually adopt this practice. At least a couple of lawmakers have taken note of this counterproductive divide between what women need and what authorities under the devolved dispensation are willing to give. Senator Loren Legarda has filed Senate Bill no. 78 seeking to mandate provincial and city governments to allocate part of their internal-revenue allotments for a quarterly breast-screening program through manual examination or mammogram. Meanwhile, Senator Aquilino Pimentel calls for the establishment of regional breast-cancer centers to raise public awareness about the disease. A component of the program is the involvement of the Department of Education through the inclusion of breast-cancer awareness in the high-school curriculum. For cervical-cancer screening, Diza notes that lack of cytopathologists, especially in public facilities, to handle the laboratory work for pap smears hamstrings efforts to promote early detection. The two to three months' turnaround for lab results due to the high workload of lab personnel can discourage even those women convinced that they should have the procedure. A simpler procedure, acetic-acid wash, is being tested as a screening tool in several major urban locations. It involves painting the cervix with acetic acid to check for breaks that would indicate lesions. This is a procedure where results can be obtained in a single patient visit. For the economically better off, private medical institutions have begun offering cancer-screening packages specifically for women. St. Luke's Medical Center has recently introduced a bundle of tests for the early detection of breast, cervical, and ovarian cancers. The package includes clinical examination, pap smear, mammography, and transvaginal and breast ultrasonography. And then there's the advent of vaccines against the human papilloma virus, the organism linked to the development of cervical and other cancers in the lower part of the female reproductive tract. Since vaccination short-circuits the fear of having the disease in the first place, Laudico believes this could be a better intervention in a country like the Philippines where belief in cancer's incurability is rampant, if only there's a way to make this fairly expensive option affordable to more women. For women who are well within the clutches of the disease, chemotherapy remains a prevalent mode of treatment in the country, although it need not be so, especially for breast cancer. There is now a move to promote hormone therapy, which, although not necessarily cheaper in the long run than chemotherapy, might be more appropriate for the hormone-receptor-positive breast-cancer patients who are said to comprise the majority of women with the disease. The 2003 World Cancer Report notes that the "driving force for medical oncology comes from the USA, which spends 60 percent of the world's cancer-drug budget but has only four percent of its population." It adds: "Huge cultural differences exist in the use of chemotherapy, with USA-trained physicians following aggressive regimens for patients who in other countries would simply be offered palliative care." "For practically all solid cancers, the main treatment is surgery," says Laudico. "Ang problema, dahil na-promote nang husto ang chemotherapy, nalimutan na ang surgery." He notes that many Filipino surgeons from different parts of the Philippines are already equipped to do mastectomy, although the same does not hold true for radical hysterectomy, that's why radiotherapy is still the more common treatment option for cervical cancer. More resources should also be poured into palliative care. According to Laudico, the WHO actually recommends prioritizing palliative care among developing countries where the proportion of patients in advanced stages of cancer is higher. He sees this as part of a long-range planning for government budget allocation in cancer management which will eventually include a highly focused campaign stressing the curability of cancer. M |
