Doctor attacks South African government for failing women while spending billions on arms deals

03/16/04

Hamburg, Germany: A leading South African cancer doctor has attacked his country's government for wasting money on "luxuries" such as defence while failing to implement a basic breast screening policy that could prevent many women dying from cancer.

Professor Justus Apffelstaedt told the 4th European Breast Cancer Conference that, while billions of rand are being spent by the government's Department of Defence in "questionable" arms deals to buy unnecessary military equipment, the health budget had not grown to a similar extent and "a coherent screening policy, as formulated in 2000 by outside consultants for the National Department of Health, is still not noted on the website of the Department, even less implemented."

Prof Apffelstaedt, an associate professor of surgery and head of Surgical Oncology Services in the Department of Surgery at the University of Stellenbosch, South Africa, urged the developed world to apply political pressure to help build better breast cancer care in Africa. He told the conference in Hamburg today (Thursday, March 18): "Political pressure needs to be exerted to shift priorities from luxuries such as defence to health care. Women must be empowered in the traditionally male-dominated societies of Africa. Developed countries can play an important role by making aid and trade relationships dependant on this political shift and by committing themselves to long-term collaborations with African institutions in breast health training and service."

Twenty per cent of South Africans have health insurance, and breast cancer diagnosis and therapy provision for them is as good as in developed countries. However, the remaining 80 per cent have to rely on the state provision, which has been marked by "stagnation and even regression in the past ten years" according to Prof Apffelstaedt.

"Mammography is largely limited to seven tertiary hospitals and breast cancer treatment has stagnated at the level of 1990. Newer drugs, notably aromatase inhibitors, taxanes, navelbine and trastuzumab are not available. Radiation equipment is outdated and breakdowns are frequent. Waiting times for radiation in breast conservation are four to six months," he said.

"Furthermore, in an environment with stagnating resources, policy priorities have shifted from tertiary services to primary health care, which is a laudable aim, but the concomitant starvation of tertiary services means they cannot handle the increased workload generated by the expanded primary services.

"There is no coherent breast cancer policy in place. In 2000 the Department of Health commissioned me to write a paper on screening. I suggested that a mammographic screening service in South Africa would cost about one billion rand (nearly 116 million euros) and was an unaffordable utopia that would be impossible to implement due to a lack of skilled mammogram readers. Therefore, I suggested a nurse-based clinical service, which would be implemented from the centre, starting with the large teaching hospitals and extending as the nurses were trained, to the peripheral primary care centres.

"This would cost about 42 million rand (about 4.8 million euros) for the whole country. Such a system was implemented successfully in Singapore. Unfortunately, contrary to Department of Health promises, the paper is still not even available on its website. As a result of this inaction in breast cancer care, women with breast problems present at a late, symptomatic stage and cure is often impossible. Surgery is the only treatment that is readily available."

Prof Apffelstaedt contrasted the 42 million rand that it would cost to set up a nurse-based clinical service with the 46 billion rand (about 5.2 billion euros) that the country spent recently buying four naval ships. "There are no obvious enemies of this country that would require defence at sea, making an investment in such major war machinery questionable," he said, alluding to reports of the alleged roles of the country's deputy president, Jacob Zuma, and politicians, Toni Yengeni and Mac Maharaj, in the arms deal and their financial relationships with the arms dealer and suppliers involved in the transaction.

He pinpointed a number of other factors that have contributed to the lack of a coherent breast cancer care policy: "Large-scale emigration of health professionals to other English-speaking countries, equipment and medicine costs spiralling out of control with the currency devaluation, the challenge of AIDS, and a national health care policy motivated by political rather than pragmatic decision-making."

Prof Apffelstaedt's solution to the problems in South Africa and in other African countries where resources are limited is to go back to basics. "Training should be according to 'Western' guidelines adapted to regional availability of resources. It is important that the basics of cancer diagnosis and therapy are taught properly – there is no point in treating patients with expensive chemotherapeutic agents, exhausting resources while, for example, the staging of the patient is incorrect. Health authorities are obliged to achieve the greatest good with the limited resources available; this may mean that there should be strict cost-benefit analyses and treatments decided upon by the authorities in collaboration with the health service providers. This approach necessarily leads to the centralisation of experience and equipment in diagnostic and treatment centres, but these centres will fertilise the areas around them. In the end this achieves equitable treatment for all patients."
Abstract no: 235 (14.15 hrs Thursday 18 March, Hall 8)

In Egypt, the Cairo Breast Screening Trial (CBST) has shown that when hard-to-reach women are personally invited for clinical breast screening conducted by female doctors, a high rate of breast cancers can be detected.

Dr Salwa Boulos, consultant radiologist and vice-director of the Radiology Department, at the Italian Hospital in Cairo, said that the women attended local clinics after trained social workers had conducted door-to-door visits in an identified area of Cairo, close to the hospital. Female doctors carried out a physical breast examination and women with abnormalities were investigated further at the Italian Hospital, where mammography, ultrasound and biopsies could be performed. About eight breast cancers per 1,000 women were found after the screening programme in the first year, and when half the women were contacted again in the second year, two cancers per thousand women were detected.

"We believe that survival would have been improved for these women as a result of our study, " said Dr Boulos. "This suggests that more lives could be saved if a study with sufficient power proves feasible. We may need about 30-50,000 women in total to provide a statistically significant answer."

Dr Boulos concluded: "A substantial segment of women in the community are resistant to attempts to involve them in the whole process of screening. They are a high risk sub-group and have a prevalence of breast cancer at least as high as those who attend, while their delay in attending is probably contributing to advanced disease at diagnosis. There were indications that as the project proceeded there was increasing willingness in the community to participate. This is encouraging and initiation of screening in other districts should be seriously considered. I believe it is important to expand the study to other areas in Egypt and possibly to other countries in the Middle East."
Abstract no: 233 (14.15 hrs Thursday 18 March, Hall 8)

Breast cancer is a public health problem in Brazil: both incidence and mortality are increasing and not enough cancers are detected at an early stage, according to Dr Jose Bines, a medical oncologist at NCI Brazil, in Rio de Janeiro. "It is the number one cause of cancer death in Brazilian women," he told the 4th European Breast Cancer Conference.

"More than 40,000 women were diagnosed with breast cancer and 9,000 women died from it in 2003. Thirty years ago eight in every 100,000 women died from breast cancer but this has increased to 12 women in every 100,000 now. Thirty per cent of women with breast cancer still present with locally advanced disease. There is much room for improvement and strategies are being implemented to change this picture. A large national breast cancer project is being planned and soon will incorporate screening mammography after the age of 50.

"However, the increasing cost associated with treatment adds to the burden of dealing with breast cancer in Brazil. Currently, treating breast cancer with chemotherapy and hormonal therapy represents approximately a quarter of the government's cancer costs."
Abstract no: 236 (14.15 hrs Thursday 18 March, Hall 8)

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