Essay Paper on Public Health Service aspects of Breast Cancer
by Andrew Glover
Population: Population of the developing nations with potential risk factors of developing Breast Cancer and diagnosed cases of breast cancer. This population of developing nation is important as they have inferior diagnostic infrastructure and lack a robust incidence recording system. These shortfalls are superadded with the unplanned urbanization (Igene 2008).
Incidence: Breast cancer has seen an increasing incidence in developed and developing countries. With an increase in incidence from 8.1 million in 1990 to 11.5 million cases by 2002, it is now seen with one million new cases every year with 400,000 mortalities (Igene 2008). Though the incidence is higher in first world countries like United States and northern European countries, the mortality is low due to increased awareness and better health care access (Caleffi 2009). On the contrary, developing countries experience a lower and steadily increasing incidence but account for three-fourth of the total deaths due to breast cancer (Igene 2008).
Prevalence: According to a WHO technical report, half of the cancer victims live in under-developed nations, which have merely 10% or less of financial aid for cancer control and care (Igene 2008). This itself outlines the extent of burden the public health services in developing nations are facing.
Significance: Due to importance directed to curb communicable diseases, cancer and other non-communicable diseases suffer low financial aids. This has posed breast cancer as a significant public health problem and hence urged to study this cancer in a social environment (Igene 2008).
Etiology: Among the nine modifiable risk factors that were studied by Irimie et al. (2010), behavioral factors included active or passive smoking, alcohol consumption, obesity, and dietary insufficiencies. There is a strong association found between these risk factors and breast cancer (Irimie 2010).
Expressions: It is found that fluid from the ducts of breast possessed higher concentrations of tobacco chemicals then the blood of the patients. Carcinogens present in tobacco are known to cause irritation and easily interfere with the basic defense mechanism of the body against cancer (Irimie 2010). Even moderate consumption of alcohol with deficient intake of vitamin C and folate increases the risk of developing cancer (Irimie 2010). Obesity in post-menopausal women is found to increase the risk of breast cancer by 1.5 times than in pre-menopausal women. This is due to the increased and continuous estrogenic stimulation, as fatty tissue continues to produce estrogen post menopause. The levels of estrogen in overweight women are reported to be almost double to that of lean women (Irimie 2010). A direct correlation of diet content with the incidence of breast cancer is lacking. Many parallel trials and studies have shown no statistically significant data to strongly associate high fruit and vegetable intake with lower incidence of breast cancer. However, consumption of high fiber fruits and vegetables with benefits clearly results in lower Body Mass Index and a lean body (Irimie 2010). Studies have also mentioned the benefits of various key anti-carcinogenic factors or stimulators within the diet that can modulate the breast cancer burden (Na and Surh 2008).
Etiology: Few of the important social dimensions responsible for the increase prevalence of breast cancer are poverty, unemployment, and stress. A sedentary lifestyle marked by physical inactivity as a byproduct of urbanization and/or stress has been completely linked with breast cancer. A study of 65 patients by Irimie et al. did reveal all patients of breast cancer were neither having any leisure physical activity nor their job profile was physically strenuous (2010).
Expressions: Psychosocial stress and biological factors has been explained as a probable cause of impaired lactation. This lactation insufficiency results in small period of breast-feeding and is associated with altered mammary gland development and endocrine disruption (Rudel 2011). The association of physical inactivity with a variety of diseases is underrated. Physical inactivity can express as lethargy, a manifestation of depression, or can be a part of luxurious side effects of technology and urbanization. Physical inactivity has been shown to induce hormonal imbalance (reduced insulin), obesity, altered prostaglandin levels and damaged immune system (Irimie 2010).
Etiology: Air pollution especially in urban areas, smoke inhalation due to household fuels, and genetic predisposition are important risk factors (Irimie 2010). Each of these factors play independent role in causing breast cancer. A family history of breast cancer in first and second order relatives is an obvious non-modifiable risk factor (Irimie 2010). Urbanization is said to an important factor in breast cancer risk profile due to many subfactors, which include pollution, obesity, lifestyle, stress, and physical activity; most of these are psychosocial, where as presence of aerial polycyclic aromatic hydrocarbon adds the environmental edge of urbanization (Irimie 2010).
Expressions: Apart from psychosocial stress and biological factors, environmental exposure to carcinogens is one important factor that affects wholesome and sustainable lactation, resulting in increased incidence of breast cancer. Numerous studies have hence probed and proved an association of dioxin, atrazine, genistein, and many others in the mal-development of breast tissue (Rudel 2011). It is also argued that high density of breast tissue in urban residents when compared to adipose breast of rural counterparts can be a cause of cancer (Irimie 2010). Fertility when young and high parity is observed in non-cancerous rural population when contrasted with elderly primigravida (first pregnancy post 30 years) and null parity of the urban women struck with breast cancer. This is manifested as a 30% increased risk of developing breast cancer in urban nulliparous women (Irimie 2010). Presence of polycyclic aromatic hydrocarbon in traffic pollution has found to simulate estrogenic effects on breast in population thus disrupting physiological endocrine functioning (Irimie 2010).
Prevention, at all levels, plays an important role in improving health status of a nation. Early diagnosis and treatment has proven to improve survival rates and reduce costs spent on tertiary health care (Jacobsen 2011).
Primary prevention: Breast cancer is affiliated with a variety of non-modifiable factors like family history, reproductive and menstrual factors (Irimie 2010). However, cancer and in some cases specifically breast cancer, is related with modifiable risk factors like smoking, alcohol, oral contraceptives, dietary habits, etc. The awareness of these risk factors is untaken by health organization that has helped ease the incidence by increasing general awareness over a span of time (Jacobsen 2011). However, developing countries face a huge disease burden, especially infectious. Additive financial crunch doesn’t permit a developing nation to carry out such awareness programs. This has hence resulted in a low-incidence and high-mortality pattern in such countries (Igene 2008). An interventional cohort study carried out in Brazil discloses this fact and accounts the financial inadequacies and inability to train health care professionals. The country’s present screening for breast cancer using mammography is held every two years for women belonging to the age group of 50-69 years, while the recommended screening protocol defines the age group to be 40-69 years with annual intervals (Caleffi 2009).
Secondary prevention: Early detection and treatment is the prime objective of secondary prevention. There is no dispute to prove its effectiveness. If focus is optimal, increase in immediate diagnosed cases in the event of preventive campaign/program and behavioral modifications brought about by general awareness in the long run, is inevitable. Such is the success example of National Breast Cancer Awareness Month (Jacobsen 2011).
Tertiary Prevention: Providing health services mainly in the form of treatment once diagnosis is made and symptoms are revealed, is the mainstay of the tertiary prevention. Developing nations face the axe of deteriorating environment and unstable organizational setup. This results in the down moralizing of the health taskforce and manpower and results in a negative affect on the health services (Igene 2008). For instance, majority of the deaths in the age group of 45-59 years of age reduce the working population of the sub-Saharan Africa (low income countries) and this directly cuts the country’s income and downgrades its economy (Igene 2008).
Public Health Policy Implications
Developing nations are confronted by a lack of structured screening program and in some cases like Nigeria a complete absence of specific breast cancer screening campaign (Igene 2008). This conforms to the long waiting lists at a few specialists performing tests, procedural delays in diagnosing, and treatment (Caleffi 2009). This has resulted in a high quantum of inequalities present in the health services of the developing nations. Bringing in the decentralization policies can reduce these inequalities. Such decentralization measures undertaken by the Swedish and the Cuban government have resulted in improvement of the health standards of their respective countries (Igene 2008). Another important implication suggested by Caleffi et al. would be useful especially for the developing nations (2009). This includes the introduction of multi-disciplinary approach involving all physical, imaging and pathological examinations to be done at a single health care centre. This approach utilized a trained nurse or a breast surgeon along with a computerized system that took care of all the appointments and generated monthly reports of all the cohort applicants (Caleffi 2009). This resulted in the delivery of screening, diagnosis and treatment all at one center. What is important to understand by this study and an initiative is that the main scoring point was the increase in the compliance of the patients. This clearly indicates that public awareness and active participation of the health care unit are vital to the success of any public health care and policy measure (Caleffi 2009). Igene suggests an interesting three-tier approach for developing nations to curb the breast cancer burden (2008). These approaches urge the nation to build technological capacity to strengthen health policy application of early diagnosis, uplift spirits of the returning medical professionals from western nations and last but not the least to develop a tertiary and palliative care system for terminally ill patients (Igene 2008).
Igene, H. (2008). Global Health Inequalities and Breast Cancer: An Impending Public Health Problem for Developing Countries. The Breast Journal, 14(5), 428–434.
Caleffi, M., Ribeiro, R. A., Filho, D. L. D., Ashton-Prolla, P., Bedin, J. A. J., Skonieski, G. P. (2009). A model to optimize public health care and downstage breast cancer in limited-resource populations in southern Brazil. (Porto Alegre Breast Health Intervention Cohort). BMC Public Health, 9(83).
Irimie, S., V., M., Mirestean, I. M., Balacescu, O., Lisencu, C., Puscas, E. (2010). Risk Profile in a Sample of Patients with Breast Cancer from the Public Health Perspective. Applied Medical Informatics, 27(4), 21-30.
Rudel, R. A., Fenton, S. E., Ackerman, J. M., Euling, S. Y., & Makris, S. L. (2011). Environmental Exposures and Mammary Gland Development: State of the Science, Public Health Implications, and Research Recommendations. Environmental Health Perspectives, 119(8), 1053-1061.
Jacobsen, G. D., & Jacobsen, K. H. (2011). Health awareness campaigns and diagnosis rates: Evidence from National Breast Cancer Awareness Month. Journal of Health Economics, 30(1), 55-61.
Na, H. K., & Surh, Y. J. (2008). Modulation of Nrf2-mediated antioxidant and detoxifying enzyme induction by the green tea polyphenol EGCG. Food and Chemical Toxicology, 46, 1271–1278.
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