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Why do we have the highest rates of breast cancer in Asia?

  • Posted On: 11th June 2013
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Pakistani women have the highest incidence of breast cancer in Asia. Is it just bad luck or is there more to it?
“Worldwide, more than one million new cases of female breast cancer are diagnosed each year. It is also the most common female cancer in both developing and developed countries” (Bray, McCarron, Parkin; “Breast Cancer Research,” 2004, BioMed Central Ltd.). “More than 90,000 of the one million global cases of breast cancer are from Pakistan, and half of that number from Punjab. About 10% of them were diagnosed, out of which 75% of them did not seek treatment and died within five years.” (University of Health Sciences Controller of Examinations Dr Junaid S Khan speaking on ‘Cosmetic Options in Breast Disease Management’ (Daily Times, October 28, 2007).
That means there are only 2,250 women in Pakistan who are treated for breast cancer out of the yearly 90,000 cases!
Pakistani women get the disease at a far younger age than Western women, with larger lesions, and are more prone to metastatic cancers.“The predominant morphology is a higher rate of infiltrating ductal carcinoma” (“Detection,” Sohail & Alam, JCPSP 2007 Vol 17 (12) pp. 711-712).
The highest reported (and researched) rates in the world are among Achkenazi Jews, who have a genetic mutation that has been reproduced via inter-marriages within their race. Why is it that around 1 in 7 to 8 women in Pakistan get breast cancer during their lives, while it inflicts 1 in 20 women in India, a country that is similar in terms of women’s ages during childbirth, marriage and socio-cultural landscape? Then again, we all know that marriage between first cousins is still a common practice here, whereas in India, Hindus only marry cousins when they are 6 times removed. Many of them also follow vegetarian menus rather than, say, feasting on nihari, gosht and paye cooked in ghee.

Ignorance plays a big role in the too-late-to-be-effective diagnosis of breast cancer in Pakistan. Here, if you go for a routine mammogram/breast sonogram, people look at you strangely and even the receptionist asks you why you’re there and if you have cancer (I kid you not!). That’s the whole problem. There shouldn’t be something wrong when you go. It ought to be a normal part of one’s health schedule just like routine gynaecological and dental checkups. Internationally, women get annual pap smears and mammograms and no one bats an eyelid. Here, it’s culturally unheard of to get yourself checked unless you have a noticeably hard lump and are forced by family members to consult a doctor.

Breast cancers in Pakistan often go undetected for so long that the majority of people are already in their third or fourth stages by the time they realise they have it: “Pakistan faces a high burden of breast cancer disease with late stage presentation being a common feature. It has been seen that more than half of the patients present in advanced stages (stages III and IV). Regular clinical breast examination and mammography of women according to the internationally accepted guidelines can result in down-staging of breast cancer of asymptomatic women. However, there are no national screening programs for breast cancer in Pakistan. In the Pakistani context, educating the women about the risks of breast cancer constitutes a first step towards early detection of breast cancer, so that women would be able to judge their risk and take relevant measures” (“Breast Cancer Risk Factors among Nurses in Teaching Hospitals in Karachi,” Ahmed, Mahmud, Hatcher, Khan; 2006 Aga Khan University study).
Many harmful pesticides and herbicides banned in developed countries are sold in developing countries and are identified as human or animal carcinogens, found in water supplies as well as in air and dust in homes (please refer to the “DDT” section ahead). Ever since I can remember (and this dates back to the 1980s), Pakistani TV has been full of advertisements of ‘kissans’ using magical ‘urea’ and the like, spurning organic manure for profit-reaping cheap pesticides. Harmful chemicals linger in crops even after they are washed and cooked, and enter our bloodstreams. In the meantime, western countries have adopted organic farming. People pay higher prices for organic items and shop at whole food stores, it’s considered very fashionable to eat organic. At the International Training Seminar on Organic Farming in Islamabad, Dr. Kausar Abdullah Malik, Member Planning Commission and Ex-Chairman Pakistan Agricultural Council stated that Pakistan imported five times more pesticides than normal to control cotton pests for increasing production, and this has had an adverse effect on the cotton crop, reducing it considerably. He said that organic farming was a more environmentally responsible approach to produce high-quality food and fiber (APP report, April 28, 2008). He also thinks that DDT should be continued here because it ends malaria and is perfectly “safe.”
Although our research is scanty and there are no official reports, various health agencies have estimated that over 40,000 women die of breast cancer each year in Pakistan.
I wonder how many women’s lives would have been saved if they had been diagnosed sooner.
I wonder how many women would have gotten cancer in the first place if we didn’t use so many harmful chemicals in pesticides and other substances.
I wonder if our children can be saved from future agony if the government were to ban harmful chemicals, many of which are already prohibited in most countries.
I wonder when gynaecologists will start citing mammograms and breast sonograms as mandatory checkups for women in their 30s and upwards, instead of waiting until they are already stricken with the disease.
I wonder when, along with Polio and other awareness drives, breast self-testing will be explained to rural and urban women.
I hope it’s before we have the highest rates of breast cancer in the world.
More can be found on the topic in “State of the Evidence 2008The Connection between Breast Cancer and the Environment” (edited by Janet Gray, Ph.D., published by the Breast Cancer Fund at This study unveils the various sources, which increase our chances of contracting breast cancer, most of which, unsurprisingly, pertain to Pakistan:
Q & A with Dr. Natasha Anwar, Consultant Molecular Biologist at Shaukat Khanum Memorial Cancer Hospital in Lahore:
Why is the rate of breast cancer highest in Asia among Pakistani women?
Natasha Anwar: “We are still not sure why. However, it is likely that certain environmental and genetic factors are contributing to the high incidence of this cancer.”
Is there genetic testing available in Pakistan for hereditary breast cancer genes BRCA-1 and BRCA-2? Who are likely candidates? (e.g. when two or more of their family members have had breast cancer before menopause?)
NA: “Diagnostic testing for BRCA1/2 mutations is currently not available in Pakistan, however, a research project is underway at SKMCH & RC that is identifying BRCA-1 and 2 mutations in patients with hereditary breast cancer. If a patient has a very strong family history of breast or ovarian cancer they and other members of their family are offered testing. There are specific criteria set out for genetic susceptibility testing, and it is only offered to individuals with a high risk of developing breast and or ovarian cancer. A high risk patient/family includes more than one first degree relative (mother, sister, daughter) with breast or ovarian cancer, more than one second degree relative (aunt, grandmother, cousin) with breast or ovarian cancer, a diagnosis of breast or ovarian cancer in these relatives at a young age (50 or younger).”
I’ve read that breast cancer among men exists but is rare. Have any men with breast cancer been treated at SKMCH?
NA: “Yes, breast cancer in men is rare. Between Jan 1, 2008 and Jan 31, 2009, of a total of 953 cases of breast cancer, only five patients were men (data courtesy of the Clinical Cancer Registry and Data Management section SKMCH & RC).”
From the study by the Breast Cancer Fund and the chart given, which do you think are applicable for Pakistan?
NA: “They may all be applicable; we need to carry out more specific research in order to determine the risk factors that are contributing to the development of breast cancer in Pakistani women. Another aspect is diet.”
Was my conjecture about inter-marriages being a possible reason for the high rate of breast cancer in Pakistan ludicrous or does it seem a possibility?
NA: “Not at all ludicrous, in fact this is something that researchers are investigating at the moment.”
Have there been any breast cancer drives in Pakistan at all?
NA: “Yes, SKMCH & RC initiated a breast cancer awareness campaign on October 25, 2008, and the Pakistan Pink Ribbon National Breast Cancer Awareness Campaign has also been active in this regard.”
What are the chances of survival for a woman if her cancer is diagnosed at an early stage?
NA: “Current data suggests that if breast cancer is detected at an early stage, before it has spread beyond the breast, the five-year survival is about 98% to 100% in the US.”
By ‘survival,’ do you mean 5 years or more?
NA: “Normally, when we talk about survival we specify if it is a 5-year or 10-year survival analysis. This does not mean that these women will survive only five years or 10 years. Doctors measure the success rates for cancer treatment by seeing how women are doing five or 10 years after treatment.”
Is the government or the private sector doing anything to help promote/fund breast cancer awareness, diagnosis, and treatment?
NA: “As you know, SKMCH & RC treats 70% of its cancer patients free of cost; they are treated as patients would be anywhere else in the world. We have skilled and experienced medical staff and excellent facilities that enable us to provide the best possible care. Patients are treated according to international protocols using the same medicines and drugs being given to patients in Europe and the US. The majority of our patients are women with breast cancer, and we see plenty of patients with advanced stage disease. It is more difficult to treat women who come to us with advanced breast cancer. To try and increase awareness and also educate women about breast cancer we have also been conducting various awareness sessions in schools and colleges. Our Nursing Division holds regular breast self examination sessions at the hospital and they have also visited various companies and institutes to conduct sessions for female employees. We have also initiated a pilot breast cancer screening project, which is being run in vicinity in Lahore Pakistan. This will hopefully help us diagnose any breast cancer cases earlier.

There is another NGO working on Breast Cancer Awareness by the name of Pakistan Pink Ribbon Breast Cancer Awareness Campaign.”

Is there anything else you’d like to add that women and men ought to know?
NA: “Never ignore your symptoms. Certain cancers are completely curable if detected early so please if you are concerned consult your doctor or visit the hospital. It is important to be aware of the risk factors, signs and symptoms of developing cancer.”

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