Breast cancer is the most commonly diagnosed cancer among Maltese women. It remains the most common cause of death from cancer among women and Malta is no exception. According to local awareness group Action for Breast Cancer Foundation, a woman in Europe is diagnosed with breast cancer "every two minutes". A woman dies because of breast cancer every six minutes. This silent killer seems to disproportionately affect the female gender with a staggering ratio of 84 females to one male case.
When one analyses the trends in incidence in the number of new cases of female breast cancer, these appear to be on the increase. In Malta, within a period of eight years, the number of diagnosed cases rose from 207 in 1997 to 245 cases in 2005. This is an increase of more than 18 per cent! Although this may be due partly to an increased life expectancy it does not really coincide with the fact that it largely affects the age groups between 50 and 69 year olds. Moreover, greater awareness increases detection. Unfortunately, this detection is not necessarily achieved at an early stage. Hence, many breast cancer cases, of all ages, are presenting themselves at an advanced stage of the disease. It is clear that early detection exponentially increases the rate of success in curing this cancer. Therefore, awareness, education and screening are vital if we are to succeed in overcoming this dreaded disease.
The knowledge about the causes of breast cancer is incomplete. Fewer than 10 per cent of all breast cancers are primarily due to hereditary factors. However, females with a strong family history of breast cancer have an increased risk of getting the disease at a younger age. Hormonal factors have been extensively studied and females who have their first pregnancy early on in life have a reduced risk. A diet rich in saturated fat has also been associated with an increased risk of breast cancer. However, the protective effect of a low-fat diet remains subject to interpretation. It is clear that the most important factors in decreasing mortality are successful diagnosis and effective treatment.
The incidence of female breast cancer is highest in the northern European countries, namely the Netherlands and Scandinavia. Lower incidence is found in the southern countries such as Portugal, Spain and Greece. Contrary to popular belief, Malta does not have the highest incidence of the disease in Europe. It is still also true that the incidence rates for Malta are higher than the European average and approach more those of the northern countries than the rates of neighbouring countries.
What role is the state playing in the fight against breast cancer? The Ministry of Health is tackling this phenomenon from various angles including prevention to treatment and ongoing support.
Malta's Breast Cancer Unit was set up in 2000. It is now well into its eighth year of operation and deals with an increasing number of referrals to the clinic. The unit is manned by three nurses with experience in dealing with such cases. The role of these nurses is to ensure continuity of patient care and support throughout the case process.
The demand on the breast cancer unit has trebled over the last seven years. An average 20 new cases are opened every week. This runs concurrently with the 50 to 60 follow-up cases that are seen to at the clinic. Clearly, there is an overload on the system and, hence, priority is given to those patients with indicative symptoms. In fact, any suspicious cases are seen to and investigated within 24 hours. Consequently, the demand for mammograms has increased. In 2006, a total of 4,219 mammograms were carried out. This is an increase of more than eight per cent over the previous year.
There are a number of tests that can be used to screen for breast cancer.
Mammogram: This test is an X-ray of the breast. It is carried out to find tumours that are too small to feel. The ability of a mammogram to detect breast cancer may depend on the size of the tumour and the density of the breast tissue. The experience of the radiologist may play a determining role in this detection.
Clinical breast exam: This is a simple procedure wherein the doctor carefully feels the breast for any unusual lumps of the breast and under the arms.
Breast self exam: Such an exercise is carried out by the individual and is similar to the procedure of a clinical breast exam.
Thermography: Unlike mammography, ultrasound and MRI, which measure structural changes, thermography picks up areas of greater heat generated by cancer cells, inflammation and infection. Thermography detects temperature differences that can occur where cancers have grown to 200-300 cells in size, when mammography detects cancers that reach a much greater cellular size. This in no way decreases the important merits of mammography. Thermography also reduces the discomfort of X-ray procedures.
Screening and therapy: It is abundantly clear that screening for cancer before an individual has any symptoms is the best course of action in fighting this disease. When abnormal tissue or cancer is detected early it will be easier to treat. Therefore, timing is paramount for a successful outcome.
As stated earlier, there is no unique screening test that is both readily available and sensitive for women of all age groups. This depends on the timing of the screening process as well as patient compliance and motivation.
The government budget proposal for a national breast screening programme has in itself raised the subject of breast cancer high on the national agenda. The implementation of this programme will not be a simple task. So far, a full-time breast surgeon post has been created. In tandem, the addition of two qualified radiologists should help in this regard. Furthermore, the introduction of state-of-the-art digital technology at Mater Dei Hospital should enable the assessment of mammograms overseas.
What remains a crucial problem is the demand for specialised human resources which require surgeons, invasive radiologists, pathologists and ancillary paramedics and other professionals. The introduction of a state-of-the-art oncology service such as the two new linear accelerators (costing some €6 million) and a PET scan (to be installed in Zammit Clapp Hospital) will surely serve in good stead. Incidentally, this equipment will be co-financed by European Union funding.
Unfortunately, as awareness and state commitment are on the increase, the phenomenon of breast cancer has become subject to political controversy. Indeed, unconstructive criticism and unrealistic expectations compounded with cynical comment will only hinder matters. Furthermore, this will only disturb the tranquillity of our dedicated medical professionals as they get on with a very difficult job. One sincerely hopes this controversy will be put to rest since we should all be pulling in the same direction towards the eventual success of an up and running breast screening programme for all women and of all ages.
Ms Galea is a PN candidate in the fourth district.