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Breast Cancer Epidemic in Botswana

Breast cancer awareness around the worldPenn Medicine physicians aren't only treating people with breast cancer in Philadelphia. We're also trying to make a difference across the world.

One of our hematology oncologists, Yehoda Martei, MD, is currently in Botswana, treating people with breast cancer and conducting research to stop the incidence of breast cancer cases.

Here, she talks about breast cancer prevalence in the world and Botswana and her work abroad.

Breast Cancer Prevalence in the World

The majority of newly diagnosed cancer cases worldwide are in low and middle income countries (LMICs), and more than two thirds of cancer deaths occur in LMICs. As much as we are familiar with the scourge of cancer and its devastating effects on patients and their loved ones in the developed world, the rising cancer epidemic in the developing world poses a much greater public health threat.

Although more cancers diagnoses and deaths occur in LMICs, there are disproportionately less global resources allocated for cancer control in the developing world. Subsequently, in some of the world’s poorest regions, including sub-Saharan Africa, the majority of patients diagnosed with cancer will die from their cancers -- and often painfully due to lack of adequate cancer treatment and palliation for pain.

Breast Cancer in Botswana

Breast cancer is one of the most commonly diagnosed cancers among women in sub-Saharan Africa. In Botswana, a middle-income country in Southern Africa, breast cancer represents the second most common cancer diagnosed among women, after cervical cancer.

Similarly to many other countries in sub-Saharan Africa, Botswana faces the dual burden of cancer and HIV/AIDS. The country has been a success story for HIV due to the enormous strides made in diagnosing and managing patients with HIV/AIDS on HAART (medication treatment approach). However, this also means that it faces a high prevalence of HIV patients.

There is a substantial amount of people who are being diagnosed with both breast cancer and HIV, which presents unique challenges in managing their treatments, as well as opportunities for patients, health care providers, researchers and the local government to help.

Collaboration with Penn Medicine

The Botswana University of Pennsylvania Partnership (BUP) is a longstanding collaboration between the University of Pennsylvania and the Government of Botswana to build capacity in clinical care, education and research in Botswana.

Dr. Yehoda Martei advocating for breast cancer patients in Botswana

There is a critical lack of research to quantify how to increase access to cancer care and how to deliver safe and quality cancer care in some of the world’s poorest regions. The argument of poor infrastructure is not an acceptable choice while people die.

As part of the BUP, I have been working in Botswana with the ultimate goal of providing quantitative data that highlight gaps in care. As a group, our intent is to design informed interventions to improve the quality of access to systemic therapy and delivery, as well as treatment outcomes in breast cancer patients. I've focused my research on how to leverage current resources to deliver the much needed cancer care and to change the outlook of cancer as a death sentence.

As we celebrate groundbreaking and revolutionizing therapies in cancer care, it is important to remember that a substantial portion of cancer patients in Africa cannot get basic treatment.

Stock-Outs in Botswana

My first trip to Botswana was two years ago, after having conducted previous research and clinical work in other African countries including Ghana, Uganda and Tanzania.

It was readily apparent after exposure to the health care facilities that Botswana has more resources compared to neighboring African countries, including a national health insurance plan that covers generic cancer medicines and a few targeted therapies for free for its cancer patients. However, gaps in care do exist.

One of the challenges providers face is the issue of “stock-outs,” a situation in which a cancer drug that they intend to prescribe to a patient during their treatment is not available (AKA out of stock). This situation is not unique to Botswana -- drug shortages and stock-outs are a global challenge -- but there is limited research quantifying the scope and impact of stock-outs.

In collaboration with providers and representatives from the Ministry of Health, our initial research goal was to quantify the availability of essential medicines for cancer in Botswana as a means for highlighting gaps. By showing the gaps, we hoped to drive health care innovations and interventions to improve access to cancer medicines and treatment outcomes.

Our analysis showed that 40 percent of cancer medicines on the essential medicines list were out of stock for a median duration of one month. If you are or have been through cancer treatment, you know that most drugs are given every two or three weeks. These stock-outs can lead to delays people in receiving the therapy they need, which could be fatal.

As part of the drug stock-out, we revealed that the amount of chemotherapy drugs needed were being underestimated and the types of chemotherapy needed were being misrepresented.

By quantifying and giving evidence of this happening, we have established a need to improve the quality of access to therapies. And better access means improved outcomes for those with breast cancer.

Hope for Breast Cancer Patients in Botswana

My passion in global oncology stems from the fundamental belief that the location where a breast cancer patient is diagnosed -- whether it is in Botswana, Rwanda or the United States -- should not define whether you live or die from your cancer. Having had the privilege of treating breast cancer patients both in the United States and Botswana, I have seen that no matter the location, every person has the same anxieties about taking care of their families and the same hopes to live to see their children grow and to live out their dreams.

Dr. Yehoda Martei with a breast cancer patient in a clinic in Botswana

I recently had a clinic visit with a 49-year-old woman with breast cancer, new spine metastasis and back pain. Her biggest concern was whether she would be able to dance at her daughter’s wedding. Thankfully, the appropriate therapies were in stock, and we could get her the right treatment.

Another young breast cancer patient agonized about losing her breasts. Breast reconstructive options are not available in Botswana.

In another visit, a 26-year-old woman asked what would happen if she decided not to go with the proposed treatment plan. She explained that she was recently orphaned; she had buried her mother after many months of suffering from advanced cervical cancer. She described the experience as traumatic and wondered if there was an easier way to die.

The perception of cancer as a death sentence remains prevalent even in countries like Botswana, where more resources for cancer control exist. Some of the rewarding experiences for me are seeing a minority of breast cancer patients still alive three, four, five years after their initial diagnosis. I am optimistic that this could be the common face of breast cancer in Botswana in the near future.

Hope for Those with Breast Cancer Around the World

This research area is challenging and at times daunting, but equally rewarding. There is an African proverb that says “it takes a village to raise a child” -- or in my case, to nurture a global oncology researcher.

I give many presentations about my work and at the end, I always include an acknowledgement slide. My slide keeps growing with more and more individuals and organizations. It attests to the commitment of the leadership of the hematology-oncology division, the cancer center and the fellowship program, the mentorship I have received from distinguished Penn faculty in the Abramson Cancer Center and beyond, the support of the clinicians and nurses in Botswana who deliver heroic care to these breast cancer patients, and the generous donations we have received.

I am optimistic that with more research funding, support and health care interventions, breast cancer care in Botswana will be another success story, just like HIV.

About This Blog

The Focus on Cancer blog discusses a variety of cancer-related topics, including treatment advances, research efforts and clinical trials, nutrition, support groups, survivorship and patient stories.

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