Theresa Justin lives in Makurdi. She was only 41 when she was diagnosed with stage two breast cancer in June 2017. She recalled feeling calm when the doctors told her because she remembered a woman in her neighbourhood who had survived breast cancer.
Jamal Aliu, a 65-year-old resident of Abuja, was diagnosed with Leukemia.
“When they told me I had Leukaemia, I didn’t even know what it meant, I had to Google it,” Mr Aliu said.
Many Nigerians have similar experiences: most cancer patients in the country only become aware of the nature of the disease at the point of grave illness. And many are not aware of choices they can make when it concerns cancer.
Cancer refers to uncontrollable growth of cells that can occur in any part of the body.
The World Cancer Day, marked February 4, is an initiative of the Union for International Cancer Control (UICC) to raise awareness of cancer, the second leading cause of death worldwide, and promote the prevention, detection and treatment of the disease. The theme this year is “I Am and I will”, focusing on “personal commitments to help reduce the global cancer burden”.
Every individual and society must consciously make decisions to prevent the development of cancer.
Nigeria’s cancer burden is difficult to determine due to the lack of data. However, according to the International Agency for Research on Cancer (IARC), 70,327 Nigerians died from cancer in 2018 alone, while 115,950 new cases were recorded the same year.
In Nigeria, the cancer death ratio is 4 in 5. That means 80 per cent of people diagnosed with cancer in the country lose their lives to the disease. it is one of the worst cancer death statistics in the world.
New research is showing that cancer is preventable. The World Health Organisation (WHO) found that between 30-50 per cent of all cancer cases globally were preventable. It is important to note that factors like family history and age can predispose an individual to develop cancer. Some types of cancer can, however, be prevented by avoiding the known risk factors and engaging in early detection methods.
Common risk factors for cancer
Smoking and tobacco use: Tobacco smoking is the single most preventable cause for developing cancer. This includes second-hand smoking, which means being in an environment where there is tobacco smoke and inhaling such. Smoking is linked to 14 different types of cancers. 6.1 per cent of cancer cases in Nigeria is linked to smoking, mostly lung cancer. However, smoking also causes cancer in the mouth, upper throat, larynx, oesophagus, lung, liver, pancreas, stomach, kidney, bowel, ovarian, bladder, cervix and blood.
Alcohol consumption: Substantial evidence shows that alcohol consumption, especially in excess, causes cancer. Alcohol consumption has been linked to bowel, mouth, pharynx, larynx, oesophagus, breast and liver cancer. The risk of developing cancer from alcohol consumption increases when combined with smoking.
Obesity: Cancer predominantly occurs amongst overweight and obese adults. Research has found that obesity is linked to higher risks of developing cancer in the breasts (after menopause), bowel, womb, oesophageal, pancreas, kidney, liver, upper stomach, gallbladder, ovarian and thyroid, as well as myeloma (cancer in the plasma cell of the bone marrow) and meningioma (a brain tumour).
Diet: Research has shown that many of the food we consume have carcinogenic (cancer-causing) properties. Specifically, red meat and most processed foods, which form a large part of diets, have high risks for cancer. For example, red meat has been associated with the development of pancreatic and prostate cancer and also increases the risk of colorectal cancer. A better diet that consists of fruits and vegetables can reduce the risk of developing cancer.
Physical inactivity: Maintaining a healthy weight and increasing one’s level of activity can contribute to the prevention of cancer. Research has shown that physical inactivity increases the risk of developing colon, breast and endometrial cancer.
Viruses: Cancer-causing viruses, including certain types of human papillomavirus (HPV), cause cervical and other types of cancer. Cervical cancer is ranked the 2nd most common type of cancer in Nigeria in both sexes, with 14,943 cases annually.
Hepatitis B and C also cause cancer. In Nigeria, liver cancer is the fifth most common cancer in both sexes and the third most common in men. Hepatitis is the most common risk factor for liver cancer. The Human Immunodeficiency Virus (HIV) is also a risk factor for developing Kaposi Sarcoma (cancer that affects skin and lymph nodes) and Non-Hodgkin Lymphoma (cancer of the lymph nodes). Most of these viruses can be prevented by vaccinations, except HIV.
Exposure: Exposure to certain substances can cause cancer. These substances include asbestos, chemicals at the workplace and solid fuels (charcoal and firewood) in the household. Despite it going out of fashion two to three decades ago, the asbestos ceiling is still used in many homes in Nigeria.
Most cleaning agents in the oil industry contain benzene, a substance known to cause Acute Myeloid Leukemia (AML; a cancer of the blood). Additionally, exposure to ultraviolet (UV) rays from the sun can cause skin cancer. Exposure to other environmental carcinogenic pollutants also increases one’s risk of cancer.
Awareness, observing signs and early screenings
Screenings refer to tests which help to detect and diagnose cancer. Screening aids in cancer prevention as early detection improves the prospects of survival through the removal or destruction of cancerous cells before they progress and spread (metastasises) to different parts of the body. Colonoscopy, mammography or Pap test are examples of screening to detect cancer. Some experts regard screenings as the most vital step in winning the fight against cancer.
Screenings are particularly important especially when the risk factors are considered. This includes the preventable factors outlined above as well as non-preventable ones such as one’s age or family history of cancer. Those susceptible in this respect should have more regular screenings.
“I didn’t drink, I didn’t smoke, I never did,” Mr Aliu said. “I had never been to a hospital or admitted to one. When we are strong, we think we’re supermen that is why I always tell even young people to check yourself”.
According to Mrs Justin, “If I had the strength I would advocate for cancer awareness. I was a social worker, so I counselled people on HIV for four years. I told them that HIV was not a death sentence. The reason so much progress has been made in HIV is the amount of advocacy.”
Signs and symptoms of cancer
Theresa reported at a hospital after she noticed a bloody discharge from her nipples. For Mr Aliu, the symptoms were vague – fatigue, weakness and dizziness. Nonetheless, he said that he instantly drove to the hospital.
The American Cancer Society developed a simple acronym “C.A.U.T.I.O.N” which helps individuals to be watchful of the seven most common signs of cancer:
C: Change in bowel or bladder habits
A: A sore that does not heal
U: Unusual bleeding or discharge
T: Thickening or lump in the breast or elsewhere
I: Indigestion or difficulty in swallowing
O: Obvious change in a wart or mole
N: Nagging cough or hoarseness
For breast cancer, women should be familiar with breast self-examination techniques. Regular mammograms (x-rays of the breast) are also advised once a woman reaches the age of 40. From age 40 – 45 years, women can decide to start regular mammogram exams, but it is advised that this step becomes yearly from ages 45 – 54. After the 54-year mark, the regularity of the tests can reduce to once in two years, and continued as long as a woman is in good health. An MRI is recommended alongside this test for women with higher risk such as women with a family history of cancer.
Colon and rectal cancer and polyps can be screened from the age of 45 for everyone. This test is stool-based or by visual examination by a doctor. This test continues up until age 75, but for people predisposed by family history or genes, this test can continue till age 85.
Cervical cancer screening starts at age 21 with a Pap test, done every three years up to the 29th year. Women between ages 30 to 65 years should have a Pap test and an HPV test (called co-testing) every five years but can do a once-in-three-year pap test. After 65 years no testing should be done if previous tests have been normal, but women with a predisposition to cancer of the cervix should continue for 20 more years even after age 65.
If a woman has had her uterus and cervix removed, she does not need to do a Pap test. In addition to these tests, young girls and women can be vaccinated against HPV to prevent cervical cancer. HPV vaccines are available in Nigeria, though not given as a basic vaccine, hence would incur a cost. All women should, however, take the screening for their age bracket even if vaccinated.
After menopause women are at risk of developing endometrial cancer and should report any bloody vaginal discharge, women with higher risk should have a yearly endometrial biopsy.
Screening for lung cancer is done with a low dose CT scan at ages 55 – 74 years in persons with fairly good health, who currently smoke or quit smoking in the last 15 years, or have had at least 30 pack years (total significant smoking duration) of smoking history.
Significant years of smoking is measured in pack-years, which is arrived at by taking into cognizance the average number of cigarettes in a day by the total years of smoking over a factor. This is usually measured by the examining physician. The benefits of this screening should be discussed with a doctor.
Prostate cancer testing should start at age 45 in this environment with a PSA test and digital rectal exam. Subsequent testing intervals would depend on the PSA level.
Getting vaccinated for Hepatitis and knowing one’s status can be the first step towards screening for liver cancer. Ultrasound screening at routine health checks is a good follow up.
Cost of cancer management
For many especially in Nigeria, the biggest concern is the cost of tests and treatments. Pap smear costs between ₦5,000 and ₦10,000 in most hospitals. PSAs costs about ₦10,000, CTs range from ₦70,000 – ₦100,000, biopsies from ₦3,000 upward, depending on what is being looked at.
A vial of fludarabine costs about ₦40,000, and that of Rituximab about ₦260,000. On average, a cancer patient spends about ₦150,000 – 500,000 on a single dose of chemotherapy, and about ₦1,000,000 on a single course of radiotherapy. The absence of instituted screening protocols, health insurance and advocacy underscore the struggles many faces as they deal with this devastating diagnosis.
Mrs Justin also talked about the issue of the cost burden of tests and treatments. “That is the problem with cancer, the treatment cost. It is not the sickness that is killing people, it is the cost. I met so many women who died while receiving treatment”.
Mr Aliu also said, “I had to sell my truck to be able to afford my chemotherapy treatments, my new diet and a hospital room.” But he is still struggling to complete his chemotherapy course. Reflecting on his prognosis, Jamal said, “I don’t know how I am going to do it, but I refuse to give up. I could not walk four months ago, but now I can take a few steps.”