October, the month traditionally associated with cancer awareness, has come and gone. Apart from the daily focus on Covid-19, the impact of cancer on women’s health has not really received any attention. Globally and nationally breast cancer is still the most commonly diagnosed cancer among women, followed by cervical cancer. Too many women are still diagnosed with advanced and metastatic disease and too many are dying silently. 

Disparities in breast health services in South Africa remain a reality. In the US, the American Association for Cancer Research published a Cancer Disparities Progress Report. The disparities and issues mentioned in this report resonate with the South African situation. The Breast Cancer Control Policy was adopted in 2017 by South Africa’s National Department of Health (NDOH), but to date not one of the provincial health departments has implemented this policy.

To implement the policy, a provincial department is required to ensure that, at primary healthcare level, the job descriptions of registered nurses are adjusted to include clinical breast examinations as a primary screening modality. This policy further requires that healthcare workers are appropriately trained. 

The NDOH will begin its online training platform early in 2021. 

The policy further requires a referral system to triage patients from their local primary healthcare clinics to secondary hospitals for diagnostic mammography and subsequent treatment services, which in most cases are situated at tertiary hospitals. The time it takes from screening to treatment can in some cases be from six to 12 months. In shocking contrast, in the private sector this trajectory of care is three weeks.

Most women with breast cancer diagnosed at a public healthcare facility present with advanced breast cancer. Delays in treatments, specifically radiation, will hugely impact on the outcome of treatment. What is further alarming is that the NDOH is experiencing severe challenges in accessing mainstay cancer treatments. It had to advertise a supplementary tender for cancer medicines in May 2020, after nearly 61 medicines were classified as non-awards. 

Access to life-saving trastuzumab treatment remains unavailable in the Western Cape as it is classified as an unfunded mandate. Treatment centres in other, more under-resourced provinces have indicated the same. In the private sector trastuzumab treatment for early HER2 breast cancer is now classified as a prescribed minimum benefit (PMB). The treatment guidelines have been updated to follow international best practice of six months of treatment rather than 12. It can therefore no longer be argued that treatment remains unaffordable, given that it will cost about R45,000 as opposed to the previous cost of nearly R123,000. 

In the private sector, Mylan biosimilar drugs have overtaken the originator product, Herceptin SC, which in 2019 was listed as the fourth-highest earner in the Mediscor Review Report. 

Breast prosthetic services are not available in public healthcare. This means that a woman who has had a breast amputation (more acceptably referred to as a mastectomy) has to find an alternative way to hide her disfigurement. Project Ditto of Reach for Recovery, a cancer support group, provides indigent women with a breast prosthesis at no cost. This organisation is dependent on private-sector funding. 

Public healthcare patients undergoing orthopaedic amputations are assisted with prosthetics. Are we of the opinion that a breast, because it is not visible, does not warrant a prosthesis? Women using private healthcare have the opportunity to claim for a breast prosthesis as well as reconstructive surgery from their medical schemes. 

Palliative care and support services are underfunded. This situation has been exacerbated by the economic impact of the coronavirus pandemic and subsequent lockdown. Many hospices have had to close down because they are reliant on funding from members of the public, whose shrinking disposable incomes are no longer directed to charities. It is alarming that basic support services are no longer available because many non-government organisations assisting cancer patients and their families receive no state subsidies and must survive on public goodwill.

 Patient navigation is vital in a country where most public healthcare cancer patients are served by a clinician who cannot speak their language. Cancer treatments are difficult to explain to any person and if this cannot be done in their mother tongue, or where the vocabulary to describe and explain some treatments does not exist, it becomes increasingly challenging to treat patients with the required dignity and respect. 

Both the Breast Health Foundation and CANSA were able to implement a very successful patient navigation programme called Phakamisa (isiZulu for “to uplift”) over the past six years. Although industry-funded, patients at public hospitals benefited directly from this one-on-one service. However, funding for this vital service has been redirected by a biopharmaceutical company AstraZeneca to an awareness campaign rather than one benefiting patients directly. 

It is to be doubted that the NDOH will develop a supportive strategic framework soon, and thus patients will have to rely on their own support for the immediate future. 

Most patients are discharged without appropriate palliative care medicines, which are out of stock on a regular basis. In the private sector, most oncology practices have oncology social workers as part of their practices and medical aids will pay for this service. 

Whether you live should not depend on where you live. How you manage your disease or how you die should not depend on that either. Adequate medical treatment remains a basic human right.

Metastatic breast cancer affects most women using public healthcare facilities. Metastatic breast cancer patients remain an underserved community, whether they use public or private healthcare services. This is a group of women who do not subscribe to the notion of Pinktober. No, they want to be recognised for the challenges that they face in living with metastatic disease and the non-availability of services and treatments. CANSA and Breast Health Foundation initiated online support services for this. But we also know that most women using public healthcare do not have the ability to connect online, as disposable income is rather redirected to maintaining the family than spending it on such vital support for themselves. 

All of this is taking place in a country where the government proclaimed its commitment to the development and empowerment of girls and women. The president announced that an additional R5-billion had been allocated for programmes focusing on gender-based violence. It is also time to #StandUpSpeakUp about the severe lack of focus on women’s health issues. 

Advocates for Breast Cancer as part of the Cancer Alliance is calling for the government to allocate funding not only to the fight against gender-based violence, but also to equitable health care (and not the rhetoric of the National Health Insurance project). This means funding for the treatment of cancers that have major cost implications for the state, and most, importantly, major physical, psychosocial and economic implications for girls, women, families and broader society, as well as for the health ministry budget. 

We need accessible breast screening and diagnostic services at community and district levels of care, and diagnostic and treatment services at district and provincial levels of care. Moreover, we require appropriate allocation of funding to train healthcare practitioners and to properly equip breast cancer units at hospitals in all provinces, as well as to provide affordable medication. DM/MC

Salomé Meyer is a project manager at the Cancer Alliance’s Access to Medicine campaign. She dedicates this article to the unsung heroes who are not and have never been recognised for their struggles with metastatic breast cancer.