Liu Lichun, age 40, a breast cancer survivor, photographed at home in Shanghai, China.
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Speaking Out
If the developed world does not always do a good job of keeping itself well, health-care leaders there do understand that to fix the diseases you've got, you first have to talk about them. That is often not remotely the case elsewhere. In early September, Dr. Chiun-Sheng Huang, an oncologist at Taipei's National Taiwan University Hospital, examined a woman in her late 60s who had come to him for the first time. He discovered a tumor in her left breast so large that it had broken through her skin. She claimed she had first noticed the mass 17 years ago. The diagnosis was almost certainly terminal. When Huang asked the woman why she'd waited so long, she replied, "Because it didn't hurt."
Taiwan is one place in Asia where women have access to regular mammograms. Yet Huang says that if this woman's case is extreme, it's not extraordinary. "Women do not want to talk about their breasts," he explains. "So they ignore pain or illness."
The situation is little better elsewhere. Nigerian breast-cancer survivor Betty Anyanwu-Akeredolu says mothers in her country are reluctant to reveal that they have breast cancer, fearful that if they do, no one will want to marry their daughters. "Some women would rather go to church to pray for the lump to disappear," she says. Mukerjee, the breast-cancer survivor from Kolkata, tells the story of a patient whose very presence halted a family marital procession. "When the crowd saw her, they wouldn't go further," she says.
But things may be changing. Non?governmental groups such as Komen for the Cure and the World Health Organization sponsor lectures, professional gatherings and promotional events to educate women and caregivers about the disease. Grass-roots initiatives are sprouting up in places that never dared mention the disease before. Dr. Mohamed Shaalan, a breast surgeon in Cairo, reports that in Egypt, religious leaders now speak out in favor of breast-cancer awareness and screening, making it clear to husbands that their wives must be examined regularly — by male doctors if need be. In Hungary, where every woman from 45 to 65 now gets a free annual mammogram — with even travel costs covered — breast cancer has dropped from first place to third as a cause of death among women. In neighboring Romania, however, things aren't as hopeful, and a new organization called Common Destiny is working to increase awareness and testing. In China the country's anticancer association launched a nationwide drive in 2005 to provide a million women, ages 30 to 70, with a free mammogram within the next three years.
The results of even the most aggressive efforts may be mixed. Mobile mammography units have taken to the field in South Africa to improve that country's woeful rate of detection and treatment. But when a suspicious mass is found, timely follow-up visits are difficult for the mammography teams, so it is left to the woman to visit a hospital. Often she won't. "If you live 60 km from a clinic and you feel a lump and it's painless," asks Dr. Aaron Ndhluni, a private breast surgeon in Cape Town, "are you going to walk the 60 km?"
Money is a problem too. In Egypt, mammograms cost about $50, in many cases a month's income. Onyango, the Kenyan breast-cancer survivor, remembers that when her doctor told her she should have a mammogram, her first thought was, "How much will it cost?" The answer may be only $20 in Kenya, but for people who live on less than $1 a day, that could easily be out of reach.
Even in Japan, nobody's idea of a struggling country, cost is a barrier. In 2000 the Ministry of Health, Labour and Welfare called for the introduction of mammography for all women over 50. As of 2005, only 7% of women follow that recommendation. The price tag of a single machine is about $262,000, and a mammogram generally costs a patient $90 out of her own pocket. Says Dr. Fujio Kasumi, breast-cancer chief at Juntendo University Hospital: "People don't do [tests], thinking it's a waste of money."
Getting Well
For those women in the developing world who do get help, the path to recovery can be no less fraught than the path to diagnosis. Thirty years ago, treatment automatically meant mastectomy. By the 1980s, studies showed that for tumors that had not spread, all that might be required is a so-called lumpectomy, in which only the mass itself and the immediate surrounding area are cut away, provided that surgery is followed by radiation to destroy any rogue cancer cells. The subsequent need for chemotherapy depends on the degree of spread, the type of cancer and other variables. As more women are being treated for ever smaller tumors, even lumpectomies can be further refined.
These days fewer than 40% of American women opt to have mastectomies. That percentage, however, soars in other countries. In Korea more than 50% of patients have mastectomies, mostly because they are afraid of secondary cancers. Frequently, such radical surgery is the only option offered a patient. When Ye Danyang, a 41-year-old editor at Beijing TV, found a tumor in 2002, doctors hinted that her resolve to preserve her breast was to choose beauty over life. And, in most cases, a mastectomy is cheaper. "A lumpectomy requires additional, expensive treatment," Xu, the Beijing surgeon, says bluntly. "Patients believe, with a mastectomy, you cut off the breasts for $125, and they're done."
Chemotherapy decisions are similarly dictated by pocketbook considerations. The greater likelihood of ER-negative breast cancer in Africans and Asians means that such drugs as the estrogen blockers are not on the menu of pharmaceutical options. That rules out one of the cheapest and most available breast-cancer drugs in Africa: a $150-a-dose generic version of tamoxifen (and even that would be far too expensive for many women). Traditional chemotherapy may cost $20,000 or more. Merely determining which type of cancer a woman has may require genetic testing, which can add an additional $3,000 to the bill.
In some cases, governments, private hospitals and nongovernmental organizations are all coming together to address such problems. Mexican President Felipe Calderón, recognizing that his nation is falling behind in detection and treatment rates, has now included the equivalent of up to $20,000 for breast-cancer treatment per individual in the national health-insurance plan. The U.S. State Department is working with the government and business community of the United Arab Emirates to expand breast-cancer awareness and treatment in the Middle East. Jordan's King Hussein Cancer Center is becoming a hub for treatment throughout the Arab world. The Komen group, founded in Texas 25 years ago, has now expanded worldwide, with more than 125 international affiliates, and has invested $1 billion so far into research and outreach grants and help for underserved women.
It's too early to say if these efforts indeed mean a start toward ending the global breast-cancer crisis. In the rich world, a diagnosis of breast cancer may bring terror, but a terror lightened by hope. Elsewhere that is still not the case. If the developed world can work to globalize wealth, then it should be similarly able to globalize the opportunities for health. At last, a curative army is mobilizing to make that happen. Many women are surely still destined to sicken and die before its work is through, but many more will learn to battle a disease that, for now at least, they can't even name.
— With reporting by Maithili Chakravarthy/New Delhi, Hanna Kite/Hong Kong, Jeffrey Kluger/Budapest, Megan Lindow/Cape Town, Dolly Mascarenas/Mexico City, Amany Radwan/Cairo, Jason Tedjasukmana/Jakarta, Michiko Toyama/Tokyo, Jennifer Veale/Seoul, Isabel Vincent/Rio de Janeiro, Jane Walker/Madrid and Jodi Xu/Beijin