The economics of breast cancer awareness in Bangladesh

A popular definition of Economics is ‘the science of allocating scarce resources to maximise benefit’. The scarcity of resources in the health system of Bangladesh needs no further explanation when we look at facts and statistics – Bangladesh is one of the lowest spending nations in public sector healthcare.

Healthcare spending is up by just 3.2% even as the national budget sees 12.34% rise over the past few years. The allocation for health sector in the proposed budget for the 2023-24 fiscal year has been reduced to approximately 5 percent of the national budget from 5.4 percent in the outgoing fiscal year, whereas WHO recommended percentage of public spending on healthcare is 15% of the whole budget for developing countries like ours. Healthcare in Bangladesh is mostly financed through out of pocket (OOP) expenditure by individuals, making cancer an extremely catastrophic disease for any given family.

As per the National Cancer Research Institute, the treatment cost of an average cancer patient is BDT 639,000 per year, while the annual income of an average family is around BDT 389,064 [HIES 2022], implying that a cancer patient’s survival will consume almost double of the average family’s annual income. There are only 208 oncologists in Bangladesh for the entire population, only one palliative care unit for cancer patients in the public sector (BSMMU), only one radiotherapy center outside Dhaka which is in Chittagong Medical College Hospital. How scarce our resources are to fight cancer cannot be accurately calculated, as we don’t know the total number of cancer patients in absence of a national cancer registry.

In this case, prevention is not only better than cure, but rather the only cure we can afford. Since it is impossible to screen every Bangladeshi citizen for every type of cancer, or to eliminate all causal factors, our success in battling cancer as a nation will largely depend on our strategies to halt the progress and lower the incidence rates of the most common cancers. 

Like the rest of South Asia, breast cancer is one of the leading reasons of premature deaths of Bangladeshi women. More than 13,000 women in Bangladesh are infected with breast cancer every year and over 7,000 die, according to data from the International Agency for Research on Cancer (IARC). Breast cancer has been reported to have the highest prevalence rate (19.3 per 100,000) among Bangladeshi women between 15 and 44 years of age. Despite being the cause of thousands of premature deaths and impoverishments every year, Breast Cancer awareness in Bangladesh and attitude towards the disease is shockingly inadequate and passive.

A study conducted at Sheikh Hasina Medical College in 2021 showed about 30.5% of respondents were aware that pain in the breast was a major symptom of breast cancer. However, knowledge of other symptoms were generally poor - merely 18.4%, 17.8% and 16.7%, recognized itching, painless lump in the breast and bloody nipple discharge as signs of breast cancer. Majority of the respondents were not aware about other signs of breast cancer like nipple retraction, discoloration of nipple skin, change in breast size, rash around one of the nipples.

A Chattogram based study showed that neighbors (18.6%) and relatives (18.1%) were the leading sources of information on breast cancer. Among the total, 69.5% knew about breast cancer, however, only 14% of them knew about screening tests and 61.5% were unaware of risk factors for developing breast cancer. 

Ideally, the sooner a cancer case is detected the higher the chances will be of saving the patient’s life without catastrophic healthcare expenditures, as early-stage cancer requires lesser complicated interventions. But, and even better scenario would be to screen individuals before the onset of cancer. It is common wisdom that when there are not enough resources to screen the whole population for a disease, we should screen the group of people who are at higher risk of developing the disease in near future. For breast cancer, commonly pronounced risk factors are family history of breast or ovarian cancer, old age, menopause, late or too early marriage and pregnancy, previous exposure to radiotherapy, obesity, consumption of alcohol and tobacco etc. However, some studies in the United States have shown that a large number of female breast cancer patients under 50 were not considered at high risk for the disease.

Hence, the conventional idea that young females who do not have family history are safer than others, therefore they do not need to be screened routinely, might not be helpful. Even if screening only the high-risk groups would work, it would not be a viable option in Bangladesh because we don’t have any cancer registry or centralized database for cancer to track family members of affected patients, and long-term mass screening programs can be very expensive.

Screening and early diagnosis can only save 10-30% of the lives, and in a health system where 70% of the funding is out of pocket expenditure (OOPE), with additional burden of wrong diagnosis and mistreatment, such programs do not prove to be practicable. So, what could be the best-buy approach to battle breast cancer? 

October is observed as Breast Cancer Awareness Month worldwide. Bangladeshi organizations, such as the Breast Cancer Awareness Forum and several government or NGO-run bodies, run campaigns to raise awareness about the disease in this month. While campaigns contribute significantly in making the disease familiar to the people, effectiveness of such campaigns depend largely on how people receive the information, and how it changes their attitude towards preventive and precautionary practices. There are three things that can make large differences – 1) engaging, and appropriately designed awareness campaigns for each specific target group, 2) making Breast Cancer Self Examination (BCSE) a routine practice in every household just like handwashing and teeth-brushing, and 3) mandating for each healthcare facility to maintain their own cancer database so that individuals with family history can be more closely monitored.

Since awareness campaigns through electronic and social media cover a much bigger audience than physical campaigns such as seminars and boot camps, the government should prompt responsible organizations and authorities to take advantage of these smart technologies and digital platforms. To make sure the whole of Bangladesh is aware of breast cancer self-examination (BCSE) methods, which is a totally cost-free screening women can do at the comfort of their own home by themselves, we need to actively discourse the stigma around female organ diseases first and train women from diverse backgrounds to self-examine their bodies systematically.

As Bangladeshi women tend to have a poor healthcare seeking behavior, empowering them to take charge of their own wellness can have great impact on their overall health, besides giving families an economic tool for prevention. Community healthcare practices should be promoted so that women who detect a symptom through BCSE know exactly how to seek help. Campaigns must make it clear that any lump, tenderness or other abnormality detected through BCSE should be followed by a clinical breast examination by a trained healthcare provider, before going for a mammogram.

Both physicians and the common people should be aware that repeated exposure to the radiation of mammography can in fact trigger the onset of cancer in high-risk human bodies, so using this technology should be a calculated step. Awareness campaigns must not be limited to high-level seminars, rallies and decorated functions, but rather should reach every household of every community where our mothers and daughters are living their busy lives, unaware of the danger of this deadly disease.

The writer is currently pursuing a Master’s in Public Health (MPH) at department of Non-Communicable Diseases (NCD), Bangladesh University of Health Sciences (BUHS), besides working as a public health researcher