Breast cancer remains the leading cause of cancer-related morbidity and mortality in women in Pakistan. As per global cancer observatory (Globocan 2020), the number of new cases of breast cancer diagnosed in women in Pakistan was 25,928. There were 13,725 deaths from the disease.

Delayed presentation by patient and delay in the diagnosis of breast cancer by healthcare system are the major factors behind these alarming figures. Consequently, many women are diagnosed with an advanced stage and have a significantly poorer survival rate.

Essentially, we have two major tasks at hand: identify ways to minimise the incidence of breast cancer and develop means to recognise the disease early in order to improve patients’ long-term outcomes.

To have a better understanding of these issues it is imperative to see the bigger picture. The healthcare expenditure is Pakistan is currently $45 per capita, one-third of this amount is spent by the government. The rest is out-of-pocket expenses by the patient.

This and the lack of primary care provider, particularly for low-income, uninsured and marginalised people, illiteracy combined with no patient navigation, misconception and poor knowledge about the disease and its symptoms, lack of a national cancer screening programme for early identification, deficient health facilities in rural setting where a majority of population resides, are some of the factors preventing us from reaching the health goals.

When it comes to breast cancer, many women suffer in silence and are afraid of sharing their concerns with family members or friends. Furthermore, in the absence of an effective primary care system, continuous and seamless care cannot be achieved and health outcomes are poor.

A study carried out in Lahore revealed that although 84 percent of women had heard of breast cancer, only 35 percent were aware of one or more risk factors and 65 percent knew one sign or symptoms of breast cancer. Just 4.9 percent of those above 40 years had had a mammogram in their lifetime (JPMA 2009).

As a result of lack of awareness, a huge percentage (89 percent) of cases in Pakistan are detected at a late stage and 59 percent at an advanced stage (BMC Women’s health 2021). Various risk factors are associated with breast cancer.

Actions must be taken to address the risk factors, including adulteration of foods, especially milk. Consumption of low-fat diet, education and counselling about healthy eating and exercise must be emphasised.

In addition to age, gender, use of oral contraceptive pills or hormone replacement therapy (HRT), medications to induce ovulation, being overweight, lack of physical activity, unregulated food industry and intermarriages are some of the factors associated with increased risk of development of breast cancer among Pakistani women. Some of these risk factors are modifiable.

Considering how burdensome it is for patients to get an early diagnosis, they must know the symptoms and signs to look for. Clinical features associated with breast cancer in symptomatic women include breast lump, breast pain, nipple retraction and nipple discharge. Moreover, the probability of having cancer with a breast lump increases with age; 4.8 percent in those aged 40-49 years vs 48 percent in above 70 years of age (BJGP 2014).

Although breast cancer is rare in men, their lifetime risk is about 1 in 833 (www.cancer.org), the common presenting symptoms remain same as the females.

Detecting cancer early though screening reduces rate of death from breast cancer. A number of screening methods like breast self-examination, clinical breast examination, ultrasound, mammograms, MRI, etc, are available. Do our people know about them and have access to these investigations? What are the reasons why women are reluctant to undergo screening?

Finally, to deal with the growing incidence of breast cancer there is a need to develop multi-strategy interventions (preventive and therapeutic). Actions must be taken to address the risk factors including adulteration of foods, especially milk, which reduces its nutritional value and causes health problems.

Consumption of low-fat diet, education and counselling about healthy eating and exercise and protective role of breast feeding must be emphaised. Health messages whether targetted to a population or tailored for an individual must be delivered effectively.

It is vital that we understand the lifetime risk of having this cancer and what we can do to minimise it. Evidence-based awareness and preventive measures, particularly for high risk populations must be made available. Perhaps it’s time to appreciate the true value of primary care, too.

The writer is an assistant professor in family medicine at the University of Health   Sciences, Lahore