Nurses were training women in rural Mexico to examine their breasts for cancer when one raised her hand to object. If she lost her breast, Harvard University public health specialist Felicia Knaul recalls the woman saying, "My man would leave me" — and with him, the family's income.
International cancer specialists meet this week to plan an assault on a troubling increase of breast cancer in developing countries, where nearly two-thirds of women aren't diagnosed until it has spread through their bodies.
Adding to the problem, some worrisome data suggests that breast cancer seems to strike women, on average, about 10 years younger in poor countries than it does in the U.S. No one knows why.
"Today in most developing countries you see a huge bulge of young, premenopausal women with breast cancer," says Knaul, who heads Harvard's Global Equity Initiative and herself was diagnosed at age 41 while living in Mexico.
"We should help them to know what they have and to fight for their treatment."
But from Mexico to Malawi, stigma like Knaul witnessed a few weeks ago may prove as big a barrier as poverty.
"One of the trainers said, 'If he'd leave you for that, he's not worth having,"' says Knaul. But she acknowledged that will be a hard message for some women's economic realities.
"It's not a trivial consideration," agrees Dr. Lawrence Shulman of the Dana Farber Cancer Institute, who is part of a team working to begin cancer care in parts of Africa where "the women are often seen as really either vessels for producing children or as sex slaves."
But some success in treating HIV and tuberculosis in those areas has him "hopeful we can make a difference. I don't think it's a pipe dream."
Tuesday, Knaul and Shulman bring together an international task force of health specialists and prominent charities to begin planning a two-pronged approach.
First, train midwives and other rural health providers to perform regular breast exams, using the power of touch in places where mammography machines simply are too expensive. That will not catch the very smallest tumors, but specialists agree it could improve diagnosis dramatically in some areas.
Second, the task force will start negotiating lower prices for generic chemotherapy for poor countries, following the same model that has helped transform AIDS care in parts of Africa.
You do not need in-country cancer specialists to administer that chemo, says Shulman — just a network of oncologists who can provide help or instruction to local health officials by e-mail or phone, like he has advised colleagues in Malawi.
Breast cancer long has been considered a cancer mostly of wealthier countries. Indeed, about 192,000 new cases are expected in the U.S. this year, where long-term survival is high thanks in part to good screening.
The true prevalence in most developing countries is unknown, because of poor diagnosis and bad record-keeping. But new Harvard research estimates they will be home to 55 percent of the world's 450,000 expected breast cancer deaths this year.
The report predicts the poorest countries will experience a 36 percent jump in breast cancer by 2020.
One problem: In wealthy countries, earlier diagnosis can lead to breast-saving surgery instead of breast removal. Even countries like Rwanda and Malawi have clinics that perform mastectomies if patients can travel to the capitals, Shulman says. But few have radiation equipment, making breast-conserving surgery there not an option yet. (He is hunting a radiation unit for Rwanda but says that's in the very earliest stages of planning.)
Mexico is a mixed situation, with radiation, other treatments and diagnostic mammography available in some places. That is how Knaul — whose husband is a former health minister of Mexico — was diagnosed, early enough that mastectomy and chemotherapy give her good odds.
But she fumes that while Mexico's poor and rural women often get Pap smears to check for cervical cancer, "no one even suggests they check your breasts" at the same visit. She founded an advocacy group — Cancer de Mama — to help, noting that Mexico's insurance program for the poor covers breast cancer care but they must get diagnosed first.