Cancer's Uncounted

Nearly any developing country has some idea of its HIV rates, its maternal death ratio and how many of its children have had polio vaccinations. But information about cancer prevalence? 

That’s sparse. 

After a dozen years of doing surgery overseas, Adam L. Kushner, MD, MPH ’99, wants to know more about the people he isn’t helping. “Only the strongest are making it to the hospital,” he says. “We don’t know how many are dying without getting to the hospital, dying in the villages. We just have no idea.” To advocate for more surgical care in developing countries, Kushner needs data.

He and colleagues have begun to collect it. For starters, two recently published studies investigate untreated breast masses in Rwanda, Sierra Leone and Nepal.  

“This is important because breast cancer is the most common cancer in women,” says Kushner, an associate in International Health at the Bloomberg School and founder of the nonprofit Surgeons OverSeas. “It’s very treatable if you diagnose it early. A chance to cut is a chance to cure.” Kushner says that women in these countries often delay seeking care until a breast tumor has taken over the whole breast, breaking the skin and causing a foul-smelling infection—usually too late to cure. 

Of 3,175 people in Rwanda and 3,645 in Sierra Leone, 4.6 percent and 3.3 percent reported that they had untreated breast masses. (Most were women.) Those numbers suggest an unmet need to evaluate breast masses in more than a half million people in Rwanda and 185,000 in Sierra Leone, according to the study. 

Kushner’s former student, Shailvi Gupta, MD, MPH ’14, oversaw a similar survey in Nepal. Of 955 women interviewed, 15—or 1.6 percent—reported a breast mass. (Nine did not pursue care despite believing they needed it.) Nationwide, these results suggest that 70,000 Nepali women may have breast masses “that require at least a surgical consultation,” writes Gupta, a resident in the UC San Francisco-East Bay Surgery Program.

African women said they didn’t seek care mainly because the mass did not interfere with daily life, while Nepali women primarily feared the medical system. In all three countries, some women said they couldn’t afford care.

Kushner and Gupta contend that surgery has been neglected in global health efforts. (Kushner develops this argument in his new book, Operation Health: Surgical Care in the Developing World, to be published this spring.)

“Surgery is such a daily need,” says Gupta. “If someone has a hernia, if someone has breast cancer, if someone has road trauma, they need surgical care. The public health community can no longer afford to leave surgery out of the conversation.”