In China, Breast Cancer Treatment Scarce, Outdated

BEIJING (WOMENSENEWS)– Such was the media frenzy after the death of 33-year-old Chinese pop star Yao Beina from breast cancer this winter that one team of reporters donned scrubs and snuck into a hospital morgue to photograph her body. They were roundly denounced, but state media, seizing upon the tragedy as a teachable moment, could do little more.

In its coverage of Yao’s death, the staunchly nationalist Global Times spoke with a doctor who admonished women to buy better-fitting lingerie. An oncologist interviewed by China Daily urged women to probe their own breasts for lumps regularly, though such self-administered exams have only proven effective for women who have been tutored first by a doctor. Even the World Health Organization offered advice that, while solid, seemed closer to common sense than solace: girls and women should lead a healthy lifestyle and breastfeed if possible to lower their risks.

For the vast majority of Chinese women there may in fact not be much more they can do.

While women in the U.S. and Europe are urged to consult their doctors if they discover irregularities in their breasts and to screen regularly once they reach a certain age, such advice does not easily translate.

Doctors are in short supply here and mammograms have proven less accurate at detecting cancers in Asians, whose breasts are smaller and have denser tissue than other women’s. Even with adequate detection, China’ hospitals are ill-equipped to handle the upsurge in breast cancer.

A review of research on breast cancer in China published in the Lancet last year concluded that detection, diagnosis and treatment for breast cancer "urgently need to be improved." Misdiagnosis, long wait times, drastic surgeries, excessive chemotherapy and, perhaps most important, catastrophic expense lead many to avoid detection in the first place, often seeing it as little more than a death sentence, the review found.

Breast cancer is one of a roster of non-communicable diseases that have surged with China‘s economic development, bewildering a health care system already understaffed, overly centralized and prohibitively expensive. Efforts to raise awareness have largely failed to convey useful knowledge. And reforms to the system, while dramatic, have done little to ease access to screening and treatment; they may have made the situation worse.

New Disease Burden in China

"China is facing an epidemiological transition with non-communicable diseases replacing infectious diseases as the leading killer," Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations told Women’s eNews in an email interview. "But the country’s development model, the governance structure and the health system are not ready to handle the changing pattern of the disease burden."

Breast cancer is the most frequently diagnosed cancer in Chinese women, with an age standardized rate (ASR) of 22.1 cases per 100,000 people, according to GLOBOCAN estimates from 2012.The incidence is low relative to the United States, where the ASR was 92.9 cases per 100,000 people in 2012, but that is changing.

Since 1990, the number of new cases detected has been growing at twice the global rate. By 2010, China accounted for 13 percent of newly detected breast cancer cases around the world with about 208,000 new cases, according to data from China‘s National Office on Cancer Prevention and Control.

Much of that growth was in cities. Urban women are twice as likely as rural women to be diagnosed with the disease. The cancer is more commonly found in wealthy than in poor women. It’s likely that many rural cases are never recorded. Hospitals are scarce in the countryside and people tend to shun those that do exist, choosing a faraway city hospital if they go to one at all. But modern city life, where people eat more and move less and do so amid a haze of pollutants and where women tend to wait longer to have fewer children, is itself thought to accommodate the disease.

Campaigns to raise awareness about breast cancer have brought a human face and, perhaps, even a glamorous aura to the disease in this country, where the disease affects women with a median age nearly 10 years below that of women in the West (in China the mean age at diagnosis is 45 to 55 years old). But it hasn’t done much beyond that.

As an ambassador for China‘s Pink Ribbon Campaign Yao, the pop star, had posed nude after a 2012 mastectomy, described the scar on her left breast as a "badge of honor" and topped the charts with a spunky survivor’s anthem. She was slight and luminous with a girlish quality that belied a powerful voice. She sang "Let It Go" for the Chinese language version of Disney’s 2013 animated blockbuster movie "Frozen."

One survey of women in Eastern China found that while a majority of women knew of the existence of breast cancer, few understood risk factors or symptoms. For example, 70 percent did not know whether family history of the disease was a risk factor and nearly 60 percent were unaware that a lump could be a symptom of cancer, according to the study, which was published in BMC Public Health in 2014. Even fewer women knew about the risks of long term hormone replacement therapy or symptoms like discharge and sunken nipples.

Health Care System Overhaul

All of this could change quite quickly as China overhauls its health system in an attempt to appease patients who have become increasingly angry — often resorting to violence — over neglect and abuse within the system. Some economists believe people are so petrified of becoming sick that a rising middle class chooses to save for medical disaster rather than enjoy the fruits of new wealth.

In 2009 the government began to roll out broad insurance schemes for the poor and ordered companies to insure workers. At the same time it has encouraged private investment in hospitals and throughout the health care industry and eased the entrance of foreigners into the sector, in the hopes that competition will improve care and lower costs.

By 2011, health insurance coverage had climbed to 95 percent. While broad, coverage is fragmentary and shallow. State insurance for the poor provides less than $70 a year. Employer-provided coverage varies. In his annual work report earlier this month, Premier Li Keqiang promised to implement a scheme for universal coverage for major diseases, including breast cancer.

But the costs that patients will cover with that help — between 10 percent and 30 percent — are still too much.

Largely because the cost of patented drugs remains prohibitively high, less than half of patients with metastatic breast cancer receive a second round of chemotherapy and only a quarter are treated with a third set of chemotherapies, according to 2011 research published by Kantar Health, a U.S.-based firm that does market research for pharmaceutical companies. Furthermore, patients are far more likely to be treated with toxic chemotherapy than with newer drugs that target cancer cells, Linda Zhao, director of clinical and scientific assessment at Kantar told Women’s eNews in an interview.

Streamlining the approval of new drugs and capping prices could bring "landscape change," Zhao said.

Huang, from the Council on Foreign Relations, was less optimistic. While China set about its most recent round of health care reform in 2009, a year before U.S. health care reform became law, rising prices mean that care is no more affordable than it was in the past.

Huang fears that reforms are heading toward a two-tier system: one for women who can afford treatment and another for those who cannot.

"Inequalities may continue to exist if the benefits offered by the state schemes become an inferior good only consumed by the poor and the marginalized," Huang told Women’s eNews. "By maintaining an extremely fragmented system in health insurance coverage, with different benefit packages accorded to different segments of the population, the new health care reform to some extent reinforced the problem of inequality in accessing care."