Breast cancer is the most frequently diagnosed cancer among women around the world, making it a significant public health problem.1 The disease affects both men and women, although it is rare in men, accounting for just 1% of all breast cancer diagnoses in the United States and less than 0.1% of cancer-related deaths.2 In Egypt, it is the most common cancer in women, accounting for 32.4% of all female cancers and the second most common cancer in both sexes after liver cancer (16.4% of all cancers).3
Historically, about 3,500 years ago, ancient Egyptians were the first to describe breast cancer (although the word “cancer” was not used) in the Edwin Smith Surgical Papyrus. The author of this papyrus is unknown, but it may be Imhotep, an architect, high priest, and physician who lived between 3,000 and 2,500 BCE in the era when the pyramids were built. The writer of the Edwin Smith Papyrus concluded that a bulging breast tumor was a grave illness, but the Egyptians struggled to treat it with cautery, knives, and salts, as well as adding arsenic paste, which became known as “Egyptian ointment.”4
Fast forward to recent years, when an international team—including researchers of anthropology led by Professor Miguel Cecilio Botella López of the University of Granada’s Department of Legal Medicine, Toxicology, and Physical Anthropology—has discovered the world’s oldest known cases of breast cancer by conducting computed tomography scans of two mummies found in the pharaonic necropolis of Qubbet el-Hawa in Aswan, Egypt. Following their thorough analysis and studies conducted on the two mummies, the team has established that the woman died around 2,000 BCE and revealed evidence of breast cancer.5
Cancer in Egypt Today
Most patients with cancer in Egypt are treated in governmental hospitals that belong to either the Ministry of Health, including specialized cancer centers distributed across Egypt, or oncology departments in university hospitals. The first specialized cancer center in Egypt (and the Middle East generally) was the Egyptian National Cancer Institute, founded in 1969.
Breast cancer is the most prevalent cancer among Egyptian women, and the burden of the problem is increasing due to better diagnosis, more exposure to risk factors, and increased population and life expectancy. The first governmental specialized breast cancer hospital was established by the National Cancer Institute in 2013. A second specialized governmental women’s cancer center was inaugurated in 2018, under the auspices of the Ministry of Health. All these governmental centers and hospitals provide services for all patients for free. Nongovernmental hospitals also provide cancer care in coordination with the government. Some patients choose to be treated in the private sector.6
“The median age at diagnosis of breast cancer in Egypt is a decade earlier than in the Western world, and this has extremely significant social and economic implications.”— Aalaa Mahmoud, MBBCh, MSc
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The mean age at diagnosis of breast cancer in Egypt is relatively young (51 years),7 and this has extremely significant social and economic implications. Moreover, most breast cancer cases present as locally advanced or metastatic disease rather than in early stages.8 More than 40% of patients present with T4 tumors, and 75% have positive lymph nodes at presentation,9 resulting in a poor prognosis. In a prior study, we found that Egyptian women contribute most to the delayed presentation time, not health-care providers.10 Low levels of awareness, a lack of mass screening programs, and sociocultural beliefs have all been suggested as explanations for the late presentation.
Most breast tumors diagnosed in Egyptian women are invasive ductal carcinomas, and they are estrogen receptor–positive and/or progesterone receptor–positive in less than half of cases.9 However, little information is available on breast cancer trends by hormonal subtype in Egypt.8
Barriers to Screening
Egyptian women have generally waited until they were ill to seek medical care, and studies show that 77% opt not to have a mammogram unless their doctor requests it. According to the same studies, 71.4% blamed a lack of privacy, 69.2% felt medical checkups were unnecessary, and 64.6% indicated the cost of care as barriers to mammography.11 Given these issues, early detection remains critical, particularly in low- and middle-income countries like Egypt—where the disease is diagnosed late and resources are limited—in order to downstage breast cancer, allowing it to be treated more effectively and at lower cost.12
In October 2007, during Breast Cancer Awareness Month, Egypt launched the Women’s Health Outreach Program, which offered free breast mammography screening for Egyptian women older than age 45, and detected cases were referred for free management at the governmental hospitals without follow-up. Across the 27 Egyptian governorates, 12 mobile units equipped with digital mammography machines were used in this program. Only 20,098 women in three governorates were screened from the beginning of the program in October 2007 until February 2009.13
According to the 2006 Egyptian census, there were more than 5 million women aged at least 45 years.14 So this program could not be considered a national screening program as it could not cover the 27 governorates, with many women having no access to it. Also, it failed to improve the attitude and awareness of Egyptian women about the early signs and symptoms of breast cancer.15-17
Key Initative
In order to develop a more culturally appropriate strategy to encourage women to utilize screening services, Egypt launched the first universal breast screening program as a presidential initiative (part of the 100 Million Healthy Lives presidential initiatives) to highlight the importance of this health issue. It started to operate in July 2019 and gradually covered all 27 Egyptian governorates by December 2019.
The initiative is targeting 28 million women across all governorates (ie, all those ≥ 18 years old). Screening with a clinical breast exam is provided for women aged 35 or more, as well as for younger women with symptoms and risk factors, and treatment and follow-up are offered free-of-charge to diagnosed cases, according to recent protocols. In addition, core goals of the initiative include education regarding reproductive health, family planning, healthy lifestyles, and breast self-examination; as well as detection of noncommunicable diseases such as diabetes, hypertension, and obesity.18 In June 2021, the Minister of Health Dr. Hala Zaid announced that 16 million women have been examined from July 2019 to June 2021, representing about 57% of the target population.
“Political support, community partnerships, identification of barriers to early detection, and media campaigns have all played an important role in establishing an effective screening program.”— Aalaa Mahmoud, MBBCh, MSc
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The remaining challenges to breast cancer control in Egypt include creating a good health-care system that should adopt breast cancer screening with mammography as part of its main services; establishing a well-formed multidisciplinary approach to treatment across country to achieve best outcomes; more training of medical staff including primary health-care providers, pathologists, surgeons, radiologists, and oncologists for reliable services; and the availability of full electronic data to support research and development of these services.
Conclusion
Egypt is considered a successful example of a low/middle-income country’s management of breast cancer through practical interventions that are realistic and cost-effective. Over time, Egypt tries to improve its health services to control this major health challenge, which absolutely impacts every aspect of the United Nations sustainable development goals. As a low/middle-income country, Egypt has been able to achieve substantial steps in the management of breast cancer through practical interventions that are realistic and cost-effective. All low- and middle-income countries can learn from these achievements.
UNITED NATIONS SUSTAINABLE DEVELOPMENT GOALS
- The UN’s sustainable development goals are a collection of 17 interlinked global goals designed to be a “blueprint to achieve a better and more sustainable future for all.”
- They were set up in 2015 by the UN General Assembly and are intended to be achieved by the year 2030.
The highest level of political support, community partnerships, identification of barriers to early detection, and media campaigns have all played an important role in establishing an effective screening program. More research contributing to improvement of the quality of breast cancer care and meaningful evaluation of health system performance needs to be conducted.
DISCLOSURE: Dr. Mahmoud reported no conflicts of interest.
Disclaimer: This commentary represents the views of the author and
may not necessarily reflect the views of ASCO or The ASCO Post.
REFERENCES
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Dr. Mahmoud is Clinical Oncology Specialist in the Ministry of Health of Egypt.
