MR INTERVIEWS

Dr. Maria Luisa Buch Bofill, MD, PhD
2nd Degree Specialist in Oncology
President of the Cuban Breast Cancer Control Program

An offshoot of the National Cancer Prevention Program, the Cuban Breast Cancer Control Program coordinated by the National Oncology and Radiobiology Institute (INOR) and headed by Dr Buch, was launched in 1987 in an effort to reduce breast cancer mortality in Cuba. Since cancer is the second-leading cause of death in Cuba (as it is in the United States), and breast cancer is the number one type of cancer afflicting Cuban women, the creation of the Breast Cancer Control Program was both urgent and necessary. Indeed, statistics show that from 1980 to 1999, breast cancer mortality rates in Cuba climbed from 13.3 to 19.4 for every 100,000 patients and 15.3% of cancer deaths among the female population was due to breast cancer.

Since extensive research has borne out the effectiveness of early detection, with 90% of treated patients still living after 20 years if the cancer is detected in Stage 0 (visible only by mammogram), the Breast Cancer Control Program emphasizes Primary Level Detection and Early Diagnosis. These are only two aspects of the nine point program headed by Dr Buch. MEDICC Review sat down with her recently to discuss the progress and challenges for curbing breast cancer in Cuba.

MR: Can you comment on the international validity of mammography?

MLB: It is a well known and proven fact that mammography is the only means of diagnosis able to reduce breast mortality. An argument exists about its validity as a screening program. Latest studies prove that it can reduce mortality in 20% of patients, when the design of the screening program is well conceived, and all the requisites for screening are met.

Mammography can be used for two purposes: for screening, and for breast pathology services, and in both cases, is indispensable. In modern times, no serious breast pathology service is complete without mammography equipment, because decisions regarding diagnosis and treatment, and follow-up of the patient are made on the basis of clinical examination, mammography and biopsy.

Mammography has a very specific utilization. It is not meant to be used on young women, unless there is a suspicion of them having breast cancer.

MR: How have incidence-prevalence and mortality rates been affected since the Breast Cancer program was implemented?

MLB: The breast cancer control program has not yet made an impact in the reduction of mortality, where its long-term effectiveness is shown. Incidence should continue to increase, as it happens in other countries, because its etiology is still unknown. As we mentioned before, this is a very broad program, including prevention, screening, diagnosis and hospital treatment, rehabilitation, palliative treatment, training and research. Some of these activities are more developed than others. Screening, for example, was initially restrained by the economic embargo that affects the country. Rehabilitation is now increasing its possibilities, and the other actions of the program are kept at the level of a developed country. The work carried out in primary care, that includes practically every activity of the program, is a very important contribution to its development.

MR: Have you perceived any psychological and social changes toward breast cancer in Cuban women and in society in general?

MLB: Yes, there have been changes in both cases.

Cuban women had very bad experiences and memories of breast cancer before 1959. At that time, women had no information on the subject, and they would go to the doctor only in the late stages of the disease, when it was possible. There were very few specialists and the treatment was minimal and of poor quality; women died all the time. There are still those who can remember how they watched their grandmothers and aunts die from it. There has been a need to break that psychological pattern, and educate women that we have very good specialists, means of diagnosis and even treatment in advanced cases. Now all women have a different, higher level of education, and they cooperate with the doctor in compiling information on the subject; their treatment is always discussed with them. All the advantages and disadvantages of surgery, chemotherapy and radiotherapy are explained, and they choose which is best together with their physician.

There are still women who prefer not to know or face the fact about breast cancer. But that ultimately depends on the doctor-patient relationship, and educational programs on the disease must increase. In general the change has been a substantial one in the last 40 years. The Federation of Cuban Women has been a key element in this area, especially working with the issue of self-esteem. Cuban women are very family-oriented, and they mobilize in the case of diseases, but they tend to take care of others first, leaving themselves to the last, which in some cases does not make possible an early diagnosis.