Breast Cancer in Venezuela: Back to the 20Th Century
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World Report Breast cancer in Venezuela: back to the 20th century Facing scarcity of medicines and broken-down medical equipment, women diagnosed with breast cancer in Venezuela resort to more radical means of treatment. Hildegard Willer reports. When she realised that she could not cancer, a hormonal treatment. These which is the national public hospital for continue to afford the therapy that complementary treatments allow patients with cancer, but throughout would save her life, Dennis Mercado surgeons to preserve the breast in Venezuela, he says. According to him, felt desperate. Aged 48 years, Mercado most cases. patients wait for more than a year to get had been diagnosed with breast radiotherapy and relapses and deaths cancer 3 years before. As part of her “‘Being diagnosed with breast have increased. post-surgical treatment, she had been cancer is a shock for any Diagnostic facilities are also scarce— taking the hormonal blocker goserelin woman, but if that woman there are few functioning mammo- for several years, costing about graphy screening units in the country US$100 per month. As an internal lives in Venezuela today , it and doing immunohistochemistry is medicine specialist, Mercado urges means an endless struggle...’” complicated by the inadequate supply her patients to do everything they can of slides and reagents. Romero’s list to complete their treatment; a non- But in Venezuela, these treatments of what is missing in the Luis Razetti completed treatment scheme, Mercado are no longer available in public hospital is seemingly endless—cancer says, can be useless. But as a patient, hospitals. The country’s health system drugs, surgical instruments, syringes, she could not afford to do so. Mercado has been deteriorating for the past gloves, palliative drugs, and reagents are only makes about $20 a month. 20 years; maternal mortality, for all unavailable. “At the moment we can “My hormone level was rising, and I instance, has increased by 30% since only do four surgeries a week, because knew that there was no other option 1998, according to Marino Gónzalez, we have no material”, says Romero. “A than to do another surgery”, she chair of public health at Simón patient diagnosed [in July] will be on my said. In April, 2018, Mercado had an Bolivar University and member of the operation list in December.” oophorectomy to remove both her Venezuelan Medical Academy. In these circumstances, many doctors, ovaries, the most radical solution to The decline of the Venezuelan health medical technicians, and nurses have stop hormone production. sector accelerated in 2014, when the chosen to leave the country. “The Being diagnosed with breast cancer recession started. “This recession doctors who have stayed are busy is a shock for any woman, but if that is the worst one Latin America has getting the paperwork done to leave”, woman lives in Venezuela today, it ever been in, and is among the worst says Romero. “What is most important means an endless struggle to obtain recessions worldwide”, says Gónzalez. is that we maintain our capacity to train and pay for treatment. Often, it can The country’s hyperinflation, which our oncology students.” mean losing both breasts and ovaries, has been rising since November, 2017, Therefore, breast cancer is being even though alternative treatments is set to hit a record level, with the diagnosed late. “Last year, 65% of the have been proven to be more effective. International Monetary Fund saying in cases I saw were locally advanced cancer, “Mastectomies in our hospital have July that hyperinflation could reach an risen by 30–40% in the past 5 years”, annualised rate of 1 million % by the says Gabriel Romero, head of the year’s end, setting Venezuela within breast cancer unit at the Luis Razetti the countries with the worst inflation Cancer Hospital in Caracas. He says that rates in history. “The public health oophorectomies are also on the rise in system in Venezuela is at its worst his hospital, and possibly in the whole at the moment, and it will become country, although there are no data worse as hyperinflation continues”, available to confirm this at the time. says Gónzalez. Doing radical surgery to treat breast cancer might have been standard Broken public services practice 30 years ago, says the 66-year- In his hospital “we only had two old surgeon, but nowadays, breast radiotherapy units, but these were cancer is treated by pre-surgical or damaged years ago”, says Romero. The post-surgical chemotherapy, radiology, unavailability of radiotherapy is the case Images/Getty Images SOPA and, in case of a hormone-driven not only at the Luis Razetti hospital, Health workers seen protesting in Caracas, Venezuela, on July 30 www.thelancet.com Vol 392 August 11, 2018 461 World Report whereas in 2010, only 38% of the had broken. She and other patients Varela was also prescribed tamoxifen patients came with advanced cancer”, chained themselves to a fence in front after her mastectomy 4 years ago. says Romero. “In medicine in Venezuela, of the Presidential Palace in Miraflores She is currently enjoying short-lived we are going back to the beginning of to protest against unavailability of relief from her endless struggle to the 20th century.” radiotherapy treatment. This gave get medicine as someone recently birth to the Conquistando la Vida civil brought her three boxes of the drug. Unaffordable private services association (Aconvida), a group of She still feels the consequences of In 2009, breast cancer surpassed about 70 members—most of whom the surgery, and wears an elasticated cervical cancer as the most important are patients with breast cancer— sleeve to prevent swelling in her arms cause of cancer mortality among which organises medicine donations, due to lymphoedema, a common women in Venezuela, and is the fifth offers group therapy, and organises complication. “Fortunately I was highest cause of mortality among political action. given the sleeve as a gift from abroad, Venezuelan women altogether, because, in Venezuela, you cannot get according to Luis Capote Negrín, “‘Sometimes my sister does the it”, says Varela. cancer epidemiologist and head of the 600 km trip from Barquisimeto The battle to get medication and Venezuelan cancer register. Although therapy is compounded by the faltering to Cucutá, Colombia, only to in many countries, breast cancer infrastructure for access to electricity, incidence has risen—due in part to get me tamoxifen.’” water, and transport. “At the moment, improvements in early detection— we only have access to water for mortality of patients with breast Aconvida is one of several patients’ 20 minutes a day”, says Mercado. After cancer has remained stable, thanks to organisation that have emerged 2 weeks without water, Mercado’s better treatments. Venezuela’s breast from Venezuela’s health emergency. neighbours have been getting together cancer records, however, show a slight It is part of Codevida (Coalición de to buy water from private providers. but continuing increase in mortality, Organizaciones por el Derecho a la Varela has still some hope that the said Capote. Salud), and emphasises the human Pan American Health Organization In Venezuela, doing radical surgery right of access to care. “It is important (PAHO) might be able to improve the is now often the only option to for us to struggle and fight for our drug supply for Venezuelan patients. In increase a woman’s chances to rights. We do not want to inspire pity”, her last visit to Venezuela in June, 2018, recover from breast cancer. Jorge says Varela. Patients’ organisations, PAHO Director Carissa F Etienne met Uribe, director of the private Clínica non-governmental organisations, with the president of Venezuela, Nicolás de Mamas in Barquisimeto does and foundations now have a central Maduro, health officials, and civil society two or three breast cancer surgeries a role in supplying medicine and money groups, and declared that PAHO would week in his clinic. “Women ask me to for treatments. lobby in the region to get funding for remove a breast because they cannot As a patient, Mercado feels strangled medication. Antiretroviral drugs for the afford chemotherapy and radiology”, in her efforts to get treatment, she treatment of HIV were, in July, brought says 73-year-old Uribe. Unlike the says. She received no medication from to Venezuela by PAHO’s strategic fund public hospitals, Uribe’s clinic has April onwards from the so-called High but, to date, there is no visibility on functioning radiotherapy equipment, Cost Pharmacy, the social security when cancer treatments might be but treatment can average hundreds institution that should provide free delivered with the same scheme. to thousands of US dollars, although medication for patients with chronic In a plea to mitigate his anger towards the average Venezuelan salary is diseases such as cancer. As part of her the excessive amount of mastectomies now just a few dollars a month. therapy post-oophorectomy, Mercado that he has had to perform, Uribe says “It goes against everything I have has to take tamoxifen, a generic daily he will write a letter to the First Lady learned about breast surgery, but hormonal blocker, which is part of of Venezuela to inform her of the radical mastectomy is the only way to the WHO List of Essential Medicine situation. For his part, Romero shakes increase women’s chances of recovery and costs about $20 per month. In his head, as if incredulous at the state if they cannot afford the radiotherapy”, Venezuela nowadays, tamoxifen is not of his hospital, which would have been says Uribe. available. unimaginable to any Venezuelan doctor “I have to organise for somebody to only a few years ago. When asked Fighting for access to care bring two or three boxes of tamoxifen what needs to happen to remedy this In 2015, Mildred Varela was in her from Colombia or Ecuador.