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    Health above All

Recent public health reports indicate that breast cancer has become the most spread cause of mortality in fertile female populations worldwide. Unlike other national rates, breast cancer incidence in Russia is as high as in most developed countries. Timely detection and treatment at early stage are crucial for good health outcomes; in this case life expectancy is as high as 20 years for 90% of patients. However, early detection is made problematic by patients turning up for care too late. Early detection of breast cancer and why it is so important are the core themes we discuss with Dr. Alexander Legkov, chief physician, Moscow Mammary Health Dispensary.
L.A.: Early detection of breast cancer means best chances of getting well. The earlier a malignant tumor is revealed, the higher is treatment effectiveness and the better are expected outcomes of care. Being detected while it has not evolved beyond the second phase, breast cancer may not require invasive treatment, and even if it does, surgery will be restricted to partial mammectomy. Being detected when it has gone too far, breast cancer results in complex and costly treatment, including lengthy radiotherapy, extensive mammectomy, chemotherapy, and sometimes ovariotomy...
In other words, instead of easy treatment and fine prognosis, we have to fight for patients’ life. Now, add psychological distress when a patient is informed about her di-agnosis and faces the fact that she must undergo a surgery that will cripple her for-ever. I think, it is enough explanation of why we, physicians, are so insistent about early detection of breast cancer. Unfortunately, it takes more than medicine to make ladies pass screening for it. Many patients could have lived longer and happier life, have they turned to a doctor in time.

Q.: I guess, many women are simply afraid of hearing the diagnosis named. Is not it a result of public misconception of ‘cancer’ being another word for death sentence?

L.A.: To my opinion, the most generic reason why patients visit doctors too late is peoples’ neglect to their health which is a psychological characteristic. For example, I ask, "When have you discovered this tumor?" and the most usual answer is some-thing like, "Oh, it was few years ago." Then I ask, "Why didn’t you come then?" and they use to say that they were either scared or busy. They are scared to hear about their diagnosis, so they prefer to ruin their health. And if busy, it typically means they had some pressing paperwork to finish, house to furnish, weeds to dig and so on. Are those enough grounds to dismiss one’s own health? People are simply wrong about values. They fail to understand that health is the most valuable asset a person owns — and not his house or car.
Many senior citizens are also fallible about doctors’ capacities; they seem to believe that everything that aches is curable and that their health is public health system’s concern — not theirs. Somehow it happens that while other illusions has been swept off, this one remains. Psychological reengineering is not an easy accomplishment and it never happens overnight.

Q.: To change people’s attitude to health and, in particular, to this health problem, I think, more information about new treatments and preventive care of cancer must be communicated.

L.A.: Changing popular thinking is a massive task, but we have no choice. That is why health education programs are so important. Public outreach through mass media would be most helpful. If breast self-examination guides were aired on TV half as frequently as ladies’ hygienic commercials, many women would spare a minute to ex-amine themselves and find out that they may be in need of medical advice.
Every piece of health information, and not only cancer-related, must be presented only by health specialists who would tell people the truth in such a manner as not to scare them, but to make them understand what exactly can they expect of modern medicine. Then the false idea of doctors saving anyone in any case will eventually dissipate, while people will be coming to realization that a visit to a doctor is not a thing to be postponed. However, adequate health attitudes are better formed through health education programs in school.

Q.: Formerly, physicians practiced non-informing their patients about details of their medical condition. Have regulations changed? Are individuals entitled to knowledge about actual state of their health today, even if their prognosis is poor?

L.A.: The answer may depend on a number of factors. In the past cancer patients were never informed to the whole extent for the reason of much possibility of moral breakdown when having heard the truth. Psychological balance is actually hard to maintain in such cases. Therefore, modern guidelines are so that before communicating diagnosis to a patient, her psychological type is determined and possible reaction assessed. Many women are not ready to hear the truth. However, basically patients have right to know about their health status, possible medical interventions, as-sociated risks and co-morbidity factors, and prognosis. Most patients obviously need full information, just because they might want to plan whatever time is left at their disposal.
Patient’s entitlement to be informed about his health is supplemented with strict con-fidentiality. Medical information about a patient may not be disclosed to anyone else, unless the patient has asked for it. Anyway, patients are free to tell others whatever they think necessary about their health.

Q.: I gather, ignorance about modern treatments and medical interventions applicable to breast cancer, along with strong conviction that medical science still has not in-vented anything to deal with it, drive many women to apply for what they think to be more appropriate remedies. Am I clear?

L.A.: Unfortunately, yes. Many women are reluctant to undergo proof medical exami-nation; instead, they turn to witch-healers, sorcerers, extrasensory mediums and other overabundant quacks who promise complete restoration. These cheats simply capitalize on their clients’ troubles. Many women think like, ‘Why going to surgeons who would probably cut my breasts off, while these beautiful people heal you by making passes with their hands?!" Consequences of this type of "medicine" are somewhat grave: having realized that "magic" has not worked after all, patients turn to "regular" clinicians when it is too late to effectively apply conservative methods.
Cancer is one of the most serious problems humanity faces. Worldwide, scientists struggle to find out what causes it and how it can be effectively cured. The problem is global, and international efforts to solve it are massive and have always been inde-pendent of political and ideological considerations. All cancer-related information has always been freely exchanged and communicated. Now, every week we witness an-other "savior" of the humankind who has overcome cancer and, unfortunately, is wel-come on TV screen and newspaper column with his message. Be it this simple, they would not have to advertise their private services, as many national governments were standing in line to buy their know-how of "new quick and effective methods of cancer management."

Q.: Now, the question is, are your public funding and labor resources enough to pro-vide medical screening and care to everyone who applies for it?

L.A.: Moscow Mammary Health Dispensary is the Moscow Public Health Committee establishment and its services are available to residents of Moscow and Moscow re-gion. For better understanding of volumes of care we provide, here are some figures: in 1995 we covered 77,266 patients with mammary screening and expanded to 92,000 patients in 1996, which means 20% growth. The Moscow Health Committee has demonstrated understanding of growing demand for our services and approved the community mammary care service roll-out project developed by our staff. The Dispensary will become a center for overall coordination, specialty consultations and medical research, while local branches and offices will provide regular screening for breast cancer with main focus on risk groups. The project is oriented towards long-term goals and requires copious resources. Along with mammographs and other di-agnostic equipment for local branches and offices, we need more trained profession-als. For this reason, Russian Medical Academy of Postgraduate Education and the Third "Semashko" Moscow Medical Institute has opened training programs in mam-mary care.

Q.: What would you advice our readers? And where can non-Moscow residents turn for this type of care?

L.A.: Every woman must pass annual screening by a gynecologist and a specialist in mammary diseases. However, even mid-level health practitioners — midwives and nurses of gynecological clinics — will easily detect any breast problems and readily arrange for their patients’ referral to specialists in case of any suspicious changes.

Interview by Elena CHERNOMAZOVa

Moscow Mammary Health Dispensary Residents of Moscow and Moscow region may turn up to the Moscow Mammary Health Dispensary, the first specialized institution nationwide. Services available from specialists of the Dispensary include: skilled consultations and examinations, radiological mammography, ultrasonic scanning, and cytological laboratory tests. In case of non-malignant breast tumors, non-invasive treatments are available, in-cluding various treatments with herbs, vitamins and pharmaceuticals. Unique clinical approaches practiced by the Mammary Dispensary’s specialists helped develop new technologies for outpatient breast surgery. After comprehensive medical assessment revealing no counter-indications, patients are discharged on the day of surgery. Follow-up includes a few visits to clinic to change bandages and remove stitches, which makes treatment psychologically comfortable.

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