WEDNESDAY 21 JUNE 2000

MS PUVAN MARKHANDO

  579. I now call Ms Puvan Markandoo. You are a consultant breast surgeon and you are concerned that breast cancer is increasing amongst young ethnic minority women and we should like to hear your evidence.

  (Ms Markandoo) I am currently working as a locum consultant breast surgeon at Homerton Hospital in Hackney which is part of East London where the survival rate is said to be worse than the rest of the country. Unfortunately breast cancer survival figures in the UK are some of the worst in Europe. To me this is heavily weighted, mainly due to the poor survival figures from East London. It has been stated that the survival rate of East Londoners is 22 per cent worse than the rest of the country, but this is not based on stage-for-stage figures. It is not based on the stage of presentation, grade of the tumour, on the size of the tumour, etcetera. This has been stated but when outcome figures of survival rates are announced biological factors, clinical factors, high socio-economic poverty and poor literacy need to be taken into account. These factors are very highly prominent in East London. The question I am raising is whether it is true that ethnic patients present late or is it that their cancers have different, more aggressive biological factors? I am sending round a handout which says that the incidence of breast cancer is higher among white women but mortality is higher among African-American women. Why is this so? White women with breast cancer have better survival rates than their black counterparts. These are worrying statements which are coming out. In my practice, the major bulk of my cases are ethnic patients. I am seeing more and more young women with advanced cancer. The general theory is that these people are presenting late, but to me that does not appear to be so. The two young ones I have recently treated swear that they noticed the change only in two weeks. Is it that their tumours are more aggressive? If so, what do we do to address this? A universal interest is developing in the histology of these tumours and looking into different factors, things like grade of it, the hormone receptor status, alteration in genes, differences in cytochromes and differences in chromosomes. The research I am interested in is with about ten children aged between 14 to 20 who are an Afro-Caribbean group who have presented either with multiple small lumps on both breasts or one large aggressive lump in one breast, which if it were in an older person I would put up my hand and say was cancer, but in these children it is not. What is going to happen to these in the future? All of us need to look into the histological types of these growths and that is where research money is lacking, in immuno-histo-chemical studies, in genetic studies. I have a pathologist who is interested and I am going to send this to a cyto-genetic person. I am going to take biopsies of these and send these for further studies. This is one aspect of my interest. The second interest is that these women are not keeping clinic appointments, they are not accepting screening, their knowledge of breast awareness is very poor, their knowledge of breast self-examination is very poor. How do we educate these patients? How do we make them more aware? How do we make doctors and GPs encourage patients to come forward for screening. This is where my second interest is: patient education, raising patient awareness and information provision by the development of audio-visual aids, use of tele-medicine, addressing issues of informed consent and also patient support. I have heard the other side of the story, eg from the ladies who have spoken today. This is another side of cancer management where there is a shortage of money. How do we provide authentic information to people? The National Cancer Institute you are talking about would be an ideal place where audio-visual aids are used, tele-medicine is used, where maybe support groups are brought in. Just general spread of information. I do not think I have made myself clear.

  Chairman: You have made yourself very clear. When you use examples from your own personal experience as a consultant breast surgeon, it really does strike home because you know exactly what you are talking about from first-hand experience.

  580. It is well established that the recovery rates are poorer in people from lower socio-economic groups. Do you think you have a real effect related to ethnic minority or is it just related to poverty and low income?
  (Ms Markandoo) It is a combination of things. From the histology point of view there is an interesting factor which seems to be coming up about the aggressiveness of their disease. The other thing is about poverty. They are not able to access treatment. Their lack of knowledge makes them hold back so they are coming up late. It is a multitude of factors which is giving an additive effect and making figures like 22 per cent poor survival rate in East London be published.

  Chairman: Thank you very much; that is very dramatic. Thank you for your evidence. We wish you well in your work and all that you do.