“In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurable in how much it can affect someone’s life in a positive way.”
Kathleen is a research associate at the Program in Global Surgery and Social Change at Harvard Medical School. She is also a 4th year medical student at the University of Pennsylvania. She recently returned from working at Hôpital Universitaire Mirebalais in their surgery department for six months in Mirebalais, Haiti. She plans to begin a general surgery residency program following graduation next year.
Why is global surgery essential for women’s health?
The average person in the U.S. has eight operations in a lifetime. If you’re living a long and productive life, it’s likely that at some point you’ll need access to surgery. Because of the risks of childbirth, women are more at risk of needing a life-saving surgery than the average man – particularly in low-resource settings where fertility is usually higher and more pregnancies means more risk.
But it’s not just about reproductive health. A lot of the work I was doing in Haiti was around the issue of breast cancer – and surgery is absolutely necessary as part of that treatment.
Is there much access to surgical care for cancer in Haiti?
It’s similar to many low-resource countries in that very few centres treat surgical disease and people generally live far away from them. I interviewed patients getting chemo at the hospital and most had been seeking care for a year or more.
Cost is a huge factor. Just the process of diagnosis is incredibly difficult and the cost of surgery could range from a few hundred dollars to a few thousand. Any money they had saved was gone very quickly.
Is the surgery generally safe?
Safe and effective surgery isn’t just a question of availability, but integration. Surgery in Haiti isn’t really plugged in to a larger system of treating cancer, and there’s limited pathology or chemotherapy. A surgeon might remove a lump and hope it was benign, but it’s difficult to know what they’re cutting out.
You see women going severely in debt for surgery that wasn’t a definitive cure. Four years later they have metastatic disease.
What is the impact of this?
Having this life-threatening illness, searching for so long for treatment – the whole process affects the family. The majority of women getting treatment usually had several children, and they’d be struggling to take care of them. Often kids became the breadwinners of their family, taking care of their moms. An illness like that doesn’t just affect one person, it affects the whole family.
So a lot of what we talked about during our interviews was how grateful they were to find care – to finally have someone taking care of them. The entire oncology team at the hospital is composed of women – nurses, physicians, led by a Haitian physician trained in oncology, Dr Ruth Damuse. It’s a wonderful place, women taking care of women.
What is the chance of survival?
Women would notice the lump in their breast relatively early but, particularly at the lower socio economic level, delay and delay care. They say ‘I don’t have the money to be able to do that, I can’t leave my family.’ It has to be something that affects their lives to a very large extent before they seek care, so often the lump isn’t only noticeable to them, but grossly obvious to everyone.
Unfortunately in Haiti whenever we were diagnosing it was rarely a question of ‘is this breast cancer’ – by the time the woman presented, it was very obviously so. And that is a very difficult thing, because the chance of cure becomes so small.
Does that mean the surgery isn’t worthwhile?
In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurable in how much it can affect someone’s life in a positive way.
When you can remove a fungating mass on their breast so it’s no longer infected or at risk of bleeding, you remove the stigma. The ability to move about and not have to daily worry about this gaping open wound that won’t heal, which cancer ultimately turns into – it confers a level of dignity to patients that I think is lost in the standards ways we measure outcomes. It’s life-changing.