“It reminds me of a quote I heard – that in many African countries people will say “I’d rather have HIV than cancer” because it’s much easier to get plugged in to treatment.”
Morgan is a fourth year medical student in the Department of Global Health and Social Medicine at Harvard. She’s currently based in Haiti.
Why is safe surgery essential for women’s health?
The obvious answer is obstetrics – but what I didn’t fully appreciate until I came to Haiti was the magnitude of the cancer problem. We see case after case after case after case of devastating breast cancer, and a huge portion of the general surgeries we do are mastectomies.
Who is affected?
It strikes women at such a young age in low-resource countries, and we really don’t have a good understanding of why this is. But it seems to be that more and more women in their late 20s, early 30s are presenting with cancers that progress very quickly.
We always use maternal mortality as the example of trickle-down effect on the children, the community, the economy, but more and more we’re going to see the same argument playing out here.
The cancers that only affect men hit at a much later age – in the U.S. more men die with prostate cancer than from it – so women’s cancers can have a bigger impact on the children and families.
Why are the cases so devastating?
The presentation is so late. Some academic articles estimate 80-90% of breast cancer in low-resource countries is diagnosed at stage 3 and 4 – that is lymph node involvement, metastases.
Cancer treatment requires so many things – surgery, chemo, radiation, pathology. When you don’t have access to all of those tools, often surgery is the only option. But there is a very real threat of doing unsafe surgery when you haven’t been trained in oncology.
Why is there such late diagnosis?
Because there are such high barriers to actually receiving care. The geography, the logistics, the money – the day’s work you’re losing traveling to the hospital, sleeping outside on the ground so you have a good place in line the next morning, all the while not knowing if the doctor will even be able to help you.
That’s an awfully big set of challenges to overcome for a little lump in your breast that may not cause you any pain.
How does surgery become unsafe?
Oncology surgeries can be dangerous because tumors are so vascular. You could run into significant bleeding problems if you’re not properly trained.
There’s also the risk of not getting all the cancer, or even worse, of spreading the cancer. Cancer ultimately starts at the cellular level, and if you’re not using proper surgical techniques you can miss the margins; or you can risk seeding that cancer into other cavities in the body.
Even when you have the ability to do safe surgery, you don’t always have what you need to fully treat the cancer.
Can you give an example?
A few months ago a woman arrived with a mass growing out of her face – it was roughly a quarter of the size of her own head. It was a very rare tumour that had obliterated her vision on one side. The only thing available to help her was surgery.
The team did the best job they could to remove the tumour, but we don’t have pathology, the biomedical resources we’d have in the U.S. Your natural inclination is to try to take out a tumour like that – it’s so public, and you could see the suffering on her face from the stigma of carrying it around. But it was a very tricky surgery to do.
The team was able to resect the tumour successfully but they couldn’t be sure they had removed it entirely, and last Friday she came back. The tumour was bigger than before. This time it was also more vascular and had invaded more of the bone in her face, and though we wanted to be able to help her, we knew this time it would be unsafe.
It highlights the importance of safe surgery and knowing when you can operate and when you shouldn’t, but also what else we need to be able to do to provide better cancer care – to have a more positive impact.
Why do you think that cancer treatment has been so slow to develop in low-resource settings?
If you ask a dozen people on the street ‘what is global health’ they’ll say HIV, tuberculosis, malaria, malnutrition. By focusing our efforts so much on particular diseases, rather than seeing health itself as a human right, we risk creating this dichotomy where we see other diseases running rampant, untreated.
It reminds me of a quote I heard – that in many African countries people will say “I’d rather have HIV than cancer” because it’s much easier to get plugged in to treatment. For cancer there’s often nothing.
But we know what to do about it?
We know what needs to be done, but it’s the how that is difficult. We need to prioritize the development of surgical infrastructure around the world and ensure that there is equitable access to safe surgery. The trend towards a high burden of non-communicable diseases will continue, and many of them are treatable with surgery. But in the meantime, women bear a huge burden.