breast cancer

2014/03/05

Morgan Mandigo

“It reminds me of a quote I heard – that in many African countries people will say “I’d rather haveRead more →

2014/03/05

Kathleen O’Neill

“In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurableRead more →

2014/03/05

Dr Angela Enright

“Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe forRead more →

close

Morgan Mandigo

“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.

close

Kathleen O’Neill

“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.

close

Dr Angela Enright

“Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe for her and for the children.”

Angela is Head of Anesthesia for Vancouver Island. She’s a past president of the World Federation of Societies of Anaesthesiologists and the Canadian Anaesthesiologists’ Society, and a trustee of Lifebox Foundation.

Why is access to safe surgery and anaesthesia an important issue for women’s health?

In low-income environments, emergency obstetric surgery such as Cesarean Section and ruptured ectopic pregnancy constitute a large part of the surgical volume. Women also endure other surgical conditions such as trauma, cancers and bowel obstructions that require surgical intervention.

Often they present late to the hospital and are in a high-risk state. The rate of complications such as severe blood loss is high.

But if a woman in a low-resource setting needs a surgery?

The challenges are huge. Poor transportation, long distance from a surgical facility, lack of money to pay for surgical care, distrust of the care available and late presentation all affect the ability of the patient to access timely and appropriate surgical care.

In addition, women may have cultural issues which may prevent them going to a hospital for surgery – such as requiring a husband’s permission, which may not be freely given or delayed if he works away from home.

Has global surgery kept pace with developments in medical knowledge and technologies?

There are improvements in some areas – for instance education of women, which makes them more aware of what they need and how to access it. Provision of local health care workers, such as in Malawi, has improved care and resulted in earlier referral to a surgical or obstetrical centre. Cesarean section is now most frequently performed under spinal anesthesia. That provides a measure of safety over poorly managed general anesthesia.

But you need early access, resources and skilled providers to be able to treat these patients successfully. This is still a problem, as well as practical issues, like a functioning blood bank for life-saving transfusion during a crisis.

Does surgery in these conditions become unsafe?

Yes!

What are the repercussions?

Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe for her and for the children and also for the husband, who now has to figure out how to care for his family whilst trying to work to support them.

Many women have ‘cottage’ jobs – something they can do from home which brings in some money, like weaving baskets sold to tourists. This type of income often pays for the children’s education.

Late management of surgical problems such as breast cancer results in increased morbidity and early mortality for the woman. Often other problems such as an enlarged thyroid may be left until it presents a major airway problem. Bleeding from untreated uterine fibroids can result in severe anemia and a mother bereft of energy and the ability to care for the family.

Do women play a role in delivering care too?

I would say that women provide the backbone of care in anaesthesia and nursing. Most surgical care is still provided by men.

Does this crisis get much recognition?

There is a belief that surgery is expensive and unaffordable but that is not the case. Routine surgical conditions should be treated early to return people quickly to the workforce.

Major agencies such as WHO have invested much time and effort dealing with public health issues and communicable infectious diseases. Obviously these need attention but much has been done to improve their status and it is time to turn some attention to surgery.