January 23, 2005

Taboos, social prejudices as well as intrigue need to be in order to help us understand this vital medical problem

BEING a consultant surgeon in what is probably Pakistan’s only cancer hospital, you get to meet a lot of people with a variety of notions about their illnesses. But every so often, there comes a case, a patient with a family, that isn’t clear about the problems that they are facing. And this is something that is magnified many times when it comes to breast cancer.

I came to Pakistan after a seven-year stint in the UK. My experience abroad helped me in getting a better understanding of the situation here. And it has not been pretty at all. For I have found it to be the commonest cancer among womenfolk here.

We in the East are proud to have a very close family network where relationships till three generations in both directions are loved and respected. However, like the positive aspects, there are also some negative shades to these relationships.

Recently, a 35-year-old woman, who had been diagnosed with breast cancer, came to my clinic after her surgery. Unfortunately she had to have her whole breast removed because the size of her lump was quite big. However, this procedure is now unnecessary as conserving the breast, followed by radiotherapy has the same results. Coming back to the patient, she had five children, the youngest being a three-year-old baby girl. To my surprise I noticed bruises on her arms, forearms and on further examination, also on her shins. When I asked about the probable cause, she didn’t tell me the reason. However, I asked her again, this time in the absence of her husband. It was then that she poured out, crying and heartbroken that both her husband and her mother-in-law had beaten her because they believed that she had brought a curse on the family. Subsequently, they had forbidden her eldest from going near her mother, least she might contract the same disease.

Another patient, a 27-year-old, who had had one breast removed. Unfortunately, during the procedure, it got infected and it resulted in an ugly scar. Adding further to her misery; an attempt had been made to rectify the problem by reconstructing the breast. That too had gone terribly wrong. During all this time, she could not get the desired chemotherapy, subsequently the disease came back.

When she came to me, she was accompanied by her mother-in-law. It was the mother-in-law who took me to one corner of the office and showed me the patient’s reports. Curiously, she had a big smile on her face. She saw my puzzled look and very candidly told me that doctors have announced that the disease is beyond cure and the patient hasn’t much time left. Now, all that the mother-in-law wanted to know was to make sure how long her daughter-in-law has, to live. She wanted to know that if the patient had months, rather than weeks to live. The reason was simple; then only can her son divorce his wife to marry her niece. Otherwise they will have to wait for the girl to die!

This was actually the second opinion that the mother-in-law was looking for. This young girl had been married for five years.

Then there was the 22-year-old girl who had been married for 18 months and who has a daughter just four months old. She belonged to an affluent family that is very well-educated. While I was examining her, her mother-in-law was sitting in the same room. I asked the patient if anyone else in the family had been diagnosed with breast cancer. She told me that her maternal aunt had been diagnosed with cancer at the age of 75. This patient too had had her lump removed by a well renowned surgeon of the country. The mother-in-law was told by the surgeon that this disease had affected her next generation, meaning that the four month-old girl too could get the cancer. The girl should therefore have no more children and the husband should not get close to her. The mother-in-law got the wrong idea, that this disease is communicable and had taken away the daughter away from the mother. She has sent photocopies of the histology report to the other members of the family and also reprimanded the family for not telling them about the aunt who had been diagnosed with breast cancer three years ago.

True these incidents are few and far inbetween, but it highlights the ignorance the general population suffers from about this disease. There are a few clear facts that need to be highlighted.

• Only five per cent of all cases of breast cancer are genetically related. It means that 95 per cent of the patients who develop breast cancer do not have any genetic modification that is responsible for cancer.

• There is a risk assessment module that allows the clinician and the patient to roughly figure the risk in a lifetime of the patient, if there is a strong family history of breast cancer. In general if one immediate blood-relative i.e. mother, sister or grandmother had breast cancer at a young age then the patient has a risk factor of 1.6 for developing breast cancer. This does not mean that she has double the chance of developing breast cancer, but that if compared to an otherwise healthy woman with no family history of breast cancer, her risk is more than half. In actual terms, with the incidence of breast cancer in Pakistan, it is still below the threshold of being significant. But it does mean that the woman should be careful and should have routine mammography every two years, five years before the age when her immediate relation had diagnosis of cancer.

• Breast cancer is not a communicable disease. It is not like TB or malaria that can be transferred either by living with the a patient or through mosquito bites.

• It is not associated with putting on silk or cotton clothes or with high heels. There is a general notion spread by people who call themselves experts on the topic that women once diagnosed with breast cancer should not use nylon or silk. There is no scientific basis for this claim. If it were true, women in the West would give up all the fashionable clothes or cosmetics even if the risk were one per cent. Nowadays “evidence based medicine” is practised, not “experience based medicine” that has pushed our people to ignorance.

• There is no contra-indication to have further children. If the patient has had chemotherapy, it takes two years before healthy eggs are produced and hence a gap of two years is advised. Women who are on hormone tablets for their cancer cannot usually become pregnant while on the tablets. This is usually taken for five years. There is no need to have an abortion if a pregnant woman is diagnosed with cancer in the 2nd or third trimester of pregnancy. It was an old belief that pregnant women having breast cancer have worse prognosis than non-pregnant. It is untrue. In fact, a scientifically proven fact is that the final outcome is the same if the stage at which cancer is diagnosed is the same. Abortion or termination of pregnancy has not shown to improve survival of patients with breast cancer. First trimester women with newly diagnosed cancer are advised termination because they cannot have radiotherapy as part of the treatment plan.

• Husbands need not stay away from their wives diagnosed with breast cancer. In fact studies have shown that women whose husbands are supportive and caring deal with the disease far better than women whose husbands are not supportive. In my personal experience, more than 50 per cent women with breast cancer can have their breasts conserved if it is done properly in a unit where radiotherapy and regular follow-up is available. Breast conservation surgery has become a normal procedure in the West, but unfortunately it is still in its infancy in Pakistan. I strongly recommend women to ask their clinicians about this option. There is no improvement in survival of patients who had whole breasts removed as compared to women who had breast conserved followed by radiotherapy. There is no increased risk of disease coming back.

• There is no radiation hazard to anyone living with or among patients who have had radiotherapy. Radiation therapy is a very important part of treatment for breast cancer and adds more life years to the patients.

• There are no potions or “herbal oils” that have shown to improve the outcome of breast cancer or prevent it from happening.

• There is no role of homeopathy in patients with breast cancer. Patients who waste their time with the homeopaths never do better than patients who are treated properly with surgery, chemotherapy and radiotherapy. If a lump shrinks with a homeopathic medicine, then either it is not a cancer or it would has reduced or disappeared on its own without any treatment which happens rarely.

In general, patients with breast cancer need not be without hope and depressed. With the latest development of diagnostic machines, new surgical techniques, new chemotherapy drugs and radiotherapy, there is a lot of hope. The important thing is to get hold of it earlier, see a doctor aware of the latest developments in diagnosis and treatment, try to have treatment where all specialties are available under one roof and in a place where regular follow-up is offered even after the treatment is over.

Remember a patient diagnosed with breast cancer can only be considered “cured” if she dies of reasons other than breast cancer and I can tell you that depending upon the stage, more than 50 per cent can be cured. It is very important for the patient and the family to learn to live with the fact that breast cancer can come back at any time without warning. The more positive and prepared they are the better the outcome. Removing the whole or a portion of breast is not an end to the problem, but the beginning of a journey that has no frontiers or destination.

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