OCTOBER BREAST CANCER AWARENESS MONTH – PRESERVING THE BREAST IN THE FACE OF CANCER

Cynthia* remains at the top of the list when it comes to women who helped inspire me to strive to be a Zambian woman of excellence. She was a tall lady with a dark brown complexion and a short haircut. She wore minimal make up but you still knew she wore make up if you know what I mean, just enough to accentuate her strongest points. And her attire was made up of all traditional citenge material but in cuts that leaned more to the latest fashion in Milan that year. When she spoke she did not bear an accent (local or foreign) but her words came out with such clarity. She was well educated and had a lot of international exposure. Professionally when she spoke she knew her stuff but she also maintained the traditional nuances of respecting elders even in a business forum. She told me our culture is so rich and many valuable professional lessons can be applied. In the years that I knew her, Cynthia taught me about what it means to be patriotic and care for one’s country. What it meant to stay put and bring the goodness we see out there back home. As a professional woman this was important because we often swing between two extremes adopt it all or reject it. Some days I still wonder what Cynthia would say about this or that, sadly for me and Zambia wondering is all it shall be because breast cancer took her away.

She was 40 years old when she walked into my consultation room, more accurately my boss’s consultation room (at that time I was not yet a specialist and was working under supervision). She had just been diagnosed with breast cancer. She was sent to us to receive chemotherapy before her surgery. We counseled her on her stage of disease. Unfortunately, the disease had already involved the skin and I could feel an enlarged gland (lymph node) in her armpit on the side of the cancer. We told her the disease lacked receptors so we had to act quickly as it was the aggressive subtype. We spoke about the side effects of chemotherapy, the surgical procedure that would follow and the radiation. We spoke about a lot of things. After the session ended, Cynthia looked at us dead in the eye and slowly deliberately said she was willing to undergo all sorts of things, but she would not accept to lose her breasts. She told me the chemotherapy did not scare her nor did the risk of her arm swelling in the long run. She said she had read that gone are the days that women had to lose breasts because of cancer. At this moment I cursed her independent intelligent mind, for it is those positive characteristics in most scenarios that became the Achilles heel in certain. From her eyes I could see I was not going to win this battle. Fast forward 2 years I was throwing rose petals on Cynthia’s grave.

Cynthia went on to receive chemotherapy. With each cycle she got her lump grew smaller and by the time she finished her skin was normal and lump was moving freely under the skin. The gland in the armpit could also not be felt. This convinced her more than ever that she could get away with her mission to save her breasts. One way or the other she got her breast saving surgery way beyond the recommended period after chemo and by the time she was making her way to radiotherapy her cancer had come back in the same saved breast with a vengeance. It went on to spread to her liver, lungs and bones and eventually her brain.

In one of our last conversations, as I had become relatively comfortable with her, I asked her if she would do anything different in her life. We were sitting on the bench near the hospital exit. She had just finished her last fraction of irradiation to the brain and she said these words ‘My dear Dr Lombe, our future greatness beyond measure too bad I will not be there to see it. I have no regrets as I have lived my best life and I am dying with my breasts in place’. Silence filled the gap between us; I could not believe she was being stubborn after all this. She was such a beautiful intelligent person why did she have to be so stubborn about this. My eyes swelled with tears and I stood up to leave so she could not see her doctor cry as I knew this was probably the last trip she would walk into the hospital but she reached out and grabbed my hand once again looking at me in the eye only this time she had tears too and that look of regret. She made me promise never to stop teaching about cancer and spread knowledge. She said if only she knew better.

So today in memory of my dear Cynthia I want to briefly touch on preserving breasts in the face of cancer and make you know it is not always an option. Breast cancer surgery has come a long way. Back in the day they used remove a lot of the chest muscles in addition to the breast in a procedure called Halsted’s mastectomy. This left women quite crippled. A more modern modified one removes the breast and some lymphatic channels but preserves the muscles. The outcomes here don’t compromise cure but in a few women it has been noted that the arm tends to swell due to the stagnation of lymph. In a bid to minimise all sorts of complications we are moving towards less and less surgery. However, a number of factors have to be taken into account even in the richest resourced environments. It is not a blanket recommendation.

Firstly breast cancer in the western world, where most of the data we have is generated, is a cancer of older women. They present early often caught on screening. If you remember the difference with screening and diagnosis is that the symptoms are not present. We screen those that we think are at increased risk and the tumors are often small if found this way. A morbid joke is if you live long enough you will get cancer somewhere. On the contrary our patients often present young and usually when a lump has been growing and sometimes for months.

Then there is what we call the biology of the cancer. In these older women the biology is often good having items that we call receptors to drive the cancer. These good receptors are called estrogen and progesterone. They also lack another type of receptor which encourages aggressive behaviour called Her 2neu. Now if you have been touched by cancer in low resource environment you will know that even just getting to know this receptor status is a challenge.

Some friends during the northern hemisphere summer this year got in touch, excited by the news reports that women with breast cancer can get away without chemotherapy. It once again refers to this elite group. Moreover, doctors abroad have advanced tests that map out genetic information called OncotypeDx. This gives them more confidence. We on the other hand are still contending the costs of basic pathology.

Breast conservation has its limitations. ER + elderly women with a low OncotypeDx score. The good news even if we cannot save the breasts, their reconstruction is an option. Sometimes it may not come as immediately as one would want following being cured of breast cancer but it will come. Cynthia tried to receive a treatment that was not good enough for her. Despite her relentless teaching on Zambian pride she trusted that maybe what someone out there said was better than what was being advised locally. Her end point was preserving her breast and yes it can be done for some women but not all.

I promised her I would never tire teaching the gospel against cancer. Knowledge is power. I have had too many Cynthias in my life.

*not real name

 

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