PHOTO: Eesha Azam
Beating breast cancer in Pakistan can be quite a fight. Despite claiming numerous lives every year, the stigma still sticks. It can be the most unforgiving disease, and yet, it is completely curable, provided it’s diagnosed at an early stage. Treatment can be incredibly expensive, but a number of health institutions provide medical care at subsidised rates. However, illiteracy and lack of awareness are the most pervasive obstructions to winning the battle against breast cancer. As a result, most patients are admitted at an advanced stage, when it’s too late.
Causes
While the exact causes of breast cancer are not known, those with a family history of the disease are more prone to it. “We need to identify whether Pakistani women have a certain kind of genetic mutation because of which we are seeing much younger women [with cancer] as compared to the West. For example, the Ashkenazi Jews have the highest incidents of genetic mutation and also have a hereditary type of cancer,” shares Consultant General Surgeon and Clinic In-charge Department of Surgery at Aga Khan University Hospital (AKUH) Dr Shaista Masood Khan. Consultant Obstetrician & Gynaecologist at Medicell Clinic Dr Azra Ahsan shares a similar view. “There are a lot of variables linked with cancer and I don’t think it is properly understood as to why there is an epidemic situation in Pakistan,” says Dr Ahsan.
Dr Farzana Memon, a breast surgeon at Civil Hospital, suggests environmental factors play a huge role in the high cancer rates of Pakistan. “We are a nation with an atomic energy setup so perhaps [nuclear tests are] responsible for it,” she says. However, there is no study to substantiate Dr Memon’s claim.
Tearing down the taboo
Dr Khan is keen to debunk a myth associated with biopsy. “Patients believe that if you touch a tumour with a knife or a needle, it is going to spread. These are patients who do not have complete knowledge about the tumour,” she says. In fact, she says clinical tests that determine the stage of the cancer should be done before the biopsy to confirm the disease has not already spread. “It has been proven now that if you do a biopsy and if treatment is commenced promptly, the cancer does not spread.”
Dr Ahsan, too, remains deeply concerned about women who are too embarrassed to talk about abnormalities related to their breasts. “Even educated women are ashamed to talk about the formation of a lump on their breasts. They don’t involve their families or husband until it is too late and the cancer has reached an advanced stage, when little can be done to cure it,” she says. Most women, adds Dr Ahsan, are not even aware of self-examination procedures; others don’t share the information with anyone even when they do discover a lump.
First screening centre
Amid the gloomy picture lies some good news too. The Federal Breast Cancer Screening Centre (FBSC) at the Pakistan Institute of Medical Sciences in Islamabad is nearing completion. Once completed, it will provide holistic treatment to patients under one roof. “The centre encompasses screening, early detection, treatment and cure,” says FBSC Deputy Project Director Dr Ayesha Isani Majeed. She adds the centre has procured state-of-the-art equipment, including an ultrasound machine with elastography, and a mobile mammography machine with stereotactic biopsy facility.
Dr Majeed says the centre will also provide counselling facilities in addition to treatment. “The centre will have a psychologist to counsel patients, pre- and post-treatment. Volunteers will be encouraged to help form groups of patients for the specific purpose of counselling and supporting them,” she adds.
Since the aim of the centre is to encourage breast cancer patients to seek treatment, there are plans to eventually draw government funding under the budget allocated to the centre for its recurring costs. In addition, funds from Zakat/Baitul Maal, Benazir Income Support Programme and philanthropy will be sought to ensure treatment for breast cancer patients, regardless of their affluence.
Survivor story
It was in March last year when Alizeh Ahmed*, a mother of two, was diagnosed with a breast cyst. She was in her final year of her master’s degree programme at the time. “I belong to the Aga Khani community and we have regular awareness programmes. One day, after self-examining my breasts, I discovered an abnormality and got myself checked by a physician who then suggested I go see a doctor,” she says.
Ahmed’s advice for breast cancer victims? Stay strong and have will power. She credits her quick recovery to her family, especially her husband who managed both household work and his professional duties while she was undergoing treatment. “People used to ask all sorts of questions at social gatherings about my cancer and passed negative comments about how I wouldn’t survive. But my sons once came from behind, hugged me and said everything would be fine,” says Ahmed as tears begin streaming down her face. “I lost all my hair, eyelashes as well as eyebrows due to the side effects of chemotherapy. But with the grace of God, I got everything back. It also helped that I did yoga regularly and maintained a healthy diet.”
Once at the verge of dropping out, Ahmed now gives lectures at the same university she did her master’s from, besides working with a health organisation in her community.
Raising awareness
Raising awareness about breast cancer requires a holistic approach. Dr Khan says this should not be limited to just patients. She feels family practitioners and general physicians should also be made aware to remind patients to get their breasts examined after the age of 35 and to get a mammography done at the appropriate time. Besides this, Dr Khan says public awareness via print and electronic media can encourage people to seek help at the earliest.
Another reason breast cancer patients are diagnosed at the advanced stage is limited resources at hospitals. “It should be the government’s responsibility to provide facilities of mammography, if not free, then at a reduced price. Simply doing physical examination to find the lump cannot help in early detection of breast cancer,” warns Dr Khan.
Consultant Medical Oncologist Dr Najeeb Niamutullah at Shaukat Khanum Hospital says they have a tough choice to make because of limited resources. He says only patients who can be cured are treated. For these patients, the hospital in Karachi provides chemotherapy along with all other facilities, including radiation, surgery and pathology.
Senior Consultant Clinical Oncologist Dr Noor Muhammad Soomro says he took the initiative to establish an oncology ward at Civil Hospital, Karachi. He said he had no support from the government and had to ask his friends and donors to pay for the building’s construction. At present, there are five breast surgeons at the hospital; however, there is a dearth of latest techniques and medicines.
After girls reach puberty, self-examination of breasts should be a monthly ritual. “Water retention is at its least soon after a woman finishes her period, so it is much easier to feel lumps,” says Dr Ahsan. Similarly, Dr Memon maintains young girls should be taught at schools to self-examine from the age of 13.
The general consensus remains that the state alone cannot fix everything. “If you look at the worldwide phenomena, advocacy for breast cancer has not really come from the government and the state. In Europe and the US, private groups are pretty active because they understand it is such an immense responsibility. It is a service that cannot be completely provided by the government,” argues Dr Khan.
Having said that, Pakistan needs to look towards other countries for inspiration. And it doesn’t need to look very far either. India has recently launched a breast cancer awareness media campaign. Pakistan, too, can do the same. And with a little help, it can save several precious lives.
*Name has been changed to protect privacy.
Steps to self-examine your breasts
Stand in front of a mirror that is large enough for you to see your breasts clearly. Check each breast for anything unusual. Check the skin for puckering, dimpling, or scaliness. Look for a discharge from the nipples.
Watching closely in the mirror, clasp your hands behind your head and press your hands forward.
Next, press your hands firmly on your hips and bend slightly toward the mirror as you pull your shoulders and elbows forward.
Do steps 2 and 3 to check for any change in the shape or contour of your breasts. As you do these steps, you should feel your chest muscles tighten.
Gently squeeze each nipple and look for a discharge.
The breasts are best examined while lying down because it spreads the breast tissue evenly over the chest. Lie flat on your back, with one arm over your head and a pillow or folded towel under the shoulder. This position flattens the breast and makes it easier to check.
Use the pads of the fingers of your other hand to check the breast and the surrounding area firmly, carefully, and thoroughly. Some women like to use lotion or powder to help their fingers glide easily over the skin. Feel for any unusual lump or mass under the skin. Feel the tissue by pressing your fingers in small, overlapping areas about the size of a dime. To be sure you cover the whole breast, take your time, and follow a definite pattern: lines, circles, or wedges.
Some women repeat step 5 in the shower. Your finders will glide easily over soapy skin, so you can focus on feeling for changes underneath.
Source: Johns Hopkins Medicine website
Komal Anwar is a subeditor at The Express Tribune’s magazine desk. She tweets @Komal1201
Published in The Express Tribune, Sunday Magazine, November 1st, 2015.
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