The month of October has passed and we are at the end of November already. October spells the beginning of the fall with the leaves changing colors and finally welcoming the winter. In the oncology world, October is dedicated to increasing awareness in the masses about breast cancer, honoring those who are fighting the disease, who beat it and those who lost their lives fighting this cancer.
One out of 9 women in Pakistan is at risk of breast cancer development. It is the second deadliest cancer among women after lung cancer. Incidence-wise, breast cancer is the highest among women. Female sex and increasing age are the two most important risk factors for its development. It is important to seek medical attention as soon as you can. Breast cancer is more common in females but it can affect males as well. Sometimes it runs in families.
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The symptoms everyone should watch out for
The most common symptom is a breast mass or lump felt by the patient. However, any skin discoloration or dimpling, nipple inversion, nipple discharge or breast skin thickening should compel one to seek medical attention. It is also recommended to self-palpate the breasts at least once a month to look for any changes especially a lump if possible.
According to the American cancer society (ACS), a yearly mammogram is recommended after age 45 years until age 55 and then biennial screening until age 75. This can be started earlier if a close family member (mother, sister, or daughter) was diagnosed at a younger age with breast cancer. In Pakistan, however, the emphasis is more on a monthly self-breast exam. Reluctance to seek medical attention, costs involved and limited access to mammography are some of the reasons for promoting self-breast exam in Pakistan. Self- breast exam should be done a week after the menstrual cycle as the breasts can be “lumpy” during the menstrual cycle. I would encourage women to seek medical attention sooner and advise their loved ones to do the same if a suspicious sign or symptom arises.
The five-year relative survival rate is now 98 percent for women with breast cancer caught before it spreads beyond the breast (compared to 72 percent in 1982). The Sooner you seek medical attention, the better are your chances of a cure. Cancer is a word that no one wants to hear at any stage of life and I have witnessed how it torments the patient both physically and psychologically but it carries an added financial hardship which affects the near and dear ones as well.
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My personal Journey …..
I moved to Pakistan in 2018, after completing my training at Boston University and working for two years at an affiliate hospital of the University of Massachusetts. Since moving, I have had the privilege of working in three community hospitals of Islamabad already. During this short period, I have witnessed cancer treatment at varying levels of expertise but the bottom line is that treatment is fragmented and involves a lot of resources on part of the patient/ family to arrange care. Occasionally treatment is delayed or poorly managed due to lack of access or patients misguided by poorly trained physicians.
At the time of my writing, I can state that there are only 3 US-trained medical oncologists in the twin cities up to Peshawar and that too in the private sector. At some point general practitioners, self- proclaimed classified specialists have dabbled in the field of oncology and later radiation oncologists tried to fill this gap which they are doing even now. However, their lack of proper training spells poor outcomes for the patients. Realistically, it does not fill the need of the day. Cancer in general and breast cancer in particular is on the rise due to worsening pollution, an increase in smoking, changing lifestyles and better diagnostic modalities.
Oncology is a highly specialized field and involves a multidisciplinary approach involving input from the oncologist, the surgeon and radiation oncologist, preferably within a hospital. This kind of setup is difficult to set up and run in the private sectors. I request the government to take the lead in creating such setups where specialized care can be delivered. The focus has shifted from the conventional use of three modalities- surgery, chemotherapy and radiation to highly specialized and personalized care where medical treatment is tailored according to the genetic make- up of the patient and the disease.
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Conventional surgery has moved to surgical oncology where surgeons are additionally trained in doing cancer surgeries. We need properly trained physicians who are aware of the changes and comfortable with adapting to the changes and incorporating them in their practices to treat patients locally.
How media is helping in raising awareness?
It has been a welcoming sign to see the government and private sector coming together and engaging the electronic and print media as well as the medical community joining hands to increase awareness among the masses. I feel that all these efforts will shift the tide towards seeking early medical treatment. Increasing awareness is solving only a part of the problem. Setting up more and advanced health care facilities, outreach centers and providing better training is also needed. Staffing the hospitals with well-qualified staff is also needed. In my opinion, there are many highly qualified professionals from Pakistan who have excelled in their respective fields abroad and are eager to return and serve their homeland. However, the government sector has been unable to create opportunities where these outstanding physicians and scientists can fit in.
Many patients who do have the resources choose to get treatment abroad. The major factor for this is that cancer care is not a one-stop-shop here. Some of the food and drug administration (FDA) approved drugs are not readily available. Patients have to go through the drug regulatory authority of Pakistan (DRAP) for approval each time. Some of these medicines are smuggled and the prices jacked up to cover the efforts involved in procuring the medicine but the quality or cold chain maintenance cannot be attested to.
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I can relate to this on a personal level as exactly one year back, I was in the US to do locums when I found out that my mother has a breast mass. Suspecting the worst, I had to plan urgently and accordingly. I called my friend who is an interventional radiologist at a tertiary care hospital in Peshawar who did the biopsy. I made sure that the pathology specimen goes to Karachi where I have faith in the pathology department. It turned out to be invasive breast cancer but the good news was that it was hormone receptor positive.
I started my mother on hormone receptor medicine, only to find that the pharmacy only had one month supply available. I arranged the medicine from Islamabad. I had to turn down the job offer in the US and came back to arrange for her surgery. She is doing well and I am glad about the end results. However, I do think that what if I was not in this field or if I had not worked in Pakistan, how difficult and mind boggling it would have been to arrange all this from a distance. The issue in Pakistan is that services are not standardized. I welcome the Pakistan medical council’s decision to validate the credentials of the physicians who are working in Pakistan and assure that a standard is maintained. I believe that this will improve things hopefully.
At the end of the day, it is not the number of patients I see but the quality of care I provide those matters. My hope and prayers are that I am able to provide a state of the art care to my OWN people. It would be worth it, I would like to thank USA for giving me the opportunity to learn at the highest level and the people of Pakistan for welcoming me back to be a part of an exciting path.
Dr. Yasser Rehman is a consultant oncologist at Maroof Hospital, Islamabad. He can be reached at rehmany@outlook.com. The views expressed in this article are the author’s own and do not necessarily reflect the editorial policy of Global Village Space.