He flips PowerPoint slides briskly. He speaks in the mellow tone of an empathetic doctor. He stops at a slide, and glares at the picture of a woman’s discoloured, ulcerated and bleeding breast with unease. “This woman used Septran paste to cure a lump in her breast. She didn’t know she had advanced breast cancer.”
Dr Riaz Rehman, a consultant palliative physician at Cancer Care Hospital and Research Centre has seen women suffer from breast cancer from his side of the consultation table, both “medically and socially”. “The other day a 35-year-old woman came to us for breast cancer treatment. She is a mother of a child. Her husband has kicked her out of their house because of her condition, fearing that her disease may infect their child,” he says.
It’s Pinktober, the breast cancer awareness month. Some might find the campaign crass – in showcasing TV presenters sporting pink ribbons and buildings glowing in pink light – but it does remind us that breast cancer is a serious matter. According to rough estimates, some 90,000 patients are diagnosed with breast cancer every year in Pakistan, nearly 40,000 die of it. The country has the highest rate of breast cancer in Asia.
But, in the absence of a central registry, these figures are guesswork at best. Experts rely on norms that may not reflect the true picture. Perhaps, the most accurate data is collected by 18 cancer hospitals run by Pakistan Atomic Energy Commission (PAEC) – where nearly 50 percent of all female cancer patients are registered for breast cancer treatment. Over 20,000 breast cancer patients were registered between 2015-2017. According to the Institute’s estimate, one in seven women is at risk of breast cancer in Pakistan.
These are shocking figures even if they are sketchy. They are enough to show us that it’s time for action and moving beyond symbolism of tagging pink ribbons on royal guests visiting Pakistan.
Still, it’s a far cry from the early discovery of the disease in Pakistan. “I remember when Pink Ribbon launched the awareness campaign in 2004, all TV channels said they couldn’t mention the ‘B’ word. When we started the campaign 15 years ago, our main challenge was to start a discussion on the disease,” says Omer Aftab, the Pink Ribbon CEO. He recalls, “In one case, the mother didn’t tell her family that she was suffering from breast cancer. Her daughters got to know about it at the time of her ghussal.”
Practitioners and activists have fought hard against negativity surrounding breast cancer and in acknowledging that the disease exists among us. People are more aware of it now than before. “We have reports of at least 30 percent increase in patient turnout. Mammogram machines that were left to rust earlier on are now being used to full capacity. We are getting calls from men inquiring about treatment for women in their family. Earlier this was unthought of,” says Aftab.
Aftab and his organisation have learned that the most effective way to spread the word is through the youth. “We have reached out to students in colleges to encourage self-examination and lifestyle changes to prevent breast cancer. When we talk to 500 students, we are actually talking to 500 households – because they go home and talk about it with their mothers and sisters – the word spreads.”
The breast cancer problem in Pakistan is deeper than raising awareness about it. One of the principal reasons for the high fatality rate is the gap between detection and cure – between what we know and what we do about women suffering from it. One way to bridge this gap would be to encourage patients to report early. “Women are visiting centres and clinics for the first time. Many already have incurable breast cancer. They are coming in with Stage 3 cancer. That’s too late,” says Dr Sana Zeeshan, an assistant professor (and breast surgeon) at Aga Khan University Hospital (AKUH).
Then again, it’s not only about encouraging girls to come in early with symptoms. There is a need also to dispel myths that surround the disease – among lay people as well as cancer care providers. “Doctors are recommending mammograms to girls as young as 20 years old. But mammograms are needed in women aged 35 and above. Breasts of young girls are too dense for screening to show results. Examination works better for them,” says Dr Sana Zeeshan.
Besides, screening is much less effective if treatment is delayed. “Many patients have to wait for months for treatment at government hospitals,” says Dr Rehman.
Pointing out a shortage of breast cancer care facilities, he says, “Shaukat Khanum Hospital is the only breast cancer hospital in Pakistan. It has surgery, emergency and radiation under one roof. Others are cancer departments or centres, not hospitals. We need more such hospitals – where the process from diagnosis to recovery is covered under one roof.”
Whatever has been made available to breast cancer patients in terms of awareness and treatment is concentrated at city centres. Little support has been extended to low-income patients living in rural areas. “We know that Pakistan has the highest rate of breast cancer in Asia but we do not know what’s happening in rural areas,” say Dr Sana Zeeshan.
At an AKUH breast cancer camp in Hyderabad last October, Dr Zeeshan and her team were shocked to discover that out of 120 women they examined 8 had advanced breast cancer, and were not aware of changes in their breast. “We shuddered to think what would happen if these women were screened. We also shuddered to think what would be the condition of low-income women living away from Hyderabad,” she adds.
Besides one mammography machine at the AKUH premises, there are two being operated in Hyderabad. “These are outdated machines. The films are black and white. We can hardly see anything in them.”
But the availability of mammogram machines at grassroots is likely to solve only a part of the problem. As a first step, we need to strengthen the basic health units (BHUs) providing breast cancer care. We need to train lady health workers in how to examine women’s breasts, in creating awareness, in emphasising personal hygiene, and, more importantly, in sensitising men about the possible occurrence of breast cancer among women. “Men do not allow women to be examined or screened. And, if their wives are diagnosed with breast cancer, they simply abandon them. They must be educated that cancer is curable if detected early,” adds Dr Zeeshan.
Dr Riaz Rehman’s Cancer Care Hospital and Research Centre, runs two mobile units in remote areas of the country. They are equipped with state-of-the-art mammography machines that transmit digital images to a radiologist at the central clinic in Lahore. “In the last three years we have screened 30,000 women free of cost. Out of those we detected and treated 163 cases,” says Dr Rehman.
Though these mobile units take screening facilities to the doorsteps of rural, low-income women, they have a drawback. “The problem is we can do mammography on the truck but we can’t follow up with a biopsy.”
The next goal for Dr Rehman’s cancer centre is to run a vehicle that will offer three services – mammography, ultrasound and biopsy. “This truck, funded by the OGDCL, will enable us to provide complete treatment to a patient in her hometown rather than dragging her to Lahore.”
The road ahead is long and arduous. A multipronged approach is needed to dispel myths and improve access to better cancer care. “The governments must work hand-in-hand with the private sector. They should at least develop a central registry of breast cancer patients,” he adds.
Meanwhile, let’s not keep moving our target. People must be made aware, they have to be willing to undergo treatment, human resource must be built, and the cost of treatment brought down.
The writer is a staff member