For Breasts' Sake

They came in droves, armed with mammograms and biopsy reults. Their questions similar, their races diverse... their sadness profound. The diagnosis; a reality of their worst nightmares. Various stages of...

‘What did you say, Doctor?’

‘I am sorry mam, its cancer...’

Some started as tiny, pea-sized lumps, some as mild discolouration, some as funny looking rashes on one corner of the breast, some as a nipple discharge that ‘kind of looks like blood.’ But here the breast is, disfigured, sometimes fetid and sometimes massive with no semblance to or memory of the beauty and perfection it once was. It is Carcinoma of the breast. Breast cancer.

Now many of them were poor, many illiterate but behind every reason given by those who present to the hospital late- reasons that readily evoke a pejorative appraisal from the most reluctant health care provider, is this pervading, almost paralysing fear that the thing in their breast might be breast cancer. And that, no one wants to hear or think about...

Many breast diseases are benign and many women will suffer from a benign breast disorder requiring treatment in their lifetime ranging from Mastalgia (fancy name for pain in the breast), fibrocystic disease, mastitis (breast inflammation/infection) especially in nursing mothers, to fat necrosis. Exclusion of cancer is the ultimate goal in the management of these disorders. It is said that 1 in 12 women in England and Wales will develop breast cancer in their lifetime. Of course figures vary from place to place and from study to study, but there is no doubt that breast cancer remain a leading cause of death among middle age women anywhere.

There was a certain woman in the neighbourhood where I grew up. Thinking back, I could vividly see on her face the crooked lines of sadness that doggedly subvert her once well known beauty. Of course I was too young to be bothered about what was wrong but when at some point she left for a while, came back and started wrapping a shawl around her upper body, then the rumour hit and made a lasting impression on me. It was the days of Radical mastectomy. The female breast rests nicely on some chest muscles, the most prominent being the Pectoralis major. Radical mastectomy involves removal of the breast, the chest muscles and the lymph nodes in the axilla. It was later abandoned as an atrocious procedure occasioned by an equally atrocious ailment. The said lady fought a long lasting battle with breast cancer. I don’t know who the eventual winner was.

There is no overstating the importance of the female breast to the woman and in fact the entire human race. In this day and age when the bane of diseases that were previously deemed deadly is challenged by ever increasing level of sophistication in treatment modalities especially with early detection, not to mention how cosmesis now mean everything, learning and routinely performing a breast self-examination is imperative for all...

SELF BREAST EXAMINATION (SBE)

It is best for every woman to start self-examination as soon as puberty is reached and breasts start to develop. The advantage in doing this is for the woman to get acquainted with her body and form good examination habits in readiness for the future. It is recommended for pre menopausal women over the age of 20 years to perform breast self breast examination monthly. This is better about 5-7 days after menstruation when the breast is less dense. For post menopausal women, it is advised to fix the examination for a particular date each month, perhaps the anniversary of a special occasion. High risk women might perform another examination mid-cycle and some women do it weekly. The important thing is regular observance of the routine until an habit of it is formed. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do SBE in the shower.

SBE consists of Inspection and Palpation.

Inspection

Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Look for:

Breasts that are their usual size, shape, and colour with no visible distortion or swelling. Call your doctor's attention to dimpling, puckering, or bulging of the skin, a nipple that has changed position or an inverted nipple, redness, soreness, rash or nipple discharge.

Now, raise your arms and look for the same changes.

Palpation

Next, while lying down, use your right hand to feel your left breast and then your left hand to feel your right breast. With the first few finger pads of your hand, keeping the fingers flat and together use a firm, smooth touch in a circular motion.

Feel the entire breast from top to bottom, side to side- from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast. Some women begin at the nipple, moving in larger and larger circles until they reach the outer edge of the breast. Some move their fingers up and down vertically, in rows. This up-and-down approach, like mowing a lawn seems to work better for a lot women. Be sure to feel all the tissue from the front to the back of your breasts down to the rib cage.

Palpate all over again while sitting or standing. Any unusual discovery should be reported to the doctor without delay.

This simple process might be the line between health and breast cancer.

SBE NOT FOOLPROOF!

It is recommended that women 20-40 years of age should go to the hospital at least once in three years for a clinical examination by a health professional. After 40 years of age, then your hospital visits for clinical examination should be yearly. Mammography remains the single best procedure for early detection of breast cancer. Together with physical examination, both self and clinical, the recommended annual screening mammography beginning at age 40 significantly increases the chances of catching breast cancer early.

A CTTD EXPERIENCE: DEFYING DEATH...

‘Scalpel!’

My trembling hand took the blade as I started drowning in the theatre’s aura of qualm. After infiltrating the area with the local anaesthetic agent, I made a clean, tiny incision at the site marked out by my resident. He chose to be the assistant surgeon in this minor surgical procedure with me, then a medical student earning the noble rank of lead surgeon, though as brief as it could be, by a moment of insane enthusiasm.

‘I can perform a CTTD now’, I said from behind him as he scrubbed.

‘Yes you should be able to by now.’ The reply came as a big surprise. Although we had performed some together and I had mastered the procedure so well, getting a positive, somewhat encouraging response those days was rare. As med students, we were condemned to being mere spectators in the theatre. Successful spectatorship many times was even a feat as there were many levels- med students of course always taking the back line.

‘I will be assisting you,’ he said.

The patient was a 47 year old woman who had malignant pleural effusion complicating advanced breast cancer (Accumulation of fluid within the covering of the lungs in this case as a complication of cancer spread, leading to respiratory distress). Closed Tube Thoracostomy Drainage, CTTD is a surgical procedure in which a tube is inserted into the chest to drain the accumulated fluid.

I carefully and slowly manoeuvred my way by blunt dissection through the intercostal muscles down to the parietal pleura. I got hold of the tube, pierced through the thin membrane while ‘my assistant' simultaneously pulled the purse string I made initially. This is to tighten muscle and skin around the tube, preventing air from entering the pleural space among other things. Over one litre of serosanguinous fluid gushed out immediately into the under-water seal bottle. The respiratory relief was instantaneous. I clamped the tube and applied a dressing.

I remember from our rounds then that her prognosis was ‘6 months, maybe a year’. In her pathetic state of health, she chose to ignore the repast of medical verbiage served daily to convey to her the harrowing details of her disease. She hoped against hope, taking her courses of chemotherapy like drinking water, herself offering ready natural explanations for the side effects. She was a fighter. She was still on the surgical ward when I left to complete my clinical clerkship in other specialities and that was the last I remembered of her.

Two and a half years later, then an intern, I could not recognize her as we ran into each other in the General Surgery clinic. She was a totally changed person chubbier, wearing full make up... Alive!

‘Still defying death, doctor!’, she enthused in her dialect.

‘Keep fighting, fighter!’, I returned in mine.

I do not know if she is still alive, but the memory I now have of her is that of a brave, happy woman with lots and lots of ambitions. And this is to everyone who is battling with cancer or who knows anyone doing so. Be strong and give it a fight! There is always hope.

A very dear friend recently lost her mother to breast cancer and she started a Breast Cancer Awareness Group which I joined and I am proud to be a member of. I think it is good if we can lend a helping hand to those in need and to those who need to know how not to get breast cancer. I think it’s worthwhile, I think it’s noble. It’s for the sake of the breasts, it’s for the sake of the woman. It’s for the sake of us all.