Breast cancer in T&T is no death sentence


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Category: Health Care 08 Aug 10

Dr Rajen Rampaul has recently joined the Guardian Media Group as chief medical correspondent. He has been practising in the United Kingdom for the past 12 years. Rampaul graduated from the University of the West Indies in 1995 and underwent surgical training and specialisation in breast and oncoplastic/reconstructive surgery at the University of Nottingham, UK. In 2008 he was awarded the British Association of Surgical Oncology and the British Association Plastic/ Reconstructive and Aesthetic Surgery Oncoplastic fellowship at the University of Newcastle, UK. He is an expert in breast cancer surgery, breast reconstruction, genetics of breast cancer and breast cancer in young women. He holds a doctoral thesis in primary breast cancer from the University of Nottingham. This work has received several international awards including the European Society of Surgical Oncology Scholarship, the Pfizer Global Academic Research Award, a Roche Pharmaceutical grant and the Association of Surgeons of Great Britain BJS prize. In 1999 he was the recipient of an MRC ALMANAC Fellowship for sentinel node biopsy in breast cancer.


He has published over ten book chapters and over 100 articles in his field and regularly reviews articles for several international journals. He tutors for the surgical skills programme for the Royal College of Surgeons of England and lectures regularly to oncologists and surgeons alike on all aspects of breast cancer. Recently, he led a lecturing tour to oncologists in several Central American countries on a new breast cancer drug—fulvestrant—and has been involved in the development and pivotal licensing trials. He is a member of the board of the Trinidad and Tobago Cancer Society and has been listed in the Worldwide Who’s Who in Medicine and Healthcare 2009. Rampaul is currently Consultant Oncoplastic Breast Surgeon and Surgical Oncologist at the National Radiotherapy Centre at St James Medical Complex with the NWRHA. 


Breast cancer is virulent in this country, killing more women than any other cancer. In this interview with Guardian Multi Media journalist, Ira Mathur, Rampaul explains why and tells us what our women can do to save their lives. Breast cancer is the most common cause of cancer death among women worldwide, including Trinidad and Tobago. UK figures show that one in nine women will have breast cancer at some point in their life? Are the figures similar here in Trinidad? Breast cancer in Trinidad and Tobago is the highest amongst women (men get it too but are at much lower risk) increasing in the young, in an advanced stage. In the absence of statistics in the National Radiotherapy Centre our breast cancer clinic day is the largest of all cancers compared to colon and gynaecology. We easily see over a 100 patients in one day.


What are the alarm bells, the symptoms of breast cancer?

Breast, like colon cancer, unfortunately presents when the cancer is advanced and often has no symptoms. This is why screening is so important if you want to convert a lethal disease to a chronic but manageable disease because it picks cancer up before the disease manifests itself by which time it is often too late. A massive breast screening programme is 20 years overdue in this country. Most people are coming to us after the horse has bolted and the problem is big. Some of the late symptoms include breast pain, a lump in the neck or arm, fluid and blood from the nipple. I advise all women to see a doctor they trust, and never assume that your last diagnosis is permanent. Things can change so it’s vital you keep checking.


Are all breast cancers the same?

No, every cancer is different; each woman’s prognosis and treatment plan is unique.


If you are diagnosed with cancer, what happens next? A mastectomy, chemotherapy? What are your chances of survival?

When a woman is diagnosed with breast cancer, the first thing she should understand is it is NOT a death sentence, just a journey with several stops. Secondly, she should ensure that a team of cancer specialists including surgeons should manage her treatment. It is never an open and shut case of mastectomy and chemotherapy. It will vary from woman to woman.


Is it a death sentence?

Absolutely not! I had a patient today who had lumps the size of two golf balls, making me think it had spread in all 21 glands but when I operated on her I discovered it had only spread to two. With treatment she has a lifetime before her. It’s not safe to label. If detected early, breast cancer patients can easily enjoy over 20 years of life without a recurrence


Why are younger women getting cancer?

I’m alarmed at the cases of young breast cancer patients regionally. In Santo Domingo I saw two girls—16 and 17—with breast cancer. In Trinidad I have a 21-year-old patient with breast cancer who has had a mastectomy. Her life is ruined. Every time she comes for a consultation, regarding reconstruction (and we’ve had four) she cries and we can’t get beyond that. Can you imagine the implications of having breast cancer at age 21? In all my years in the UK I have never seen this.


Why is the rate of breast cancer growing here, and in younger women in T&T?

It’s a combination of reasons. Firstly, the rate of detection is greater now. My grandmother was a simple woman who worked in the cane fields...If she had a lump she was not going to the doctor until it was particularly bad. Women today are more educated, self reliant, contribute to the home financially, and driven to access medical care and screening. They get diagnosed earlier.

Secondly, as we get more westernised in our sedentary lifestyle and diet (which plays a role in many cancers) our disease patterns such as a higher incidence of breast and colon cancers follow the west. But, unlike Western countries we don’t live in a health care environment of health education, hospitals, or systems that can cope with the disease our lifestyle generates. In the absence of support mechanisms, people lose motivation to take care of themselves, it gets worse and complications set it. Many people remain untreated. We are dying younger as a result.

Thirdly, our poor environmental record has an absolute knock on health. The books tell us there is a link between leukemia and chemicals. There is no quality control on pesticides used on our vegetables, or study on the environmental impact on our food chain. You are on record saying that the women in Trinidad and Tobago have higher incidences of cancer for genetic reasons? Half of us came about 160 years ago from India. The other half from Africa. After that initial stock there were no more immigrants to add to the genetic pool. You are an exception, as you are first generation from India. The majority of people who migrate from here marry abroad. This means our genetic pool is shrinking and bad genes are passed on and multiplied. We are not like India with a billion people or the UK with its constant influx of immigrants. We are reaching a point of inbreeding. I see a lot of breast cancers with family history which accounts for its rise in Trinidad.


Women with breast cancer have a mutation in a gene called BRCA which greatly increases their risk factor. Do you recommend this test?

About ten per cent of patients who have breast cancer and family with breast cancer share that gene. But it comes with a catch 22. A ‘positive’ means you have an 80 per cent chance of getting it. You’ve just been told you have a time bomb but it can’t tell you where, which breast, or when you will get it. Many ‘positive’ women are saying “I don’t want to live my life worrying and checking for lumps” and opt for prophylactic (preventative) surgery and reconstruction and remove both breasts. Or they wait for cancer to strike. If the test is negative and the woman develops it anyway, there is intense anger. The test requires intense counselling and is very expensive. The patent is owned by a company in the US.


What are the other risk factors?

After genetics, the largest risk factor is to be a woman. The ‘soft’ factors are older women who don’t have children, have taken the pill for a long time, had Hormone Replacement Therapy after menopause (it makes breasts dense and some cancers can hide in it making detection hard). The current evidence on the more advanced HRT leaves it much more in the balance. I say if your quality of life is bad, and you need HRT just get on and do it.


Do hormones injected in chickens contribute to the cancer?

That’s heresay and woolly stuff. You’re more likely to die of a heart attack from fatty foods.


How often do you recommend a mammogram which detects breast cancer?
Once a year after the age of 40. If you are under 40, breast density is higher. So doing a mammogram is like taking a photo in the night without a flash since some mammograms are not going to show anything. There are three types of mammograms. The first (which we still use in Trinidad) is like using old fashioned cameras, and a dark room where film is dried. The second is “digitised.” It is like a good quality camera with film which is scanned and digitised and suited to women over 45. The third is a “digital” camera which is the clearest. A digital camera is best for younger patients as it allows the camera to look at lumps and potentially cancerous lesions in dense tissues. All world class breast clinics have digital screening. We are awaiting that here.


You were brought back by the NWRHA to start a breast cancer specialty unit. When do we expect to see this in operation?

There has been progress but much of critical equipment that will allow us to run a world class breast screening and operation centre is lacking. It is devastating for me to disappoint women by putting off their surgeries. By the fourth time they begin to think I am stepping back from saving their lives. We are still awaiting funds for the procurement of these technologies. I have been calling for the early intervention of the Health Minister Therese Baptiste-Cornelis to help us save lives and await her response.


The NWRHA’s vision is to provide a one-stop diagnostic centre where we can offer patients a service where they get all of their imaging and biopsy in one visit this will lead to an opportunity if there is breast cancer to offer state of the art surgery, sentinel node biopsy and radio guided surgery and breast reconstruction. A Breast Unit is being developed and built at St James Medical Complex. Until this is done I run (at the NWRHA) a breast and reconstructive clinic open to all patients.


You are a UK-trained consultant Oncoplastic Breast Surgeon and Surgical Oncologist, how do you think your specialties can make a difference here in Trinidad and Tobago?

I’d like to work closer with surgeons and the medical fraternity and we have a real opportunity to work as a team to make a difference. We can, as a small fraternity in a small country with big problem put our heads together and share knowledge. What I lack they will have, what they lack I may have. Together, and with Government’s support, we can complete the jigsaw puzzle and save lives.


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All Articles Copyright Ira Mathur