“The doctor told me not to worry. He said as long as the mass in my breast wasn’t bleeding or painful, it would be fine. He sent me home.” – a breast cancer patient
I got into a heated argument with Dr. Zola about the delayed diagnosis of cancer in Botswana. In clinic, I had seen a young woman, exactly my age, who felt a mass in her breast more than a year ago.
She went to her local clinic, and was told by that provider that because the mass was not painful and not bleeding, there was nothing to worry about. The local healthcare provider sent her home. Meanwhile, the mass continued to grow. She went back to the clinic a few more times, but nothing happened. Finally, a couple months ago, she saw a different doctor who performed a biopsy, which confirmed that she had breast cancer. She went ahead and got a mastectomy; over 10 of the sampled lymph nodes were positive for cancer involvement. As far as I could tell, she didn’t have metastatic disease, but her breast cancer was very advanced (Stage 3), and her chance of cure was lower with all those involved lymph nodes. I am usually calm, but I had to hide my anger as I listened to her story. She was sad to hear that I recommended chemotherapy—she didn’t want to lose her hair, and she wanted more children—but ultimately agreed when I explained how she would benefit.
Afterward, I vented my frustration in private to Dr. Zola. How could that local provider be so ignorant? How can anyone see a breast mass and ignore it for months? How could the system have failed this young woman so profoundly? It was horrible, it was unacceptable, it had to change. Dr. Zola argued with me that patients had to bear some of the responsibility for making sure that they received proper care. He described a couple cases of patients who refused biopsies or ran away instead of undergoing complete investigations for their suspected cancers, because they were scared. “She should have insisted on a biopsy, she knew it was a problem,” he argued. It’s very common here for patients to go to local “traditional” healers first, who may use various herbs, multicolored strings around the waist, or knives to create patterns of scars on the tumors. Many patients are also intensely religious, and go to churches which preach that prayer is the best way to heal disease. They decide to take their chances with God’s mercy instead of coming to a hospital and getting medical treatment. Treatment can also have profound consequences on patients’ lives. Some female patients with breast cancer do not want to get mastectomies because they fear they will no longer be attractive to their husbands, and will be abandoned. Some male patients refuse to get orchiectomy (surgery for testicle removal) to treat their prostate cancer or penectomy (surgery for penis removal) to treat their penile cancer because they fear that they will no longer be men without those organs. I can do my best to explain what I predict will happen to a patient, based on my own prior experience with patients who had the same type of cancer, or based on the results of large published studies, but this often doesn’t translate well—due to differences in both language and culture.
For this particular patient, I stood by my opinion that the system had failed her. But I conceded that Dr. Zola was correct about one of the key contributors to delayed cancer diagnosis in Botswana—patients’ fear. In addition to educating local care providers about the early signs and symptoms of cancer, and the importance of referring these patients for biopsy quickly so they have a higher chance for cure, we also have to work on educating and reassuring patients about getting evaluation and treatment. If their fears scare them away from us, their cancers will progress and by the time all their other approaches—traditional medicine, spiritual practices, denial—fail, we will have very little to offer them. The key to success for treating cancer is early diagnosis and treatment. The later patients are diagnosed and treated, the less likely the treatments will be successful, and the more they will suffer. There are several NGO’s working on cancer awareness in Botswana (including the Cancer Association of Botswana and Journey of Hope but if the patients we see are any indication, we still have a lot of work left to do.