Special Feature

Conquering the Real Killers

Thousands of women in Bangladesh are dying from breast cancer each year. Lack of awareness, lack of finances and social taboo are all to be blamed for this losing battle.

Anika Hossain

“When I first noticed the small lump on my breast, I didn't take it very seriously because it didn't cause me any pain or discomfort. I ignored it for about a year before I confided in my daughter. She and her friends forced me to consult a physician. It was then that I discovered I had breast cancer,” shares Hena Kabir, as she recalls the beginning of her long drawn out battle with cancer and her triumphant recovery.

According to research, about 35,000 women in Bangladesh develop breast cancer every year, and most do not seek treatment for this deadly disease. This is because about 79 percent of the Bangladeshi population reside in rural areas, and due to ignorance, shyness, social taboos and economic reasons, they suffer silently from this illness. Most of these women have heard of cancer, but very few know what breast cancer is, so when they notice lumps or tumours they simply ignore them if they are not painful. Women in Bangladesh are reluctant to show their bodies to strangers and will therefore avoid visiting a doctor unless it is absolutely necessary, a practice which is encouraged in most Muslim communities. If a woman does get diagnosed with breast cancer, in most societies she is treated like an outcast and her disease is assumed to be contagious. In a number of cases, marriages break up and her entire family is shunned by the society. This is true for all classes of society in this country. Amongst the women who have passed away from breast cancer; there have been doctors, professors, students, day labourers and housewives. The treatment for breast cancer is very expensive and due to a lack of health insurance, most members of the populace are unable to get the care they need to survive.

Of all the different types of cancer that can attack our bodies breast cancer is the easiest to cure, but it is also the most dangerous. According to a WHO (World Health Organisation) report made in 1985, about five million people die of cancer every year, and it is predicted that this number will rise to 10 million over the next 25 years. The key to conquering breast cancer is to identify it, understand it and to know how to treat/prevent it.

Breast cancer arises in breast tissue and is simply the abnormal growth patterns of a group of abnormal cells. It is the most common type of cancer that occurs in women, but it can occur in men as well. Although women usually develop breast cancer between the ages of 25 and 50, there is no guarantee they will not fall victim to this type of cancer at a later stage of their lives.

There are different types of breast cancer. Breasts are made up of fat, glands and fibrous tissue. They have several lobes, which are separated into lobules and end in the milk glands. Tiny ducts run from these numerous glands and connect together to end in the nipple. 80% of breast cancers usually occur in these ducts. This is known as ductal cancer.

Cancer that develops in the lobes is called lobular cancer and about 10-15% of breast cancers are of this type. Other types include inflammatory breast cancer, medullary cancer, phyllodes tumour, angiosarcoma, mucinous (colloid) carcinoma, mixed tumours and Paget's disease, which is any type of cancer that involves the nipple area.

Cancers can also spread into the tissues surrounding the breast, and in such cases they are known as infiltrating cancers. The most serious types of cancers are metastatic cancers, which spread to tissues distant from the original site of the tumour. The most common sites for breast cancer to spread are the lymph nodes under the arm or above the collarbone on the same side as the infected breast, the brain, the bones and the liver.

The question that comes to mind at this point is: What are the causes of breast cancer? There are several risk factors, gender being the most important. Women are more likely than men to develop breast cancer. Age is another factor. As mentioned before, women between the ages of 25 to 50 are at a high risk, but it is not improbable for women beyond 50 to develop this disease as well. A woman with a history of cancer in one breast is more likely to get infected in the other. Genetics play an important role in the development of breast cancer. If close relatives from either side (maternal and paternal) side of the family have a history of cancer it is likely that a person will be prone to it. Having relatives with both breast and ovarian cancer can increase the risk of being infected, especially for women.

Hormones may play a role in the development of breast cancer as well. Women who start their period at an early age (11 years or younger) or experience a late menopause (55 years or older) are at a risk of developing breast cancer. On the other hand, starting their period at an older age or early menopause can protect them from breast cancer. Having no children may increase the risk of breast cancer, but having a child before the age of 30 can reduce the risk considerably. A study conducted by the Women's Health Initiave in the USA showed that postmenopausal women who use estrogen and progesterone for several years are more likely to develop breast cancer. Therefore women should take care and consult their physicians before using hormone therapy for menopausal symptoms.

Lifestyle and diet may contribute to the development of this disease as well. Studies show that breast cancer occurs more frequently in countries that have a high intake of fat in their diet. Obesity is a risk factor, especially for pre-menopausal women. A high intake of alcohol is also a risk factor for the development of breast cancer, as shown in various researches. Environmental causes such as exposure to radiation can also lead to the development of breast cancer.

In Bangladesh, women living in rural areas are less prone to breast cancer than those residing in large metropolises. This is because of the practice of early marriage, early maternity, the consumption of a low fat diet and the habit of breast-feeding. City women are usually more career oriented and tend to marry at a later age. Because of the availability of a variety of baby foods in the cities, women also tend to avoid breast-feeding if possible. The diet is also vastly different in cities as there are more fatty foods available.

The next question that comes to mind is: How does one know if they have breast cancer? There are several symptoms that may act as warning signs for cancer. Breast lumps must be checked by doctors immediately, all breast discharge (fluids) should be evaluated, especially if it is from only one breast or if it is bloody, nipple inversion is another sign that should cause concern. Redness in the skin, changes in skin texture and puckering can also be associated with breast cancer and must be immediately evaluated. “Most women notice lumps on their breasts, but will not be alarmed unless they are painful. By the time they come for treatment, the cancer has already reached an advanced stage,” says oncologist Dr Riffat Khan.

Breast cancer is not difficult to cure, but it can be expensive. Surgery is the first step toward recovery. This involves the removal of the lump and the type of surgery depends on the size and location of the lump/tumour. “The surgery can be tricky unless it takes place during the early stages of cancer. As it grows, the tumour will begin to resemble a Hog plum (Amra) seed with tentacles and will be more difficult to remove as it spreads,” says Dr. Khan, “breast sparing surgery is often possible, but this option is not widely available to women in this country. If a breast sparing surgery is conducted, the patient has to go for follow up check ups for a longer period of time than they would if the entire breast was removed. Many women require radiation therapy, chemotherapy and hormonal therapy depending on the type of cancer and the stage that it is at. “The entire process can be very costly, but the government hospitals will assist the needy with grants if they are eligible. Some patients who come from villages have to bring a letter from their village chairman explaining their financial situation in order to receive this grant,” relates Dr Khan.

Apart from the medical aspect of the process, psychological treatment is also necessary for a breast cancer patient to work toward recovery. “If I did not have my friends and family to support me and hold my hand while I went through 16 chemotherapy sessions, I don't know what I would have done,” says Hena Kabir “ it is so important to keep oneself distracted and cheerful. If you dwell on the fact that you have cancer, it can drive you mad.”

Wary of the exorbitant medical bills procured by expensive tests such as mammography and the lengthy treatment procedure, many shy away from obtaining treatment that they need. To help these unfortunate people, Parveen Ahmed, a survivor of this deadly disease, along with 12 other women formed Aparajita, a society against breast cancer, the only survivor's group for women suffering from this illness in the sub-continent. “It takes five years to find out whether you are truly out of danger,” says Ahmed “at the time when I was diagnosed, there were no proper treatment centres in Dhaka for breast cancer. We had to go to India for treatment. Things have improved now.”

Parveen Ahmed and her group formed Aparajita in hopes of making the journey toward a cancer free life easier for Bangladeshi women. The group visits various hospitals for cancer patients and selects the most needy and critically ill breast cancer patients and raises funds for their treatment. “The funds are all private donations at this point. Mostly contributions from our friends and family members. We receive donations from anyone who is willing to contribute to this cause,” she says “the most pressing concern of all the patients we visit are financial ones. Once we are able to assure them that their treatment can be paid for, it puts their mind at rest. We can then counsel them about their anxiety and stress related to having a possibly fatal illness.” The group also visits schools, colleges and factories within and outside Dhaka and speaks to women about breast cancer, trying to educate them and to raise awareness about the illness.

Dr Riffat Khan, who is also a survivor of breast cancer and a member of Aparajita has been visiting various different sites with the group in order to provide counseling. “I have recently been to a garments factory in Savar where all the female workers were completely ignorant about this disease. Some were happy to receive information and learn self-checking techniques, while others were extremely worried. I advised women to check their breasts for lumps about a week after every menstrual cycle. This is important, especially for those who have relatives who have suffered from cancer. We discovered that some of the workers had the lumps we had just described, and I advised them to come to Dhaka for further check up,” says Dr Khan.

“Being a survivor myself, I know where these women are coming from and how they feel. I remember how frightened I was when I learned about my cancer. I had to go to India for treatment because there was none available in this country back then. I lost all the hair on my head and all over my body and I had no eyebrows or eye lashes after going through extensive chemotherapy. I had hair that came down to my knees at that time and was very fond of it. My doctor had asked my family to remove all the mirrors in our house so I couldn't see what I looked like. At a time like this, psychological counseling is very important to restore ones self-esteem and ease ones anxiety. I went through extensive rehabilitative therapy during my recovery. My husband, my children and my relatives were my greatest support. I feel lucky because most of the patients who come to me have been abandoned by their husbands and families” shares Dr Khan.

The members of the Aparajita group are all survivors of breast cancer who learned how to counsel victims of breast cancer through their own rehabilitation process. “We were taught self help and counseling,” says Parveen Ahmed. Ahmed mentions that other well known places in Dhaka that provide treatment for breast cancer include the Women's Breast Cancer Hospital, The Mohakhali Government Hospital and Ahsania Misson. “All hospitals have a unit for breast cancer these days and are equipped for mammography tests etc. Private hospitals such as Square and Apollo are also good places to go if one can afford it,” she says “It costs about one lakh twenty thousand Takas a year to treat a breast cancer patient. We are trying to raise as much as we can.”

Although women are at risk of developing breast cancer throughout their lives, there is hope for prevention if they follow a certain lifestyle. Simple measures can be taken to reduce the risk significantly. Experts recommend maintaining a healthy body weight as an effective measure against breast cancer. Regular exercise (30 minutes a day) and a healthy diet rich in fruits, vegetables, whole grains and non fattening foods will help one avoid obesity and therefore reduce the risk of cancer. Studies have shown that vitamin D is effective in reducing the risk of breast cancer. Vitamin D is naturally present in foods such as egg, cod liver oil, tuna, margarine, butter (fortified) and it is also available as a dietary supplement. Hormone replacement therapy increases the risk of breast cancer and should be avoided if possible. We cannot control some of the risk factors of breast cancer, such as age, genes and the environment, however, if we make the right lifestyle choices, we may be able to reduce the risk to a certain degree.

“I think I survived the entire ordeal because I kept telling myself it's just an illness like any other and I will get better.” Says Hena Kabir “I was determined not to give up or break down. My doctors and nurses told me they had never seen a breast cancer patient as brave and strong as I was. I was able to keep myself occupied and cheerful and I even managed to make my fellow cancer patients laugh. My advice to all breast cancer patients is, be strong, do not give up and your strength will be the key to your survival,” says Kabir, who has fought a brave battle, won, and is now living a cancer free life.

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