I can now go safely when my time comes ...

Her last rite was a wedding in hospital
“Will I be able to have children after the chemotherapy treatment?” Agnes Kioko asked.

“Unlikely,” I said. “Because chemotherapy knocks out the ovaries and production of eggs is suppressed once they have been bombarded by these very strong drugs.”

As Agnes was pondering over what I had said, I added: “Also there is some controversy about whether women should be allowed to conceive once they have been diagnosed with breast cancer.

Being a disease largely attributed to female hormones, which go out of synch during pregnancy, some of us believe in maintaining the hormonal equilibrium and advise against pregnancy.

“If the patients insist on having children, we tell them to let a few years pass between the completion of treatment and pregnancy.” Seeing the disappointment on her face, I concluded: “Anyway you have three children, so the question should hardly arise in your case.”

Agnes had been referred to me by a doctor in Kitui a month earlier. She was accompanied by a Mr Baloi, whom I initially mistook for her husband. He handed me the doctor’s letter: “Agnes has a lump in her left breast. I arranged a mammogram and ultra sound and they both proved very suspicious,” Dr Tanga had written. “I sent her for a core biopsy of the lump and this has confirmed a malignancy. Over to you!”
History taking

In my history taking, it came out that the couple had been told the diagnosis, which made my life easy. In case of breast cancer, the hardest part for the surgeon is to disclose the nature of the disease and treatment. I further discovered that Agnes and Baloi were not married but lived together and had three children, two boys and a girl.

“I see you follow the modern trend,” I said to lift the gloom of malignancy which had descended on us as we were discussing Agnes’ breast cancer and what her treatment implied.

“People don’t marry anymore but live happily together and enjoy all the amenities of married life without being forcibly tied together by a piece of paper called marriage certificate.”

The reaction on the couple’s face, as far as I could fathom, said it all. Baloi’s carefree mien suggested that he enjoyed the privilege without corresponding responsibility. Agnes’s expression indicated that, as a woman, she felt differently.

After further investigations and due preparation and counselling, Agnes underwent mastectomy, which was uneventful. Her operation wound had healed very nicely, the stitches were out and I had referred her to my chemotherapist colleague. It was in connection with this referral that we were discussing the side- effects of this treatment, especially its impact on the woman’s fertility.

“Also depending upon the type of tumour, we might have to give you anti–hormone tablets,” I reverted to the main thrust of our discussion. “Nevertheless, as I said earlier, by and large oestrogens are considered to be the cause of breast cancer in women; some tumours are specifically hormone dependent. We can identify them through a special test in the laboratory.

Those which are hormone-dependent have a better outlook and are likely to benefit by Tamoxifen or Arimidex, both of which suppress the secretion of oestrogen, resulting in a better control of the disease,” I laid it all out, loud and clear.

Test results
At that point, my secretary informed me on the intercom that Agnes’ hormone receptor test result had just arrived and brought it in to show it to me. It was strongly positive suggesting that her tumour was highly hormone-dependent. I thought that giving her this good news might soften the blow of not being able to have more children.

“The result in your case has come and I am sure you will be glad to know that your tumour is strongly oestrogen and progesterone positive.”

As she looked at me asking for elaboration, I added: “You will benefit greatly from anti-hormone tablets.” As I saw a faint glow of optimism on the faces of the couple, I emphasised the main drawback of this treatment. “It is unlikely that you will conceive while you are on this drug.”

Once Agnes finished her chemotherapy, as per our protocol, I prescribed Arimidex for her, one milligram tablet daily. “In our present knowledge based on sound research, we give Arimidex for five years,” I said to her. As usual, I saw Agnes periodically thereafter.

It was last year – almost six years after her mastectomy and one year after she finished her anti-hormone tablets – that on her usual follow-up visit, I noticed something ominous. She seemed short of breath as she talked to me and was coughing a lot while I examined her. Her eyes looked a shade yellow. “How have you been?” I asked the usual question. “I’m alright,” she said. “Except for pains and aches in my body.”

At the end of my examination, I was more dismayed.

Her cough, early jaundice and “aches and pains”, as she put it, could all be explained by metastasis in her lungs, liver and bones. “I think we better do some tests,” I made the cautious remark.
Baloi and Agnes were too smart to miss the significance of my suggestion. So when they came to see me after the investigations were completed, Baloi asked me, his anxiety obvious on his face: “What do the results show?”

“I am afraid they show that the disease has recurred in the lungs, liver and pelvic bones.”

Change the drugs
Admiring the fortitude on the face of my patient, so typical of women under trying circumstances, I added: “I think I need to refer you back to Dr Ogola, the chemotherapist who treated you after your surgery. He might have to give you a different course of drugs.”

I talked to Dr Ogola on the phone and updated him on the latest developments. He was kind enough to see Agnes immediately and rang me in the afternoon. “The course of chemo I intend to give is quite stiff and it is better done on an in-patient basis. I am, therefore, admitting Agnes under our joint care.”

That afternoon, Baloi was in my office. “How long do you give Agnes?” He asked without any softening preliminaries.

“Difficult to say. Some of them respond to chemo very well. Others are not touched or, worse still, react badly,” I replied.
“I have a special reason for asking you,” Baloi explained. “Agnes is very keen that we formalise our relationship. She is talking of a wedding.”

“What a good idea!” I replied. “I don’t think that your decision to get married should be dependent on how she will respond to the new treatment. The sooner the better.”

Optimistic

“Fine, I will schedule the ceremony soon after her discharge from the hospital, after chemotherapy,” Baloi promised.

Events, however, overtook us. Agnes reacted very badly to the drugs. Her white blood cells went down to merely five from the normal 12,000. We gave her some new medicine which had come on the market to quickly boost her white blood cell count. Her haemoglobin went to half its normal level and the platelets, which help the blood to clot, also went to a dangerously low level. I told my secretary to ask Baloi to come and see me.

“How are the wedding plans going?” I asked him as he sat uncomfortably in the chair opposite.

“All ready for when Agnes comes out,” he said quite unaware of what I had called him for.
“Can you bring them forward?” I asked.

“I can, but why?” he asked.
“Agnes is not well at all and Dr Ogola and I are very worried about her,” I said.

“You mean I should take her home and arrange the ceremony sooner than planned?” Baloi asked.
“I don’t think Agnes is fit to go home.”

“So what do you suggest?”

“I will talk to the CEO to see if we can solemnise the marriage in the hospital chapel, if you agree.”

They say everybody likes a wedding and this was true in Agnes’ case. Both the CEO and the hospital chaplain were excited at the idea. “I am tired of christening babies born in the hospital and giving the last sacraments to patients. It would be nice to solemnise a marriage for a change,” the priest said.

The matrimonial instincts of the matron also surfaced and she asked the nursing staff of the ward to give all the help needed to organise the ceremony.

So, on a Saturday morning, clad in a white wedding gown, prepared by the nurses of her ward, Agnes sat on a wheel chair. Because of secondaries in the lungs, she was breathless and an oxygen cylinder with a mask was ready at hand. Baloi looked very smart in a new suit and so was his best man. Their three children were dressed in their Sunday best. The hospital provided flowers and I paid for the cake.

Wedding vows
“I am so happy,” Agnes whispered to me after she and Baloi finished taking their vows and the priest completed the ceremony. They cut the wedding cake and, like is tradition, put a slice in each other’s mouths.

“I can now go safely when my time comes, with my marriage certificate, my wedding ring and the wedding sacrament provided by the Church.”

Those were her last words to me. That night, Agnes passed away in her sleep. As I went to certify her later, I saw her clutching the bouquet of flowers, the wedding ring was adorning her left ring finger, her veil and wedding gown were lying on the chair by the side of her bed.