Wanjiku’s case is unusual. She underwent a lumpectomy and was found to have a form of breast cancer called ductal carcinoma in situ (DCIS) or Stage 0 breast cancer. It was discovered in its early stages and thus she didn’t require invasive surgery into the breast tissue.
Wanjiku underwent a simple mastectomy and immediate breast reconstruction using muscle and fat from her waistline. Her case did not require chemotherapy or radiotherapy, maybe just a drug acting on hormone receptors to lower her chances of another cancer developing. In Kenya, cases like hers are rare, as most breast cancer cancers are diagnosed in Stage 3 or 4 — and cure is difficult. DCIS (Stage 0) has an excellent prognosis, with 98 per cent survival rate of patients diagnosed, unlike those presenting Stage 3 (40 per cent) or Stage 4 (10 per cent).
In high income countries like USA and Australia, 30 per cent of all breast cancers present as DCIS and almost 90 per cent of cases as Stage 0, 1 or 2, under early breast cancer. The survival rates for these early BCs is excellent, with over 90 per cent living healthy lives five to 10 years after their diagnosis.
In 1895, over 120 years ago, an American surgeon, Dr William Halsted, wrote a scientific article describing 50 patients he treated with breast cancer. Most of his patients — 68 per cent — presented in Stage 3 or 4. The disturbing thing is that this is the current situation in East Africa now. We are 120 years behind! Breast cancer management is complex and expensive.
There are different types of breast cancer, but 90 per cent are invasive ductal carcinomas and require multiple treatment processes — surgery, chemotherapy, radiotherapy, hormonal therapies and in one in four patients, newer but expensive biological therapies. Often the order of these treatments can be varied for different patients. The rarer breast cancer types are treated quite differently, such as Phyllodes tumours which often only need surgery.
Critical to deciding the correct breast cancer treatment is a core biopsy and a test called immunohistochemistry (IHC). Unfortunately, together these cost around Sh10, 000-15, 000 but they are a crucial starting off point for breast cancer management.
Once the core biopsy and IHC is known, and some breast imaging and staging tests are performed, the patient needs to be referred to a breast cancer team that consists of surgeons, oncologists, radiologists, pathologists, and importantly, breast care nurses. This group of experts will meet and decide which treatment to start with and arrange subsequent therapies. Kenya has a long way to go before we see most of its breast cancer patients starting their treatment at an early stage. I suspect quite a number seek help from a healthcare worker early, but various delays and poor management mean they don’t get appropriate treatment until quite late.
Wanjiku was lucky as her tumour did not invade — it remained in situ — despite forming quite a large lump, and she was able to get to expert care quickly. This is where Kenya must improve. Excellent care is available in Kenya. However, patients need to be referred early and have finances to cover costs.
Dr Bird is a General and Breast surgeon working in AIC Kijabe Hospital for over 15 years now.