I quickly learnt in clinical practice as a breast surgical oncologist to always carry an extra pack of tissues. Patients can cry when they find out they have cancer. Sometimes it's tears of outrage—when a patient tells me she has been in and out of hospitals for the past 6 months and health workers have repeatedly prescribed different antibiotics for her now fungating breast mass. There are also tears of relief—as a diagnostic dilemma turns into a simple condition that only requires follow-up and no surgery. Yet watching patients cry still makes me a little uncomfortable, especially because it engenders a sense of helplessness or a visceral feeling of sharing the patient's pain. I also think how presumptuous it is to imagine I know what someone else is going through, and I often wipe away a discreet tear. As their doctor, I need to stay strong to give patients hope about the future and the journey I am about to walk with them.
So it was disconcerting when a post-operative patient burst into tears as I sat down to share lunch with her on the ward. She had been referred to our centre after a breast excision biopsy and needed a completion mastectomy and further treatment. After a multidisciplinary team discussion, we counselled the patient and her husband on the diagnosis and treatment plan and discussed the possibility of reconstruction. As a young, working mother who had to pay for her care out of pocket, she was unable to meet the costs. She had some support from Kenya's National Hospital Insurance Fund and the hospital support fund had given a bit more, but breast reconstruction is still viewed as a cosmetic procedure and few insurance companies cover it. “Let's focus on getting the cancer out doctor”, she told me. “I will deal with the reconstruction later.”
We planned for a mastectomy. But her partner and his family did not want her to lose a breast and advocated for her to drink some herbal juices, which they believed would “starve the cancer cells” and cure her. Our social worker and the team tried to overcome this impasse by educating the couple about breast cancer. In the end, the patient had the procedure. Yet our efforts also failed. Her husband sent word through a relative that she shouldn't bother going home once she left the hospital. When she was due for discharge, we scrambled to see if any of her friends could find her somewhere to stay. I was preparing my words of comfort when she suddenly smiled through her tears. “Thank you. I didn't think I could handle all this, but you have all supported me. Now I think I can go on”, she said.
A diagnosis of cancer is never easy. For the most part, families and partners are supportive. Yet I am constantly faced with stark reminders that in sub-Saharan Africa the stigma around cancer still casts long shadows, and telling a woman she has cancer comes with a complex rider that she could also potentially lose her source of livelihood or her family support. The ghosts of sociocultural constructs and patterns, both past and present, appear as constant apparitions in our patients' cancer journeys.