31/07/2016

Breast course for Nurses: annual fundraising event

We had our annual fundraiser/thank you event on Friday.  It was held at the Atlantic Imbizo at the V & A Waterfront.  Although largely sticking to the familiar format of previous events, this year we had a lunch rather than brunch.

I gave a summary of courses taught in recent months and new nuances in our approach, we then had a discussion about teaching adults rather than children.  We had contributions from different perspectives, including those of Prof Dave Woods, Joy Crane, Merunisa Mohammed, Josie Edge and Karen Hill.

Several points were raised:
-Karen Hill stressed that the content needs to be relevant, teaching things appropriate to work places
-Time spent talking needs to be short: Joy pointed out that after 10 minutes attention starts drifting off
Tony Brutus, Prof David Woods, Joy Crane
-Technology should be used appropriately (not as a barrier).  Josie Edge is my niece.  She has been visiting schools in Cape Town and noticed that as a result of less technology, there was a closer communication between teacher and pupils.
-Dave Woods recommended that we should not try and teach but to share understanding.
-Merunisa has been involved in teaching for many years and now teaches teachers.  She said that it was time to change from focus on the teacher, to the knowledge already in the class when teaching children as well as adults.

Ariella in action


After an excellent meal, fund raising took the form of an auction.  We were lucky enough to have Ariella Kuper as the auctioneer this year.

Watching her in energetic, inimitable action was remarkable.
We had many lovely gifts and I would like to thank all those who donated them as well as those who bid for them.  The raffle raised a record amount.



The event was extremely well organised: a special thank you to Michelle, Lieske, Nadia, Gadija and Josie.

Nadia, Gadija, Michelle and Josie wearing the new T shirts

As a result of all the generosity of those who support us, we can start another year of projects and we have plenty of requests and new ideas in the pipeline!

Lieske's BCN nails



09/05/2016

BISSA: a surgeons perspective

BISSA, the Breast imaging Society South Africa, held a conference at Spier this weekend. It was a joint meeting with SBI (Society Breast Imaging) and RSSA (Radiological Society of South Africa)

The majority of the first day was about breast screening.  The speakers were all radiologists from the USA so the emphasis was on mammographic screening.  There was little debate about the problems
with screening programmes.  For example: does breast screening lead to the over treatment of breast cancers that would never cause a problem?
Perhaps, not surprisingly as it was a radiological conference, that problem was attributed to treating clinicians who over treat them!  (The argument put forward was that the radiologists only diagnose the small cancers:  it is the surgeons and oncologists who over treat them).

I may be biased but I don't think that is a true reflection of the situation!

There was a lot of discussion about supplementary imaging of the breast.  Breast screening generally starts with a mammogram.  When should an ultrasound be performed?  Are more cancers picked up as a result of doing more US?  When should a breast MRI be performed?

The important question that is much more difficult to answer is does more imaging stop women dying from breast cancer?

The second morning was spent on interpretation of images: mammography, US and MRI.   Prof Michael Linver gave a talk about the role of the Radiologist as a clinician.  He stressed the importance of doing a thorough breast examination and communicating with both the women being imaged and other members of the multidisciplinary team.

The afternoon session was a multidisciplinary session.  The first talk, given by Dr Jakolsen, was about screening for metastatic lesions after the diagnosis of breast cancer.  She made 2 main points. Patients with early breast cancers (Stage 1 or stage 2A) need no screening for metastatic lesions.  Physiological screening (PET Scans) may be better than anatomical imaging for those who do.


Dr Sarah Nietz gave an excellent talk on the changing face of breast surgery. She was followed by Prof Frank Graewe who talked about breast reconstruction and then Dr Rika Pienaar who talked about how the histological subtype of the cancer should direct follow up imaging rather than stage of disease.

The final day started with Dr Simon Nayler (pathologist) who talked about the information needed from radiologists.  Once again, the need for multidisciplinary discussion was stressed.  Dr Smilg gave an excellent talk on breast changes in HIV positive men and women.  Dr Ramaema gave an overview about TB of the breast. There have been no prospective studies done on the subject.  A retrospective study done in SA by Dr Ramaema looked at the use of PET scan/MRI scan in differentiating breast TB from breast cancer.  (My experience in Cape Town is that only 50% of women who present with TB of the breast are HIV positive).  Dr Loftus gave an overview of the Xhosa perspective of breast cancer.

The majority of talks at the the conference were from the guest speakers, Prof Jessica Leung, Prof Michael Linver, Dr Maxine Jochelson, Dr Reni Butler and Prof Wendy DeMartini, who are all from the USA.  I learnt a lot from all of them but as this is a Cape Town blog have chosen to write more about the local speakers.

Many thanks to the local organisers: Prof van Rensburg, Dr Eugene Jooste and on a personal note, I would like to thank Dr Richard Tuft.  Please come to BIGOSA in Joburg on 21st and 22nd October.


26/04/2016

The people behind the Breast Course for Nurses in Harare

We have run a number of courses throughout South Africa and Southern Africa. Each one is different. Standardisation of what we teach is difficult to combine with the flexibility that makes our course appropriate to our audiences. What is standard is the amount of work involved in the organisation of a course!
Students with the Pathcare and Lancet sponsored Breast Care books

The catering department

The driving force behind the Harare course has been Dr Anna Nyakabau. She is a well known oncologist in Harare and devoted an enormous amount of time to getting the week up and running. The course was run at Parirenyatwa Hospital. It is an enormous complex of hospitals. The grounds are beautifully kept and are about 400 000 square metres. We were made to feel extremely welcome. We had our lectures in the rooms used by WHO and, everyday, had an excellent lunch served on time to a variable number of people.


Dr Anna Nyakabau






 I know that Anna had many meetings with the staff at the    hospital. For me to try and name them individually would    mean I would exclude some who had been instrumental in  ensuring the course succeeded. However, I had the              pleasure of meeting Mr Zigora, the CEO of the hospital,    and would like to thank him for his support.








Anna is a great organiser. She had the team she worked with behind, beside and in front of her! Primrose and Nyasha were at the forefront and coped with all the registrations and day to day work. The tech team: Vimbiso, Alban, Brighton, Benias and Gift, were excellent. What a difference it made to me to be able to give my laptop to various people and ask them to fix it!

Nyasha and Primrose
Dr Linda Kumirayi 




On 08/04/16, we ran a workshop on the management of the axilla in women with breast cancer. The day would not have been possible without the help of Dr Nancy Jonker and her team at the Well Woman clinic, Prof Godfrey Muguti and Prof Chidzonga from the University of Harare Medical School.
Workshop: management of the axilla in women with breast cancer
Dr Maita Mvere







A course like this costs money. There were many sponsors both of the 3 day modules and of the workshop held for surgeons on the 08/04/16. Please find their logos (in no particular order) and links to their sites below.









Dr Anna Nyakabau and Dr Costa Maonei (of Novartis)
Finally, a huge thank you to Dr Sarah Nietz who joined me for the workshop on 08/04/16, Prof Woods who joined me at the beginning of the week and Sr Lieske who was there all week.

BCN Module 1 course group
http://www.novartis.co.za/
http://www.novartis.co.za/


http://www.bardmedical.com/



http://www.pathcare.co.za/


http://parihosp.org/



http://www.lancet.co.za/ 


http://www.cimas.co.zw/


14/04/2016

Breast course for Nurses Module 3: Zimbabwe

Discussion - Module 3 course
For the first time, we have run a day for doctors and oncology sisters. By dividing the course up into 3 modules, we have been able to stratify the course content to suit different health professions. Nonetheless, we started the day with the normal breast and assessment of the breast.



When looking at the provision of health resources in developing countries, pathology has often been overlooked. Without a reliable diagnostic service, it is impossible to treat patients appropriately. It was really inspiring to hear Prof Rudo Mutasa speak about different types of breast cancer. She referred to the cancer registry of Zimbabwe and talked about the need to collect accurate data.

Prof Rudo Mutasa
After the tea break, Dr Linda Kumirayi, Dr Sandra Ndrukwa and I talked about the importance of neoadjuvant therapy in the management of locally advanced breast cancer. In Zimbabwe, as in many neighbouring countries, a lot of women have locally advanced breast cancer at the time of diagnosis. Instead of surgery always being the first intervention, it is preferable to use systemic therapy first whenever possible.

The diagnosis of breast cancer is often difficult so we had a session on breast biopsy. In most of the developed world, biopsies are done under image guidance. However, when the cancer is easily palpable, it is not always easier to use imaging: it may be accurate and more appropriate to biopsy without imaging. Dr Mvere and I ran the session and debated the pros and cons as we went.

In the afternoon, we had a discussion about appropriate breast screening in Zimbabwe. Cervical screening clinics are fairly readily accessible in most provinces. Should breast examination be offered at the same time? According to the cancer register, the incidence of cervical cancer is much higher than breast cancer. Is that a true reflection of the disease profiles or as a result of improved screening?


Doctors and oncology nurses attended the course

Many thanks to everyone involved and of course to our sponsors, to name a few: Lancet, High Tech Medical, Bettercare and all individuals that have supported the course through funding.

12/04/2016

Module 2 Breast Course for Nurses: Harare

Dr Ndrukwa
Module 2 of the altered Breast Course for Nurses was designed for doctors and RNs. We capped the number at 50 but in fact we had nearly 80 students.

Dr Linda Kumirayi is the first female to go through the surgical training in Harare. She has an interest in the management of breast diseases and gave the first lecture: benign changes of the breast. I gave a talk on the principles of cancer management and Dr Ndrukwa (oncologist) completed the session by giving the talk on side effects of cancer treatment.


At lunch time, I was invited to give a lecture in the medical school. The title was "The evolution of the management of breast cancer." I started by thanking Dr Anne Gudgeon and Dr Annetjie Scheepers
who helped with the lecture. The lecture began with the Egyptians, went through the principles of evidence based medicine and finished by discussing a future of personalised medicine.

Most of the discussion afterwards was about the incidence of breast cancer in African black women compared to white women and whether the younger age of presentation seen in that group was a reflection of the demographics of the population or whether there is a true difference. Until we have more accurate cancer statistics from around the continent, we won't know the answer. Zimbabwe does have a cancer registry. There has been an increase in the incidence of breast cancer in women. In 2001, 303 were recorded as having breast cancer. In 2012, 403 breast cancers were recorded.

Ms Francis Tsikai
Whilst I was away, the course continued with Dr Dickson Chifamba and Ms Francis Tsikai running the palliative care session. Francis spoke about the importance of psycho social issues. They both work at the Island Hospice, Harare. The chapter in the book on palliative care was written in conjunction with St Lukes Hospice team from Cape Town. The principles of palliative care are the same whether in Cape Town or Harare.





Dr Mvere is a radiologist working at the Well Woman Clinic in Harare. She ran the session on investigations of the breast demonstrating some of the pitfalls in biopsy techniques. Sr Lieske finished the day with the very necessary session on the management of locally advanced breast cancer. Something we all see too much of.

As always, a thanks to our sponsors: BARD, Netcare Christiaan Barnard Memorial Hospital, Parirenyatwa Hospital and the Association of Radiologists and Radiation Oncologists of Zimbabwe (ARROZ).

I will leave Respect to sing our thanks with Dr Anna

Respect singing "thank you"

A group of students with their sponsored books: thank you Lancet and Pathcare



11/04/2016

Module 1 Breast Course for Nurses: Harare

We are running the Breast Course for Nurses in a different way this time. We have extended the course to include sessions on the management of breast cancer. (The Breast Course for Nurses has grown out of the PEP series). The principle is that our job is provide health care workers with relevant accessible material. We asked all of the nurses present at the course on Monday to take part in the teaching.

Jasmine thanking the kitchen staff
Jasmine spent the evening studying her book and gave an excellent lecture on the normal breast. We gave her the slides, she studied her manual and the result was a comprehensive summary of the subject.

Sr Sue









Sr Sue is one of the nurses working at Parirenyatwa Hospital. She gave the lecture on lymphoedema. Proud, Thembie and Loice took us through the exercises. Sue also arranged for us to have the session on examination of the breast in the school of nursing. It made the clinical situation far more realistic. A lot of men attended the course. They volunteered as patients and we were fortunate enough to have 2 patients.



In the afternoon, we had a discussion on what can be done to increase awareness in the community. Many interesting ideas came out of the discussion. There has been a lot of work done to target HIV positive patients and many women attend for cervical screening regularly. Many nurses felt we should look at how that has been achieved. Can a similar programme be run to increase breast cancer awareness and can the stigma attached to having cancer be challenged.

Zimbabweans pay an HIV tax.  Is cancer becoming a big enough problem to justify a cancer tax?

Tholakela Khumalo and Ms Prisca Mupfumira
The course has been organised by Dr Anna Nyakabau. She has been supported by Parirenyatwa Hospital. At the beginning of the day, we had a formal opening ceremony attended by Dr Kanyowa (WHO representative), Dr M Chemhuru (Ministry of Health), Mr Mangwanya (Ministry of Health), Mr Banhwa (UZ School of Radiographers Director), Rumbidzai (Parirenyatwa Public Relations Representative), Dr Anna Nyakabau (oncologist) and Prof David Woods who was travelling with us from South Africa. Later in the day, we were joined by 2 ministers: Ms Prisca Mupfumira (minister of labour) and Tholakela Khumalo (MP). We were very pleased that they chose to stay for the discussion as to the way forward.

The course has been generally sponsored by many people.  I will list them all in the next few blogs. To start with a few, Dr Costa Maonei has been present for the whole week and represents Novartis. They paid for our transport and accommodation. We would also like to thank CIMAS, Pathcare, Sky Pharmaceuticals and the catering department!

Anna and myself at the opening ceremony
The course takes a lot of organising and a lot of time and energy. My reward is seeing nurses using the course material and teaching others having understood the issues themselves.

The opening ceremony







08/04/2016

Train the trainers course Zimbabwe

The Breast Course for Nurses is in Harare for a week.  We have a very busy week!

If the Breast Course for Nurses is to be sustainable, it has to be able to be taught without any of us from Cape Town being involved.  The first course taught in that fashion is being taught in Johannesburg. Dr S Nietz is running the course.  We are rolling out that programme so the project is self sustaining in Zimbabwe.

Train the trainers course
On Monday, we had the inaugural train the trainers programme run by the Breast Course for Nurses. Prof Woods (PEP foundation) and I ran the day.  The morning was spent discussing different modes of teaching.  We stressed the importance of teaching being viewed as a method to transfer knowledge and enable understanding. Teaching a mixed group of students, as we do in the Breast Course for nurses, is always a challenge.  At the beginning of every day, we spend time finding out who the students are and where they are from.  Our course is based on a student based style of learning.  We are faculty: our job is to provide relevant material in an understandable format and help with understanding.
Prof David Woods

Dave Woods has been involved in distance learning for the last 20 years. He gave many suggestions as to how learning could be made more interactive. HIs ideas included study clubs, quizzes, role play, case studies, assignments, games and music. The discussion extended into the use of technology to promote intertactive learning: Facebook, sharing SMS messages, Whatsapp groups and Skype.











Esther presenting her microlecture




In the afternoon we gave some of the candidates 3 slides and asked them to give a micro lecture.  We covered 16 different topics and we were amazed at the professional level of the presentations.  We were all filmed while we lectured.  Dave Woods went through the video and extracted examples of us teaching well and not so well.  It is very tough to look at your self lecturing! 

We ended the day by involving the students for the course the following day. They were given a lecture to prepare for the following day to present to the students attending the Breast Course for Nurses.