Ian Patterson

Last month, I had the privilege writing an article for Buddies magazine.  I chose to write about the  the ABS (Association Breast Surgeons) conference in Birmingham, UK. It was an excellent conference.  Unusually for a surgical conference, there was a session devoted to bullying in the workplace.

Ian Patterson was a surgeon working in the Midlands, UK.  He has recently been convicted for over-operating on women without breast cancer and doing unconventional operations on women with breast cancer. He has been sentenced to 20 years in prison.  

What went wrong?  

The NHS (National Health Service) is very regulated: much more regulated than the health service in South Africa.  Although Mr Patterson was guilty of several misdemeanours, his offences fell into 4 categories:
1. He over-managed and over-operated on women: he exaggerated their risk of breast cancer and sent them for too many investigations.
2. He did an operation that he made up called a “cleavage sparing mastectomy” It is a mastectomy that results in a lot of breast tissue left after surgery which clearly results in a more “natural looking” breast as a lot of the “natural breast tissue” was left after the operation.  
Doing Oncoplastic surgery is complex.  As the cancer surgeon, we have to sometimes accept that removing skin over the area of the cancer will leave a scar in a less acceptable place.  THE MOST IMPORTANT THING ABOUT BREAST CANCER SURGERY IS THE ADEQUATE MANAGEMENT OF THE CANCER. That should never be compromised for a more acceptable cosmetic outcome.
3. He did not follow protocols for diagnostic procedures. (Ideally all patients with breast cancer should be diagnosed without having surgery.  An operative biopsy should only be done if the diagnosis cannot be made preoperatively.)

Anyone who has breast cancer is discussed at a multi-disciplinary meeting attended by oncologists, surgeons, radiotherapists, pathologists, radiologists, psychologists, nurse practitioners etc.  These meeting are highly structured.  So how did Ian Patterson manage to treat so many women in an unconventional manner for so many years.

He was a charismatic, charming bully.
He was not a trained breast surgeon
He was not a member of any specialist breast surgery organisations

For many years, sexist or racist behaviour has been addressed in the workplace.  Bullying has been harder to define.  Harder to regulate.  A comment made by a colleague may be interpreted as bullying by one member of staff but not thought of as being offensive by another.  There has been a culture of telling people to toughen up. An impression that the “victim” of bullying is to blame rather than the person doing the bullying.

Ian Patterson was reported in 2003 to hospital management.  A report was commissioned.  He was investigated by a head and neck surgeon.  (Not a breast surgeon).  In 2007, he was reported again.  He was allowed to choose the panel who investigated him!  The whistle blower was noted to have “personal difficulties”.  Mr Patterson was asked to refrain from doing unconventional treatment but was allowed to continue practising. At the end of the day, it was his patients who brought charges against him.  He was found guilty and his work colleagues were criticised for not being more forceful in their objections to his management.  

He has cost the NHS £17.4m so far. It is projected that it will cost £34m in total when all the claims have been settled. 1200 patients’ management have to be reviewed

How can we learn from this sorry story and prevent it happening to an individual?  Wherever possible, choose a surgeon who specialises in breast cancer management and regularly attends breast conferences and ensure the surgeon works in an MDT.


Breast Course for nurses CBMH

We have just finished another Breast Course for Nurses at CBMH.  It was a similar model but as always, there was something new.  The health care workers attending the course were a mixture of state and private nurses.  Not only did they come from different sectors but also from different disciplines.  Midwives, oncology sisters, ward staff, academic nurses, radiographers and clinic staff.  It is always more rewarding to teach a mixed group of health care workers as each discipline contribute a different viewpoint to a discussion.
Kate and Astrid giving lecture on lymphedema

The course was run over 2 days. Day 1 covered familiar territory.  Clinical assessment of the breast, benign breast changes, special investigations of the breast, wound care, lymphedema and advocacy and community working.  The lectures were given by a variety of people including Sr Karen Hill, Britta Dedekind, Sr Lieske, Linda Greeff, Kate and Astrid.  A huge thanks to all of them.

Day 2 concentrated on breast cancer.  The morning lectures were given by Dr Boeddinghaus, Dr Maurel, Dr Raats and Dr Dedekind.  Different aspects of breast cancer management were covered. After the tea break, we had a new session.  Dr Magda Heunis ran the session on follow up of breast cancer patients.  In Tygerberg breast clinic, we are in the process of developing a policy for breast cancer follow up.  We had a discussion about what a follow up programme should involve:surveillance for a new breast cancer, assessment of side effects from breast cancer treatment, psycho social support and a network for referral if there is another problem.  Who should see breast cancer survivors?  How often should women be seen?  How often should they be offered a mammogram? Thanks to Magda for giving a comprehensive overview.

Dr Riette Burger was involved in our program for the first time.  She is passionate about palliative care and has introduced a course for students at US.  She ran the palliative care session with help from Sr Margot van der Wielen from St Lukes Hospice.

Cornelli (Lancet) demonstrating a core biopsy
For me, this course was a lovely mixture of my colleagues from CBMH and my new colleagues from Tygerberg Hospital. I look forward to being involved in more public/private breast cancer initiatives. Thanks as always to Mr Tilney for his continued support for the Breast Course for Nurses. Congratulations to Wendy Bokwe who won the spot prize for suggesting yellow as a colour for breast cancer campaigns.

Thank you to Pathcare for sponsoring the Breast Care books that each participating student receives as their study material.  To all of our sponsors for this course: Pathcare, Netcare CBMH, Lancet Laboratories, Morton and Partners and all of those that gave time to lecture and prepare the course, a massive thank you!

Last but not least, it was wonderful to be with the familiar trio: Sr Karen, Sr Lieske and Michelle. Without them, none of this would ever happen.


Flamingo list. Tygerberg Hospital: over 100 procedures

Earlier this year, I started working at Tygerberg Academic Hospital (TBAH), Cape Town. I last worked there 18 years ago and returning has been quite remarkable.  I am working in the Breast and Endocrine unit with Dr Karin Baatjes and Dr Ilna Conradie.

In 2016, they started participating in the Flamingo project. The project was set up by a group of cancer survivors and volunteers, spearheaded by Dr Liaana Roodt. They fund "catch up theatre lists" which are done on Saturdays by volunteers. Initially, they were only at Groote Schuur Hospital. The result was that the waiting time for surgery for people with breast cancer dropped from 3 months to 6 weeks. Since Tygerberg has become part of the project, there has been a similar reduction in waiting time for surgery for breast cancer patients.

I have been involved with the last 3 lists.  In total, there have been 11 lists done over 9 Saturdays. 101 operations have been done benefitting 90 women with breast cancer.  The lists require enormous commitment from surgeons, anaesthetists, medical students, nursing staff, support admin staff and, of course, the Flamingo Project.  Last Saturday, we had 2 lists.

Prior to theatre, all the patients have to be admitted by the surgical team, (Dr Firdaus, Dr Changfoot
and Dr Botes). The patients are in the 2 main surgical wards, D3 and D5, (thank you to the nursing staff on duty).  Mr Visagie, (the theatre boss) coordinates their transport from the wards to theatre where they are looked after by the nursing staff. Sr Theron co ordinates the theatre nursing teams.  On Saturday,  we had 10 theatre nurses involved.

Once in theatre, they are anaesthetised by volunteer anaesthetists from both the department of Anaesthetics in Tygerberg Hospital and private anaesthetists. Thanks to Prof Levine and his team.
The operations were all done by Ilna Conradie, Karin Baatjes and myself.  Our assistants were medical students from the US surgical society.

In total, over 30 staff gave their time freely last Saturday.  Quite remarkable.  All of this is made possible by the management at TBAH (Dr Chiaparilli, Dr Maart and Dr Muller) and of course, Dr Liana Roodt and Project Flamingo.

The benefit to the women having their surgery at the weekend is immediate and obvious.  However, there is a benefit all our patients with breast cancer  operated on at TBAH as their waiting time is decreased.  From all of us, on behalf of the hundreds of patients who have benefitted either directly or indirectly, THANK YOU to the donors and supporters of Project Flamingo.


Kenya's 1st Annual International Breast Cancer Symposium

Sr Lieske recently attended the 1st Annual International Breast Cancer Symposium in Nairobi, Kenya. The following is a summary that she wrote of the 2 days that she spent there:

Lieske, Samuel and Julie
"I arrived on Wednesday evening to a green, lush and beautiful Nairobi. I travelled with Julie Belloni of Sysmex who was one of the sponsors for the symposium. Her colleague, Samuel, fetched us from the airport. He took us to have a taste of the local cuisine: pork and mukimo (a dish made from potato, maize, peas and onion).

The symposium was hosted by the Aga Khan University Hospital of Nairobi and the venue was the beautiful Trademark Hotel. The theme was "Updates in Breast Cancer Management" Both local and international speakers presented a wide variety of topics.

Day 1, session 1 started with a overview of the historical evolution of breast cancer management by Dr Miriam Mutebi, a local breast surgeon. Dr Mutebi has been involved with previous Breast Course for Nurses courses in Cape Town. Following this were lectures about the surgical and medical management of breast cancer.

Session 2 was mostly about imaging for breast cancer. The Aga Khan offers mammography, tomosynthesis, ultrasound, CT scanning and breast MRI. Stereotactic biopsy is available but there is no MRI biopsy currently available. With very few trained and qualified breast radiologists within Kenya, many of the peripheral hospitals and clinics offer ultrasound imaging but the images are sent to Aga Khan for interpretation. Session 2 ended with a presentation by Tayreez Mushani. Ms Mushani is the co-ordinator of the Oncology Diploma Program in Nairobi and she developed the curriculum for this programme, a first such programme in the East African Region. Since commencement in Aug 2016, 23 nurses have trained in oncology.

Session 3 included case presentations. Early breast cancer, Her2 heterogeneity and metastatic breast cancer cases were presented and discussed.

Lieske, Tayreez and Margaret
The day ended with 3 workshops. The members of the symposium signed up for the workshop of their interest. Track 1 was a surgical pathological workshop. Track 3 was a palliative care workshop. Track 2, which I was involved with, was an oncology nursing workshop. It started off with breast clinical examination (CBE) training by Tayreez Mushani and Dr Margaret Barton-Burke, a professor of oncology - department of nursing at the Memorial Sloan Kettering Cancer Centre. The nurses then got to practice CBE on models. We then went on to a session about lymphoedema. There are currently no trained lymphoedema therapists within Kenya. The Breast Course for Nurses material was used. I started with the anatomy and physiology of the lymphatic system. Following this, we went through the Lymphatic Education Africa risk factors. We then went on to go through exercises that the nurses can share with their patients. There was a lot of enthusiasm and I hope that there will soon be a few trained lymphoedema therapists in the country.

Nursing oncology track
Day 2, session 1 was mostly to do with patient support including the role of counselling and psychosocial support. I gave a talk on the use of alternative information sources used by breast cancer patients and how these sources often influence the way that patients manage their breast cancer.

Advocacy presentation

Session 2 was about advocacy and policy for patients with breast cancer. David Makumi, chairman of the Kenya Network for Cancer Organisations and passionate cancer control advocate, gave a presentation about local perspectives on patient advocacy. He asked important questions such as "are patients receiving the best possible care?" and "is care being delivered by a multidisciplinary team as it should be?"

Nursing oncology programme
Session 3 had breakaway sessions with various topics.

The symposium ended with reflections and goals going forward. Dr Mutebi presented 5 aims including:
1. promoting regional technical collaborations
2. promoting greater participation in the global oncology community
3. reducing duplication of efforts
4. creating guidelines that are easily updated and disseminated
5. widespread participation within the African oncology community

Dr Mutebi, Dr Mwanzi, Lieske

Well done to all the organisers and sponsors on a brilliant first symposium filled with relevant information and workshops! A special thank you to Dr Miriam Mutebi for inviting me to attend and speak.

Thank you to the Breast Course for Nurses and Dr Jenny Edge for getting me there and back again.

And of course, when in Nairobi...always make the time to visit the giraffe sanctuary. You may even be fortunate enough to kiss one!"

Lieske at the Giraffe centre

- by Lieske Wegelin