28/09/2014

Emergency poetry

Last weekend, Tony and I had the pleasure of attending a couple of sessions at the open book festival.  It really is an excellent annual event here in Cape Town.

This year, The British Council supported a performance poet- Francesca Beard.
Francesca Beard
We spent a wonderful hour listening to her involve her audience.  She interspersed her poetry with audience questionnaires. One was about how we would choose to die. Given the 7 options, I found it difficult to choose between being eaten by the lion (I was tempted by the promised rush of adrenaline before the incident) or dying in outer space hoping to be found by George Clooney.

Her poetry was diverse.  The poem that I felt made the most impression was The poem that was really a list.  It is quite a tough poem so don't open the link if you are feeling fragile.

Thanks to the Book Lounge for organizing such a wonderful event. It's wonderful that it boosts networking through the book illustrator and 'poems to go' sessions.

Another poet came to my attention this week and that was the "Emergency Poet",  Deborah Alma.  She drives around the UK in an ambulance administering poemcetamols from the Cold Comfort Pharmacy.

Deborah Alma administering poetry





 

Have you ever felt the need for an emergency prescription of poetry?

21/09/2014

Hormone receptors in breast cancer

This joke has been told many times: a surgeon, physician and pathologist were out on a pheasant shooting trip.  They noticed a particularly interesting bird flying in the air.  The physician said "I wonder if that could be the rare lesser spotted pink crane.  Perhaps it is a juvenile red collared duck.  Do you think we are too far north for it to be a spotted hawk? "
"There's only one way to find out" replied the surgeon.  She aimed her gun and shot the bird dead, then gave it to the pathologist who made the diagnosis -- a pheasant.

We always believe that the pathologists can provide us with the definitive answer.  What I remember from pathology lectures at med school is being presented with picture after picture of pink shapes with a various number of black dots.  Generally, the darker the slide, the worse the diagnosis.  Have things changed since labs have become more automated?

A portion of breast tissue imbedded and waiting to be processed
A couple of weeks ago, I invited myself to the pathology lab at Well Woman diagnostics and looked at how the estrogen receptor (ER) status is assessed.  After the diagnosis of breast cancer is made, it is important to know the prognosis of the cancer and  to predict how it will respond to the various treatment modalities available.  One of the mainstays of breast cancer treatment is endocrine therapy (Tamoxifen, aromatase inhibitors and Goserelin).  The higher the ER, the more likely endocrine therapy is to work.

The process involves many steps of fixing and unfixing and is partially automated.  Tissue can be taken from the tumour using a biopsy needle which gives a core of tissue.  A representative part of the tumour must be biopsied.  When the tumour is placed in formalin, the time must be written on the jar as the formalin MUST be fixed for at least 6 hours.  The tissue is cut up and parts are imbedded in paraffin.

Phumeza Siziba slicing up specimens and preparing slides
Thin slices of tissue are sliced by hand and placed on a slide and then stained.  This allows the basic diagnosis of to be made.













Nahwahl Isaacs processing the tissue for ER testing.
If there is a breast cancer, a representative portion of the tumour is then processed a second time and the ER receptors are tested.  In order to do that, the "bridges" have to be opened up, a stain with an avidity for the receptor attached and another stain to show up the previous stain added.





At the end of the day, the staining is quantified by the pathologist.


Even in a first world lab, there are many steps involved and many possibilities for error to creep in.  My last blog dealt with the issue of diagnosis and management of breast cancer in low income countries.  I didn't deal with the paucity of reliable laboratory services in Southern African countries.  In South Africa, we are lucky to have access to world class facilities. To get serious about improving breast cancer management in low income countries, access to reliable pathology services is as important as access to drugs.

Many thanks to Nicole Morse and Judy Whittaker from Well Woman diagnostics for letting me spend time in their lab.





14/09/2014

BIGOSA: the management of breast cancer in low income countries

The 3rd BIGOSA meeting was held on Saturday 30th August.  The day before, on Friday 29th August, we had a preconference meeting sponsored by Novartis.

The meeting welcomed oncologists and surgeons from Namibia, Zambia, Mozambique, Botswana and Zimbabwe.  We discussed the challenges of the management of breast cancer in poorly resourced countries.

We don't have accurate statistics about the incidence and management of breast cancer from Southern Africa so in many cases our management decisions are based on small cohorts of patients or on descriptive statistics.  With or without gaps, the data is important.

The afternoon session at BIGOSA was dedicated to the same topic.  Excellent talks were given by Dr Ines Buccimazza, Prof Lynette Denny and Dr Pillay-Van Wyk.

When it comes to managing cancer in in low income countries, the problems are enormous.  Although there were many points discussed, a few are presented here:

  • We don't have disease registries.  Although we are used to seeing tidy pie charts dividing up the causes of mortality into those due to infectious diseases, trauma and non communicable diseases, the overlap between them is enormous.  To illustrate this, an estimated 40-60% of all cancers in Southern Africa are due to infectious diseases: HPV causing cervical cancer and HIV causing Karposi's sarcoma.
  • South Africa has many more cancer centres (especially in the private sector) relative to neighbouring countries. (Zambia has one).  There are few radiotherapy machines, limited imaging facilities and problems with spare parts and maintenance. Drug supplies are erratic.  Access to medication is limited.  The sparsity of resources and support systems mean women spend many months as inpatients in hospital.  For example, in Mozambique, a woman undergoing routine treatment for breast cancer may occupy a hospital bed for 9 months.  This would be unheard of in USA/UK.
  • There are very few trained cancer specialists.
  • For many women, just getting diagnosed with breast cancer and getting screened may take many months.  (Figures presented from Botswana suggested delays of up to 1 year) 
  • The many social challenges within poorer communities are  compounded by the devastating effects of civil unrest and war.

In her talk Ines asked whether drawing up guidelines for breast cancer care specifically for use in low middle income countries was condoning or perpetuating sub-standard care.  She concluded that whilst guidelines alone are not enough to improve care, following the same protocols used in high income countries is simply not attainable.

If we are to achieve anything about the plight of the thousands of women developing breast cancer in poorer countries, we need to start putting cancer care high on the government's agenda and be creative in our approach.




02/09/2014

BIGOSA 2014

Yesterday, the 3rd BIGOSA conference was held in Cape Town.  It was well attended with delegates from throughout Southern Africa.

Rro Dr Sylvia Heywang-Kobrunner and
Prof Apffelstaedt
The invited guest speaker was Prof. Dr. Sylvia Heywang-Kobrunner from Munich.  She gave 2 talks: one presented the case for routine mammography screening in Germany and the second talk dealt with the confusing and controversial issue of intermediate lesions found on screening mammography.

The rest of the speakers were from South Africa.  The topic for Dr Judy Whittaker's talk was "Traditional prognostic indicators vs molecular prognostic indicators"  This is a huge subject.  Traditionally, the management of breast cancer has been based on what the tumour looks like microscopically (the grade and the presence of tumour cells in surrounding vessels), the size, the involvement of lymph node and the ER and PR sensitivity.  However, there are many tests available that look at the genetics of the tumour. In time, they may take over from traditional pathology.  Dr Karen Fieggen gave an excellent talk on the impact of Angelina Jolie discussing her decision to have a bilateral mastectomy.  Time will tell whether she has changed the overall pattern of practice.

After the tea break, we had a second talk from Prof Dr Heywang-Kobrunner.  She was followed by
Dr Shane Barker who gave a
Dr Ines Buccimazza and Dr Shane Barker
comprehensive overview of the surgical techniques used by plastic surgeons to re create a nipple after a mastectomy.  He was followed by Dr Rika Pienaar who discussed the management of the side effects of endocrine therapy used to treat breast cancer.  Many women give up taking their cancer drugs because of the side effects.  The onset of menopausal symptoms can be overwhelming.  Her bottom line was that women should be encouraged to exercise, lose weight and modify their diet. Dr Voster gave a presentation on how women with bony metastatses should be managed.

Ann Steyn standing with Dr Baatjes in front of the BIGOSA banner

At the end of the morning, Ann Steyn gave a 15 minute talk on the role of advocacy in developing countries.  It is the first time a breast cancer survivor has been invited to address BIGOSA and I hope she will be the first of many. As always, she gave a succinct presentation outlining the work being done by ABC and the enormous amount that still needs to be done.

The afternoon was spent discussion the management of breast cancer in low income countries and I will write a second blog about that.

Every year, a prize is given by Mrs Stathoulis for the best free paper.  This year's winner was Dr Ettienne Myburgh.  We said good bye and thanks to our president-Prof Apffelstaedt and our secretary Dr Karin Baatjes.  We welcomed out new president-Dr Ines Buccimazza and our new secretary Dr Chas Chacala.
Dr Ettienne Myburgh

Next year's conference will be held in Durban.