22/02/2015

Well Woman Clinic Harare

During our recent trip to Zimbabwe,  I had the pleasure of visiting the Well Woman Clinic in Harare and was really impressed.  They have facilities for cervical screening, breast screening and bone density scans.  Screening is all about prevention.  What do we mean by prevention of a disease?

There are 3 types of prevention:
-Primary prevention is when the disease can be prevented by not being exposed to the causative agent.  A classic example is asbestosis.  If you haven't had exposure to asbestos, you won't get asbestosis.
-Screening for any disease is an example of secondary prevention. You look for the disease early in order to improve survival.
-Tertiary prevention is about prevention of the complications of a disease.  For example, if diabetes is treated effectively, there is less chance of going blind.

The mammogram room at the clinic
Mammograms pick up 85% of breast cancers.  They can pick up pre cancer (DCIS) and are often combined with US.  Tumours >5mm can usually be detected. However, breast screening is a complex subject and there are many aspects of the screening debate that I have raised before.  Countries such as the UK and USA constantly review their policy.

One sobering fact remains.  Cancer can be missed by both mammograms and ultrasound.





Sr Louw in the reception area of the clinic
Mammograms in women with dense breasts are more unreliable: cancers are white on a mammogram. If the underlying breast tissue is white, a cancer may not be seen.  Once you have gone through menopause, the breast tissue becomes less dense and so mammograms become more reliable. (This explains why mammograms are only recommended in women over 50 in Europe).


Lobular cancer is less likely to show up on a mammogram.  The woman may be reassured by a "normal mammogram"  and so may present at a later stage.  Lobular cancers are often easier to feel than to image.

To have  breast screening done properly, all women should have an examination as well as a mammogram.   At the Well Woman Clinic, in Harare, I was really impressed to see that they combine clinical examination with a mammogram.  There are 2 radiologists who work there: the founding partner, Dr Nancy Jonker, and Dr Maita Mvere.  There are 4 clinicians (Dr Landman, Dr Mhlaba, Dr Cowper and Dr W Samaneka) who see all women prior to mammographic screening and determine whether/not they should have a mammogram.  Although they work in the same building, they are independent and so will not refer a woman for a mammogram if they feel it is inappropriate.  The atmosphere is relaxed and the ambience appropriate.



The other health practitioners who are there include Miss Allaart (dietician). Ms Petra Mesu (psychologist), Ms Kathy Harter (social worker) and Sr Georgie du Plessis (SRN).  Many thanks to Sr Riana Louw (practice manager) for taking me to the clinic.

Sr Louw, Dr Jonker, Dr Mvere, Dr Landman and Mr Machingauta (accounts)
I would encourage any women in the area needing advice about appropriate screening to make an appointment to be seen there. Phone  +263 4796492/3/4/6



15/02/2015

Bulawayo Course Day 2

The second day of the Bulawayo course was also really well attended.

Dr Vuma and Dr Cingonzoh
I was delighted that with all the input from participating doctors and nurses.  After I had given the morning lecture, Dr Vuma took over and discussed the side effects of chemotherapy. Then Dr Mucheni discussed complications of surgery and Dr Chingonzoh gave an overview of the costs involved in treatment. There are no radiotherapy facilities in Bulawayo at present - the 2 machines in the city are still being installed, and the plan is to have at least one working shortly.

As in Harare, there is no hospice building but there is an "at home" palliative care service provided by Island Hospice.  We had 4 palliative care nurses who helped run the palliative care session. Thank you to all of them.

Dr Makosa




The last session of the day is a discussion about community projects.  Mater Dei Hospital is about to open a well woman clinic which will be run by Dr Makosa, an obstetrician and gynaecologist.  Her presentation urged all health care workers to put into practice the examination of a woman's breasts at any available opportunity.  She listed examples that were appropriate times: the time of cervical screening, antenatal visits and any woman admitted to the hospital for a routine procedure.








Noma taking notes in the discussion session


To address the situation we broke up into small groups and discussed potential community projects.  The group I facilitated suggested that they should educate women about the causes of breast cancer and try to dispel myths. In my private practice in Cape Town, I am often asked questions concerning causality of breast cancer: the source of most information and misinformation comes from Dr Google. In Bulawayo, access to the internet is limited so there are different beliefs about causation and the effects of treatment.



Some of the common misconceptions concerning causality included:
1. Money stored in the bra
2. Cell phones carried near the breast
3. Witchcraft:      -dreaming of a black cat breast feeding form one of the breasts
                            -a neighbour casting a spell

As a result, many women will consult a traditional healer before a health practitioner.

Language is a problem: as the disease is often advanced at the time of diagnosis, many women associate the word cancer with death.  The word for radiotherapy in Shona is "kupiswa" and in Ndebele is "ukutshiswa".  Both words mean "you will be burnt".  Understandably, people are reluctant to consider having treatment.
A huge thanks to Prof Lynne Blackburn, Prof Karen Lasater and Sr Lieske
Thank you to everyone who took part and made the course possible: the local faculty, Sr Jamieson, Dr Mitchell and once again, to our sponsors.



14/02/2015

Breast Course for Nurses, Bulawayo Day 1

We have travelled to Bulawayo to start another course.  This course is quite different.  We are part of a programme being run by Dr Phil Mitchell with staff from Knoxville Tenessee.  The program is the result of many years of collaboration between principally Dr Mitchell, Dr King, Sr Jamieson and the Rotary clubs of Knoxville and Bulawayo.  The result is a training school that will based at the Mater Dei Hospital in Bulawayo.  Yesterday, was the dedication of the facility.  Prof Enweren, a urologist at Mpilo, was the MC.

Mr Macheka, Mr Alvord Mabena, Prof Roy King
Mater Dei was started in 1950 years by the Franciscan nuns.  Today there are very few nuns left but the Hospital is one of the larger hospital in Bulawayo.

The current training programme has been running for 2 weeks and has responded to the needs identified by the local nursing and medical school.  Several ATLS courses have been run and nurse trainers have been trained.  The trainers included surgeons from Knoxville and South Africa.  In future, the plan is to have further similar courses and operating theatre and ICU courses run from the facility.

Prof Roy King is a pathologist from Knoxville and he has coordinated a programme of pathology teaching for the local medical school.  Judy Whittaker has joined him in giving a series of lectures.

Learning to examine the axilla
The nurses course was included towards the end of the 2 week training programme.  We had over 80 health personnel attending the course.  About 10 of them were doctors. They have come from different  hospitals in Bulawayo: Mpilo and UBH. As the course progressed, the teaching was taken over by doctors from Bulawayo.





Dr Mucheni demonstrating biopsy techniques




We were priveleged Dr Makosa, Mr Tamanga and Dr Mucheni joining us for the day.  
Two nurses from Knoxville (Sr Karen and Sr Lynne) have provided excellent support for Sr Lieske.












Thanks to the kitchen staff for providing food promptly!

11/02/2015

Day 2 Harare breast course for nurses

The second day of the breast course in Harare was just as much fun as the first.

The day started with Dr Anna giving a talk about treatment of breast cancer.  She modified the standard lecture to include local statistics.  About 5000 new cases of cancer are registered every year in Zimbabwe and about 1500 people die annually.  60% of cancers are caused by infections (Karposi's sarcoma from HIV and cervical cancer from HPV are the main two)

Sr Fairall with Pretty Kusendwa
We were lucky enough to have 3 sisters from the Island Hospice in Harare.  One of them, Sr Konnie Fairall offered to run the palliative care session.  The group was split into 4 and each group were given a "patient" to discuss.  That formed the basis for the discussion on palliative care.








The class practising the post operative exercises




After an excellent lunch, when everyone was feeling sleepy, Sr Lieske led the session on post operative exercises.  Over the last decade, exercise has been recognised as being an essential part of post surgical and post cancer management.  The exercises she taught were breast cancer specific but all the participants felt more relaxed after doing them.






Portia from Novartis
The course was really well organised.  I would like to take an opportunity to thank our 2 main sponsors: Novartis and Baard.  













Sr Mativenga and Dr Anna Nyakabau

To the many other sponsors that keep our course afloat: thank you.  Once again thanks to  Dr Anna Nyakabau and her team: Sr Mativenga and Primrose.  We look forward to seeing you again soon.







10/02/2015

Harare Breast Course for nurses

It is many years since I was last in Zimbabwe and it is just as lovely as I remember it being.  Sr Lieske and I arrived on Sunday and met up with Dr Anna Nyakabau as soon as we arrived.  We had a planning meeting and then spent a lovely evening at her house with her family.

Yesterday morning, we started our course.  We have about 40 nurses and the majority are from the oncology unit at Parirenyatwa Hospital. Other are from the school of nursing, NGOs, the Well woman clinic and the hospice.  The course is being held at the Bronte Hotel.

On day one, we spent time on the diagnosis of breast cancer.  We concentrated on clinical assessment of the breast and special investigations.  We were joined by Dr Miata Mvere, a radiologist who works at the Well Woman Clinic in Harare.

Primrose Mafunda and Dr Anna Nyakabau
Primrose Mafunda works with Dr Anna.  She helped Sr Lieske with all the organisation.

Our aim is to ensure the sustainability of our course.  As well as training the trainers, we need to train organisers and I am sure that Primrose will be able to run the next course we have in Harare: thank you.
Parirenyatwa Hospital








During the day, I had the privilege of visiting a mutidisciplinary ward round at Parirenyatwa Hospital.  It is always fascinating to hear how other groups are managing their patients within a resource constrained setting.

In the evening, the members of the oncology and surgical department joined Dr Nyakabau and me at the Bronte Hotel for a workshop






Students in Sr Lieke's group learning about the pitfalls of FNAs
A big thanks to our main sponsors Novartis who made the trip possible.

03/02/2015

I've got cancer what's your excuse


Last year, I asked some women visiting my rooms to fill in a questionnaire about sources they had utilised to find out more about breast cancer.  Not suprisingly, many women had read various books on the topic.  What was suprising, however, was that many of the books they had read were not specifically about breast cancer but about cancer in general.

A couple of weeks ago, I met Sherri le Mottee and she was reading "I've got cancer, what's your excuse" She has kindly written a review and by clicking on the book below, you will be able to read it.  If you read any books that you found informative, please feel free to share them with us.

Sherri: thank you.

 r