Day 1 Breast Course Oshakati, Namibia

Prof Celestine
We are running a course in the north of Namibia.  We are based at the Destiny Hotel, Oshakati, and
have group of 30 students.  The majority of nurses come from the peripheral clinics in the surrounding area.  One sister came from the Caprivi Strip: she spent 12 hours getting here.  We also have two nursing lecturers from the University of Namibia who are based at Oshakati Hospital and two of the senior sisters from the department of health. The majority of the sisters are involved in cervical screening programmes. One of the challenges they face is the variable time they wait for the results:  some sisters wait for a few weeks.  Others say they wait for many months before getting the results.

There is one oncologist and one radiotherapist in the Namibian public sector.  They are all in Windhoek.

Dr Brown
There are many other challenges faced by the nurses in managing a woman with breast problems.  There is only one mammogram machine in the north of the country.  It is in Oshakati Hospital.  Most clinics have weekly transport to the hospital but the nurses do not have easy access to imaging.

At the beginning of the morning we concentrated on clinical assessment of a woman with a breast problem.  Once again, we had our good looking model: Dr Oscar Benyera.  In the afternoon, we were joined by Dr Brown.

Maria at the cytology workshop
Dr Brown is a local surgeon who did his post graduate training in Johannesburg.  He has a particular interest in the management of breast problems and is one of the few surgeons in the north of Namibia.  He gave several lectures and taught the workshops.

I taught the workshop on the limitations of the use of cytology.  I was very impressed at the knowledge of the nurses I taught.

Many thanks to the people who have made the course happen. The Namibian Department of Health, the University of Namibia Medical School and our sponsors: Novartis and Pathcare.  It has been a real pleasure having Dr Oscar Benyera and Susan van Zyl with us: thank you.

Susan van Zyl and Oscar Benyera

Day 3 Namibia

Day 3 of our Namibian trip was spent visiting 2 hospitals in the North of Namibia.  We flew from Windhoek to Ondangwa and spent the day travelling with Prof Celestine Mbangtang and visited 2 of the regional hospitals.  

The new part of the hospital meets the older part:
Our first stop was Oshakati Intermediate Hospital.  The hospital has about 750 bed capacity but may admit up to 800 patients.  The main part was built in 1965.  It is made up of many individual single storey buildings linked by long walkways.  The hospital is gradually being rebuilt.  The surgical ward we visited was opened 2 years ago and is very clean and modern.  One of the women we met on the ward was admitted for investigation for her breast cancer.  The distances in Namibia are vast which does not permit an efficient out patient service.

There is a small oncology unit in the older part of the hospital.  Only patients with Karposi's sarcoma are treated with chemotherapy in the unit.  Any woman with breast cancer who needs chemotherapy is referred to Windhoek.  Surgery can be done at the hospital and the waiting time for surgery is relatively short although  there are many emergency operations that compete for theatre time.

We then drove to Engela Hospital which is a smaller hospital.  There are 250 beds and there are only 6 full time doctors working there. Although they have a theatre complex, they do not have surgeon so cannot do many procedures.  When we visited, there was an out reach programme running.  There were specialists from around the country who had gone to Engela Hospital for 3 days.  We went into the theatre suite and met surgeons from Rundu and Windhoek.  It is the first programme of its kind to be held in Engela but is part of a much bigger outreach programme.

Engela Hospital is very near the Angolan border.  there is a campsite outside the hospital where Angolans stay, waiting to be admitted to the hospital to have their baby. It must be so hot inside the tents.  When we were there, it was 40C.

Our driver:Tonata

Cows along the roadside
Thank you to our guide Prof Celestine Mbangtang and our driver, Tonata


Breast Course for Nurses: Windhoek, Namibia day 2

Dr Fynn
On the second day, I always spend less time teaching and local faculty take over.  The day started with Dr Fynn, a radiologist working at Katatura Hospital,  showing mammographic and US images.  There are 2 state hospitals in Windhoek: Katatura Hospital and Windhoek State Hospital.  Katatura is the admission hospital and Windhoek is the tertiary hospital. 

The library at Katatura Hospital
While Dr Fynn and Sr Lieske were running the course, I was lucky enough to visit Katatura Hospital.  There were a couple of things that struck me.  The first was how clean it was despite the fact it was very busy. The second was that it has a library for the nurses and medical students.  There are a number of hard copies of journals and books but the librarian informed me that the have internet access to ejournals on line.  I had a chat to a few of the 6th year medical students who are about to be the first graduates from the University of Namibia Medical school.  

Dr Abigail Mukendwa
Dr Abigail Mukendwa gave the lecture on the complications of breast cancer treatment.  It was the first lecture she has ever given: she did really well.  Thank you and congratulations.

Prof Celestine ran the session on palliative care. He has been in involved in the field for many years.   He noted the need for psychological, physical and spiritual harmony to live a complete life.  He defined spirituality, not as religion, but as the “connectivity between people that is not physical”.  

In his excellent talk, he said the difference between a good death as opposed bad death was being ready to die.  In order to help achieve that, it is imperative that health care workers communicate with the family.  Communication is talking less and listening more.  He reminded us that no amount of morphine will cure spiritual pain.

The last session of the day was on community projects and how to use the information learnt on the course to make a difference to women living in their communities.  The students broke up into small groups to come up with suggestions.  One of the biggest challenges is to get care to remote communities.  Do you advocate to get more access to care in the larger centres or do you aim to take care to the communities through the existing outreach programmes.

Well done to all the students.  We look forward to hearing about your projects.  Once again, thank you to University of Namibia Medical school, Namibian department of health and our corporate sponsors.


Breast Course for Nurses Namibia day 1

Sr Lieske and I are in Windhoek for the BCN. It is hot and dry! We are teaching in the University of Namibia Medical School.  The course has been organized by the BCN, University of Namibia
Medical School, the Department of Health (Namibia) and is sponsored by Novartis.  We have 23 nurses and doctors attending the course from all around the Windhoek area.  Namibia is a sparsely populated country (population 2million).  Many of the clinics are isolated and run by nurses.  
Prof Mbangtang, Dr Benyara, Dr Forster, Prof Nyarango

The course was opened by Dr N Forster, the deputy permanent secretary from the Ministry of Health.  As a medical doctor, he started his career working in primary clinics. Since becoming involved in the department of health, he has continued building primary health care clinics. The emphasis of the health department has been on prevention of disease and promotion of health care.  In his talk, he noted that NCD (non communicable diseases) are becoming an increasing problem in Namibia.

The Dean of the University of Namibia Medical School, Prof Peter Nyarango, welcomed us.  He stressed the point that medical education doesn’t happen in buildings.  The initial teaching happens there but real learning happens in the field.  He made the interesting point that the diagnostic process begins in the home.  It is imperative for all us who are health practitioners to transfer our knowledge so not only health care workers are empowered but families are as well.

Mary examining Oscar
The day followed the pattern of lectures and practicals.  We were fortunate enough to have a good looking model for the examination practical: Dr Oscar Benyara from Novartis. 

 Prof Celestine and Dr Abigail Mukendwa assisted with the the teaching in the afternoon.  

We have been invited to run the breast course in Namibia to help with the opening up of a breast clinic in Katatura. It is very encouraging to see that our course is being used as part of a health department and University of Namibia initiative.

As always, a big thank you to our 2 main corporate sponsors for this course: Pathcare who sponsored the books and Novartis.

Thank you to Pathcare for supplying the books


BIGOSA: 4th conference

The 4th annual conference of BIGOSA was held last weekend.  My previous blog covers some of the topics covered by the overseas guest speaker, Prof Stuart Schnitt.  Other highlights of the programme included talks from local experts with 6 free papers.

Dr Louella Ritz (radiologist) runs the Bone and Breast Care Centre in Johannesburg.  She discussed "New imaging modalities: fad or fact?"  Her talk centred around the advantages of tomosynthesis and showed the youtube clip explaining the advantages of 3D imaging.

Dr Conrad Pienaar
She was followed by Dr Conrad Pienaar (reconstructive surgeon) who discussed the advantages of the DIEP flap over the TRAM flap.  The main argument for a DIEP flap rather than a TRAM comes from consideration of the blood supply.  Both the DIEP flap and the TRAM flap use fat from from the abdomen but the DIEP is an anatomically more logical reconstruction.

We then heard from our radiation oncology colleagues.  Dr Vorobiof gave us an overview of the new guidelines for chemotherapy. He discussed the exploitation of hallmarks as being the future of systemic therapy.  Dr Landers followed with "Innovations in Radiotherapy".  He foresees a future where radiotherapy will be  individualised according to the risks posed by the tumour. (At present, the majority of women who need radiotherapy get standard 50Gy external beam radiotherapy).

Dr Hodgson, an anaethetist from Durban, discussed the use of local blocks for breast cancer surgery.  Most breast surgeons do not utilise local blocks and it is something we should be looking at.  Six free papers followed.  The Olga Stathoulis Prize for the best paper was given to Dr van Schalkwyk from Bloemfontein who presented a paper entitled "Prognostic subtypes in stage 3 breast cancer."

After lunch, Donnee Ness gave an excellent paper on new modalities utilised in the management of lymphoedema.  She concentrated on the diagnostic modalities being used to assess patients and her research based in Durban.

Eighty percent of breast cancers are endocrine positive so the majority of women with breast cancer will be advised to have endocrine therapy at some point in their management. Their symptoms tend to last longer than those experience by women going through natural menopause and managing them can be challenging.  Prof Davey shared his extensive experience with us and discussed the therapeutic options.   The last talk of the day was given by Dr Coetsee who gave an overview of fertility issues facing breast cancer survivors.

To all the local organising committee: thank you for oragnising an excellent conference.  To all the sponsors: thank you.  A special thanks to Dr Ines Buccimazza and Lisa Vickers from African Agenda.

Dr Ines Buccimazza

BIGOSA: Prof Schnitt

Last weekend was the 4 th BIGOSA meeting.  The group has grown in strength over the last 4 years with this meting, in Durban, being the biggest so far.

The invited speaker was Prof Stuart Schnitt, a pathologist from Boston.  He gave two talks.  The first
addressed the contentious question of what is an adequate margin.  What is meant by that? Surgery for breast cancer falls into two categories: a mastectomy or a wide local excision (breast conservation).  If a mastectomy is not indicated and breast conservation is decided upon, the cancer must be removed with normal tissue around the lump.  The normal tissue is known as the margin.  What is an adequate margin?  Does removing more tissue reduce the likelihood of the cancer recurring?  It is a debate that has continued for many decades. As surgeons, we tend to assume that the pathologist's report stating that the margin is 1 mm or 5 mm or 1 cm is absolute. It is much more complicated than that!  There are many pitfalls that may occur in the processing and interpretation of the pathology.

Over the last 10 years, evidence has led us to conclude that annadequate margin is no cancer at the edge of the specimen.  There is no advantage in having a 5 mm margin over a 1 mm.  "More is not better, it is just more".

His second talk was about DCIS, ductal carcinoma in situ, pre cancer of the breast. The diagnosis of DCIS has increaed markedly since mamamograpahic screening programmes were been introduced in the 1980s.  Initially, all women were advised to have a mastectomy after the diagnosis of DCIS.  That was based on the assumption that DCIS always progresses to invasive cancer.  It was seen as a chance to prevent women getting cancer.  Once again, it is more complicated than that!  Approximately 12 % of women who die of other causes will have DCIS in their breast.  The pre cancer did not cause them a problem. They died of other causes.  How long had it been there? Conversely, DCIS may become invasive cancer fairly rapidly.  Prof Schnitt notes that whilst we have made considerable strides in understanding more about the biology and behavior of invasive cancer, little has changed in our understanding about DCIS.

The questions we need answered are:
When do we need to treat DCIS and when should we observe it?
When can we simply remove DCIS and when do we need to give radiotherapy or do a mastectomy?

The problem is that if there is a recurrence after removal of DCIS, half the time, the recurrence is an invasive cancer.  The opportunity to prevent cancer has been lost.  Clinical trials have identified women who are more likely to have a recurrence after a simple excision.  Prof Schnitt took us to the newer areas of research.  Molecular studies are being done trying to predict which types of DCIS will progress.  The focus of interest is moving from the seed ( the cancer cells) to the soil (the surrounding cells).

Is this history recurring in a new guise?  In 1889, Stephen Paget, an English surgeon wrote a paper about why some cancers metastasize and other don't.  In that paper, he said, "When a plant goes to seed, its seeds are carried in all directions; but they can only live and grow if they fall on congenial soil."

The 2 lectures given by Prof Schnitt were certainly the clearest and most enlightening I have ever heard on the subjects.  We were very fortunate to have him as our guest speaker.


Yesterday, I had the privilege of listening to Prof Wim de Villiers discussing the question of
Prof Wim de Villiers
transformation at Stellenbosch University.  The lecture was at the Table Bay Hotel and was organised by the Cape Times. (It was advertised as a breakfast but the food offering was below an expected standard given that the Table Bay Hotel is a 5 star hotel).  However, the lecture was up to expectation.

Debates about transformation in higher education are generally confined to addressing the issue of increasing diversity of academics and students at the institutions.   I am not in a position to comment on diversification in institutes of higher education and will leave the debate to those who are.

Last October, I went to a debate about transformation in higher education at the Baxter Theatre.  It was hosted by UCT.  Max Price (UCT), Johnathon Jansen (University Bloemfontein) and Professor Phakeng (UNISA) formed the panel and each gave presentations.  The most memorable presentation was given by Prof Phakeng.  Amongst the other points she made, she argued that universities should be ranked by the local relevance of their research rather than on whether it is taken up by the international academic community.

In his lecture, Professor de Villiers also broadened the discussion to ask how universities can make themselves more relevant to the society they represent.  The town of Stellenbosch has one of the biggest discrepancies between rich and poor of any area in South Africa. Should the University of Stellenbosch concentrate on getting global recognition or should it concentrate on trying to provide solutions to local problems?  Prof de Villiers gave an example of how the law faculty has been involved in dealing with local issues.

The University of Cape Town have been running a series called "Cafe Scientifique".  Academics from the science departments at UCT present their research.  Both the public and industry are invited.  The aim is to bridge the gap between academia and practical application.

There is no doubt that there is much to do in bridging the gap when it comes to breast cancer research and access to care.  Prof de Villiers is a medical doctor and I hope he broadens his definition of transformation to include more equitable access to health care.