There are five specialty trained and registered breast surgical oncologists in Kenya. Four men and one woman. That woman is Miriam and yellow is her colour of healing.

Traditionally, surgical oncology was done by general surgeons. With general surgery there is unfortunately heterogeneity in training, but that is shifting in medicine with sub-specialising to offer improved treatment by homogenising the skills in each branch of surgery, and specific to body parts.

This sub-specialising is bringing about better treatment and recovery of patients. There are several steps in the treatment of cancer outside of surgery. A multi disciplinary approach is used and several other clinicians sit with the surgeons to map out the best treatment plan for a patient. This includes medical oncologists who offer chemotherapy, radiation oncologists who give radiation treatment, pathology, radiology and other supportive clinicians. This team is critical to the management of any cancer as and is the standard of care in any centre offering best practice for cancer care. This is important as the world has moved to individualised treatment. Care for patients with similar cancers can be very different depending on patients unique features or concerns.

Beyond that, having more women in breast oncology is seen to help mitigate the stigma that is still culturally existent around breast cancer. “The stigma also creates family disintegration to the extent that some women have been left by their spouses or isolated by their community after their diagnosis,” explains Miriam. Due to a number of barriers including financial barriers, health system related barriers and socio-cultural barriers, women are diagnosed with advanced disease and frequently do not complete their treatment.

“More female doctors coming into the practice has the potential to improve access to care by addressing some of these socio-cultural barriers. For instance, colleagues have shared that older women are more likely to accurately talk about their symptoms such as vaginal bleeding or discharge after menopause, which could imply cervical cancer, with a female colleague. In addition, some ladies are not comfortable having their breasts examined by clinicians of the opposite gender,” she says.

It was initially postulated that low levels of education could perhaps perpetuate cancer stigma, but research has found that the stigma permeates all areas of society, irrespective of levels of education and social strata, making it a highly social and cultural issue requiring innovative strategies to counter.

In 2019, the first ever International Oncoplastic Cancer Surgical Skills Workshop was organised by the Pan-African Women Association of Surgeons (PAWAS) in collaboration with the Aga Khan Hospital and the Surgical Society of Kenya(SSK). Twenty eight local and international professionals shared their skills and expertise with local clinicians over a three day period. This included both didactic and practical sessions including cadaveric dissection to enhance surgical skills in a controlled environment and live surgery.

One key emphasis was the multi-disciplinary cooperation required in the care of patients with cancer without breaks in their treatment. For example, exploring the fact that some patients should be given chemotherapy before surgery for better surgical outcomes or having a conversation about breast conservation before a patient begins chemotherapy. This requires members of the multidisciplinary team to communicate, plan and agree beforehand on the best treatment for a particular patient.

“Multidisciplinary collaboration also provides checks and balances for the clinicians in the different specialisations that make up the team. As the saying goes, when you have a hammer everything looks like a nail,” explains Miriam, “it’s never about one’s ego, it’s always about what’s best for the patient. And even if you know what’s best, it does not hurt to consult.”

Dr. Mutebi always tells her patients that they have to take charge of their health even as she does her best as a clinician in guiding them and offering the most suitable treatment.

At Aga Khan where she is based, they have adopted a walk-in breast clinic where you do not have to book an appointment to make it convenient for the patients.

Dr. Mutebi demonstrates how to self examine for breast lumps

“We are rapidly moving away from the patriarchal approach in medicine where I come down the mountain with the ten commandments of what was going to happen to your health to patients being more proactive about their health.”

Men also have breast concerns. For men, breast cancer is less prevalent and forms about 5 percent of all breast cancers . Breast cancers do however tend to be more aggressive in men because they have minimal breast tissue. Other issues experienced by men include the growth of breasts known as gynecomastia, which can be quite traumatising and could be indicative of other health issues affecting the kidneys or liver. Gynecomastia could also be due to medication or simply hormonal changes, especially in the adolescence and young adult phase.

Majority of breast cancers still occur in women. “When women come to see us, we have found the cancer is never usually their direct concern. It’s more of what’s going to happen to my children, what will happen to my family, and if the fears are not unpackaged, then the doctors are not necessarily dealing with the problem,” Miriam says.

The first is to realise that 9 out of 10 lumps and other breast concerns are not cancer. Modern practices in health, as with the breast clinic at Aga Khan, require clinicians to take time to address the patients concerns but also to instruct on breast health and awareness such that by the time they leave, they are more educated, enlightened and empowered about their breasts and any other health concerns they may have.

Despite rising awareness, we still sometimes treat our cars better than we treat ourselves. After every couple of miles, we take the cars to the garage for a service/ check up whereas with our own bodies, we wait for a break down, before we seek help, ” says Miriam.

In sub saharan Africa the narrative has unfortunately been that cancer equals death. This is mainly because diagnosis happens at advanced stages, due to a number of reasons, compared to data in the West where cancer has become another chronic disease. What we are now saying is that if detected early and treated appropriately, cancer can be cured. Even with more advanced cancers, there is always treatment. The goals of treatment may change to controlling the cancer rather than cure in more advanced cancers, but with advances in medical therapy, patients are still able to live for longer periods with their cancer under control.

Breast cancers are nonetheless complex and there is still much to discover about them. Breast cancer is an umbrella term for a disease that has many different types which behave in different ways. There may also be some associated genetic and racial factors. They can be broadly divided into hormone negative and hormone positive cancers. African and African Americans were postulated to have higher levels of hormone negative cancers which behave more aggressively.

Research now a priority for countries in Africa

Recent research has found that the triple negative breast cancers vary in frequency in different parts of Africa. In some West Africa populations, like in Ghana, and in African American populations, who are anthropologically similar to West Africans , there is a higher rate of triple negative breast cancers. However recent research in East Africa, for instance in Kenya and Ethiopia, suggests that these tumours are found in about equal measures to Caucasian populations. This underscores the premise that Africa is not a country and more research is needed across the continent to give us a true picture of what is happening in different communities.

One of the reasons for previously high recorded rates of triple negative disease in certain parts of Africa, has been shown to be by how tissue specimens are handled before they get to the lab. Women who were hormone positive and whose specimens were not properly prepared could end up getting an erroneous diagnosis of a hormone negative tumour. This has treatment implications as patients could potentially miss out on about 5-10 years of life-saving treatment. This is why doctors in leadership, as Dr. Mutebi herself, have put emphasis and effort around educating other clinicians on proper handling of specimens before they get to the lab. “We have been working closely with the national ministry and oncological (KESHO, AORTIC), surgical and pathology groups to ensure that correct specimen handling occurs,” she explains. Luckily, the Aga Khan Hospital recently received a grant to train health workers on the handling of specimens for cancer diagnosis.

All in all, it is true that people of African ancestry are more prone to being diagnosed with breast cancer at an earlier age than in Western counterparts. On average, African women tend to be diagnosed with breast cancer about 10-15 years younger than their caucasian counterparts. This is one of the guiding motivations that led Miriam to specialise in breast cancer. “I started my medical training reading that cancer was a disease of the 5/6th decade but on the ground I realised the facts were different and that most women were in their 30s and 40s, and I asked myself – what is going on?!” Traditionally it was believed that not having children and never having breast fed could increase the chances of cancer but despite having multiple children and breastfeeding, which should have been protective, African women were still getting diagnosed at a young age with more aggressive disease.

“Currently we are conducting research to and collecting data to help improve our understanding of breast cancers and tumour biology in our region. As part of of a multicentre study across Kenya, we are collecting blood, saliva and tissue from our patients to create a bio depository in order to study the genetics of these tumors in the local context and hoping to extrapolate meaningful clinical information,” Miriam explains. This may eventually help to guide how chemotherapy and other targeted interventions could work specifically in our population here in Kenya and people of African ancestry.

The Africa Cancer Coalition, a group of oncologists from the continent, have also recognised that the Western guidelines around cancer care are not always generalisable and may not necessarily work as prescribed in Africa. They are now looking at how to better customise the standards of providing oncology care for the African context to ensure that the patient benefits from best practice. These concerns go deeper into accessibility to the resources and equipment stipulated in the Western guidelines and how to ensure that best practice is not compromised with the limited resources. Forty six guidelines have already been customised to suit the African context for best practice. The devil however is in the implementation of these guidelines, which is the next step.

“Despite all the challenges, it’s a good time in medicine in Africa, we have our work cut out for us and there is a rising consciousness on our role as clinicians in advocacy and pushing of policy with government and other partners.”

Health is a fundamental right. Questions such as a mother asking ‘where should I leave my children during treatment’ cannot be ignored, Miriam asserts. Luckily, she believes there is good will from the Ministry of Health in Kenya. She looks forward to Sub Saharan African countries raising the GDP devoted to health from the current 1 to 3 percent to above the 7 percent seen in developed nations. The collaboration between government and clinicians such as Miriam is also important in guiding priorities. For example, investing in mammograms with no one to read them beats the purpose of screening . In Kenya, the average age of cancer diagnosis is 48. So again, would we rather install mammograms or invest in capacity building to detect the tumors early enough? Miriam says the government is now listening and working collaboratively with clinicians to improve access to timely treatment.

Being able to impact the people she interacts with everyday but also stepping back and looking at how to have a bigger locus of impact is what wakes Miriam up every day.

In sub saharan Africa, data says we need approximately another 143 million surgeries to prevent death and decrease disability, implying that 9 out of 10 people do not have access to safe surgery.

By the time Miriam was graduating in general surgery in 2012, she was only the 5th female general surgeon in Kenya. The number of female surgical trainees has exponentially grown but is still at significantly at lower levels. Though women form more than 70 percent of the health workforce the training focus has traditionally been on nursing and other allied health specialties. While these components are essential to and are the bedrock of health systems, we also need to start prioritising the enrolment and retention of women in medical studies to advanced levels.

For instance in our medical schools across Africa currently, the female demographic is around 50 to 60 percent. We are not tapping into 50 percent of the workforce that could fill this gap in the need for surgeons. Brain drain is another factor due to the less favourable conditions for doctors in Kenya and in the continent at large.

Outside hospitals Miriam enjoys non-operational theatre and other hobbies

Miriam, who is also a role model to the many upcoming doctors she trains, urges them to have pursuits outside medicine. Besides flying, Miriam loves theatre, and not the operational one!
She reads voraciously and loves to explore different cuisines when time allows. She believes that family is also important to keep one grounded and she always finds time to go home to mum and dad for some TLC, before running back to save lives and sit on boards.