Adult: Breast Cancer

DR. RUTH'S STORY:
A young physician opens the first breast cancer clinic in rural Haiti.

“The smell was overwhelming,” recalled Dr. Ruth Damuse. “Many of the women waiting for breast exams covered their faces. Some actually left the clinic.”

“There was a woman, Patricia, she was by herself. I took her into the exam room and lifted her shirt,” continued Dr. Damuse. “Her left breast was gone. Cancer had eaten it. All that was left was a large, open infection.”

	Dr. Ruth Damuse

During the course of that visit, Dr. Damuse, who heads up PIH’s oncology program in Haiti, learned that her patient’s cancer had been growing for at least a year — slowly eating her breast until nearly nothing remained. Living far from the nearest health center and unsure what to do, the patient, Patricia, had regularly packed the wound with mixtures of herbs and leaves in hopes that these holistic remedies would combat the infection.

Breast cancer affects more women in Haiti than any other cancer. Roughly 831 out of every 100,000 women are diagnosed each year — this in a country where few women have access to regular medical care. And although breast cancer is often treatable when it is diagnosed early, most women in Haiti only come to a clinic when something is noticeably wrong — often when the disease is quite advanced, Dr. Damuse said. Because women don't always seek care, the actual breast cancer rate is likely much higher.

Since starting a weekly breast cancer clinic in June 2011, Dr. Damuse has diagnosed some strikingly advanced cases of breast cancer. Patricia’s case was the most complex that she’d seen — an arresting reminder of the work that remains to be done, from basic education to healthcare access.

PIH and its Haitian sister organization Zanmi Lasante (ZL) are working to address this dire issue. With generous support from the Avon and Lance Armstrong Foundations, they began scaling up the oncology program earlier this year.

Since it opened in 2011, ZL's breast cancer clinic at Clinique Bon Sauveur in Cange, Haiti, has served hundreds of women. Each week, Dr. Damuse performs approximately 40 exams and diagnoses three or four cases of cancer. 

As of April 2012, ten patients were receiving chemotherapy for breast cancer, and an additional 30 to 40 were on Tamoxifen, a hormonal drug that slows the growth of new cells in the breast. ZL staff perform two to four surgeries (mastectomies and lumpectomies) on women with breast cancer each week. That number increases to roughly 10 operations a week when visiting surgeons assist in the clinic.

A little knowledge can save women’s lives

	Zanmi Lasante clinicians learn how to give breast exams at a recent training.

“The people living in the Central Plateau don’t know cancer,” Dr. Damuse said. “It’s not a word they know. People living in Port-au-Prince might know what cancer is; people working in health care know. That’s it.”

In response to the need for better education, Dr. Damuse, working with ZL’s women’s health, community outreach, and training teams, has trained a cadre of community health workers (CHWs) about breast cancer. CHWs are ZL's most effective strategy against a wide range of health challenges because they work and often live in the community with patients.

Once trained to recognize the signs and symptoms of breast cancer, community health workers will become key members of the team in identifying and treating the disease.

Dr. Damuse is also holding breast cancer trainings and refresher courses for clinicians at all ZL sites. Dr. Damuse uses a breast exam torso — a life-size replica — to demonstrate where growths might occur and how they might feel. She encourages doctors and nurses to teach women how to check for signs and symptoms related to breast cancer.

Though Haiti has one of the highest breast cancer rates in the Western Hemisphere, just a handful of cancer-focused doctors serve a population of 10 million people. Dr. Damuse hopes that by training ZL staff to screen for breast cancer more effectively and regularly, more women will receive lifesaving care and early detection screenings.

Diagnosis and treatment of a complex disease in rural Haiti

If a woman has an unusual lump or swelling, Dr. Damuse will perform a biopsy. ZL staff in Cange — working in a room just yards away — quickly inspect and diagnose the extracted cells. More complex tissue samples are either sent to a laboratory in Port-au-Prince or to the Brigham and Women’s Hospital in Boston for further analysis.

Biopsy results may take anywhere from a few hours to a few weeks. Dr. Damuse uses the time to explain to each patient what breast cancer is and what it can do to her body.

For women whose cancer results are positive, ZL provides chemotherapy and surgery in Cange. Health care providers spend about a month to complete prep work to treat a cancer patient, including initial diagnostic tests, biopsy and surgery, and receiving results of pathology studies, Dr. Damuse said.

Because Dr. Damuse is an internist, not an oncologist, she relies on colleagues in the U.S. for training, feedback, and advice. “We work with an oncologist at Dana-Farber Cancer Institute who helps to triage our patients in Haiti,” Dr. Damuse said. “We have a weekly call with her to discuss the current cases and to establish treatment plans.”

During the first three months of 2012, surgeons at Cange removed lumps or performed mastectomies on 80 women — about four a week. Roughly 75 percent of surgeries result in total mastectomies. However, ZL lacks the resources for reconstructive surgery.

Little can be done in Haiti for cases of advanced cancer that require more than surgery and chemotherapy. Radiation therapy is not yet a part of Haiti’s health infrastructure, so ZL sends some patients to the neighboring Dominican Republic for radiation treatment. For women with advanced cancer, Dr. Damuse also works closely with ZL’s psychosocial support team to offer palliative care and pain management.

Patricia’s prognosis is still uncertain. She has been prescribed antibiotics and pain medicine, which Dr. Damuse reports are working. Once her infection subsides, the ZL team will have a better understanding of how far Patricia's cancer has spread and what next steps will need to be taken. 

The future of PIH/ZL cancer services

Though they did not train specifically to treat cancer, Dr. Damuse and her team are serving as one of the strongest cancer clinics — if not the only one — offering free services at a hospital in Haiti.

“In Haiti, access to cancer care is limited and only people who can pay will receive it,” said Dr. Damuse. The few private oncologists located in Port-au-Prince charge for their services. In Haiti, few people can afford that expense.

Though the challenge seems daunting, this is only the beginning of ZL’s cancer initiative. Dr. Damuse recently added two full-time nurses and a social worker to her team. Beyond helping Dr. Damuse keep the clinic running, this small staff provides psychological support, organizes surgeries, and coordinates care outside the clinic.

The oncology program is slated to move from Cange to ZL’s new state-of-the-art Mirebalais National Teaching Hospital in late 2012.

Until then, Dr. Damuse will continue providing breast cancer services to women in Cange — screening and caring for girls, mothers, and grandmothers from across Haiti’s Artibonite and Central Plateau Departments.

Learn more about PIH’s work in Haiti, and Mirebalais National Teaching Hospital.