One morning in 2019, Marie-Claire Nshongore woke up to a sharp pain in her left breast, one she had never felt before. The pain remained constant and gradually intensified over time. Upon self-examination, she discovered a small lump in her breast, and when she looked in the mirror, she noticed that the affected breast appeared slightly more swollen compared to the right one.
"It felt quite sensitive, there was a bit of irritation and redness. The nipple had in a way sunk in and also felt painful. I quickly checked with a friend who advised me to go for a mammogram," Nshongore said.
At 34, she was informed that she had breast cancer, but luckily, it was detected in its early stages, making it treatable. Without hesitation, she took action.
"I immediately started the treatment process. I was told it was still on stage two, and the cancer cells were still in the breast tissue and the nearby lymph nodes but it was curable," she added.
It took a combination of treatments including surgery, chemotherapy, radiotherapy, and hormonal therapy, in and outside Rwanda, for her to fully recover. Luckily, she survived a mastectomy, after doctors realised that she had healed well.
Nshongore is one of the lucky few who manage to escape the grim reaper that breast cancer is. It is one of the most fatal types of cancer. Last year, the Ministry of Health revealed that annually, Rwanda diagnoses at least 650 cases and of those, about 600 turn out fatal.
According to Dr Theoneste Maniragaba, an oncologist at Rwanda Cancer Centre (RCC), which is located at Rwanda Military Hospital (RMH), who also heads the Cancer Unit in the Non-Communicable Diseases Division at Rwanda Biomedical Centre (RBC), breast cancer has become a major burden not only for Rwanda but the world.
The disease is a challenge mainly due to a number of factors, including late diagnosis, which complicates the treatment process, while in other cases, beliefs such as witchcraft and attempts to treat the disease using herbal alternatives make it difficult to deal with it early.
"Breast cancer is a global cause, considering the database of GlobalCan, which is a WHO database that enrols all cancer types every year. It has been revealed that breast cancer is the first globally in terms of incidences and prevalence.
"In Rwanda, it is the first type of cancer diagnosed, according to the data provided by the Rwanda Cancer Registry of 2022. This year we have recorded about 660 patients with breast cancer," Maniragaba says.
These are cases that have been diagnosed, have symptoms, are currently under treatment or are awaiting appropriate modalities of treatment, mainly because breast cancer treatment requires different models of treatment.
Among those modalities are surgery, radiotherapy chemotherapy and other types of treatment that are hormonal in nature, all of which require the full attention of medical professionals.
Maniragaba said available data points to cases of breast cancer increasing in the short term, with diagnosed incidences expected to shoot to 1,200 - twice the current number of registered cases.
"This, first of all, means that the problem is there, or we have it here in Rwanda. However, the number of patients seeking treatment is still very low," the oncologist says, attributing it to a number of factors mostly linked to lack of understanding.
"Among these includes low levels of awareness in our population and the second factor may be what we call health system delays," he said, pointing out that patients first go to health posts and health centres which might not have the capacity to detect these non-communicable diseases.
By the time they are transferred to the district or referral hospital for care, the condition has escalated. In other cases, social factors are blamed, where some people associate breast cancer with witchcraft and consult traditional healers instead of health professionals.
Others will not just seek treatment due to financial constraints while some downplay it in the starting stages, only to realise how serious the disease is later.
"Socioeconomic and sociocultural factors are a major problem," he said, pointing out that in some cases people believe breast cancer cannot affect men, which is a myth.
A growing problem
Maniragaba said breast cancer cases started increasing in 2007 and statistics show that the disease is not relenting.
"When you look at our graphs from 2007, they keep increasing. You can see the increase in prevalence, especially the new incidences," he said, adding that it is the leading cancer in terms of deaths.
"It is the leading cancer in terms of mortality and even morbidity. Unfortunately, it is also claiming people of a young age. 70 per cent of these deaths are of patients aged between 40 and 50," the medic says.
This increase is also attributed to improved diagnosis, considering that in 2007, the country had only one pathologist and one oncologist, but today, there are more than 20 pathologists and more than 10 oncologists and surgeons who can operate breasts.
Maniragaba explains that even though the cases were few in 2007, it is not because they were not there, but it is mainly because many cases went undiagnosed, much as the risk factors are more today than they were then.
Among those, he mentioned lifestyle changes, obesity, late pregnancy, hormonal imbalances triggered by different family planning methods as well as many other conditions that were less prevalent then.
Today, thanks to awareness and sensitisation, people do regular screening and treatment because you cannot treat what you do not know.
Maniragaba said most of the signs of breast cancer are self-examined and people should quickly react as soon as they see unusual signs, including a lump in the breast, redness, inflammation, and changes in colour and more, all of which should be a reason to act immediately.
This also includes looking back in one's family background to see if there is a history of cancer as hereditary factors play a key role in determining one's vulnerability.
Once these signs are observed, health professionals take up the case, running several tests and scans to identify the mass and the state it is in -- whether cancerous or not. Each case is dealt with individually, given the extent of the disease.
After running the tests and scans, doctors determine the treatment course and modalities, depending on the age and strength of the patient.
Medics also check the primary source of cancer and its ability to move or metastasise in medical terms, which includes checking if it hasn't spread to other parts of the body, including the lungs, liver, brain and other organs.
After these examinations, doctors can decide the best course of action. Maniragaba said that while breast cancer is common among women, accounting for more than 95 per cent of the diagnosed cases globally, evidence and available data from WHO shows that at least five per cent of diagnosed cases are found in men.
"In Rwanda, 97 per cent of the cases recorded are found in women while 3 per cent are men," he says.
A tough calling
As an oncologist, Maniragaba is human too, and dealing with breast cancer cases takes a toll on him, especially when he has to deal with the disease in its end stage -- that is stage four, where it is nearly impossible to treat.
The high mortality of the diagnosed cases means that as an oncologist he gets to meet patients whose cancer is advanced, and those can be pretty delicate cases to deal with.
"Stage four of breast cancer is very painful. When the patient comes to me with such a condition upon diagnosis, I feel for them. The first thing I do is reveal the bad news, but it requires some form of compassion," he said.
Maniragaba said delivering the news that the cancer metastasised is done in a manner that the patient is given reassurances that it is not the end of life and that there is something that can be done to prolong their lives, as much as possible.
He added each individual case is handled differently, but the main focus at this stage is to minimise pain offer psychological support and also engage the family as part of preparing them for the inevitable.
Maniragaba said that normally at stage four, breast cancer is irreversible but what they do mostly is offer palliative care and other forms of treatment such as shrinking the tumours using chemotherapy to minimise the effect.
The cases also respond differently, with some reacting well while others feel the side effects of the intensive treatment. It also varies from one gender to another. All these cases and how they react help them understand and improve cancer-related care.
Most importantly, the treatment can only be successful if there is not only consent from the patient and the family, beyond that the patient has to have the hope and courage to fight, which is one of the most important factors in cancer treatment.
A rigorous process
The assessment looks at many things, including the aptitude to be able to undergo surgery, sustain anaesthesia, chemotherapy and its effects and most importantly have the desire to fight. Most times such patients will elongate their lives depending on their attitude and response to treatment.
Maniragaba pointed out that in most advanced cases, perhaps some organs are already struggling, the patient does not have enough blood, or they have other conditions that complicate treatment.
It is something doctors have to deal with but most importantly the focus is on minimising pain.
However, when a patient is fit and shows good performance in terms of responding to treatment, they can elongate their lives but, in most cases, it is impossible to reverse it to stage three, hence the high mortality rate.
In other cases, some patients do not receive the news well, and might even take days to take it in and come to terms with the news, for others stress and depression will set it. It is a complex situation.
For oncologists and other health professionals involved in the treatment process, it goes beyond just medical procedures but also offering psychosocial and physiological support, and also ensuring that breast cancer patients access the right treatment. At this point, it is not just the oncologist.
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Among other things, cancer treatment comes at a heavy cost for patients from vulnerable households but luckily in Rwanda, the government has ensured access to treatment such as chemotherapy and other therapies at no cost in different hospitals including RMH and Butaro hospital in Burera District.
The same applies to most pain management drugs such as morphine, which can be accessed in different forms, whether it is tablets or intravenous, depending on what the doctor prescribed, determined by the level of pain.
"The government provides these drugs for free. We have availed these services in all our treatment centres, including here at the Rwanda Cancer Centre.
"Whenever a patient requires it, the doctor just prescribes it and the patient goes to the pharmacy or dispensary and they are given these drugs for free," Maniragaba told The New Times.
Other common cancers
In terms of prevalence, breast cancer is followed by cervical cancer in terms of mortality and morbidity, but what is more scary is that it is increasingly becoming more prevalent among young women, which wasn't the case before.
"Unfortunately, it is affecting patients of young age, with more than 70 per cent of the cases detected in people aged between 35 and 50. Cervical cancer is followed by prostate cancer which is also affecting men of a younger age," he observed.
Maniragaba said more efforts need to be directed towards awareness and sensitisation so that people can test and treat early because most cancer cases are treatable when seen early.
"The Government of Rwanda through RBC is putting more efforts in awareness and early screening to make sure that people within our communities can know and identify symptoms early and get referred to treatment as soon as possible," he said.
That is the only way to minimise cancer incidents. Maniragaba urges people to listen to and understand their bodies and seek treatment early instead of wasting precious time on other alternatives such as herbal treatment.
The adage 'early detection saves lives' goes beyond just saving lives but would also save the country millions of francs spent on treatment and drugs, given the burden the disease has become in recent years.
