Haston Charlotte talks with a calm and confident endearing voice, sharing her story of how she survived one of the deadliest diseases, cancer. The 50-year old mother of one from Kagugu in Gasabo District was able to beat breast cancer, thanks to early diagnosis and treatment which was administered when the disease was still in its first stage. "I was lucky to get early diagnosis and treatment before the disease had spread and in its first stage, before the worst could happen,” she says.

A former nurse at King Faisal hospital, Charlotte says that during her professional routine of working with medical doctors that were screening and giving treatment to patients, it, one day in 2014, occurred to her that she should as well go for a medical test.

"When I went for screening, I was shocked by the results which were positive. This left me anxious and fearful. I never imagined myself having breast cancer. It was a disease that I would read about and see patients fighting with; but now here I was.”

However, since the cancer was in its first stage, Charlotte says she was able to get all the treatment she needed. Her medical insurance cover also came in handy to save her from the would-be high treatment costs. She received treatment at King Faisal Hospital, Kigali, between June, 2014 and January, 2015. She is totally healed and is now working at King Faisal Hospital as a midwife.

Charlotte is also in an initiative known as Breast Cancer Initiative in East Africa (BCIEA) that provides support to breast cancer patients and survivors.

Charlotte is among the many people in Rwanda that have benefitted from awareness campaigns and early cancer diagnosis and treatment. Awareness has been, especially, created through behaviour change communications spearheaded by the Ministry of Health through the Rwanda Biomedical Centre (RBC).

Breast cancer awareness

As part of the activities to raise awareness on breast cancer, the Breast Cancer East Africa (BCIEA) has organised a cancer awareness walk on November 4 which will start from Christian Life Assembly, Nyarutarama.

The walk and activities of the day will highlight aspects such as early diagnosis, treatment, as well as types of cancer, among others.

Breast cancer remains one of the commonest cancers affecting women all over the world, including Rwanda. According to statistics from RBC, the burden of breast cancer in Rwanda is still high.

Breast cancer is the second leading cause of death in women, after cervical cancer. Annually, there are around 550 cases of breast cancer patients who seek treatment. Among them, only 30 per cent are seeking medication while at an early stage, while the remaining cases seek treatment when the condition is in advanced stages.

Dr Aimee Muhimpundu, the non-communicable diseases division manager at RBC, says the major risk factors for non-communicable diseases (NCDs), including breast cancer, are tobacco use, alcohol abuse, physical inactivity and unhealthy diet.

She encourages people to reduce exposure to the risk factors so that they avoid getting such non-communicable diseases.

"People should engage in more active lifestyle habits, at least 30 minutes per day, take a diet rich in fruits and vegetables and go for check-ups once a year,” she says.

Muhimpundu, however, advises that those affected already should follow the guidelines provided by their medical care providers to avoid further complications.

Measures in place to ensure early detection

According to Dr Francoise Uwinkindi, the director of Cancer Diseases Unit at RBC, the biggest challenge is that people seek treatment late, when the condition is in its third and fourth stage and there is less that can be done to cure it.

At this stage, he explains that the cancer cells have already spread from the breast to other parts of the body such as the liver, lungs and even bones, making it hard to heal completely.

The good news, he says, is that when detected early, cancer can be treated completely unlike in its advanced stage where only palliative can be provided.

"At an advanced stage, we can only work on symptoms and control the pain. This is the most common situation among the patients we attend to,” he says.

Uwinkindi notes that at least 65 per cent of patients with breast cancer come when it is at an advanced stage. He adds that for this reason, the Ministry of Health is putting much effort in creating more awareness about breast cancer so that people are in position to read the symptoms and signs of breast cancer early and seek timely treatment.

He says awareness campaigns have also been done on platforms such as social media, through NGOs activities as well as in the community, where people have been trained to avoid NCDs including breast cancer.

Uwinkindi says 100 cells across the country are among the places where such activities are carried out. Depending on how people will embrace the initiative, he says the same awareness campaigns will be rolled out to other places all over the country.

During these on-going sensitisation drives, women are taught and encouraged to do monthly self breast examination.

"Since we are working with the community, we are expecting to have many people turning out for early diagnosis,” he adds.

Uwinkindi says mammography is the best way to screen breast cancer, but since it’s not widespread in the country, best clinical examination is being used.

"At the health centre, when health workers discover that a woman is having the signs of breast cancer, she is transferred to the district hospital where advanced investigations are done to rule out the suspicions of breast cancer or differentiate it from any other breast lamp,” he says.

At district level, when found out to be breast cancer, he says the patient is transferred to referral hospital for more examination to establish if it’s exactly breast cancer.

According to Paul Balinga, a senior officer in the Cancer Diseases Unit at RBC, health workers in the community have been trained on how to do clinical exams so that they can help people to seek early treatment.

He notes that they have also introduced checkups for women above 35 and men above 40 years, which is being covered by community health insurance.

"Such people are encouraged to visit a health centre at least once a year to check for NCDs, including cancers,” he says.

Balinga further notes that since people are using their community health insurance for checkups, it is easier for them to turn up in big numbers for screening and treatment because it’s affordable.

With this ongoing awareness, Uwinkindi says in future they are expecting to see a less number of people coming for treatment at an advanced stage.

Management

Meanwhile, Uwinkindi says there are three treatment options for cancer in the country which include surgery to remove the tumor, radiotherapy and chemotherapy. In most of the cases, there is a combination of these three modalities to ensure comprehensive treatment.

"The purpose of all this is to make sure if the disease is not confined at the breast we prevent the spread of the cancer cells to other parts of the body,” he says.

Uwinkindi says surgery is done in all referral hospitals such as Kanombe, Butaro, King Faisal, as well as Butare Teaching Hospital. However, when it comes to chemotherapy, the services can be only found at Butaro and King Faisal Hospitals.

He also says there is ongoing construction for a full-fledged treatment unit for breast cancer at Rwanda Military Hospital in Kanombe, which is expected to be done by January next year. With this facility in place, cancer patients will be able to get all the required treatment locally, and not having to travel abroad for radiotherapy.

In cases where there is no hope for a patient to get cured, Uwinkindi says palliative care and chemotherapy are used to reduce the tumor and the pain as well.

"For patients whose breast cancer is at stage three and four, the pain is so intense, and that’s why we also provide pain control to relieve the pain,” he says.

Such patients, Uwinkindi says also need counseling, social, emotional and spiritual support for them to feel cared for.

Behavior change communications (BCC)

Mark Hadenimana,a senior officer in the Cancer Diseases Unit at RBC, says it is hard to determine the real cause of breast cancer, just like other types of cancer, apart from cervical cancer which is caused by human papillomavirus (HPV). He, therefore, says there are many factors that increase the risk of one getting the disease.

For instance, Hadenimana says there are some modified factors, where a lot can be done to prevent one from getting the disease, while; on the other hand, there are unmodified factors, where nothing can be done to prevent the possibility of one getting it.

He explains that lifestyle-related factors fall under modified factors.

"We are focusing on these factors during the breast cancer awareness campaigns this month. Among them, there is excessive consumption of alcohol which is not only a risk for breast cancer but also other types of cancer. Being overweight is another factor, and here, people are being encouraged to do physical activities to reduce their weight,” he says.

One not being physically active is another risk factor, which he says, initiatives like the car-free zone come in to encourage people to engage in free physical activities that are being spearheaded by the government.

Uwinkindi also says another risk factor is a woman not having children. He explains that breasting feeding is among the preventive factors for breast cancer. "Therefore, not having children means that women won’t breastfeed, increasing their chances of developing breast cancer.”

Women who have children, on the other hand, are encouraged to exclusively breastfeed their children to avoid the risk of developing the disease, he says.

"When breastfeeding, there are some physiology changes in the body that a woman goes through which are behind developing breast cancer. When they are not highly concentrated in the body, it reduces the chances of developing breast cancer,” he says.

Additionally, Uwinkindi says another risk factor is hormonal therapy after menopause.

"When a woman is in her menopause stage, they start to undergo physical changes on their body. Because such women don’t have the hormones that help keep their body firm, some can develop low self-esteem and due to this, they resort to taking hormones that will help them maintain their young and firm figure. Such kinds of hormones are also risk factors for one to develop breast cancer,” he says.

Unmodified factors

For these factors, Uwinkindi says there is little that can be done, but he urges people to go for regular checkups to detect the presence of breast cancer so that they can be treated early if they have the disease.

Such factors include age, especially those aged above 60, as well as a history of family members who had breast cancer. Also one being a woman poses higher risk of getting breast cancer compared to their male counterparts.

Achievements and challenges

There are several medical facilities in the country that are treating cancer, among them, Butaro Hospital and referral hospitals which can carry out surgeries. According to Uwinkindi, radiotherapy treatment is expected to be in the country by early next year to provide comprehensive cancer treatment.

Also, palliative care is another achievement when it comes to managing patients with advanced stages of breast cancer, just like any other type of disease that need such services.

For diagnosis, the services are available in most of the hospitals in the country. Community checkups initiatives are also another big achievement helping a big number of people to come out for early screening, thus helping in curbing the burden of the disease.

Hadenimana says although much has been done to raise awareness, there is still more to be done to help reduce the number of those turning up for treatment at an advanced stage.

He says they are trying to look for more innovative ways that will see them reach out to more people. Hadenimana says they are partnering with different organisations and telecom companies to improve breast cancer awareness.

Challenges

Inadequate awareness is still a big challenge when it comes to breast cancer detection according to Balinga. He says quite a number of people still don’t have enough knowledge about breast cancer.

For treatment, Balinga says treatment facilities in terms of equipment and human resources are still not at a level where comprehensive treatment for breast cancer should be.

"There are also other new drugs that our patients do not have access to because they are expensive. Also people turning out for treatment at stage three and four is still a huge challenge,” he says.

Balinga says about 50 patients are being referred outside the country for further treatment by the government annually, and about 12 patients are referred outside the country a month for radiotherapy treatment.