Our second-year surgical resident, a Chadian fellow by the name of Asaph, came into my clinic office, which was just across the hallway from his own. We were in the midst of a typical clinic day, but he hesitated before starting his patient presentation.
“It is a very large breast tumour…” he said in his characteristically monotone voice.
I was unfazed. Breast cancer is almost always far advanced by the time we see them at Bongolo Hospital. The breast itself is often morphed into a large tumour. Usually we perform what’s called a toilet mastectomy: an operation to remove the breast, not so much to cure the cancer (which is undoubtedly already spread to other parts of the body) but simply to allow the patient the dignity of dying without a necrotic tumour seeping out of the chest.
I walked into Asaph’s surgical office, but I was hit by a wave of nauseating malodour. A thin, older woman sat uncomfortably on the exam table, her hand helplessly trying to apply pressure on a spurting arterial vessel emanating deep from within a gigantic, fungating mass protruding from under her left arm. It was hard not to gasp.
Even by African standards, this was the worst case of neglected breast cancer I had ever seen. The mass mushroomed out from the lateral portion of the left breast, weeping, oozing, painfully bleeding. I could not even make out the depth of the tumour; the bottom of it seemed to disappear into an abyss of putrid, slimy, cancerous flesh.
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The larger, whitish, donut mass on the bottom is the main tumour. The dark ball with pink spots above it are the lymph nodes to where the cancer has already spread.
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Vous venez d’où? I asked the patient and her son. Where are you from?
Ntoum, they answered. Près de PK quatre-vingt.
Ntoum? I repeated back, incredulous. Mais c’est loin! Comment est-ce que vous êtes arrivés ici?
The city of Ntoum was, under the best of circumstances, a 7-hour drive away, just outside the capital Libreville. With all the Covid-19 internal travel restrictions, I thought it impossible for patients to get to Bongolo from that far away. The patient’s son, however, simply shrugged his shoulders. Undoubtedly he has paid a pretty penny, both in transport costs and in petty bribes, to get his mother to our little jungle hospital, travel restrictions be damned.
The lady, perhaps the age of my mother, looked at me sadly. I tried to ask some more questions about her previous treatment, but the answers were unsurprisingly vague and fruitless. She had noticed something growing a couple years ago, and even sought out a diagnosis at a well-known academic centre in the capital. However, either from lack of funds or simple denial, she pursued no further studies or treatment, until the suffering became literally unbearable.
Frustrated by her ambiguous answers, I demanded how she could have delayed seeking treatment for so long. She merely lowered her gaze. Her shame was palpable.
I stopped with my line of questioning and softened my voice.
Ça va, ça va. Vous avez bien fait d’arriver ici. On vous soignera. Ça va aller.
She looked up again and nodded gently. It would be ok. We would take care of her.
It took a week of hospitalisation and blood transfusions before she was halfway healthy enough to go to the operating room. Finally the day came. The OR team met for its usual Pȿalɱ and praẏęr at the beginning of the day. Then I prepped the team for the day ahead.
Ça va durer, eh? C’est une mastectomie avec un, peut-être deux lambeaux pour la reconstruire. Je pense que ça va prendre entre cinq et six heures. Apprêtez-vous!
The OR team raised their eyebrows. They weren’t used to operations that might last five or six hours.
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Halfway through the operation, the tumour and local metastases were removed, and this was the resultant soft tissue defect.
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In total the patient ended up being under anesthesia for seven hours. The Halstedian mastectomy was bloody and tedious; the axillary metastases had to be delicately teased away from the axillary vein and the thoracodorsal neurovascular bundle. Two musculocutaneous flaps, one from the latissimus dorsi and the other from the external oblique, came together to fill in the gap left over from the tumour extraction.
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The skin and muscles being held up represented the reconstructive flaps utilised to help cover the large post-mastectomy defect.
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C’est ça, le boulot! the OR team said triumphantly at the end of the case. It had been long and taxing for everyone involved; we were all underequipped and underqualified. But the team was proud of their work. Cases like this didn’t come too frequently.
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At the end of the case, the patient had stitches and drains galore, but no more tumour.
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Two days later, even with hundreds of stitches and several silicone drains sticking out from her back and belly, the patient was sitting up in bed, her eyes bright.
Ça va, maman? I asked. You doing ok?
She smiled—the first real smile I had seen since she had come.
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We could have discharged her from the hospital a few days later, but seeing as they had a long way to go back to Ntoum and with the uncertainty of return travel for routine follow-up, we decided to keep her in the hospital until all her drains came out, a process that would usually take a few weeks.
A couple weeks later, Asaph entered my surgical clinic office again.
“I have another case of breast cancer,” he started, and then paused slightly. He shook his head.
“It is in fact the same as the other lady. The same thing…”
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And now...for some family pictures!
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Nolan celebrated his 5th birthday in April, surrounded by his friends, receiving lots of presents, and eating his specially-requested "airplane cake."
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Some of our children's favourite activities when heading to the local town for groceries.
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