FAY­OLA K J FRAS­ER

The mor­tal­i­ty rate of breast can­cer in T&T has been es­ti­mat­ed at ap­prox­i­mate­ly 23 per 100,000 women, with one in nine women de­vel­op­ing breast can­cer in their life­time. How­ev­er, there ex­ists a less ob­vi­ous bat­tle that many women di­ag­nosed with breast can­cer are forced to con­tend with, aside from the ob­vi­ous pri­ma­ry con­cern of sur­vival. Grap­pling with the de­ci­sion whether to un­der­go a mas­tec­to­my (re­moval of the breast) is of­ten a griev­ous and dif­fi­cult time of tur­moil for many women with breast can­cer, with many ex­ter­nal par­ties of­ten di­min­ish­ing this men­tal and emo­tion­al bat­tle to con­cern for aes­thet­ics.

Be­ing a core part of the fe­male and fem­i­nine iden­ti­ty, hav­ing breasts is far more than aes­thet­ics, as it re­lates to re­pro­duc­tion and re­la­tion­ships, and the loss of them can cause great­ly di­min­ished feel­ings of fem­i­nin­i­ty.

In T&T and the Eng­lish-speak­ing Caribbean, Dr Ra­jen Ram­paul, med­ical di­rec­tor of the Pink Hi­bis­cus Breast Health Spe­cial­ists, is a Breast and On­coplas­tic Sur­geon trained in sur­gi­cal on­col­o­gy and plas­tic surgery. In his role as a breast can­cer spe­cial­ist, he looks af­ter women with sim­ple and com­plex is­sues such as breast pain, screen­ing, di­ag­nos­ing and treat­ing breast can­cer, and re­con­struct­ing women’s breasts af­ter can­cer re­moval surgery.

Be­fore Ram­paul’s re­turn to T&T from the Unit­ed King­dom (where he at­tend­ed the uni­ver­si­ties of Not­ting­ham and New­cas­tle), al­though there was a high rate of mas­tec­to­my, there were no doc­tors lo­cal­ly who ad­dressed breast re­con­struc­tion.

Ram­paul is du­al­ly spe­cialised, mean­ing that he can per­form a mas­tec­to­my and re­con­struc­tion at the same time. He was a pi­o­neer of this ser­vice, open­ing up op­por­tu­ni­ties and av­enues for women to re­ceive care from the mo­ment of their di­ag­no­sis, through­out their jour­ney with can­cer to re­build­ing and re­con­struc­tion.

The mas­tec­to­my is the surgery for the re­moval of breast tis­sue as a means to treat or pre­vent breast can­cer. Mas­tec­to­my can re­fer to a to­tal mas­tec­to­my, where the sur­geon re­moves the en­tire breast, and pos­si­bly a few un­der­arm lymph nodes, a skin-spar­ing mas­tec­to­my, where the skin over the breast is left in place while the tis­sue, nip­ple and are­o­la are re­moved, a nip­ple-spar­ing mas­tec­to­my where the breast skin and nip­ple are saved and a dou­ble/bi­lat­er­al mas­tec­to­my, where both breasts are ful­ly re­moved. In some cas­es, a mas­tec­to­my is done to re­duce the risk of get­ting can­cer for women who are at high risk, such as those with a BR­CA gene mu­ta­tion.

A woman can al­so be treat­ed with breast-con­serv­ing surgery (lumpec­to­my), which saves most of the breast.

In essence, a mas­tec­to­my or lumpec­to­my is a pri­ma­ry op­tion for women di­ag­nosed with breast can­cer to rid them­selves of as many of the can­cer­ous cells as quick­ly as pos­si­ble.

Women in T&T to­day have more op­tions. Ram­paul in­di­cates that with ad­vance­ments in med­i­cine, full mas­tec­to­my has even be­come some­what out­dat­ed. There are new tech­niques that he has em­ployed in T&T such as fat graft­ing, which im­plants stem cells to re­grow and re­de­vel­op breasts, and re­con­struc­tive surgery fol­low­ing a mas­tec­to­my or lumpec­to­my. He cred­its the evo­lu­tion of med­i­cine with of­fer­ing women the op­por­tu­ni­ty “to feel whole and not de­formed”, as the mas­tec­to­my can of­ten be a bru­tal op­er­a­tion.

Ram­paul has pub­lished re­search along­side psy­chol­o­gist Dr Ar­i­anne Shep­herd, fo­cused on the link be­tween de­pres­sion and body mu­ti­la­tion that ac­com­pa­nies mas­tec­to­my in T&T.

Ac­cord­ing to their re­search, over 80 per cent of women who un­der­went mas­tec­tomies were sub­ject to de­pres­sion, aban­don­ment by hus­bands, failed mar­riages and bro­ken homes. “It be­came dif­fi­cult for these women to re­turn to work or re­sume nor­mal ac­tiv­i­ties, as they suf­fered with shame,” he says, ex­plain­ing the phys­i­cal, psy­cho­log­i­cal and psy­choso­cial im­pact of this life-chang­ing surgery.

He de­scribed the way that many women felt about their can­cer di­ag­no­sis as “earth-shat­ter­ing, dev­as­tat­ing and lone­ly”.

For many women who right­ful­ly feel con­cerned about the af­ter-ef­fects–both men­tal and phys­i­cal–of mas­tec­tomies, be­cause of the pro­gres­sion of sci­ence and med­i­cine, there are now op­tions that do not in­clude full breast re­moval, or of­fer im­me­di­ate re­con­struc­tion of the breast.

Ram­paul’s mo­ti­va­tion to serve women through­out their breast can­cer jour­ney is clear. He ad­vo­cates for the im­por­tance of holis­tic care, in­clud­ing spir­i­tu­al and psy­cho­log­i­cal in ad­di­tion to the phys­i­cal, as up­on re­ceiv­ing their di­ag­no­sis many women leave his of­fice dev­as­tat­ed and lone­ly. “My prac­tice re­volves around the woman,” he says, “and my role is to sup­port and as­sure them that there will be a to­mor­row”.

Ram­paul is pas­sion­ate about his work and is an ad­vo­cate for an­nu­al screen­ing and ear­ly de­tec­tion. Ear­ly de­tec­tion, ac­cord­ing to Ram­paul, can pick up even the tini­est ab­nor­mal­i­ties, which some­times in­di­cate pre-can­cer, mean­ing un­usu­al cells which may or may not even­tu­al­ly be­come can­cer­ous. At that stage, he said, “the treat­ment is less and the op­tions for full sur­vival are greater”.

His pro­fes­sion­al stance calls for a mul­ti­par­tite ap­proach which al­lows for the high­est like­li­hood of ear­ly de­tec­tion. This ap­proach in­cludes the com­bi­na­tion of self-checks, an­nu­al mam­mog­ra­phy, ul­tra­sounds if nec­es­sary and doc­tor’s ex­am­i­na­tions. He al­so en­cour­ages women to not on­ly do their an­nu­al mam­mog­ra­phy but to con­sult with their doc­tors to un­der­stand their risk pro­file as it re­lates to can­cer and seek as­sess­ment as soon as they no­tice any un­usu­al changes.