Ensuring best of breast health

BAVINA SOOKDEO

“Get screened, try to understand your breast health and don’t look away from it. It does not have to be a painful journey. Breast screening is now painless and can be done before you can even finish your lunch break. You don’t have to take a day off from work and you don’t have to take tablets for it – it is pain-free and short.”

This is the message Dr Rajendra Rampaul is sending out to women as Breast Cancer Awareness Month comes to an end.

Rampaul is a breast oncologist and oncoplastic surgeon with a career in the medical field since 1995. He is medical director at Pink Hibiscus Breast Health Specialists, an institution committed to delivering care for all aspects of breast-related concerns. What sets Rampaul apart in the Caribbean medical landscape is his expertise in state-of-the-art modern breast oncology procedures such as oncoplastic surgery and radio-guided procedures such as radio isotope-guided sentinel node biopsy and radio-guided lesion localisation. The practice is considered the gold standard internationally, especially in the US and Europe.

In an interview with Newsday, Rampaul generously shared his insights on breast health, addressing common concerns related to breast examinations, particularly for the big-breasted woman, and on breast reconstruction options.

Questioned on the challenges of breast examination for individuals with larger breasts, Rampaul acknowledged the challenges faced by Caribbean women, particularly those in Trinidad and Tobago, who often have larger breasts. He said while self-examinations are pivotal for breast health, it’s crucial to discern the distinctions between individuals with smaller and larger breasts. Self-examinations, while effective for smaller breasts, may not be as accurate for those with larger breasts. He emphasised the necessity of modern techniques, particularly mammography and ultrasound, to ensure a comprehensive assessment of breast health.

For individuals with larger breasts and women at large, Rampaul recommended a best practice of annual breast screening involving mammography and ultrasound. This combined approach, he stressed, surpasses a simple clinical examination, ensuring thorough evaluation of deep breast tissue.

Additionally, he highlighted the significance of ultrasound, particularly for women with dense breasts, as it enhances the efficacy of mammography.

Does size poses a challenge for the big-breasted woman to get a biopsy done?

“No, because in best practice you are supposed to do a biopsy with imaging (an ultrasound or mammogram). You are not supposed to do a biopsy with your hands only (feeling something) – you cannot function like a blind person, walking around in the dark feeling where the light switch is, so imaging such as ultrasound and mammography is the gold standard and in fact, the only defensible way to perform a biopsy. If you are now going around in this year, doing breast biopsies without these technologies, you are highly likely to miss it.”

While breast cancer surgeries are undeniably life-saving, they can leave patients with external alterations that pose emotional and practical challenges. Rampaul stressed the significance of breast reconstruction in helping patients regain confidence and improve their quality of life. Reconstructive procedures are designed to restore a sense of normality to survivors’ lives.

This raises questions about the available options and specific challenges, especially for individuals with larger breasts.

Rampaul pointed out that when breast reconstruction is omitted from the equation, one is left with oncology surgery alone. In this scenario, unlike procedures such as hysterectomies, which do not result in noticeable external changes, a woman who loses a breast is acutely aware of the external alteration. This awareness can lead to concerns about others noticing the missing body part.

Rampaul, who returned to Trinidad after a UK National Oncoplastic fellowship, played a pivotal role as the pioneering surgeon in developing the first public breast cancer clinic at the St James Hospital. His initial exposure to women in Trinidad revealed a significant gap in breast reconstruction services. His research into breast reconstruction, mastectomies, and cancer surgeries uncovered a troubling reality: many women felt ashamed to return to their normal lives. Shockingly, 80 per cent of these women grappled with concerns of abandonment by their spouses, and a majority experienced depression, with some even contemplating suicide.

He explained the consequences of mastectomy extended beyond emotional struggles. Women who had undergone these procedures found themselves constrained, living as if in a cage they could not escape. They struggled to reconcile their post-surgery appearance with their past selves. Everyday activities, such as donning a favourite dress, became challenges. Clothing no longer fit correctly, twisting and shifting as they walked. Sometimes, one breast would hang out of a bra while the other did not fit in. Additionally, the larger breast might shift to the side, further exacerbating the issue.

These profound challenges prompted Rampaul to explore how to improve the lives of these women. Reconstructive surgery was a significant solution. It allowed patients to regain their confidence, enabling them to wear the wedding dresses they had always dreamt of or to participate in cultural celebrations like Carnival.

He said cancer surgery can, in many ways, be likened to imprisonment. He noted that patients are trapped in a cycle of worry about their future, living under the shadow of impending medical scans. This burden tightens like a noose, impacting every minute of their lives.

“Time becomes both a gift and an agony. So, reconstructive surgery helps to add a small balance to that prison that they have to live in. It is one thing to be alive, it is another thing to realise you may not be alive…you are cheated of the one thing you thought you would never be cheated of – peace of mind.”

As for options, he pointed out there are many options for reconstructive surgery and many to help build back a breast. “Some of those options can begin at the time of cancer surgery and some begin after. It is a complex process how you negotiate through it, but I offer all the forms and all are available but not every woman’s body type or type of cancer means that all the techniques are suitable for her. It is a very tailor-made approach of what fits into her life, the type of person she is, how old are her children, what type of work she does, what type of cancer she has – it is a complex story.”

There are many misconceptions when it comes to breast health and breast-related procedures.

Rampaul pointed out, “There is a misconception that mammography hurts, and that is untrue in the modern age.”

He emphasised the importance of seeking care from accredited and dedicated breast health centres to ensure that patients receive the best possible experience.

For patients navigating breast health issues, breast cancer diagnosis, and treatment, organisations like Pink Hibiscus Breast Health Specialists offer invaluable support. Rampaul encouraged individuals to reach out through its Facebook page (https://www.facebook.com/pinkhibiscustt) to discover accessible support groups in their area.

Rampaul is deeply concerned about the mental health of women after surgery for breast cancer and for further support he suggested clinical psychologist Dr Arianne Shepherd.

Addressing some of the emotional and psychological challenges that breast cancer patients typically experience after undergoing a mastectomy, and how these challenges affect their overall well-being, Shepherd said, “A patient’s emotional and psychological response will be affected by existing social, cultural and psychological factors.

"It is common, however, to experience psychological discomfort such as anger, anxiety and/or depression, increased concern about body image, negative changes to their perception of self and a fear of the future as it relates to cancer recurrence. The extent to which these challenges cause disruptions to their daily life and routine influences overall well-being. Adequate support from loved ones is critical.”

How does the process of adapting to the physical changes brought about by a mastectomy impact a patient's self-esteem and body image?

“Culturally, self-esteem is often strongly tied to body image and so a mastectomy can be internalised as disfigurement which can affect a woman's ability, post mastectomy, to feel whole. For some, it can also mean a loss of femininity. Any drastic and involuntary change to a woman's body image can feel very disorienting and painfully difficult. If this is met with marital or sexual disruption it can further reinforce feelings of inadequacy and shame.”

On strategies or therapies that can help patients navigate these challenges and feelings of grief and loss, Shepherd pointed out that some general strategies would include “being as open as you can with people you trust about your diagnosis and treatment, talking with other women who have been through this phase of treatment, and if in a relationship, involving your partner as much as possible. Speaking with a mental health professional to address specific challenges to self-worth, improve coping and reduce stress may also be helpful. The key is community and support.

“It's important to normalise and validate these feelings of grief and loss. While for many, it is a necessary surgical intervention, the emotional impact is significant, and patients need to be allowed to navigate this grief on their terms. It is also very helpful for healthcare professionals to involve family members in the treatment process. This can mean educating partners and adult children about the physical and emotional challenges associated with a mastectomy, which allows for a more effective support system at home.”

Many breast cancer survivors report experiencing anxiety or depression after a mastectomy what is the relationship between physical health and mental health in these cases, and what interventions or treatments can be beneficial?

Shepherd said, “While undergoing treatment, survival mode kicks in allowing patients to successfully navigate the threat to their physical health. When this is completed, they naturally begin to reflect on what they have experienced; the ups, downs and in-betweens of the cancer journey. There is a build-up of emotions to process which can sometimes become overwhelming and result in a survivor experiencing anxiety/depression.

“Individual and/or family counselling, social support and having a sense of meaning or purpose in life is beneficial at this stage. Support groups are also a very helpful resource to assist survivors in living beyond their illness.”