MAY all the men please step outside for this one today, I would like to whisper to my sisters.
So, you have an itch on your lady-parts and maybe an odour so bad you want to run away from yourself. Maybe you even feel some unfamiliar ‘friends’ when you touch yourself. You gather up the courage to go and see a gynaecologist but when you enter the office, it is a man. Will you get onto that bed and display your goods for an examination or will you change the story and get out of there?
In today’s edition of the conversation I had with University Teaching Hospital gynecologic oncologist Dr Kalima Munalula, she encourages women to “stop being so restricted with the bottom half of their bodies” and allow even male gynaecologists, who are the majority, to examine them because that could just give them a better fighting chance if they have cancer. And if that doctor doesn’t physically examine you, she says it’s important to seek a second opinion.
Q. What are some of those symptoms of late-stage cancer?
A. For endometrial cancer, because it happens mostly in women that are past menopause, if you are past menopause and you bleed, you need to have that checked because it is abnormal for a women who has passed menopause to bleed, even if it is just one day. You need to have that checked. Also, in older women, after menopause, a watery discharge, again, you need to have that checked. Sometimes, we have some patients that have a watery discharge and it is cancer in the uterus. So you need to have that checked. I think the most important thing that everybody must understand is that you need to know what your normal is in order for you to be able to recognise what is abnormal. So you need to be aware of yourself and then you will know that ‘this is not me, there’s something wrong’, and then you go to the hospital.
Sometimes women go to healthcare facilities and the person that they see does not take their symptoms seriously, you are free to go somewhere else and get a second opinion. If the doctor is telling you something that is not making you feel comfortable or explaining what is going on, you are free to go and see someone else, it is good to get a second opinion. I think sometimes as doctors we may be wrong about what we think might be the problem in our patients and we may brush off patients that we think ‘ah, this patient is very troublesome, she is always coming for all sorts of things’, so we may be wrong and that’s why I am saying you can go and get a second opinion but really, you need to know what your normal is in order for you to recognise what is abnormal. Don’t just stay at home.
And then with the vulva cancer, some of the things that women present with is that they have an itch on the vulva and then maybe a watery discharge, sometimes you can get discolouration, maybe the skin on your vulva starts getting white or it’s looking darker, you have dark patches and there’s an itch, you need to go and have that checked. If you go to the hospital and the person that sees you does not actually examine you but they prescribe something for you, I would go and see someone else. So if you have an itch, don’t sit if someone gives you some medicine without actually examining you, because they need to see what’s going on. I have seen a lot of women who they had symptoms, they had an itch, and then they go to a healthcare facility and then someone prescribes some ointment for them to use and then they go, they come back after three months and then they are given something else…
Q. So in that case the doctor thinks it’s just a thrush or something?
A. The doctor doesn’t see it, they don’t examine. So they just say ‘try this’, and then they will go home and try that and then eventually they come and they have a lesion, they have an ulcer, so time has been lost. So if you go to a hospital and a doctor prescribes something without examining you, it is always good to get a second opinion, somebody should actually examine you even if you are just coughing, the doctor should listen to your chest, they shouldn’t just prescribe.
Q. Let’s talk about these examinations because in our society, people are so reserved, for lack of a better word, most people tend to be prudes, anything to do with nudity, the doctor coming to check you down there, people will shy away from that. So I think maybe you need to encourage people, to emphasis how important these physical examinations are.
A. Yes, like I said, for me, because I work with gyn cancers and things like that, it is good to see. You always need to see what the patient is complaining about because sometimes, it may not even be anything, sometimes I have seen patients that come to the clinic, they have been referred from one of the other health facilities here in Lusaka, a referral form has been written for them and then I look at them and I ask ‘why did they send you here’. So it is important to look, maybe the other person said ‘this is something which I cannot be able to deal with’, then they send them up to the next level, that is good. Because I look at them, I examine them and I say ‘you needn’t have come here’, but that’s good. So for me, looking at a woman and examining her is very important because that’s how I can tell to say is this something big, is this something I can do something about, but I always have to see what the problem is. So I suppose that because I am a woman, a lot of the ladies are sort of like comfortable, but it’s a fact that a lot of the gynaecologists that we have are actually male so we don’t, as a woman I don’t think you should feel so bad about being examined by a male because most of the time they are examining you as a professional and they want to do what they can to help you, when you come to the hospital you are coming for help so people should not feel too restricted about the lower half of their body. Just come, be seen and if you are given a clean bill of health, then that’s good.
Q. And speaking of the late stages of cancer, it does at some point begin to attack the other organs, right? And is that what then leads to death?
A. Yes, so what happens is that cancer spreads and the cancer spreads say by direct extension and also through the blood, because the cells, and remember, cells are small, so they can go through to the blood vessels. So cancer as it is growing, it also has the ability to grow new blood cells which previously were not there. And these get joined to the already existing blood cells and that way, cancer cells can move to other parts of the body. They can also move through lymph vessels, so these are different types of vessels that are found in the body. So by direct extension, for example in cervical cancer, initially the cancer will only be in the cervix, then it starts spreading outwards, it will go to the bones, it will go to the bladder, it will go to the rectum, so sometimes women who have advanced cervical cancer will have pain in the back because it has gone to the bones and then as it is spreading outwards into the bones, it goes to the urether which is a structure that brings urine to the kidneys and helps pass the urine, so those structures get blocked and because of that, it starts affecting the kidneys and when the kidneys are affected, because there is one component that helps us produce the haemoglobin that is required in the blood, then that production also is affected. And then if the cancer cells get into the blood, they now go to other parts, not just for cervical cancer but for other cancers, maybe they will go to the liver, they will go to the lungs, sometimes the cancer even goes to the brain, so all this happens because sometimes the cancer cells are going into the blood and moving around the body and we say that is metastatic, it has spread. So when a patient comes and we examine them, we are able to stage; cancers have four stages, stage one, two, three and four. Depending on the extent to which the disease is present, the patient could be on either one of those stages and depending on the stage, we are able to do something about it. For example, in terms of cervical cancer, if a patient comes to us stage one, usually we are able to offer an operation where we remove the uterus and most of the time they are cured and if they come to us stage two, three and four, we are not able to operate but they can go and get treatment at the Cancer Diseases Hospital. And then the other cancers for example, cancer of the uterus, if it is stage one or stage 2, most of the time we are able to operate but if it is stage 3, meaning it is affecting other organs, we are not able to operate. Ovarian cancer as well has stage one to four and we are only able to tell the stage when we take a patient for an operation, we can’t stage them before an operation is done so sometimes what we do, a patient might be too ill to have surgery so maybe we will go and just get a small piece of the cancer so that we know what type it is and our colleagues can know what type of medicine to give them. Then they will get the medicine, and then after they have improved in their condition, they will be taken for the operation. We can only tell the full stage once we take the patient to the theatre.
Q. When we watch movies, we see sometimes someone goes to the doctor and they will be told, ‘it’s already late stage, you only have four weeks to live’, are we able to make such projections here?
A. No. I am not very sure, I suppose the time that the patient is given is based on statistics that are obtained from certain people who have that same condition and they are diagnosed at that point and then they see how long after the person got that diagnosis did the continue to live. One of the statistics that is collected for the different cancers is what is known as a five year survival, so depending on the cancer and the stage, the five year survival is different. So the five year survival is very loosely, if a patient is diagnosed with cancer on day one, after five years, how many of those people who were diagnosed with stage one on day one will still be alive and how many who were diagnosed with stage two after five years will still be alive? So different cancers have different survival rates and the other thing is that, you remember I told you there’s a cancer that is associated to pregnancy? That cancer is very responsive to chemotherapy, so patients who we find with that condition, when they get chemotherapy, they recover. So the survival is quite good.