Dr Anthonia Chima Sowunmi is a Consultant, Clinical and Radiation Oncologist, at the Lagos University Teaching Hospital and lecturer at the College of Medicine, University of Lagos. In this interview, she speaks on cancer, its therapy, prevention, and other issues. Excerpts.
Q: What is Cancer?
Cancer, which is now a global burden, is defined as an uncontrolled and abnormal division & growth of the cells in the body. Normally, the cells and the tissues in the body do grow but there is a stimulus that stops the growth when the cells reach their normal size. In the case of cancer, these cells continue to grow. Till they grow out of proportion. That is basically the definition of cancer. And because there are cells in all parts of the body, you find out that any part of the body could have cancer. That means that the abnormal growth could be in any part or any tissue of the body. It could be in the brain, skull or any part of the body. It could even be in the blood vessels. There are different kinds of cancer, but to be honest and candid, nobody really knows the cause of cancer. I have a boss who would say, “Only God knows what the truth is’’. Why do we say this? Because the actual thing that makes the cells of a person to grow abnormally, nobody really knows. Nobody knows\ as well what stimulus ignites or starts this abnormal growth for that matter. Q: What are the risk factors?
There is something that we call the risk factors. These are the factors associated with people that have cancers. So, for each type of cancer, the risk factor for different kinds of cancers is different. For example, if we have fifty women with breast cancer, there are common things found in these women with breast cancer, then probably we can say, these things might be what have prompted the cancer Research along the line found common things in them, and this is what we call the risk factors. And that is why you will find two people born the same day, eating the same food, doing the same thing, have the same habit and everything, one will have cancer, the other will not. These risk factors are now what people need to know to help prevent or decrease the incidence of cancer. The common cancers we have in Nigeria in women are breast cancer, cervical cancer, cancer of the colon and rectum, which is the cancer of the intestine, so to speak, for those who really don’t know. The common cancer in men is prostate cancer as well as colon & rectal cancer. There is also what we call a lymphoma, which is cancer of the lymph nodes. The lymph nodes produce and house lymphocyte which in turn produces antibodies to attack infected and cancerous cells, so it is protective of the blood cells and acts as armies of the body. We also have the head and neck cancer, as well as liver cancer which are also common. These really are for the adults. Children do have cancers too. And the percentage of children that have cancers is about 3.3 percent worldwide. The common cancer children have is the lymphoma. We have cancer of the kidney (Nephroblastoma). We have cancer of the eye (Retinoblastoma) and Sarcomasand all these are common in children. And that’s why we tell parents that they should be very observant of their children. And that whatever they notice, they should quickly come to the hospital just to ensure that all is well. Because children cannot express themselves, it’s difficult for one to detect some of them early. But if parents are very observant, especially the mothers, it could be detected early and treated with a higher chance of cure. The key to cancer cure is early detection. Now, going back to the adult cancers, when you talk about the breast cancer, it is the commonest and that is what is all over the place. In Nigeria we see about 350 new cases per year. In my department in Lagos University Teaching Hospital, we see nothing less than 10 new cases of cancer every week. So you can calculate for yourself bearing in mind that we have other centers where people go to for a cure, even without adding the rural areas and villages. Some of these data that we have are hospital based. They are only in the urban centers. How about the rural areas where people have this misconception when things are wrong with them, they hide it and feel that it is a spiritual attack. And instead of going for treatment at the right place, they resort to the unorthodox way. And of course, it is when the ailment is advanced before they are brought to the hospital. The good thing about breast cancer is that the breast is outside. At least, when there is any lump there, one can easily be felt. And that’s why it is advised that every woman should do a self breast examination. As an adult, you should look at your breast from time to time. Use the mirror and look at the size. Check and see if the skin texture is the same or there is anything abnormal there, maybe a different coloration. Look at your nipple. If you know the way your breast is normally and you are used to the way your breast is, if there is any change, you will be able to detect it early and in doing breast self examination, it’s always advised that you should do it a week after your menstrual period. If you feel that something is there you don’t know, or you are not too sure about it, you should go to the hospital and let the doctor confirm by examining you, so that the necessary steps could be taken. Your fears could either be allayed or you are sent for further investigations. The truth is that for breast cancer, a lot of people are coming out now, with a lot of jingles and awareness campaigns in the media. There’s hardly any radio station in Nigeria that doesn’t do awareness on cancer, especially 93.7 FM which does quite a lot about cancer awareness. This has helped a lot of people and many are coming out lately. We have some in the young age groups. At times, you see children of twelve years having lumps in their breasts. But the good thing about those ones is that usually they are harmless lumps. They are not cancerous. We call them benign and they can be removed so that one feels comfortable and nothing happens. Also, for those that cancer runs in their families, they should honestly start seeing the doctors for checks as early as at the age 20 to make sure that they don’t have it.
Q: What are the preventive measures against cancer? For breast cancer, we have genetics, which means, it runs in the family. There is a gene which we call BRCA which is now what they test for those who have a family history of breast
cancer, so that they will know whether they are prone to breast cancer or not and will be able to have preventive measures. The first risk factor is that anyone that has breast is prone to breast cancer. A lot of people now are going for prophylactic breast removal in some countries. Once they run the test and they know it runs in their families, they decide to remove their breast. Of course, in the advanced countries, they do a breast implant. They have the facilities. They have health insurance. So, immediately they do a reconstruction and the replacement through plastic surgery. You don’t even know that there is a replacement for their breast. It’s not like they are flat-chested. Now the second thing is what we call hormonal. Breast cancer is related to the hormone. For the women it is the estrogen. Some women who have an over expression of estrogen are prone to cancer. And that is why in the treatment of the cancer, part of the investigation is to see what their hormone receptor status is, which we call the estrogen receptor status and the progesterone receptor status. If they are positive, they give them anti-estrogen to counter the excess of that estrogen. We also at times have sporadic gene mutation that doesn’t run in the family. The person doesn’t really know and at the end of the day, the person just discovers that she has a lump which turns out to be cancer. Nobody can say why the mutations are there, but, when that happens, it is important to go for treatment.
Then, there is also what we call the estrogen window. The time at which a girl starts her period to the time she stops the period is what we call the estrogen window. Research shows that when the estrogen window is large, that is like starting early and stopping late, the person is prone to breast cancer. To start late and stop early, the chances of having breast cancer is remote. Because any time the estrogen is being produced during the menstrual circle, it has an effect on the hormones of the body. It is also said that when a woman breastfeeds her baby it is a protective measure, but those who have their first pregnancy at about age 35 are prone to breast cancer. So the advice is that breast feeding is protective against breast cancer. It is advisable to start your family early and breastfeed as a protection from having breast cancer.
When it comes to the environment, we have the natural radiation. We have the issue of radiation from chest x-rays. At times radiation after about 16- 20 years could cause secondary cancer. But, of course, in Nigeria we don’t use so much radiation. Chest x-ray is within the normal health routine, but it is not something one should do on a regular basis.
A lot of women, at times, will notice a lump, but they stand in denial and will do nothing about it. It is important for their husbands who are the ones that always touch the breasts during foreplay to examine the breasts of their wives. Some women don’t even examine their breasts. If husbands notice any lump, they should notify their wives. There are some breast cancers that the lumps are not visible in the breast; but the lumps are visible in the armpit. All you will see is a big swelling in the armpit. When you notice a swelling in the armpit, go see your doctor. It is possible it could be a breast cancer that’s not palpable because it is inside the duct of the breast, so it won’t be palpable. If you notice that, it is also good to go for the necessary tests to be carried out. At times, one can have a lump due to a cut or a little swelling that is painful. When you take antibiotics, it goes. Or maybe, you shave your armpit and you have a cut and you take an antibiotic and the swelling under the armpit will go. If you notice it is getting bigger and it is painless, you ought to see a doctor. Men also have breast cancer and the percentage is about one percent. When they have it, theirs are usually very aggressive.
Treatment There are three main types of treatments namely Surgery, Chemotherapy and Radiotherapy. When we talk of cervical cancer, the cervix is actually the neck of the womb, and because it is on the inside, people don’t get to know on time. In the risk factors, I would say first that promiscuity is number one, when a woman has multiple sexual partners which lead to infections; they are obviously prone to having cervical cancer. It is also common among people who have many children. People with five or more children are also prone to cervical cancer. The reason is that any time they have sexual intercourse, the cervix, which is the neck of the womb, is traumatized. At times, if the cervix is traumatized, the wound will heal and then be traumatized again with constant sexual activities. With the regular trauma and with the infection, you now find out that the cells around the cervix will start changing and it might over the years change to abnormal cells and become cancerous. That is why we go to schools to sensitize the school children that they should refrain from sex at the early age. The irony of cervical cancer is that it is associated with what we call human papilloma virus (HPV) and it is the strain 16 and 18 that are implicated. The bad thing about the virus is that at first intercourse there is a high probability the individual could contact it. If one contacts it, it will not surface until 15 to 20 years later. So if the child was ten and at the first sexual intercourse she was unfortunate to have the virus, if you count 15 to 20 years down the line, the child will be around 25 years. So, if the child comes up with cervical cancer, it is hazardous because that is the time the person is beginning to start life. If we look across or between the ages of 30, 40, and 45 and above, because of early onset of sexual intercourse, and the moral decadence in the society now, many people will have cervical cancer in the years to come. You know that the society is in trouble because that’s the reproductive age and the productive age of the nation as well. That is why we have now this HPV vaccine even though there is a lot of debate on the vaccine. When the vaccine came out some people were not happy about introducing it to children. Some said that if you give children, they can now become very promiscuous just because they have protection. Some because of religion don’t want their children to have it. In Britain they start from about age ten or as early as nine. In Nigeria they have started giving it to children, but the consent of the parents is needed. A lot of adults want to take the vaccine. Before you can have the vaccine and for it to be effective, you have to do what we call a PAPS SMEAR, which will show that your cervix is healthy and that you don’t have this human papilloma virus or cervical cancer. So, when they give you, it is preventive against having the infection; but if you already have it, the vaccine is not going to do much. Q: What are signs of cervical cancer?
The cervix is inside, so one might not know. It starts with bleeding. When some ladies mate with their sexual partner, they notice they are bleeding. It’s not that they are virgins and not that they have not been having sexual intercourse, but somewhere along the line they notice what we call post coital bleeding. Some would have continuous watery discharge for a long period of time and they don’t know what is causing it. Some will have bleeding over a long period of time, all these needs to be looked into to ascertain the cause. For older women, who have stopped their menses and suddenly they have this discharge, which a times is because of the way the vagina is, they can easily get infected. The fluid may be brownish and watery. Initially, it is not smelly, but along the line because of infection, it becomes smelly. Some will notice bleeding after they stopped their menses 10 years ago. This happens even without sexual intercourse. I realized that a lot of women don’t wash inside their vagina. Some say that they don’t have to dip their hand inside and wash. As far as I’m concerned it’s your body. If you squat, you can clean out with ordinary water and dip your hand and wash properly. There are some women that you do a vaginal examination for and when you are through with them, you can’t stay in that room. The whole room is smelly. I am not even talking about those who have cancer. I have had chats with women and I asked, “Why don’t you dip your hand inside your vagina and wash? For example, you’ve menstruated; you just wash the outside forgetting that the blood came from the inside. All the blood will probably not go immediately, even when you stop. So, along the line you are prone to infection. You need to dip your hand and wash. It’s important. If the vagina is clean and there is good personal hygiene, the chances of any organism infiltrating or causing infection is slim. Other signs are those noticed when the cancer is advanced. Examples are if the person is losing weight, a lot of lower back pain and the signs that are not really specific, but definitely you will notice the vaginal spotting. We have the colon and rectal cancer. If you notice that you have bowel problem or your blood level is very low and you don’t know what is causing it, you should see a doctor. If you notice that you have diarrhea mixed with constipation over a period of time, it’s important that do a test to know if there is blood in the feces. Most times when you are forty and above don’t eat much of red meat. Eat fish, chicken and a lot of vegetables. The truth about health generally is that we should take a lot of fruits and vegetables and non sugary diets, because sugary stuffs or food favour cancer. We should reduce our sugar intake. Fruits like oranges help to detoxify the body; we should learn to take a lot of water. Eighty per cent of the body is made up of water. We need the water for cleansing. A bottle of coke has eight cubes of sugar. If you keep taking it every day, as you grow older, your body cannot metabolize those things so easily, because it is degenerating. A lot of our foods are carbohydrate and the final break down is sugar. So we should try as much as possible to exercise as well and check our cholesterol and reduce them for our own personal healthy living. If you notice anything that is unusual and it is persisting for three months to six months, you should go for proper checkup to know what to do. A lot of us don’t do annual checkup. Even doctors are guilty as well. It is just because we don’t have that habit of going for regular checkups.
When you tell people about test, they will shout, but they are ready to use that same amount for party (Aso-ebi). If you calculate the money they use for Aso-ebi in one year, it would be more than the cost of annual checkup. You should have a plan for annual checkup. We hope that government would put in place programmes that run annual check and would subsidize it because the health of the citizens is important. A healthy nation is a wealthy nation.
Now we go to that of prostate cancer, which are what afffects men. One of the causes is old age. But recently, younger people have been reported to have it; before, it used to be in the age range of sixty to seventy years. Now, you see people of forty years having prostate cancer. Once you are fifty, you do what we call prostate specific antigen (PSA), because prostrate produces that antigen which if tested is found to be high in level. In normal digital rectal examination, the prostate can be enlarged, also if PSA value is high, it tells us that something is happening because it has its own normal values. Some don’t even know until it spreads and they are rushed to the hospital. One of the presenting signs in men is having difficulty to urinate at that stage. Normally with age, men do have prostate enlargement and the enlargement does not mean cancer. But before you get to that stage, if you find out that in the past your urine was free flowing without struggle and suddenly you find that the flow is getting smaller; you should watch it. When some men have that kind of symptom, they will find it difficult to tell their wives and they might feel that it is the woman they slept with outside that gave them sexually transmitted disease (STD). But even at that, you can walk up to your doctor and tell him and let him examine you properly. We’ve seen cases of prostate cancer that has already spread to the bones before the men present in the clinic; and those affected can’t walk and some persistently have lower back pain. Some have regular urinary infection. When you are fifty and above, you can do other radiological examination to ascertain your situation. If it is an ordinary enlargement, that is easy; you would be given a drug that would help reduce the size of the enlargement so that your urine flow could be normal. We talk of the colon & rectal cancer, also known as COLORECTAL Cancer which affects both men and women. We also have the head and neck cancer. Because of the way the head is, at times it is internal and some others are external. It could affect the eyes, the tongue, the nose, which could be blocked or any part of the head or neck tissues or organs. If you see any symptom that you are not too conversant with, and you treat for infection and it is not going, or you don’t feel satisfied with the doctor you have seen, you have every right to have a second and a third opinion, but most importantly, anything done early is good for longevity. Don’t take things for granted. Always do the necessary thing when you see things out of the ordinary.
Then for the children, it is important for the parents to observe them very well. When we talk of cancer of the kidney which is common in kids, most of the time, the child could urinate blood. Most parents notice a bulging of the kidney when they are bathing their children. Or they could notice the abdomen is distended somehow. If it persists, it is important they take the child to the hospital. Then for the eye which is called Retino blastoma, the parents will notice that when the child is walking, he/she does not see very well. You must take the child to the eye doctor. For some of them when it is prominent, the eye looks like a cat’s eye, it shines/ reflects like that of a cat, and then you know that something is wrong with the child. We have what we call lymphoma. At times, in some parts of the body you notice that there are some swellings or the baby is losing weight. You have to run tests. The way the situation is now, one in every 6 men, and one in every 8 women have cancer. By 2020 the experts say that 75% of cancer in the world will be in the developing countries because of poverty, ignorance, and limited awareness. By 2020 it is estimated that we will probably have one in ten for men and one in twelve for women. The rate at which it is now, the global estimated number for cancer is about 12 million. They are saying that by the time it is 2020 we will probably have almost 20 million and about 75% of that will be in the developing countries. In advanced countries, researches are being done alongside screening programs. They have insurance schemes for cancer unlike in the developing countries where the awareness programs are very few. Some people ask, “Where do I go?” when they detect cancer. If they detect something, they should have easy access to care. If you visit the government hospitals, you do a test, though; the process is very cumbersome and frustrating. From there, you get the treatment, even though the drugs are very expensive. There are basically three types of treatments. Once you notice an abnormal growth at any part of the body, apart from those in the blood, it has to be cut off. But you can only have it cut off when you detect it early. Seventy-five percent of our patients don’t come in early; by the time they show up, they are in stage three or four. Stage one and two are early and manageable.
When it gets to three and four it spreads and that’s when they come to the hospital. And at that point, there are limited things we can do. In overseas, they have a cancer center. When you have been diagnosed, right from the investigation to the treatment, you are taken care of. It makes things easier. And that’s why a lot of people go outside, especially those who can afford it. Honestly, cancer treatment is global. The first one is surgery to remove the growth. The second one is to give the chemotherapy and anti cancer injections, depending on the type of cancer. There are some people you tell they have cancer and they cry, go home to die because the money is not there. The cost of cancer treatment ranges from about fifty thousand and above for a cycle or course of chemotherapy. You are supposed to take a minimum of six courses, six cycles in every three weeks or every month. Some of the drugs are about one million naira. The type of cancer determines the type of drug and treatment. In countries where they have insurance scheme, and with research and production of newer drugs for better outcome, it makes it easy for the doctors when treating the patients and they give out their best. We really need the government to intervene as we need a cancer center. The third type of treatment is radiation which comes after surgery and t chemotherapy. The radiotherapy centers in the country have one machine and now some of these machines are not functioning, so the patients have to stop their treatment. In other African countries, in a center like their teaching hospitals, they have four or six radiotherapy machines. We should have at least two machines in each center, so that whenever one breaks down, we have another to fall back on. In LUTH, we run our machine on generators all the time because of the sensitive nature of the machines. Power fluctuations damage the machines, so we use diesel 24/7. The cost of radioptherapy is between N100, 000 and N150, 000. Now, when you are running your equipment on generator and when your machine breaks down, what happens to the patients. You have to look for somewhere else. Every urban city should have a radiotherapy center and it should be accessible so that people can go there. You don’t have to travel miles to other states to get a radiotherapy center, because people who go through treatment, need to have their loved ones around them. They are already depressed because they are diagnosed with cancer. And when they take this treatment, it makes them feel unwell. They need to rest and be in a conducive environment, not to talk of the additional cost of paying for the hotel accommodation. The problem is that a lot of people fall into wrong hands. The people who are supposed to be treating cancer are the clinical and radiation oncologists. We have what we call Onco-surgeons and Onco- gynaecologists. They are there to carry out the surgery and send patients to the clinical and radiation oncologists to give chemotherapy and radiotherapy if need be. That is their specialty. We have very few. I don’t think we are up to thirty in the whole country. I’m a clinical and radiation oncologist.
We find out that a lot of cases are mismanaged and later pushed to us. With all the new advancement in medicine globally, it’s difficult for one to cope with the advancement in each specialty now, not to talk of dabbling into other people’s specialty. In developed countries, you cannot treat a patient if the sickness does not fall under your specialty. There are times you stop treatment with a particular drug. By then you should have seen a visible change. There is always need to change when the person is not responding to treatment. It’s also important for the patients to know their rights. You can get any information on the internet. It is your right to know what the doctor is treating you for and it is good for you to get the right specialist that you need for anything that is troubling you. When it comes to cancer, people are living in denial. Frequent questions they ask themselves are ” I don’t have the right to have cancer, why me? I’m Dr. Anthonia Chima Sowunmi. I’m Consultant Clinical and Radiation Oncologist, working in Lagos University Teaching Hospital and also a lecturer with the College of Medicine, University of Lagos. My first degree was in University of Ibadan. My specialization was in the University of Lagos. I was the first female to be trained as oncologist in the University of Lagos for clinical and radiation oncology. I have other colleagues working in UCH, Ibadan and I have been attending a lot of courses overseas to update my practice in what is happening. Now in cancer, they are going genomics. I attend a lot of international conferences to keep abreast. Recently, I attended the one on cancer, medicine and hematology organized by Harvard. I am a member of the American Society for Clinical Oncology; I attend their conferences so that I can give my best and help to reduce the incidence of cancer.
Last year in LUTH, we had breast cancer cases (new & old cases) of over 2000 patients, while that of cervical cancer was over 1000. There should be a lot of mass campaign and screening program as well. Women feel more comfortable with the female doctors. So, most of the time, we have a lot of women that come for treatment. I believe that with proper awareness and help from government, we will be able to reduce and achieve the goal in the incidence of cancer.
Q: Is there a spiritual angle to cancer?
Yes, but what I don’t want people to do is to leave the orthodox and go about for the alternative. They come to us when it is advanced. Both have to work hand in hand. Always feel free to discuss with your doctor any steps you are taking. For everything in life, there is a spiritual angle to it.
Q: What about this issue of strikes in hospitals and politicians always going overseas for treatment?
The International Atomic Energy Agency, IAEA, has honestly been very helpful in organizing conferences where the African oncologist meet, so that we could do networking and meet ourselves and help to develop cancer treatment, most especially in the area of radiation. I spoke to a colleague who said that in his country they passed a law that nobody should go overseas for treatment, so that they could develop what they have on the ground. Having seen what is available there, why can’t they provide it here? Our hospitals are in deplorable and pitiable states. Someone asked why I do not wear suits to work and I told him that I would die of heat because most times there is no electricity to use fans or Air conditioners. Cancer patients are already depressed, then, the heat will add to their depressed states. If you get to a hospital overseas, it is so beautified and heavenly that it helps patients to forget about their problems, at least, for a while. But here, the state of our hospitals will make a patient feel condemned to death. On the continuous strike, at times, they get it wrong. They are saying that the doctors are asking for too much but the issue here is infrastructure; the theaters and the equipment which they need to do their work but that are not there. Our machines have broken down for long and a lot of money is needed to repair them. Why can’t the government help with these things? When they have ordinary headache, they go to America to collect paraceatamol and they forget that they will not stay abroad forever, but they will still come back to be monitored. When a patient is at the last stage of cancer, if they are not stable enough, they cannot be flown out.
So, why don’ we repair the ones on the ground? They way things are going, anybody could have cancer. We need the facilities. Even though we fly in the specialists to come and repair those machines. We do not even have some important machines for cancer investigations/ follow up such as the PET-CT. This machine is so sensitive that it picks out the dead cancer and the active ones from the patients which give a clearer direction on what to do. In India, these machines are available. We send samples overseas for some investigations even up till today.