The Price of Neglect In Breast Cancer

Figure 1: Right auto-amputated breast cancer with maggot-infested wound.

Summary
A case is presented of a breast cancer associated with a maggot-infested wound in an elderly Nepalese woman who received no care for six months.

Case Report
A 70-year-old nulliparous widow from rural Nepal was brought to our referral-level hospital with a six-month history of a non-healing wound of the right breast. She had suffered from a progressive lump in the breast, which later ulcerated, for the last year. Her relatives noticed some maggots in the wound. Menarche and menopause were at the ages of 13 and 49 years, respectively. Her husband died a few months after their marriage, when she was 14 years old. Since then she had become a heavy smoker and consumed homemade alcohol regularly. She stopped these habits five months ago when her neighbors explained that this wound would not heal unless she gave up alcohol and smoking. She had been staying alone in a small house for almost 40 years. She had never sought modern medical advice. Her past medical and family history were not contributory to the present illness. She was brought to the hospital only because her relatives found that the ulcerated foul-smelling wound was not getting better with local herbal treatment. Moreover, the presence of maggots in the wound provoked them into taking her to a medical center. She was unaware of the malignant nature of her disease. On clinical examination, she was a thin-built, moderately nourished elderly female who was very concerned about being examined in the outpatient clinic. On local examination, there was a large irregular ulcerative growth (10 by 12 cm) with a necrotic base and many maggots in the right breast which had essentially undergone auto-amputation (Fig. 1). There were three fixed axillary lymph nodes and the arm was swollen on the same side. The left breast and axilla were normal. Incisional biopsy revealed infiltrating ductal carcinoma. Thorough wound debridement was done. One course of broad-spectrum antibiotics and tamoxifen (20 mg/day) was prescribed and advice given on regular dressing of the wound at the local health center. After two months, the patient was much better with a smaller wound now free of maggots. She has continued to take tamoxifen and is being followed up regularly.

Discussion
Many breast cancer patients in Nepal do not attend health care services because of ignorance of health issues in general. In addition, social taboo plays an important role in prohibiting women from seeking medical advice, especially in rural Nepal. A female with a breast lump or other abnormality will usually refuse to visit a doctor due to the taboo connected with examination by a male doctor. Our recent review of breast cancer cases reveals that patients were not aware of the disease for a mean duration of 8.3 months1.This could be one of the main reasons why the majority of the female breast cancer patients present with advanced stage disease. In the present case, the patient did not try to share her trauma with others, even after progressive changes in the breast for a long time. Only after auto-amputation of the breast and evolution of the foul-smelling wound was she brought to the hospital. By this time, the wound was putrefying and infested with maggots.

Fortunately the presence of maggots in the wound compelled her relatives to bring her to the hospital. Interestingly, maggots provide debridement of necrotic tissue and have been used therapeutically in this way. Although the therapeutic use of maggots has declined since the advent of aseptic wound management and antibiotics, maggots may have a role in the debridement of certain complex wounds2. Maggots secrete proteolytic enzymes and antibacterial substances, both of which aid in wound debridement.

Conclusion
Cancer education may be the most important remedy for breast cancer in developing countries at the socioeconomic level of Nepal.

Submitted by Yogendra Singh and Pukar Maskey, Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. References available upon request from INCTR.