Advanced Breast Cancer in Yaounde, Cameroon: A Case Report

Extent of disease prior to mastectomy.

The patient, a 26-year-old single woman living with her parents while studying law at the University of Yaoundé, discovered a nodule in the left breast in July 2005 through self-palpation. Initially, no action was taken. In February 2006, she developed mastodynia (pain in the breast) which led to a consultation at the Jamot Hospital. It was noted that her grandmother had developed breast cancer after the age of 50 years. Menarche was at age 15. She had taken oral contraceptives (Stediril) for a total of five months and had had one previous elective abortion. Nodulectomy was performed at Jamot Hospital and histology was read as a fibroadenoma. In May of the same year the patient was seen at the Obstetrics, Gynaecology and Pediatric Hospital of Yaoundé with a mass in the outer portion of the left breast, measuring approximately 8cm in size. A needle aspiration was performed, which showed the presence of carcinomatous cells. After a clinical, biological and radiological assessment, the tumor was classified T4NXM0. At this time the patient was also found to be 14 weeks pregnant (single foetus). She was advised to undergo a therapeutic interruption of the pregnancy followed by neoadjuvant chemotherapy, but refused further therapy.

In July 2006, she was seen at the General Hospital of Yaoundé, where she was determined, by ultrasound examination, to be 21 weeks pregnant. She expressed a desire to preserve the pregnancy. Further assessment at this time included blood counts, liver and renal function tests, serum calcium, bone scintigraphy, mammography, breast and abdominal ultrasound, and a chest x-ray. On 26th July the staff of the cancer department advised her to undergo a therapeutic interruption of the pregnancy followed by neoadjuvant chemotherapy. However, the patient again declined to accept the advice since she did not wish to lose her child and made this clear in a letter of refusal on 17th August. She asked for a medical report and a referral abroad. On 16th September 2006, staff members accepted the patient’s refusal to undergo therapeutic termination, and chemotherapy with doxorubicin and cyclophosphamide was initiated in the Medical Oncology Service of Yaoundé General Hospital. On 20th September 2006, after 28 weeks of pregnancy, the patient spontaneously delivered a live female infant weighing 1200 grams. The baby died the next day.

In October, an abdominal ultrasound examination showed suspicious hepatic nodules. Additional cycles of the same chemotherapy were administered on 11th October and 13th November 2006. The patient was then referred to the Gynaecology Service for a mastectomy, but this was not performed because of the patient’s apprehension and financial difficulties. Instead, she undertook a traditional medicine remedy comprising the application of clay to the diseased breast accompanied by night prayers.

On 29th December 2006 due to progression of the tumor the patient returned to Yaoundé General Hospital. Additional chemotherapy with docetaxel and doxorubicin was administered, the drugs being given free of charge by the National Cancer Control Committee (NCCC).

The patient failed to return for follow-up until June 2007, when mastectomy and radiotherapy were performed. Subsequently, however, she suffered a local recurrence in the form of a 7cm mass and was also found to have ascites. Palliative care was administered.

Discussion

This case raises a number of issues, including the young age of the patient, the history of breast cancer in the grandmother, the role of hormone contraception in the causation of breast cancer and the management of cancer in a pregnant woman. Although the nodule that she discovered by self-palpation was removed, it is possible that it was not a fibroadenoma. When breast cancer was diagnosed, approximately 17 months later in the same breast, she initially refused therapy because she did not wish to have the pregnancy terminated, causing four months delay (May to September) in the initiation of treatment – unfortunately to no avail, since the child was born prematurely and died within a day. Her cancer progressed in spite of chemotherapy: hepatic metastases were suspected after only one course of treatment. She initially refused mastectomy and radiotherapy, at least in part because of significant financial difficulties, and opted for traditional medicine instead. In spite of the tragic circumstances, she was grateful for the assistance of the NCCC and the solidarity and collegial approach to medical decision making by the staff of the Cancer Department. Even in this intelligent young woman who practiced breast self-examination, her cancer was already advanced by the time she started therapy and financial issues were clearly a factor in her refusal of medical treatment in favor of traditional medicine.

Paul Ndom,
Yaoundé General Hospital & INCTR Cameroon, Yaoundé, Cameroon

Readers are invited to comment on the several issues raised by this case by letter or e mail to INCTR. Selected letters will be published in the next edition.