Breast Cancer Awareness Month: Breast cancer is top cancer killer of women in Guyana – Dr Ravi Motilall

By Lakhram Bhagirat

Guyana’s healthcare system lacks the infrastructure for data collection and research. However, that does not stop physicians from accumulating data; and according to General Surgeon Dr Ravi Motilall, breast cancer remains the top cancer killer of women in Guyana.
Dr Motilall, an oncologist, arrived at this conclusion based on the cases he has encountered along with those his colleagues have encountered in the field. However, he warns that the data is subject to change if comprehensive research is done in the area of cancer.
“In Guyana, I would say breast cancer is still the number one killer. Because if you look at literature, they will tell you that it’s lung cancer in the developed world, but we don’t really have the data (in Guyana)… the numbers as it relates to breast cancer, like the age and stage. But my opinion is that it still is the number one cancer killer in women in Guyana,” he said.
The surgeon recently sat down with Sunday Times and undertook to explain breast cancer in the Guyanese context, in an effort to bring awareness to the strides made locally to detect and treat the disease.
Breast cancer occurs when some breast cells begin to grow abnormally, dividing more rapidly and increasing accumulation. They, in turn, form a mass or lump, which can metastasize through the breast to lymph nodes and spread throughout the body.
In Guyana, early detection of breast cancer or cancer in any form is generally rare, according to doctors, since the culture is to address a problem when it arises. Dr Motilall explained that most of the cancer patients are usually diagnosed in the late stages – either stage three or four – which is not a good thing, since it increases their chances of dying from the disease. It is for those reasons that he and other physicians encourage early screening and regular breast health checkups.

Screening and checkups
According to Dr Motilall, breast cancer screening is not a hard procedure, but Guyana lacks a formal screening programme, and, as a result, there is late detection. He called for the introduction of a formal breast cancer screening programme that would streamline the age at which women in Guyana commence checking their breast health.
He recommends that the programme, if and when implemented, should start screening women at the age of 40, despite the international recommendation being 50.
“Based on what we see, anecdotally, in our population, we should probably start screening at 40. The reason being…a very high population of breast cancer in people younger than 50, which is not really supposed to happen. What that is saying is that we probably have risk factors, high number of risk factors here in Guyana, and those risk factors are probably genetic; but we haven’t done any genetic study, and that’s an area of interest. It would be interesting to know what is our genetic profile,” the doctor explained.
Genetic screening for breast cancer involves the BRCA1 and BRCA2 genes, which are important to fighting cancer. They are tumour-suppressing genes, and help keep breast, ovarian and other types of cells from growing and dividing too rapidly, or in an uncontrolled way.
Dr Motilall has said the BRCA genes predispose patients to early breast cancer, but once detected, it can mean early intervention, whether surgical or medical.
With Guyana’s small population, the genetic risk factors are increasing, according to the doctor, and that may possibly explain the reason why younger women are being diagnosed with breast cancer. He added that physicians have been seeing persons in their late 20s and 30s having advanced stages of breast cancer, and that is a major cause for concern.
Screening for breast cancer commences with a breast examination by a physician, after which either an ultrasound or mammogram is recommended. If a suspicious lump is discovered, then a biopsy is done. With the absence of a formal screening programme, most physicians have their independent screening programmes which they utilize to treat patients.

Intervention
Once the screening process is completed by a general practitioner or a qualified physician, and suspicious lumps or masses are discovered, then Dr Motilall or other oncological surgeons become involved. They are responsible for confirming the diagnosis and putting forward possible treatment plans.
“Breast cancer these days, it has changed. Like in the past most people think that breast cancer is just surgery, it’s not really just surgery anymore; there’s certain steps, like if the doctor finds a lump in the breast,” he explained.
Once the suspicious lump is discovered, there are a series of steps the surgeon would activate. Initially, the surgeon would do a fine needle biopsy, but that has been disregarded, since Dr Motiall said that literature indicates it does not provide enough information for a complete diagnosis. Instead, surgeons now do what is called a core needle biopsy, where a much bigger needle is inserted into the breast to remove tissue samples for testing. The test would determine whether the lump is cancerous or not.
There are two other steps that can be activated as well, where doctors could remove the lump completely for testing, or the most dreaded one is removing part of the lump – which indicates that it is really big and cannot be completely removed.
Once you have those three done, physicians can start considering treatment.
“That’s where the big deal comes, because, at this point, most women are thinking of the choice of cutting their breast off. So I think that (is) another thing that women are fearful of,” he said.

However, Dr Motiall detailed that the treatment plan has changed, so much so that physicians are now looking at the biology of the disease, rather than at just cutting off the breast.
“What that means is that we know (that) once a woman is diagnosed with breast cancer, it is considered a systemic disease, meaning it’s involving her entire body. Now, that might sound scary, but what that tells us is that we need to look for something called receptors. Receptors are certain markers that, when we do the biopsy, we test for, and those things actually would help us, guide us,” Dr Motilall related.
When tested, if the receptors are negative, then that indicates bad news, and would ultimately result in the patient being advised to do a complete mastectomy (breast removal). But if there are positive receptors, then there is the option of lump removal or mastectomy. The lump removal – referred to as breast sparing surgery – is as effective as mastectomy, according to Dr Motilall.
“Your chances of survival are the same. The biggest difference is the person who just have the lump out needs to get radiation therapy, and the person who has the breast out may not need radiation therapy. There are some instances where they might, but if you just have the lump removed, you have to get radiation. Then it comes down back to those receptors, and based on those, we can decide if you need chemotherapy or you need hormonal therapy,” the doctor said.

Survival
He added that there is a lot of work in the field of breast cancer that needs to be done in Guyana, and noted that the common misconception is that only women can develop breast cancer. Males also have breast tissues, and quite often their cancer is discovered way too late, after it has invaded the chest walls, essentially making it difficult to manage.
Dr Motilall stressed the importance of early detection and its link to higher survival rates.
“All those self-breast exams are no longer sort of recommended. It’s still encouraged in our population, mainly because we have some catching up to do. What they find is, in the First World countries, a lot of women come in with lump that doesn’t really need anything. So, they have discouraged it, but in our country, I would say if you find a lump in your breast, you come see me or someone and get it sorted.”

Dr Motilall
Dr Motiall is a product of Mahaica, East Coast Demerara (ECD), and comes from humble beginnings. His hard work and determination, coupled with the sacrifices of his parents, are primarily responsible for him being where he is. He has always wanted to enter the medical profession since he was a child.
He got his secondary schooling at St Stanislaus College in Georgetown, and later did undergraduate studies in biology at the University of Guyana. He then moved on to the University’s School of Medicine, where he graduated as a doctor.
Dr Motilall was not satisfied with being a general practitioner and sitting behind a desk, so he started residency training in the field of orthopedic surgery, and later moved into general surgery. He completed his general surgery residency through a collaborative programme between the Canadian Association of General Surgeons and UG.
Through general surgery, he was introduced to oncological surgery, and he has been performing procedures in that field ever since.
“Every time I do an oncological surgery and get my patient to recovery and then see them and their family in a few years, it’s a gratification that outweighs any renumeration. Like you can’t weigh that in gold, in the sense that you do it because you want to see them be happy with it,” he explained.