The others
Removing breast cancer does not bring the nightmare to an end. As Yasmine Fathi finds out, women who have undergone a mastectomy often become outcasts
"At first I was numb. My family was around me and didn't give me a chance to think. Only when I went home, and stood in front of the mirror for the first time did I realise what has just happened. I had a mastectomy," said Manal Sabet, 46, a breast cancer survivor.
Sabet's testimony illustrates a post-mastectomy drama of realisation common to women who have had a breast removed, typically in the treatment of advanced stages of breast cancer. As life goes on for women who have undergone mastectomy, realisation is replaced by alienation. In Egypt as elsewhere, these survivors -- now missing a body part that defines their femininity on personal, conjugal and social levels -- must cope with manifold psychological traumas.
The stigma of mastectomy may be especially virulent in Egypt, however, where awareness about breast cancer is lacking.
"Unfortunately in our society many [mastectomised] women are abandoned by their family and friends, some may never get married and a lot get divorced," says Dr Mohamed Shaalan, professor of surgery at the National Cancer Institute (NCI) and the chairman of the Breast Cancer Foundation of Egypt, a group that promotes breast cancer awareness.
Lack of awareness is itself a primary reason why many women need mastectomies in the first place. According to Dr Amr Mabrouk, professor of plastic surgery at Ain Shams University, many women are unaware of, or wilfully ignore, the symptoms of breast cancer until an aggressive mastectomy is the only option left.
Several interviewees who have undergone mastectomies blamed their hectic lifestyle for their failure to attend to their developing tumours. "I'm a wife and a mother," Nour Shehata, 43, said adding "I also have to take care of the house, run the errands, and make sure there are three meals on the table every day. I have no time for tumours."
Dr Salwa Boulos, a mammographer at the Italian Hospital in Cairo, recalls a woman who failed to notice that one tumorous breast had grown twice the size of the other.
"The woman was so busy she didn't even have time to look at herself in the mirror," Boulos said.
Both of these women come from low income households. However, according to Shaalan, negligence is not limited to poorer women. "One of my patients is the wife of a doctor, and not once did she do a mammogram or a monthly check- up," he said. "We have no awareness in Egypt. If she had come earlier we would not have had to do a mastectomy."
Those that suffer shattered self-images following mastectomies would affirm the adage that an ounce of prevention equals a ton of cure. Many women express shock and horror when they wake up from surgery and find themselves mastectomised. Nadia Adel, 46, said that she goes into crying fits every time she looks down at her chest. "For me it's not such a big problem because I'm old, I'm a grandmother, but still, whenever I look down I feel self pity," she said.
Sabet refused to enter the operating room without a tranquiliser. "I consider myself a very strong woman, but this is such a cruel situation, I could not face it without being sedated," she explained.
Some women even feel obliged to hide their altered bodies from their family members so as not to broach an uncomfortable subject. Hoda Nasser, 42, a three-year cancer survivor and mother of four, has been able to hide her disease from her youngest daughter since her surgery. "Only once when I was coming out of the shower with only a towel wrapped around my body, did she suspect something. But I told her it was nothing and closed the subject," she said.
Sometimes ridicule contributes to the devastation of self- image. Sabet remembers walking around the hospital a couple of days after her mastectomy when three women looked at the void where her breast had been and burst out laughing. "I felt so angry at that moment, I just wanted to march up to them, open my shirt, and say 'Why don't you laugh a little bit more?'" she said.
Mervet Asam, 45, recalls imprisoning herself in her home following her mastectomy. Although she was veiled, her loose garments making her chest amorphous, neighbours and friends who were aware that she had a mastectomy would stare at her chest whenever she left the safety of her home. "I became a prisoner in my own home and fell into a deep depression. It took me a long time to be able to leave the safety of my apartment again," she said.
Suad Murad, 34, bought a khemar (a veil that flows down to the waist) to wear when guests visit in order to hide her chest from their stares.
In addition to a negatively altered body image and abject self-consciousness, breast cancer survivors face rejection from their husbands.
Mariam Abdallah, 46, who underwent a mastectomy last July, remembers her mastectomised neighbour complaining that her husband refused to sleep in the same bed with her following the surgery.
Often these women find themselves as social outcasts for no reason other than falling victim to a life-threatening disease.
"I always say that I never knew that cancer was contagious until I got diagnosed with it," Sabet said. Although it is not uncommon in Egypt for people to believe that they might "catch" cancer, Sabet's ironic remark concerns the distance others tried to maintain from her after her mastectomy. "I actually think that some of the women stopped calling because they felt I would envy them because they had breasts and I didn't," she said.
Compensating for the loss of a breast is difficult given the expense of such treatment and widespread ignorance about available options. The cheapest options are sponge (LE80) and silicon (LE500 to LE600) prostheses.
Alternately, breast reconstruction operations are authorised and widespread in Egypt and cost between LE6000 to LE15,000. Mabrouk points out that some surgeons choose to perform the surgery three to six months after the mastectomy. This time lag is due to some surgeons' worries that reconstruction immediately after the mastectomy would provoke complaints about the unnatural appearance of the reconstructed breast. Another school of plastic surgery promotes immediate reconstruction, thus sparing women the trauma of living without a body part for any period.
However, Boulos emphasises that it is important to explain before surgery what reconstruction is, since some women find the concept difficult to grasp. She tells the story of one patient who asked for an immediate reconstruction. When she woke up and found both her breasts intact, she thought that she was never sick and refused to return to the hospital for treatment. "It took me one month to convince her that she had cancer and that she needed chemotherapy," said Boulos.
Most interviewees, however, refused reconstruction. After several operations and heavy radiation and chemotherapy treatment many women dread the prospect of lying on the hospital bed again, even if it will help recoup lost self-image. "After six months of chemotherapy and 20 sessions of radiation I did not want to go under the surgeon's knife again, even if it meant that I would have normal looking breasts again!" Sabet exclaimed. Another problem with reconstruction is the widespread fear held by many women that implants can induce cancer. Mabrouk insists this fear is unfounded.
Age, cultural background and economic means largely determine the choice made about reconstruction. According to Mabrouk, a sophisticated woman who has a busy social life would probably reconstruct to improve her self image, as would a young unmarried woman.
Besides the process of psychological healing, healing physically after a mastectomy can also be arduous -- especially given heavy domestic responsibilities. Nahed Mustafa, 42, unable to wait for her wound to heal completely, wraps a towel around her chest when she's cooking because the heat from the oven irritates the suture.
Complications occur when plans include more than the regaining of household activities. Mastectomy can become a huge obstacle to an unmarried woman who wishes to find a spouse. Sabet, who was divorced three months before her mastectomy, remains without a soul mate. She complained that several times after her mastectomy she met appropriate suitors who disappeared from her life once they knew of the procedure. "My father told me not to tell them until we are in love. But why should I wait until I'm in love with him? Why should I wait until I become emotionally attached? Why should I wait until my heart gets broken? Don't they know that this could happen to any woman?" she asked bitterly.
