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"Various places on the globe lack the proper knowledge, infrastructure and workforce to adequately treat cancer. In Africa, one doctor is focusing her efforts to change all that. This ASCO Education podcast spotlights Dr. Miriam Mutebi, the first female breast surgeon in Kenya. One of Dr. Mutebi's goals is to improve women's health and cancer care in Africa and includes attaining her pilot's license to reach remote areas of the continent. Dr. Mutebi reflects on her life growing up in Kenya (1:21) and her inspiration for getting into medicine and pursuing what was at the time a male-dominated specialty (5:07). She also details how cancer care has improved in Kenya in the last decade (12:49) while there are ongoing challenges of working in low-resource settings (23:25). Speaker Disclosures Dr. Miriam Mutebi: None Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Resources: ASCO Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 1) ASCO Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 2) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Pat Loehrer: Welcome to Oncology, Etc. an ASCO Education Podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. Dave Johnson: And I'm Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas. Pat, we have a terrific guest today that ties in very nicely with your interest in global health. I'd love for you to introduce her. Pat Loehrer: Thanks, Dave. Battling cancer is truly a global effort, both in research and in treatment. However, there are various degrees of quality in these fields, depending on the economic health of a particular region. Our next guest is trying to optimize cancer care in Africa. We're very excited to talk to her. Dr. Miriam Mutebi is one of the most prominent cancer doctors in Africa. Dr. Mutebi is the first female breast surgeon in Kenya, and she's currently assistant professor in the Department of Surgery at the Aga Khan University in Nairobi, Kenya. She's on the board of directors for the Union of the International Cancer Control. She has trained and studied at top hospitals in New York and South Africa. Dr. Mutebi is so focused on increasing women's health in Africa that she's trained to be an airplane pilot in order to connect with hard-to-reach areas. Disclosures for this podcast are listed on the podcast page. Thank you so much, Dr. Mutebi, for joining us from Kenya. Can you start off by telling us a little bit about what it was like growing up there? Dr. Miriam Mutebi: I grew up in Nairobi, which is a pretty urban setting to grow up in. So, most of my childhood was spent…I think it was probably a much simpler time where, you know, you would play in the street, go off to somebody's house, spend the rest of the day there and come back at the end of the day. But in terms of growing up, I think I was one of those super nerdy kids, for want of a better word. One of the sorts of things that got me interested in reading and learning and challenging myself was actually my dad. Because what would happen was we had to go to school, I would say almost about 30 kilometers bus ride, and my dad would be like, "Well, if you're on the bus for that long, you can as well, you know, carry a book and made it nice and exciting." So I remember sort of discovering the library at my primary school and going like, "My word!" Because you get access to all these different experiences and worlds. I mean, you're going in and reading, you know, The Chronicles of Narnia, you're reading about Enid Blyton and different experiences, you're reading all these different worlds and getting to, you know, identify to some extent with the core values that exist. It doesn't matter where the books were centered. And so that for me was an almost, I would say, idyllic growing up, because for me it was like, "Yes, books, check; running around, check." That's, I think, what I remember most about my childhood. Dave Johnson: It sounds like your father was a powerful influence in your youth. Can you tell us more about your father? Dr. Miriam Mutebi: Sure. My dad, how old is he now? He's going to turn 74. One of the things that he always says, "It costs you nothing to be kind." And so he would generally– Sorry, I'm just going to stop a little bit. I'm getting weepy. Dave Johnson: I'm sorry. Dr. Miriam Mutebi: It's okay, it's okay. Shame. Dave, you pushed the button. Dave Johnson: It's not our intent to push a button. It sounds like your dad's a wonderful person. Dr. Miriam Mutebi: No, it's fine. Pat Loehrer: Both Dave and I have daughters, and we feel the same way. So as weepy as you're getting, I can guarantee you that he's going to feel the same way on the other end. Dr. Miriam Mutebi: No, it's just that he hasn't been well recently, so it's just– Dave Johnson: Oh, I'm sorry. Dr. Miriam Mutebi: Yeah. Okay, cool. Let me see if I can stop getting a little weepy. Yeah. So one of the things that he frequently says is that it costs you nothing to be kind, and I think that's one of the things that he sort of instilled in us that you need to think beyond yourself. You always need to sort of think about what is the other person going through and how can I help to make it better. Now, my dad, he has a really interesting sense of humor. I think it's where I get my cheesy humor from as well. But he always talks about what we call the 11th commandment, which is, don't take yourself too seriously. And so I think that was part of the grounding steps that he sort of helped to instill in us because he was working– I mean, sort of looking back, our parents, I would say, got married at a very young age and had several kids that they were raising. And sort of looking back, you're thinking they were probably just doing the best that they can, right? But I think he did a fairly decent job, I hope. Dave Johnson: So, Miriam, when did your interest in medicine begin, and who was the inspiration for that? Or if there was someone that inspired that? Dr. Miriam Mutebi: At the end of high school, I remember I wanted to do five or, rather, was it six different things. And so I wanted to do medicine, I wanted to write, I wanted to do architecture, I wanted to do law, I even forget what the other things were. There was like two other things on my to-do list. And I think part of the genesis of that was because, as part of the high school training that we go through, we had to do the international sort of baccalaureate, and what that entails is we have to do components of creativity, action, and service. And so at the end, I'm like holding back to father dearest, and I'm like, "Dad, I have six different things I want to do, and I don't really know about." And he was like, "So why don't you spend a bit of time, sort of just going through each of those, like shadowing these different specialties?" And so we managed to track down his lawyer friend, spent time in the hospital, spent time in the pharmacy, just shadowing the pharmacist. I actually went to work briefly for a publication house. Eventually– Oh, yes, in architecture as well. So then I managed to narrow it down to, "Yes, okay, I want to do medicine, and I want to write." And so I went back to my dad and said, "Dad, okay, I have two things I want to do." And my dad was like, "Well, if you do medicine, you can write. But if you write, then you might not necessarily be able to do medicine." So that's how I sort of wandered into medicine. Although I still say there's still the great African novel waiting to get out. But again, with medicine, I think I'm guilty of what we call 'end of rotationitis', where at the end of the day, you finish a rotation, and you're like, "I can do this. I can do this." So I think going through different rotations– I think for me, the drive– Well, the slow narrowing down to surgery was really around, unfortunately, the time when we were doing our rotations, and this was just really at the start of the 2000s in Kenya. And the challenge around that time was we're really just at the tail end of the HIV epidemic, and not everyone had access to antiretrovirals. And it was an incredibly harrowing time, I would say, for the healthcare profession, just because there was still a lot of stigma around HIV. And what was happening was that we would go to the wards and find patients had been abandoned. And there was a general sort of pervasive sense of hopelessness because people didn't have access to the medication, they'd been abandoned, and unfortunately, not much was being done in terms of active management to patients. Whereas then that was like on the 7th floor, and then you would go four floors down to the surgical ward where patients come in, they're bleeding; you take them to OR, they get better, you send them home. And so, for me, the timing was like, "I need to do this. At least I could see where I was making an impact." And so that's sort of how I wandered into surgery. And I'm sure, as I said, with, of course, the developments now, the experience, of course, for medical rotations, they're entirely different, but that's how I sort of ended up in surgery. But then, how I sort of found myself in breast surgery was actually because– for me, what stood out about my breast rotation was really looking at what we were reading in the textbooks, which was breast cancers, the disease of the sixth and seventh decade and a "poster child" for this is the elderly nun who's never had any children, who's had this prolonged [inaudible]. And I'm sitting there and looking at the clinic, and I'm like, "These patients are in their 30's and 40's. All of these traditionally protected factors, like having multiple children, having breastfed, ticking all the boxes, but they're still coming in with these kinds of cancers." And so just thinking this is totally different from what the textbook is saying, and somebody needs to get to the bottom of this, and that's how I found myself going in along breast cancer surgery and also research into women's cancers and things. Pat Loehrer: My sense is that Kenya and many African nations were male-dominated. I don't know what it was like for you going to medical school, but particularly in surgery, it tends to be a male-dominated field. What was that like as a woman? In many ways, I think you were breaking some glass ceilings. I'm sure other women are doing similar things, but tell me a little bit about that experience. Dr. Miriam Mutebi: I would say bewildering for both parties. Because we had to do several interviews just in different institutions before getting into a surgical residency, and I remember these senior professors sort of peering down their glasses and looking frankly bewildered and asking the most bizarre of questions, which I don't think anyone would sort of get away with in this day and age. I remember somebody asked me, and this one always stands out in my mind because somebody asked me on the interview route, "So what happens if you get a patient in ICU and you start to cry?" I'm like, "Well, first of all, I'm guessing that I am crying because I'm having a bit of empathy for the patient. And I think that actually probably makes me a better clinician because I am really truly seeing the patient rather than bed X with diagnosis Z. This is like Mary, mother of one, two, three, and whatever." But it was really bizarre. Then somebody asked me as well, "Okay, so what happens when you're on call, and you have to breastfeed?" And I'm like, "Well, let's see. This is a tough one." You could tell as well that they were really out of their depth. So, eventually I settled on the Aga Khan just because, in terms of the faculty and the interviews, I got a sense that they were a little more open to the idea. And that's because I think one of my earlier mentors, Prof. Raja, who is our former chair of surgery, had come in from the Aga Khan in Pakistan. And for him, it wasn't anything unusual to see women in surgery. So, like, "Yeah, come along. We'll train you and stuff." And he was also pretty inspiring in terms of the decision to get into surgery because, for him, their approach to at least surgical training– and we always tease him and say, we all drunk the Kool-Aid because we kind of came back. Because it wasn't about just training surgeons for surgery's sake, it's about how do we become leaders, how do you impact care in your region. And so it was never about just learning surgery; it's how do you use the tools that you have in order to improve the health of those around you. In the Aga Khan, you're sort of, one would say, in a position of privilege. Just the backstory to those listening who might not know about the Aga Khan, it's a private university hospital. But I mean, as a private center, then, of course, I would say there isn't any difference, one would say, between the Aga Khan and most of the international hospitals anywhere in the world. But it was always sort of driven into us that this is a privilege that you're having. And how do you use this privilege to elevate the communities around you? Pat Loehrer: Let's talk about breast cancer, if you will, in Kenya. You mentioned it that when you first went into it, patients were coming in with advanced disease, they still do. But how has the field of medicine changed in Kenya during your professional lifetime as it pertains to breast cancer? Dr. Miriam Mutebi: While we still have the majority of patients diagnosed with advanced disease, the scenario ten years ago was that patients would get diagnosed with advanced disease and frequently would not complete their care. And if we did a deeper dive into the reasons behind this, we saw a constellation of factors. One being the fact that patients were having to pay out of pocket, resulting in financial toxicity, catastrophic health expenditure. And then the other major barrier was the health system itself. And again, to some extent, that still exists where we know, at least on average in sub-Saharan Africa, patients are going to see 4 to 6 healthcare providers before a definitive diagnosis of their cancer is made, which of course, again, translates into delays in ultimate treatment. Another area that we frequently don't necessarily talk about as much are the social-cultural barriers that exist and, to some extent, are still pervasive in some communities. What we see is, one, there's a lot of use of alternative therapies. There is still quite a bit of stigma around cancers. There is what we call collectivism, where we always say in Africa, 'our community is our strength'. But sometimes, that sense of community is a double-edged sword because then, if the patient is losing agency, then that becomes a real concern. Because what we find, for instance– I'll give you an example, I'll have a patient come in and discuss, and maybe she has early cancer, and discuss the options of having breast conservation versus a mastectomy. And then you will find maybe she goes home to have a think, and then a c…
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