The curious case of a missing patient

During my years working at the Muhimbili National Hospital (MNH), I got to learn about different cancers haunting the people in Tanzania, whether aged or young. One common among those was the cancer of the cervix. In this process, I also had interesting encounters with victims and survivors of cancer.

At MNH, a day never passed without receiving an in-patient diagnosed with cancer of the cervix in the gynaecology ward. Medically, doctors refer to it as the ‘carcinoma of the cervix’, simply ‘cacx’ in their medical jargon.

Often referred as shingo ya kizazi in Swahili, a cervix, biologically speaking, is a point of entrance to a woman’s womb.

What I noted in the due course at MNH is that most women with cacx are only prompted to seek health-care when they notice “unusual bleeding from the vagina.” Such unfamiliar bleeding often occur either after a sexual intercourse, after menopause or in between their menstrual cycles, as reported by the patients.

Cacx has been found to be associated with early sex debut, having multiple sexual partners and tobacco smoking.

Like most other cancers, cacx can be treated successfully when diagnosed early. But that’s often challenging since its symptoms are not easily noticeable in early stages. This now makes cervical cancer screening a prerequisite.

My encounter with a cacx patient

I was on my 24-hours call duty when Neema*, a patient from Mwanza, was brought into the ward. She had travelled all the way to Dar es Salaam after being referred from Bugando Hospital.

Upon arrival, she appeared wasted, sad-looking and pessimistic. But later, she cheered up. Unfortunately, she had lost her previous medical report and the referral letter that had been filed at other hospitals about her disease condition.

Since she had lost her crucial documents, we had to take fresh tests and samples by examining her.

She was so nervous about the medical procedure but during the process, we managed to push through.

What I did was to keep her well informed about the procedure, however, at one point, she broke her silence and said, “It will be painful, won’t it? I responded, “No, it won’t, but it might be a bit uncomfortable.”

Then I instructed her to lie on her back on the examining table with her knees bent. I asked her to place her feet on the supports “stirrups”, then I asked her to slide her body toward the end of the table, and let her knees fall open for an external visual inspection, which enabled me to do what we call in a doctor’s language as ‘speculum examination’.

I was able to examine her cervix and managed to see an abnormal tissue in her cervix. Usually, every cancer has stages—stage I, II, III and IV. A cancer stage is one of the most important factors for doctors in making treatment choices.

I had not yet staged Neema’s cancer but I was keen on that. My fear was that my senior doctors would bombard me with tough questions if I didn’t.

Thereafter, we told Neema that she would have to be admitted a month at least as the tests results would take longer than usual. For Neema, spending her day and night in the ward was not a choice. She neither had relatives in Dar es Salaam to accommodate her nor was financially strong to keep travelling to and fro.

Bad news or good?

As she waited for her preliminary test results, I decided to request for an ultra sound test for her—to rule out any womb or abdomen injury.

When results came out, I was surprised upon reading the findings. She was pregnant. The report said, “A single viable intrauterine foetus seen, with gestation age of approximately eight weeks.” But, was that supposed to be the surprise? Absolutely not.

Here is what surprised me!

After learning about the results, Neema wondered how she could have become pregnant while her husband had been away for three years. She looked sincerely down in the dumps.

She humbly asked me not to reveal the “pregnancy issue’’ to her relatives—especially her in-laws who had accompanied her from Mwanza, and of course, we didn’t spill the beans.

Since then, she never worried again about the cervical cancer, which she had been diagnosed with initially; rather she spent most of her time thinking about how she could conceal her pregnancy issue.

Escapades continue the next morning

As doctors and nurses thronged the ward for the routine rounds the next morning, I had to officially reveal Neema’s ultrasound report. Her case caused a lengthy discussion. She actually had a “cancer-cum- pregnancy,” that’s a pregnancy on top of cancer.

It was decided, after the lengthy discussion, that I go back to her the following morning and help her decide on the options—of whether to reveal or not to reveal her situation to other members of the family.

Before another morning came, unfortunately, she had escaped from the hospital. Till my time at MNH, I neither saw nor heard from Neema.

*Not her real name

The author is a medical doctor, researcher and young scientist based in Dar es Salaam.