I want to thank Veet Academy who gathered us all today to discuss such an important topic. During the month of October, one thing that comes to our mind and what we see on social media, television and everywhere else is breast cancer awareness. So this month has been dedicated to this disease and we are all gathered here for this disease’s awareness only. I’ve noticed it often especially in our country Pakistan that people think why should we go to a doctor for this disease? Why should we get it checked? Oh my god, what has happened to us? You know, all these kind of things. These things happen in our households but, we are not used to these things. It is still considered a taboo to this day that we shouldn’t go to a gynecologist if, you are not a married woman. I think this is something which I wanted to say as a woman and I am so honored to be a part of this Veet Academy Breast Cancer Awareness Session. I want to ask girls why they feel shy talking about his issue. We should all give 5-10 minutes to ourselves and get ourselves checked and this is a very important part of our life. This is why we have gathered here today and the best part is that we will introduce a survivor who went through breast cancer fought it very bravely and is a very strong woman. I am sure you all must know her, she is a very famous writer film maker and a motivational speaker also: Asma Nabeel. We also have Doctor Kausar here with us today. She is the one you can talk to and get information from about breast cancer. We have so many questions regarding this issue like how breast cancer occurs, how do we know if we should visit a doctor or get tests done and all such questions So please welcome Doctor Kausar. And the third person I will introduce is someone because of whom we are all gathered here today. RB Pakistan Health’s Marketing Director, Humayun Farooq He is going to tell you why they decided to do this event for girls because in our country, we don’t have many such events. I am so happy that Veet has organized this event and with that said, please welcome Humayun Farooq. Hello everybody, Humayun Farooq, I am the director marketing for Reckitt Benckiser Health Pakistan. I feel very happy, we can feel this pink positive energy as I call it, around us. I am sure that this will become a very interesting platform today. Veet is Pakistan’s leading grooming brand, but we don’t talk much about Veet Academy, which we should. Firstly, what is Veet Academy? Veet Academy is the purpose leg for Veet brand The way Veet talks about women’s grooming similarly Veet Academy talks about grooming women’s personality traits. We’ve been doing this program across Pakistan for at least a decade. We have different pillars or personality traits in this upon which we groom women. Now that I have talked about grooming women I’d also like to mention one of the insights we got while gathering information around the dynamics of Pakistani women We understood one thing that a Pakistani woman believes in sacrificing be it for her husband or children. She works too, but at the same time she feels guilty also and this is why she does not take care of herself. This insight is extremely painful for us to see because we understand that if she takes care of herself, she can save herself from many diseases. This leads me to my today’s topic that is breast cancer awareness. I don’t know how many of you know this but breast cancer is the second leading cause of women’s death in Pakistan. This is something for which you only have to take out 10 minutes in 2 months to get yourselves checked and have some awareness around you, and you can save yourself from a great risk. Today’s discussion and guests are only here to create awareness This is us trying to spread our message to women. The reason we have invited all of you is that you guys are the opinion leaders for us and it is very important that we reach maximum number of women through channels like you. We have three very inspiring ladies over here All three of them are amazing in whatever they do. I met Asma in an event that we had and I heard her story and I was so touched and I told her ‘you know what, this is not the last time that we are meeting’, and here she is again And Dr. Kausar, obviously, I met her at a breast cancer awareness talk. She is the one who told me all of these facts that I am discussing with you guys. I realized that we have a brand, we can help the society so why not. Whatever they tell you, please ensure that on your respective channels you spread this information because our only reason is to spread this information as much as we can is to save numerous women from this disease. Thank you so much. Thank you so much Humayyun. Now we want to know from Asma, who has faced all of this about how she struggled with this disease. Let’s talk to her. I think this is the first time I have played something like this on a public platform. Sorry, I myself got a bit emotional today. You were talking about my journey, I think a lot was there in the video that I shared here today. It was not a very very easy time for me. Making a 10 slide video and adding music for some expression, it’s very easy right now. Two years of my life were extremely tough because in 2012 I was diagnosed with fourth stage and it was a very very sudden thing for me because no one in our family had it which is a myth about which the lady doctor here will talk about it too that it is because of family. No grand-mother, no aunt, no great great-mother, no sister, no one. So I call myself the first lucky one in my family who suffered from it. Lucky because if I wasn’t lucky, I wouldn’t be sitting here today, so that’s why you know. I feel whatever happened is because I had to come here and I had to do what I am doing now. So with every negative there a positive, which we normally don’t see. I went through two surgeries. After the first one we got to know that I am still not cancer-free. I underwent a second surgery called mastectomy. After that I had 18 rounds of chemo, which I believe a more tough time than the surgeries. I was that women who would run away from the cannula when I was delivering my two babies. I used to make the doctor promise that just after the delivery, they would remove the cannula. My surgeon was Rufina Soomro and I requested her that the day I undergo my surgery it would be done in the morning and when I come back to my senses you would put me on oral medication, though it did not happen. But, before taking me to the OT, she promised me, she said yeah it would be like this, don’t worry. So I went there, it was a bit difficult when it started and it was a really tough time after the surgeries. Yes there was a time where after my 6th, 7th chemo, I was going to office I was working and I was trying to lead a normal life because I think the most important thing for any person who is going through is to lead our phase of the life because, we ourselves are very fond of dumping ourselves. Our surroundings try to dump us and demotivate us. But I never got demotivated, I think it all happened because maybe Allah was really kind enough with me. These things don’t happen with a lot of people, but I think it was a different journey for me very spiritual, very coming back to my faith and coming out as a very strong woman. When the chemos started, then again I won’t say that there was no problem. Chemos began, I went to work till 6th chemo. After the 6th chemo, there was a very serious reaction of a medicine and I nearly saw death. I, literally, recited the kalma and underwent seizure attacks. I was rushed to the hospital at night and three days of my life I will not call it a coma, but three days I was unconscious. and till date I don’t remember those three days of my life. After three days when I first opened my eyes, the first person I saw was my son who was four and a half at that time and he was jumping in happiness and he was here and there shouting, “Mama woke up! Mama woke up!”. I had a small, very weak smile on my face and then the rest of the world appeared in front of me which was my whole world. And that day my perspectives, my life, my thought process, everything changed Just like they saw that when someone sees death from real close you literally get to know what actually happened and you realize then that this is not the actual life and the life we are running after, is not the ‘life’ The day I returned I got the feeling that it’s my rebirth and Allah has given me another life. I was gone, I was somewhere else, I was not in this world I was not here for those three days, and I could have gone too. But if I have come back, I need to start living a more meaningful and purposeful life. Maybe I spent a meaningful life before this too, I was in advertising, I was at the peak of my career when it was diagnosed, I was the creative head in one the leading advertising agencies. There was nothing miscalculated in life, nothing felt wrong and when all of a sudden you collapse you either go here or there. And I am very lucky I came here on the right side and a very positive side because the day I came back to my senses, I promised Allah that this a rebirth and I would do something more than what I was doing and after that I think that from there to here where I am sitting today, it’s just happening. I don’t call myself a very religious person or anything, but my faith got very strong after all this and my perspective of life changed completely. I was a very thankless person actually, we all are. We are very thankless We don’t realize all these little things around us, and we brutally ignore them in our daily lives But I realized that because taking a sip from this water bottle here is a task for me because when I was under chemo, my mouth and throat was full of blisters. I was given food after numbing myself, there was a medication given to me for it so my mouth was numb and that’s how I was fed and I wouldn’t feel a thing. But, I knew that I am getting energy. So the day I tried water for the first time as a normal human being, I realized then that oh God, what zone are we in and we are so thankless. Every morning we wake up, we have little issues like there is no electricity, the driver is not here and such things every day we are cribbing over little things all those perspectives changed in my life and I started struggling to do something different from what I was doing. As a person I automatically changed after my life threatening experience and I understood the meaning of life and how to take care of life better. Above that, I myself started to struggle that I need to do something more than what I am doing. After that, in terms of my profession, the writing thing because I used to write short stories when I was on the creative side. We used to write commercials and short stories, and there were few friends who were pushing me constantly that you are not just doing it, that you have to do it and you can do it. So I increased that struggle and I seriously feel blessed because I think the first drama I wrote was ‘Khuda Mera Bhi Hai’, which was on a transgender child and it aired on ARY. I wrote ‘Khani’, which was a blockbuster I didn’t get what actually happened. Then I wrote ‘Bandhi’, I wrote ‘Dil Kya Karay’, I wrote one of the films, which is ‘Maan Jao Na’ I wrote ‘Surkh Chandni’, which is a story about acid survivors and there are a lot of other projects which will hit the screens soon Insha Allah. It’s happening now and I think it’s happening because of my faith I talked about that got really strong, so I don’t feel like that it’s whose writing, I feel like it’s coming from somewhere and it’s happening because I feel the chosen one now and I feel very privileged because after so much pain as our religion says it that if you happily bear the pain, a very positive zone is opened for you. So whenever we are in pain, we forget about the positive and we are always crying that ‘oh God, why me? Why me? Why me?’ I think my plus point was that I never asked Allah ‘Why me?’ I accepted it and that acceptance is something that I would like every woman and every man to understand that this acceptance is very very important. Whatever time is coming just accept it because that is your time now. So live in that now, stop cribbing about it, you never know what lies ahead of you. When I went to Liaquat National after reciting the kalma I didn’t know I would be sitting here today, but it is happening and it’s for real. Once I was at another motivational speaking and one of the aunties came up to me and touched me like this and I was like, “Aunty what are you doing?” I was in the US and she said, “Are you for real?” and I said, “Yes aunty I am for real, what is wrong with you?” She said, “What kind of things are you talking about, no normal person talks like this.” And I said, “Aunty when you see and you go through so much, you often go in a non-real zone, but actually that’s the real zone.” Wherever I go, whatever I talk, I think that’s the most important thing to understand what actually is like right now so that is like the one part about health and everything. I think as a woman, your presence here is really nice. The speech you gave here felt like one of us is talking. What I feel my mistake is, which I would like to talk about through this platform to the females that we are all running after relationships and worldly things; mother, house, husband, children, family, brother, in all this we forget I actually am. I have a job, I have to look after my house I think that Allah has made females a multi-tasker we are multi-taskers by default. Because of this females often get in trouble, because they are doing everything while multitasking but they are not thinking about themselves. And that is something that I always try to promote and educate females that this is one thing that I did wrong in my life. I was getting some type of feeling from Allah because I was often under on and off fever when I was in advertising. At times I would get fever after a week, or after 15 days, and again sorry doctor, but we are all complete doctors, we know we have to take a Panadol and I was on my own self-assessment that yes I often get tired, but it must be because of my ongoing pitch my client has got me under stressed, the brief is not right, all of those things. All of it was self-assessment that I am not getting enough sleep, my kids are young I take care of them at night, in the morning I wake up and go to work but I never thought about it once that I should at least get myself checked from a doctor because I didn’t have time for myself. I used to say, “Yes, I’ll go, nothing’s going to happen, okay its fine.” We never about these things. If my child gets sick, would I leave him? No, I’d leave everything I would say if they want to kick me out of my job, they do that! My child has an appointment, which is very difficult to get it nowadays from these doctors. so I am taking him there This kind of attitude should be in women for themselves too I need to think about myself. Since 2 years I was getting those signs if maybe I was activated to those signs 2 years back it might have been the second stage, or maybe the first maybe it would have taken me 5 chemos instead of 18. I am not saying that I wouldn’t have to go through that process, but maybe it would have reduced maybe the problem related to health would have lessened too and in terms of financially also. Alhamdulilah we are blessed that we can get ourselves treated on 100% payment too we have everything, but there are a lot of people who don’t have these privileges and it’s really important for them to get diagnosed early. And for getting diagnosed, you have to take out 5 minutes every month, give yourself time do you self-assessment and if you are 35 or 35+, get your mammogram done. What’s the rocket science in this? The two tough years of my life that I went through was because of that ignorance and my self-assessment that it’s fine, I work a lot, I am a real hard worker; nothing pays in the end in the end its only you all alone on the bed and nothing is happening. So I have seen the toughest in my life and it’s my humble request to all the females and on whatever platform the discussion is being going to, even in your households you have your help; the maids, or the female help in your house. I am lucky enough, I am alive sitting here talking to you guys you guys are lucky enough to hear out what we are here to talk about but there is no one to tell all of this to the help in your house, and our focus that we both are here through Samina Alvi’s platform and we usually talk in lower SECs because no one is there to tell those females. So it’s my humble request that you go and talk to them and talk to your younger sisters talk to your daughters to all the young mothers I am not giving chance to Dr. Kausar to talk. I want to ask something, just like you told us that you ignored it for two years and got to know about it after two years what were the symptoms you went through in these two years that you used to ignore a lot? I told you I was always feverish, but it’s different in every person every body reacts differently and sometimes, honestly, there is no symptom you just need to be vigilant about it. There is no scientific reason as to why it’s increasing or no scientific reason that why is it the second leading cause of death in Pakistan, Asia there is no scientific reason as to how is it diagnosed each year in 90,000 females, out of which 40,000 die so that’s a very bad percentage And I personally feel that I am not a doctor, I don’t have a science background but I feel that shyness is one of the bigger problems, about ‘Oh how would I talk about breast cancer’ Oh God, the way Allah has made our hands, nose, finger, eyes, breast by the way breast cancer can happen to men too so it’s just a biological difference. For a while, if we take this thing out of this connotation, then it becomes a health connotation. All these mindsets and taboos, and it is very important to talk to your daughters. I am a daughter of a young mum, my daughter is 11 and a half, I am a mother of a very young daughter. Ever since I have joined Samina Alvi’s platform and our activity has increased, so few aunties came to me. They had the audacity to talk to me about it and I shared a post on my Facebook page also. They said, “Why are you talking about it so openly?” I said, Excuse me?” They said, “You have a daughter, she is 11 and a half.” And I said, “Yes, so?” And they said that it can affect her future, because they think that it will be transferred genetically. Fine I need to be more careful about my daughter now, that’s perfectly fine. God forbid this doesn’t happen, but if it does, should I leave the rest of this world’s daughters? I can’t do that. So whatever I am doing right now I am doing it for my daughter also, for the sake of my daughter and for the sake of so many other daughters who are over there whose mothers don’t talk to them. So the second humble request that I have is that please, start talking about it! The word ‘breast’ needs to be made common now. Like the way we go to a restaurant and say that we need a breast piece. Why there are no cheeky smiles on anybody’s faces? but when we talk about going to a doctor then our fathers and brothers and men of the family start moral policing us which is ridiculously, I mean I don’t know, Dr. Kausar will share some stats now. We will share with you examples about how treatments of different girls have stopped. I have seen it. They get divorced, as soon as a woman is diagnosed with it her husband hands her over divorce papers. And this is the lower SEC thing that people relate to it that a woman is characterless if she is going through breast cancer. This thing is present in the lower SECs by the way. We go to places like interior Sindh, interior Punjab, men feel like this, which is why women are afraid to tell And because they are scared to tell, they are nearing the fourth stage. These are all the reasons, this is the society that we are living in. Just right now we were laughing about just like how on Eid Milad-un-Nabi, the naat khwans start getting booked we start getting booked on October too! We haven’t kept the month of October as breast cancer awareness month because we have to talk about it the whole year; 90,000 women is not a joke. Sorry, over to you and over to you, I won’t stop talking, this is my problem! Thank you for sharing this, it’s very important and not only in October, but we should do this all year. I am a very healthy woman, but still whenever October starts I realize that I need to go. I went to Rufina Soomro, I got myself checked. Not only did I get myself checked, but also got my maid checked as well. She was like, “Ma’am what are you doing and why me?” At this level, we need to reach out to them because they don’t know. She was facing so much trouble only going with me and it was such a hassle for me to take her. So it’s a request from my side as well that talk to the maids in your home and take them along with you because they don’t have means. They might go with you, but they won’t go from their own homes. They will never go. Thank you so much Asma for this very inspirational talk you did. You make me cry when I see your video, it really makes me cry. I am very happy that she is here with us today and she told us her story, we get to learn a lot from such people It’s not important that we only bring here the survivors there might be someone who is facing this in our family or friends We should go talk to them and tell them that she is an example in front of us. Not only her, but there are a lot of women in Pakistan who are survivors, but do not wish to talk about it So thank you so much Asma that you talked about it. We will now talk to Dr. Kausar and know about what tips she would like to give to females or the women at home to make them aware of breast cancer. Thank you for inviting me. Well, you should have asked me to speak before Asma because her story was really touching and emotional You know as a doctor probably we don’t have emotions or we cannot emotionally link to somebody so things are very different. When patients come up to me, I really give them time, I really speak to them they discuss about their family issues or whatever is going on with them plus, dealing the disease also. You find out so much about the lives of other people, so when the patient is suffering from some minor diseases and they come and start crying, so I tell them, “It’s fine, you have this disease but you are fortunate enough that you are not facing a lot of other things.” Sitting on the other side of the table, as a doctor we get to know a lot about other people’s lives and then you are thankful for your own life because at the end of the day we are human beings too and we feel that why is this happening with us. Once I had a patient, she was very young around 35, 36. She came, she sat down, a very educated woman and biopsy report revealed that she has cancer. I told her that look this is the diagnosis and she said yeah I do have a strong family history. I said okay we can conserve the breasts and I am trained in this and this and that could happen. Quietly, she stood up and she said, “Okay.” That was kind of surprising because disease diagnosis always have an emotional attack on the patient. They sit down, either they show emotions they cry or they get upset. Many people say that we spend a good healthy lifestyle then why did it happen to us. When she stood up I said, “Can you please sit down?” She sat down and I said, “Look whatever I am telling you if you have questions ask me. Even if you have 100 questions ask me because I am an expert in this disease or go to another expert because when you leave my office, you are going to talk about this disease and you are going to ask your relatives, your friends or whoever, maybe they don’t know about this disease you can get certain information or ideas that won’t relate to you and will misguide you.” And then she sat down and she started crying. She said, “My husband is going through a disease I didn’t want this disease right now because he is facing renal failure, its treatment and everything.” Then you think about other’s life that it’s not disease, there are social factors also there is family also, they are dealing with other multiple factors as well. Like a patient comes to you who has a kid of 2 years, and they think this is the end of life. Nowadays I am seeing a girl who is just 32, 33, was trying to conceive conceived, 6 or 7 weeks of pregnancy and diagnosed with cancer. This is such kind of disease and as a human, as a doctor you also suffer when you look at such patients. You really feel that you should spread about this disease, you should speak about it you should provide information wherever you can from grass root level to educated people to a platform where there are even doctors who don’t know about the disease. Like in the beginning when I used to work on breast conservation I had a patient and I did her surgery and everything and she would always come and say, “Someone has advised me to sit under the sun because its rays are important for me.” And I was like, “Okay.” And then one day she would come back and she was like, “People asked me that why didn’t they remove my breast and why did they conserve it, the disease is still inside me, and my doctor is not good.” Then I had to explain everything. When she left, her son was in Italy, she went there and had a chemo, radio, everything from there and when she came back she said, “I wanted to meet you again because wherever I went,” and that was an Oncoplastic technique a real good one, so she said, “Every doctor asked me they said where did the surgery happen?” to which she replied in Pakistan. So the doctors said, “Okay there are surgeons in Pakistan like this who do these techniques who use these surgeries.” So she said, “My son told me that even if you have flu, you will go to the same doctor.” I said, “Okay thank you so much for trusting me now.” It’s just that we don’t know much about this disease. We should know about it, we should know about early disease we should know about how we can actually take care of ourselves. Yes we can’t prevent this disease, but how can we detect this disease early. Wherever I speak, I tell them that if you check on internet, if you find brochures there are things about breast cancer that has something like lump or nipple discharge or skin appearance like an orange peel. So this is what I tell them that all of these things are related to the advanced disease we have to detect the disease too early if we are discussing these diseases on these panels. My presentation is displayed. I actually got involved in her speech, I became too emotional and dramatic. I am Dr. Kausar Rehman. I am a breast oncoplastic surgeon so I deal with breast cancer and do surgeries where we can conserve the breast. We can give actually good aesthetic result post-surgically for cancer. Before we start, this is anatomy for breast of every one of us. There is chest wall, this is what we should know that there is chest wall at the back. In front of chest wall we have breast tissue and ductal system in the breast tissue, skin overate and nipple-areolar complex So this disease can appear anywhere from breast tissue up to nipple that can actually affect or invade chest wall also if its tumor of this area, so we should know this. What is breast cancer? This is a cluster of malignant cells. Why do we have cancer, any cancer in our body? We have a regulating system in our body, which controls rapidly growing cells so if that system is affected by any means; by DNA change, by environmental factors, by diet factors or genetic, that will actually not control over growth of cells and they turn or they behave like cancer tissue. The same thing will happen for breast cells, that if they are rapidly growing, they will form a lump, a cancer. It is rarely diagnosed in men, less than 1% of men are also affected, as he said. I am here, but actually this is for men awareness also, less than 1% of men are affected, I am dealing the second case of men breast cancer also these days within last one month. Though it rare, but not very rare, men should be aware of this disease also for their families, for their sisters, for their mothers, for themselves as well. Most commonly diagnosed cancer in women. Leading cause of death. In every two minutes, women are diagnosed with breast cancer. 1 woman die with breast cancer every 13 minutes. Death rates are declining because of screening mammograms or because of awareness programs. When we talk about causes, we actually don’t know what are the causes, but we do not that there are risk factors which can cause this disease. There are certain risk factors which are not in our control, there are certain risk factors which are in our control. We can actually modify or change our lifestyle to be safe. Like early onset of periods, late menopause of course that’s not in our control, but having pregnancy at younger age is probably in our control. Our lifestyle has also changed now, if we think about our grandmothers or great grandmothers there is someone in our family who had breast cancer in those generations as well. But there must be so many families who did not have breast cancer in those generations. Why? Because girls were married at early age, they had kids at earlier age, they had many kids; six or seven was normal, so they used to breastfeed their children for more than two years. After this the main factor is genetics. If someone’s mother or aunt suffers from it, or the family has a history of ovarian or breast cancer, or any other kind of cancer like stomach or pancreas, then the chance for the girl to have breast cancer in such family increases. But as she said and we are seeing women who don’t have family history of breast cancer, but they are suffering from this disease. This problem is not only on our side, but it is also present in the west that if breast cancer is diagnosed at a younger age, it is too aggressive by the time patient comes to the doctor. It is not the fault of the patient actually. It’s not even your fault that you didn’t think about you. It’s just that the disease is so aggressive, by the time you reach doctor it has either locally advanced or it has spread to your body, so you usually go to stage 3 or 4 to your doctor when you are young. Why? Because you are not enrolled into screening program and wherever there are awareness programs, they usually say that the one who are above 45 or above 50, they can have this disease, but girls are having this disease earlier than that age also. Mainly when it’s genetic, then they know about it too. Like I know families who have ovarian and breast cancer in their family, then those girls they know actually that yes we have this disease. I have operated on girls who knew about this also. But, by the time they come to us, tumor is actually around 3cm or plus. Contraceptive pills when we use to read about this is what I said earlier also I was surprised that how can somebody take contraceptive pills for 14 years 12 years because contraceptive pills less than 10 years doesn’t cause breast cancer, more than 10 years can cause. Young women they do need contraceptive pills not that you leave it after using it for 5 to 6 months because it can cause disease, no but if you use it for prolonged period. But again, it’s part of west, our books come from there, we follow literature of west. There it’s like that from an arc, the girls are sexually active, they need contraceptive pills from a very young age. Our culture is different, so we shouldn’t stop taking contraceptive pills, but we should not take them for prolonged period. Obesity again is a factor. Vitamin D deficiency is an imagine factor, which we relate this to breast cancer also, and all of us are Vitamin D deficient. So Vitamin D and Calcium replacement is necessary too, for your health and for this disease. What the presentation could be? Lump in breast, nipple discharge if it’s bloody and tenderness or a lump in the armpit also even if it’s not in the breast. Swelling of whole breast. Appearance of skin like an orange peel, we call it peau d’orange appearance. This is what I said that whole breast swelling or whole breast involvement or nipple retraction or skin’s orange peel appearance is presentation of advanced disease. We should not let this disease to go to that extent. We should diagnose or detect this disease in us or anybody else in the family who discuss this with us, they should detect this early as a small lump in the breast. Facts about this disease. 1 in 10 have breast cancer. Obesity, age above 50, being woman is actually a risk factor, getting closer to age 50 is a risk factor. where can this disease spread? So we were talking about stages. Early stage when the tumor is around 1cm or very small that is stage 1. The charm of diagnosing this disease in stage 1 is having a very good aesthetic result after surgery. Actually no one can tell that this patient has undergone breast cancer surgery even if you see her naked. Plus, we do have facility of gene testing in our country, we have done it on patients. We sent the block 4 oncotype DX gene testing where we can tell whether this patient needs chemotherapy or not. We have had this on patients. There are lucky fortunate patients who never had to undergo chemotherapy, they just had radiotherapy for breast conservation. Then in stage 2 the disease actually spreads to the lymph nodes which the nodes in the armpits, which actually drains the area of our arm and breast. So if disease goes to axillary node or armpit node, then that patient does need chemotherapy, but again we can conserve the breasts in those patients as well. In stage 3 tumor is actually big, it has actually spread to lymph nodes. 4: the disease has spread to whole body, either lung, liver, bones or brain so that is the disease which we call advanced disease. Patients come to our clinic and ask, “Which stage are we in or which stage is our mother having this disease.” I tell them that if it’s stage 1, we need to find out if our patient is in stage 1 because they won’t need chemotherapy then, but for that we have to do certain other tests. Or if its stage 4 where, as a surgeon, I can’t play any role then I have to refer my patient to an oncologist. Stage 2 and 3 are important for doctor, for surgeon to find out what to do, what to plan from surgical point of view or from treatment management point of view. This is where I said this disease can spread to liver, lung, bone and brain. And I have seen a very educated woman with brain nets. I have seen a woman who works in hospital actually at a good position with locally advanced disease, where she never found out because the lesion was in the lower part of the breast and if you have heavy breast, you actually don’t feel the lower part. We will come to that part later of self-examination. There is no science of self-examination, you should be breast aware. What can we do to prevent this disease? That is an early detection plan, self-examination, regular clinic checkups and screening mammograms. How do we examine ourselves? This is what I tell everyone if I go somewhere to talk about this disease or I spread awareness this is what I tell them. There is no science, don’t follow the brochures. Don’t, which are on internet or wherever. Look at yourself in the mirror, lie down and examine yourself, then stand up and examine yourself. Just as she said, and this is something what I do as well, this is what all of us do. If we have to take out time for ourselves, we never do this. I have kept Vitamin D inject in my clinic so that whoever comes to my clinic and I find out they are Vitamin D deficient, I just inject them. I just inject them. Why? Because I bought Vitamin D capsules, I kept them in my fridge I will never come to you. I am scared of you. I will never come to you. I never wanted to have capsules and we actually threw them in the garbage. Then I thought okay, I kept Vitamin D injection in my pocket. This is not a story, I have actually done this. I kept Vitamin D injection in my pocket and I thought that whenever I go to OT and my nurse can do this, I can have Vitamin D injection. Being doctor, I myself am phobic to injections so I really don’t like injections. At that time I thought ‘Maybe tomorrow. Maybe tomorrow’ and for a month I never had Vitamin D injection then I said okay I should keep this for my patients, whoever comes to my clinic, she should get Vitamin D injection because we cannot make decisions to have something specifically or specially to ourselves. Self-examination is a similar thing too. If we think we have to take out time, we never. So while taking shower, there is no science in it. Once a month, after your periods finish, just while taking a shower examine your breast, the whole breast and armpit. You are already scrubbing your body, just swipe your hand across your breast and your armpit too, so you will get to know Also, you will have the feel of your breast in your brain. A very minute change can alarm you and tell you to go to doctor. I have seen patients with heavy breasts detecting a tumor of less than 1cm, which actually at times surprises us also because at times, we can’t even do that. At times tumors less than 1cm are not detected in mammogram also, but there are women who are too vigilant and come to us. After self-examination is mammogram. Mammogram is x-ray of breast. Often women are scared of mammogram, they think that if we go, this will be a painful procedure or mammogram compresses your breast. It’s painful, yes it does compress, but it’s not that painful. If you look at the benefits of mammogram, I think a little while to discomfort is really okay to bear. Have something which can be too early. Even if something is cooking in your breast, you can actually detect the disease. Even if you don’t feel the lump in your breast, you can detect that disease in mammogram. For less than 35 year of age, ultrasound is beneficial. Ultrasound are sound waves and they are not harmful to body, even mammogram rays are not harmful for your body. There are girls who are sent to radiology by their gynecologists or by their physicians or maybe even by their surgeons also. Even if they are younger than 35, they are sent for mammogram, and when the radiology people refuse to take them, they come back to us and say that they didn’t do a mammogram, though we were recommended to have this. It’s not that mammogram is really harmful under the age of 35, it’s just that mammogram is not beneficial under the age of 35. They young women, they have dense breasts, the dense breast appears white against black background and if we want to see cancer, or lump or any other disease, that appears white against grey or black background, so it’s not visible, so it is not beneficial to you. This is why you are told to go for ultrasound instead of mammogram, in a younger breast. So this is what we said, examining yourself, mammogram and screening mammogram. Okay so do you have to do for screening mammogram or I have to go for screening mammogram? No, these are women who are closer to age 50 who have felt nothing in their breast, but since they are at risk of having this disease, they should book their screening mammogram. In west, they get letters from their relevant hospitals and they are booked for their mammogram. At our side it’s like we are spreading this awareness. Whoever in your family, your aunt, you mother, you neighbor, whoever you know your senior colleagues who are closer to age 50, they should schedule their mammogram, they should go and get a screening mammogram done. I will end here I can take questions if anybody has. Let me sit. Before taking questions I have to add a few things, the culture and society part that I wanted to talk about. Yes we should clap for Dr. Kausar first. Whenever I go through this presentation with Dr. Kausar, I thoroughly enjoy it because everything has been told in very much detail. We have a lot of males in the background, can they all please pay attention towards me and please come forward Moiz come forward. I need attention of all the males, who are counting how many people will have tea, please you too come forward. Problem is that there is everything, there is fear, women even run away after going to the doctor. Patients come in, they attend a session with you and never come back. Their backstories are completely different, those are societal pressures and not scientific pressures. We have a marvelous system here when it comes to treating a patient, cancer patient. All our doctor and hospitals are great. Be it poor or rich, we have treatment facilities for everyone, it’s just that you need to find out. Our conditions are way better than those found abroad. I had the option of going abroad, but I opted for Pakistan and I opted for staying here. There are a lot of problems that the acceptance of males in our house is declining, it is for educated households too not only about the lower SECs. There was a patient next to my chemo bed who belonged to a very normal family, this is my first-hand experience that I am sharing with you and that time I felt so lucky that chemo didn’t matter. The day she was diagnosed, her husband divorced her, she had no parents, her brother and sister-in-law rejected her because they thought their kids will inherit the disease. But she was such a resilient and brave girl, I still know her I know she is alive and is doing good, and also at that time she had a 7-month-old child as well. So her husband left everything and said whatever she does, she will do it on her own. She is a resilient woman, she fought with it, she is fine Alhamdulilah, she’s surviving, she’s working, everything is happening. The point is that who has given the right to all the men, with all due respect to the males like you who are supporting females like us. All of the males here today maybe you support it at your homes, but there are men among us who don’t support it we need to find out and talk about them, and only males can do this, women will say anything but the males just won’t get it. When a male talks to another male, that’s a separate thing and since last year we talk about going everywhere and we only have sessions with women, but I believe that we should call the men too, I need to talk to them because it is very important to change their mindset, it is very important to tell them that how important it is for them to understand that this is a matter of life and death, this is not a joke. Then there was another patient whose father called her back home, because he felt like her daughter is not married, and even the lady doctors are treating her and everything. We really misuse our religion, I am saying this on this platform. We have a beautiful religion, nowhere does our religion tell us to not take care of our health. In my point of view, our life is a gift of Allah, a gift of God. Allah has made our lives a blessing and has asked to be thankful to all our blessings, and you can be thankful for your health by taking care of that and if you are not taking care of that then I am very sorry whoever says that if a girl gets breast treatment then God knows what will happen and that this is wrong from religion’s point of view; then that is 100% incorrect, there is no religion involved in it, there is nothing like it. Someone is referring to religion. Then we meet a lot of females who come crying that we can’t get treated because our mother-in-law is saying something, or our husband will leave us. Honestly at that point I tell those women that those husbands who will leave you, you leave them first, because if he has no respect for your life, just leave him, he is no good for you. It’s all a matter of acceptance and acceptability and understanding that this is not a joke. The other day I went to IBA, and this very painful thing for me, I scolded the young boys because when I started talking about the breasts, I went there as a motivational speaker, there was a weird giggle and I said, “Excuse me, who giggled in the boardroom?” I started acting like a teacher over there. I said that you guys think of it as a joke? Ask me when I was on the hospital bed, ask me when I underwent two surgeries, ask me when I was having chemo, then you should have come and giggled. We have mothers, sisters, and daughters at home. And all of the men here, I beg you to talk to the boys around you also because there is a lot of talkability now in the females. I have been working since 4 years about this and since 2 years I have been a part of this group and we have seen change in these 4 years. Women are getting very receptive, they want to talk about it, they want to learn about it. I think the obstacle that is coming is the male attitude, is the rejection of the families,is the rejection of the women when they dump them, when they are made to eat in separate dishes, or tell her she is characterless, or when she is dying people come and tell her to ask forgiveness, Allah must be punishing you for some sin. At that time I just want to kill those people, but we need to change as a society, we need to change as a mindset and I know it will not change in one day, but I just promise myself every day that I will keep on talking about this thing till I feel like yes there are even 50 males who agree with me, and till now I still haven’t got a gathering of 50 men. So at least aiming for 50 men is not that big and I think those 50 will multiply so this is a request to all of you who are sitting here right now, it is a matter of life and death. 40,000 females dying every year means 40,000 households getting affected. Some women might have children, someone’s brother must be dependent on her, someone’s husband must be dependent on her, someone’s mother must be dependent on her; we are not thinking about those things, what we are thinking about is only the societal taboos We are only thinking about if the girls was good or bad, if she is being punished for her sins, how to reject her. And finally on the last note, if a women goes bald please stop looking at them as if she is an alien. Please. Sorry I didn’t notice that. I am so sorry. The day I underwent chemo, I was very finicky and I am still very finicky about my hair. Even a day before my surgery I went to get blow dry done because I thought if the surgery is successful, people are going to come visit me so at least my hair should be perfect. I was that sort of a person, and people were thinking the cancer has affected my brain, that was not true. I was trying to numb myself with all those things. So a person like me, and for every women her hair, her breast and losing her breast and hair is not that easy. It’s not that easy for me to come and sit here. It was a very tough time that has put me here today and has given me so much confidence to talk about it so openly about it because I seriously give a damn about anything. Now whoever thinks whatever let them do that because I know what I am doing and I know what I am doing is right. So when I asked the doctor, she told me that 14th day, you will lose your hair after your first chemo. I had this long hair so what I did after my first chemo was to straight chop them. I donated the hair I know somebody to whom I donated them. And after that on 14th day my hair started to lose and I was taking bath and a strand of my hair came into my hands and I was like, “Oh shit! This is happening.” I came out of the restroom I told my husband that I am taking the car keys, I am going to the salon of my friend and I am getting it shaved. He said go, I said fine and I went there and got it shaved. I came out of the salon, just like you I was there. Yea I am thinking to start such work again. When my friend was shaving my hair, she was crying because since the last 17 to 18 years ever since we grew up, my hair streaks, blow dry and all of them was done by her. So shaving the head was a big problem for her, but I was laughing and I was like, “Don’t cry, don’t cry. Don’t put me in that situation where I will start crying and I will get demotivated and I don’t want to go into any demotivated zone.” So I went out very confidently and opened my car, her salon is located in Bukhari, and people started looking at me in such a way that I got so uncomfortable with myself. I pushed myself so much, 3 or 2.5 chemos, but I cannot cover my head. It’s a good thing, it’s a bad thing I don’t know, I still don’t cover my head, but people pushed me to do that because when I used to leave my home, people looked at me in such a way that I felt like I am an alien. So patient acceptability, because when you are undergoing chemo only a patient or a doctor knows how hot you are feeling you feel like you will touch someone and they will burn, it’s that bad. So do not push the patients. One of the problems we have is that our patient support system is very wrong. So if any woman is going through this, please motivate her. Don’t go and tell her, “God knows what will happen with her now.” Because I have heard that. I have heard people saying, “God know how many days more.” Oh please, for god’s sake. My death and my life only Allah knows, you never know you can be stepping out and a car can hit you. How dare you say that to me, a person who is dying, who is fighting, who is trying to do something good with the life, who has her two little kids in front of them and you are talking to her. Please just become more empathetic with people, just become more acceptable for females. If you go abroad and you see such patients, people have a very different attitude, they take care of them, and they don’t alienate them. In our country, people alienate them so please this acceptability is necessary too because as the breast cancer rate is increasing, you will get to see more bald women. So please move around normally like a normal woman. I feel like when a woman is under treatment, again life and death is in Allah’s control we don’t know about it, but a person who is going through this process and is fighting be her strength, not that you reject her and throw her in a corner. And to all the males once again please go back and talk to your wives, your sisters, talk to your sisters to talk to your mothers also who are locked up in their houses and to everyone in your surroundings be it your driver or gardener. Because I just saw a gardener’s case who came and said my sister-in-law is diagnosed with it, but my father-in-law is not letting her go, so some of our team member called the father, explained him and convinced him. So again even in men in lower SECs should be talked to, to spread what we have told today and I think we need acceptability. Thank you. Thank you so much Asma for coming. I didn’t let you speak at all. Of course, you didn’t let me speak at all and thank you so much Dr. Kausar for coming here. And I would like to ask the audience if they have any questions that they would like to ask them, you can ask them. I have three questions. Firstly, does breastfeeding protect against breast cancer? Secondly, are PCOs a problem for breast cancer? Thirdly, just like it is said these days that chicken is given steroid injections, can this cause breast cancer too? For breastfeeding, yes it protects from breast cancer, but if you exclusively feed for 12 years, which means you have 6 children and you have exclusively breastfed them then it’s a protective factor. But we cannot stop feeding our only one child. This is what I have said, our lifestyles have changed, we do not get married at earlier age, because we are ambitious we want to work, secondly we cannot afford children more than 2 or 3 and especially if you are a working girl or woman then you go to work also and your breastfeeding cycle gets disturbed, but yes that is protective. Secondly you said PCOs. PCOs in a way are a problem for women because after marriage it can cause problem while conceiving, but PCO is protective because you are not exposed to estrogen for a longer period. So in a way, again its protective. Few days ago I had a presentation and whenever girls come to my clinic, in PCOs cycles are disturbed, so instead of every month you get periods after two to three months and then they go to gynecologist who keeps them on hormones. For few months they are okay and then the problem restarts. I tell them when you get married and then there is a problem conceiving, then take hormones. Now if you are saving one month’s Always then what’s troubling in this? If you don’t get periods for one or two months, there is no issue in that. Then from our aspect it’s protective. Third, you said chicken. Yes. Then again food, we all say that our family has no history, but how I am seeing very unusual presentation of breast cancer in young women in which you cannot even detect the thing on mammogram and they come with advanced disease. In this there are environmental factors, plus the disturbance in food. Chicken is injected, cows are hormone injected your all food is affected. But you are helpless, you are forced to use that chicken, you are bound to have the milk of those cows or whatever, so we can’t change that either, but yes that does cause. So we can avoid chicken right? It is said to avoid chicken I have not eaten chicken in the last 4 years, but still. This is what I think, I think about my daughter. So the lifestyle I had, where I grew up, we really had everything pure because my father was a landlord so we had our vegetables and fruits from our farms, chicken clean, meat was cut in front of us milk was from the house because my mother loved having cows so our house milk too, everything was pure. When I think of my daughter, nothing pure. Then I start thinking of going to that primitive lifestyle, but for that you have to make your own farms so I ask my driver to find out chicken for me that are injected, we couldn’t. Even from villages we couldn’t find those chicken. I said okay I’ll make those nuggets of chicken for my daughter, so have to do at least something for diet. Don’t deprive yourself just try to balance out. I do go for the desi one. Yes find the desi one, you will find it from somewhere. So I have just one question. If a girl finds a lump in her breast and the doctor says it’s not-cancerous so then what should they do about it? Should they let it go? Lumps of younger breasts are fibroadenomas, 16-26 year of age you can have those lumps. Each cycle, you breast tissue undergoes maturity. You do develop those lumps, they are non-cancerous, they do not convert into cancer, but at certain age there is recommendation above 35 you can’t keep something even which is harmless. So when younger patients come to us if she is 16, 17, 20, or 25, if the lumps are small we ask them not to touch them, but when they come at the age 30+ then we tell her of course someday you will plan surgery then why tomorrow? Just get rid of it today. Secondly, if she didn’t have lump at the age of 26 and she develops a lump at the age of 30 or 32, this means there is a change in breast tissue, even if it is harmless, even if it is non-cancerous, don’t keep it then it’s something which is pre-cancerous. So first of all, all of them wanted to know about earlier signs and what are the first few symptoms? And a guy asked me what is the difference between symptoms of a female and a man, are they the same or is there something different? This is what I said. Lump in breast, lump in armpit, bloody discharge from nipple; these are early signs and if we talk about nipple retraction or a swollen skin peau d’orange appearance of skin. or a huge lump in the breast, these are presentations of advanced disease So here this is what I tell you, if you want to detect a disease early, if you feel a small lump in your breast, you should go to doctor, if you feel small lump in your armpit, do go to doctor, watery discharge is not harmful, milky discharge from nipple is not harmful, but bloody discharge from nipple should be evaluated. Men or boys do feel a lump because they have nothing chest wall and skin and underneath aurora complex they just have a small disk of breast tissue, they do have. In that tissue they do develop lumps and they can detect it earlier than women because it’s really obvious when they feel themselves. And as I said I am dealing with patients, I am deal with gynecomastia also. Somebody asked me that I have to refer some boy, do you deal with gynecomastia? I said yes that is a swelling of breast tissue in boys. Is said yes I have dealt and the patient who comes to me they are from real high profile so, they come with guards, or with family or somebody. They come with family or they bring sisters or mother, but actually the boys come for treatment to me. The way we deal men also, they do feel lumps in the breast. So I see these on my blogs. Someone was asking what are the chances of getting it again for someone who has gone radiation and chemotherapy? Are there any chances that it can return again? If breast cancer is diagnosed in a patient who has no history of breast cancer in the family, they do have chances of developing breast cancer in the other breast or maybe in the body as well. The first two years, we keep our patients in close contact, we as a breast surgeon or oncologist see our patients every three months, then next year on six monthly basis, then after one year, yearly basis. After two years, the chances of recurrence reduce, but there are chances of recurrence of disease again in those patients then we yearly see that patient till 5 years. After 5 years, the chances really regress, but not necessarily that every patient should have this disease recurrence, but yes book says that there is chance of recurrence of the disease, in the contralateral breast or in the same breast or in any part of body. I got a question from a mother. She says that how can we prevent it and does it happen because of irregular sleep and bad diet? Can cancer be caused by that? Any disease, any cancer, not only breast cancer could be because of disturbed diet or disturbed sleep and disturbed mental activity that includes depression, anxiety and all these things. Improve your diet, exercise and proper sleep, yes that does affect your life, not only for breast cancer but for other diseases also. Secondly, how can we prevent the disease, we actually cannot prevent the disease, we can improve our lifestyle, but we can take measures to early detect the disease that is like having self-examination or if you find something then go to doctor, if you are closer to age 50 or 45, have screening mammogram or get yourself scanned and if there is family history of breast cancer, get your genetic testing done, it is possible in our country also I am not the best person for home remedies, but yes there are remedies. There are patients who come to me and I have seen a patient who really was glowing after treatment because she was gene negative and she didn’t need chemotherapy, I conserved her breast also. Then when she came back, she was looking very good. She said I found out this juice and this thing works for me, they have to find it on internet or somebody who is an herbalist they can tell. Thank you so much all of you for coming today and joining us. Thank you so much Dr. Kausar for coming and giving us so much information about breast cancer awareness. Thank you so much Asma Nabeel for coming and thank you so much Humayyun Farooq for attending this event and giving such inspiring speech today. Thank you everyone and if you have other questions that you want to ask these guys please do so post the session.