Dr. Mahendra Perera,
(MBBS, MD, Dip.RT)
Consultant in Clinical Oncology & Radiotherapy Honorary Fellow of Sri Lankan College of Oncologists Principal Investigator – International Multi-Center Clinical Trials.
Forty years ago cancer was considered not only taboo, but was thought to have immediately association with death. Hardly anyone talked about cancer then. Once a patient was diagnosed, their relatives begged others not to talk about it. Of course, the doctors had to tell the patient the truth but we understood their loved ones were trying to shield them from what was thought to be a death sentence.
It was a dreadful sequence of events. However, we are now in an era where the Breast Cancer has been largely spoken about in various platforms. Majority of the speakers focus mostly on its new treatment modalities along with the new term ‘Precision Medicine’ which has made a major breakthrough in breast cancer cure today.
More women are diagnosed with breast cancer than any other type of cancer. It is now estimated to be more than 25% of all female cancers. It has been widely studied throughout the world. In fact, major research on breast cancer has paved the path for breakthroughs in other types of cancer research as well. In other words, breast cancer treatment has be come a core model for other cancer treatments.
Though young breast cancer survivors who remained cancer-free, lived with excellent quality of life, they had to go through variety of psychological concerns. The term ‘five-year survival’ tells you what percentage of people diagnosed having breast cancer would live at least five years after their cancer is found. On the average the five-year survival rate for women with non-metastatic (not spread) invasive breast cancer is around 85 %. The average 10-year survival rate for women with invasive breast cancer is 75%.
If the cancer has spread to the regional lymph nodes, the five-year survival rate drops to 65%. If the cancer has further spread to a distant part of the body, the five-year survival rate drops down below 35%.
At the time of first diagnosis with breast cancer, about five percent will have cancer already spread outside of the breast and to nearby lymph nodes. This is called “de novo” metastatic breast cancer. Even if the cancer is found at a more advanced stage, new treatments still can help many people with breast cancer maintain a good quality of life for a reasonable time.
Some cancer patients were knowingly or unknowingly over-treated or under-treated for the disease. This was specially seen when there were uncertainties raised by medical specialists on debatable clinical situations. What extent to treat precisely is well understood now by the newer investigations and drugs that have been developed. These drugs are targeting the defective genes or defective pathways of cancer spreading.
This must be addressed very accurately and early during their treatment to avoid over-diagnosis and over-treatment. There are hardly any such situations observed now because of the availability of molecular diagnostic facilities and ‘precision medicine’.
In general most types of cancer treatments have improved over the time and cancer is now targeted with far greater precision than in the past. Current refined techniques in surgery, radiotherapy and chemotherapy mean that people live with fewer side effects than they used to experience in the 1970s and 80s. However, we are now seeing a newer spectrum of side effects emerging from newer treatments.
Essentially all untreated breast cancer patients will die of the disease. Their co-existing medical conditions will also increase with age. So older patients with breast cancer have a higher probability of dying of causes other than breast cancer.
On the basis of these observations, the concept of ‘Personal Cure’ emerged. A significant number patients with breast cancer achieving a ‘Personal Cure’ after curative treatment will eventually die of a different cause such as cardiovascular disease, lung disease or stroke.
The term ‘Statistical Cure’ has been defined on the basis of population survival figures. Thus, it is considered that a group of patients with breast cancer achieves cure in statistical terms if their probability of survival becomes comparable to the probability of survival in the general population.
Breast Cancer diagnosed by mammogram early (Stage I) has excellent survival figures exceeding 90% at 20 years following any form of surgical resection alone even 25 years after diagnosis. The survival of patients with stages II, III and IV breast cancer have a higher chance of relapse leading to lesser chances of survival. It is generally believed once the breast cancer spreads to other organs, the chances of cure becomes remote with most available treatment modalities.
Once the cancer is spread, surgical resection is a futile exercise and does not alter the natural progression of the disease. Breast cancer treatment is becoming more individualized as doctors learn more about the disease. It’s now seen as a disease with many subtypes. These sub types do not play a role in staging the breast cancer but becomes greatly important in treatment decisions.
The ability to isolate specific genes and classify breast cancer according to a patient’s genomic alterations, is the beginning of more tailored treatment options. There are many special tests that can tell your doctor more about breast cancer so that they can then decide on the best course of treatment for that person and use information of patient’s genes to predict how their cancer will respond to different treatments.
This is where Precision Medicine holds the promise of truly personalized treatment which provides every individual breast cancer patient with the most appropriate diagnosis and targeted treatment. Precision medicine for breast cancer involves analyzing the genetic makeup of your cells or, if you have cancer, the makeup of your cancer cells.
Once a patient is diagnosed with breast cancer, she would need a proper biopsy sample which should be analyzed on basic testing as well as at an advanced genomic testing because your genes may influence the way your body acts against cancer drugs. Such drug – gene interactions is called pharmacogenomics. It helps your doctor to see whether that particular drug could precisely work for you. At the same time, if your cancer progresses despite treatment, your doctor might recommend testing the genetic makeup of your cancer cells. This test, called ‘tumor cell sequencing’ is used to see changes or alterations in the cancer to decide on the best drug for you.
Some cancers run in families. Inherited gene mutations will increase your risk of breast cancer. We sometimes recommend a test called ‘BRACA’ gene testing for people with a strong family history of breast cancer. Women who have these genes have an increased risk of developing the disease. This same ‘BRACA’ test is used to determine whether you would respond to a specific drug when your cancer is disseminated.
Many newer genetic tests are available now, depending on a person’s family history of cancer. However, one should not have a fear that, presence of such genes would necessarily cause you breast cancer.
Early detection is not always the cure for breast cancer. But once detected early it could be successfully treated. Surgery remains the most definitive treatment for breast cancer. It could end up in total removal or partial removal of your breast whenever it is operable. Surgery cannot cure the breast cancer. Cancer needs a multi-modal treatment. Surgery would make matters worse if it is performed in an advanced stage breast cancers.
Such advanced breast cancers should be treated with chemotherapy to downsize the tumor before removing surgically. In certain situations there is no need to remove the primary breast cancer at all. Your doctor will tell you if it is so. Breast cancer is not confined to its local area. It is a disease within your whole body.
After surgery, majority of breast cancer patients will require chemotherapy, radiotherapy or hormone therapy as a single modality or in combinations. It is this added treatment which is called the ‘adjuvant therapy’ that remains the mainstay of breast cancer cure.
Solidarity and Aragalaya: A few thoughts from an educationist’s perspective
by Harshana Rambukwella
Very little in Sri Lanka at the moment inspires hope. We are facing an existential crisis that was inconceivable just six months ago. Sri Lanka is also, ironically, just a year away from marking the 75th year of its independence. As we reflect on these seven decades of postcolonial nation building, and as we confront a future of extreme precarity, our scorecard as a country is not a proud one. Much blood has been spilt in the name of postcolonial nation building and the ethno-nationalist conflict that shaped almost three decades of that history and two youth rebellions against the state speak to a history of division and enmity. While our current predicament cannot be entirely attributed to this conflictual history alone, it surely played more than a small role in shaping our present misery. It is within this context that I want to offer this brief set of reflections on what I feel is an unprecedented form of solidarity that has emerged in Sri Lanka as the aragalaya took shape. While I do not want to romanticize this solidarity because it is a highly contingent phenomenon and is shaped by the extreme nature of the current political and economic conditions, it offers us as a society, but more specifically as educators, something to reflect on as we try to imagine our role in a society that faces a painful process of rebuilding and recovery (though my hope is that such rebuilding and recovery does not mean the repetition of the tired old neo-liberal script we have followed for decades).
Before I explore what I mean by solidarity within the aragalaya, let me briefly reflect on solidarity as a concept. Solidarity is a term sometimes deployed in geopolitics. Particularly in this time of global turmoil where not just Sri Lanka, but many other countries are experiencing serious economic challenges, we see nations expressing solidarity with or towards other nations. However, such solidarity is almost always shaped by instrumental motives. This is what we might call a form of ‘vertical’ solidarity where more powerful and wealthy nations extend a ‘helping hand’ to their more unfortunate counterparts. Therefore, when India says ‘neighbourhood first’ and expresses solidarity with Sri Lanka in this time of trouble one can easily discern this as a hierarchical gesture shaped by instrumental motives. It is in reality, India’s strategic geopolitical interests that largely dominate this narrative of solidarity though one cannot disregard the critical importance of the assistance extended by India and other such ‘powerful’ nations in this time of national distress.
Another form in which solidarity manifests is through what some scholars have termed ‘enchanted’ solidarities. This is literally and metaphorically a distant form of solidarity where intellectuals, activists and others extend solidarity towards a struggle they perceive as deserving their support but without truly understanding the context in which they are intervening. This has often happened with ‘first world’ academics and intellectuals expressing solidarity towards ‘third world’ struggles which they felt were ideologically aligned with their beliefs. One example is how many liberal and leftist intellectuals supported the rise of the Khmer Rouge in Cambodia, believing it to be an anti-imperial liberation movement, only to become disillusioned with the movement as they began to see the full horror of the repression and violence unleashed by the Khmer regime. I think if we reflect on Sri Lanka’s postcolonial history, we can also find many such moments where enchanted solidarities were expressed towards various movements from people in the ‘metropolitan’ center with little understanding of the nuances of the politics on the ground.
Premised against both vertical and enchanted solidarities, scholars have also proposed what is called ‘disenchanted solidarity’. By this they mean a situation where diverse groups, sometimes with very different political and ideological agendas, come together to fight for a common cause. They are often critically conscious of their differences but face a common precarity that pushes them together to struggle and align in ways that were not possible before. Often such moments are also underwritten by anger, though the sources of anger or the objects towards which the anger is directed could be different. I would like to read the aragalaya through this lens of disenchanted solidarity. Particularly at the height of the Galle Face ‘Gota go gama’ protests – before the brutish May 9th attack symbolically ‘killed’ something of the ‘innocence’ of the struggle – there was a sense in which the different groups represented in that space were expressing solidarity towards a singular goal – getting rid of the Rajapakasas and a political system they saw as deeply corrupt – there was anger and a gathering of disenchanted solidarities. For many middle-class people, the aragalaya was a way in which to express their frustration at the lack of the basic necessities of life – be it gas, electricity and fuel – and how a corrupt political class had robbed them of their future. For those with longer histories of political activism such as the IUSF (the Inter University Students Federation) or youth activists from the Frontline Socialist Party or the JVPs youth wing or the many trade unions that supported the aragalaya, this moment in some ways represented the culmination, and perhaps even a vindication, of their longstanding struggles against a political, social and economic order that they consider fundamentally unfair and exploitative. Of course, within this larger narrative, there were and continue to be pragmatic political calculations, particularly from groups affiliated with political parties. At the same time, we also witnessed ethnic and religious minorities, often historically marginalized in Sri Lanka’s social and political mainstream finding a rare space to express their anger at the ways in which they have been discriminated against. However, the argalaya gave them a rare space to do so by channeling their anger as a form of solidarity towards the common goal of getting rid of the Rajapaksa dynasty and the corrupt political system as a whole.
But at the same time, we also saw the tenuous nature of these disenchanted solidarities in the aftermath of the 9th May attack on ‘Gota go gama’. Initially we saw another spectacular display of organic and spontaneous solidarity when health workers and office workers abandoned their workstations and rushed to ‘Gota go gama’ when news of the attack broke. But by the evening of that day the story had turned more insidious with a wave of attacks against the properties of politicians and others thought to have been involved in the attack against the peaceful aragayala participants. While we may understand and even empathize with this backlash, its violent nature and what appeared to be other instrumental motives driving it, such as the looting and revenge attacks, made it difficult to associate it with the moral principles that had animated the aragalaya thus far.
Thereafter, at the current moment I am writing, the aragalaya also appears to have lost some of its vital energy as the political configuration has shifted and the tragi-comedy of Sri Lanka’s realpolitik with its underhand deals and political mechanizations seems to have regained the upper hand.
However, what does this mean? Does it mean post May 9th the aragalaya has lost its meaning and purpose or can we push our analysis a little deeper. At this point I would like to introduce one final way in which scholars have discussed solidarity which I feel is appropriate to understand the aragalaya and the spirit that underwrote it and continues to underwrite it. This is what some scholars have called ‘deep solidarity’ – a situation where in today’s neo-liberal context where the vast majority of the population come to a realization of their common social and economic predicament and realize their common enemy is the symbolic ‘one percent’ or an insidious nexus between crony capital and political power that disempowers them. This is of course an idealistic conception but one which I feel holds true at least partially to this moment in Sri Lanka. People from widely varying social and economic strata, from different religious persuasions and people with wildly different ideological and political beliefs have been suddenly pushed together. They are all standing in the never-ending petrol and diesel queues, they are desperately hunting for the next cylinder of gas and increasingly many of them are going hungry. The privileges and the divisions that once defined them, no longer seem to be so ‘real’ and the one stark reality confronting them is a form of existential annihilation. I believe within the aragalaya we can glimpse traces of this deep solidarity and as an educationist I think it is our vital task to think of creative ways in which we might sustain this solidarity, grow it and nurture it, so that we can at least ‘imagine’ a better future. These are idealistic sentiments, but at least for me, such hope, is a political and pedagogical necessity of the current moment.
Harshana Rambukwella is attached to the Postgraduate Institute of English at the Open University of Sri Lanka
Kuppi is a politics and pedagogy happening on the margins of the lecture hall that parodies, subverts, and simultaneously reaffirms social hierarchies
No solutions to nation’s problems from draft constitutional amendment
by jehan perera
The three-wheel taxi driver did not need much encouragement to talk about the hardships in his life, starting with spending two days in the petrol queue to get his quota. He said that he had a practice of giving his three children a small packet of biscuits and a small carton of milk every morning. But now with the cost tripling, he could only buy one packet of biscuits and his three children had to share it. This is because their beloved country is facing one debacle after another for no fault of those kids or the larger nation. The latest is the failure of the government to make headway in accessing either IMF funding or other funding on any significant scale. Several countries have made donations, but these are in the millions whereas Sri Lanka requires billions if it is to come out of its vicious cycle of a dollar shortage.
There was much anticipation that the appointment of Prime Minister Ranil Wickremesinghe would bring in the billions that are desperately needed by the country if it is to obtain the fuel, food and medicines to keep the people healthy and the economy moving. But things have not worked out in this manner. The pickings have been slim and sparse. The IMF has given the reasons after the ten day visit by its staff to Sri Lanka. They have specifically referred to “reducing corruption vulnerabilities” in their concluding statement at the end of their visit. The international community in the form of multilateral donors and Western governments have prioritized political stability and a corruption-free administration prior to providing Sri Lanka with the financial assistance it requires.
The pressing need in the country is for the government to show there is political stability and zero tolerance for corruption in dealing with the prevailing crisis. It is not enough for government leaders to give verbal assurances on these matters. There needs to be political arrangements that convince the international community, and the people of Sri Lanka, that the government is committed to this cause. Several foreign governments have said that they will consider larger scale assistance to Sri Lanka, once the IMF agreement is operational. So far the government has not been successful in convincing the international community that its own accountability systems are reliable. This is the main reason why the country is only obtaining millions in aid and not billions.
The draft 22nd Amendment that is now before the parliament (which will become the 21st Amendment should it be passed) would be a good place for the government to show its commitment. The cabinet has approved the draft which has three main sections, impacting upon the establishment of the constitutional council, the powers of the president and dual citizenship. However, the cabinet-approved draft is a far cry from what is proposed by the opposition political parties and civil society groups. It is watered down to the point of being ineffective. Indeed, it appears to be designed to fail as it is unlikely to gain the support of different political parties and factions within those parties whose support is necessary if the 2/3 majority is to be obtained.
In the first place, the draft constitutional amendment does not reduce the president’s power in any significant manner. The amendment is drafted in a way that the reduction of presidential powers will only occur with the next president. The president now in office, who has publicly admitted failure on his part, continues to be empowered to appoint and sack the prime minister and cabinet ministers at his arbitrary discretion. He is also empowered to appoint and dismiss the secretaries to ministries, who are the highest-ranking public service officials. In short, the executive arms of the government are obliged to do the president’s bidding or risk their jobs. This indicates the Prime Minister Ranil Wickremesinghe, whose party has only a single seat in parliament, has no independent strength, but is there at the will and pleasure of the president.
In the second instance, the draft amendment was expected to set up a system of checks and balances for accountability and anti-corruption purposes. The pioneering effort in this regard was the 17th Amendment of 2001 that made provisions for a constitutional council and independent commissions. According to it, the members of all state bodies tasked with accountability and anti-corruption functions, such as the Bribery and Corruption Commission, the Human Rights Commission, the Police Commission, the Public Service Commission and the appointees to the higher judiciary were to be appointed through the constitutional council. The 17th Amendment made provision for seven of the ten members of the constitutional council to be from civil society.
Unfortunately, in a manner designed to deal a death blow to the concept of checks and balances, the draft amendment sets up a constitutional council with the proportions in reverse to that of the 17th Amendment. It reveals a mindset in the political leadership that fears de-politicisation of decision making. Seven of the ten members will be appointed by the political parties and the president in a way in which the majority of members will be government appointees. Only three will be from civil society. This ensures a majority representation in the Council for government politicians, and the ensures government dominance over the political members. The composition of the constitutional council proposed in the Bill undermines the independence of the institutions to which appointments are made through the Council who will be unable to stem the wildly growing tide of corruption in the country.
It is no wonder that the furious people in the endless queues for petrol and diesel should believe that there is corruption at play in the continuing shortage of basic commodities. The government promised that ships would come in laden with fuel a week ago. Then, inexplicably, the information was disseminated that no ships were on the horizon. In any other country, except in a country like no other, the concerned leaders would have resigned. Due to the lack of fuel, perishable farm produce rots in rural farmhouses and markets in urban centres are empty and prices are rocketing up. In the meantime, the media has exposed rackets where the privileged, politically powerful and super rich, are given special access to fuel. It is patently clear that the government has failed to deliver on the results that were expected. The situation is getting worse in terms of corrupt practices.
To the credit of the Sri Lankan people, they are being patient. The bonds of social solidarity still prevail. But the anger at the self-seeking and incompetent political leaders is reaching the boiling point, as it did on 09 May. President Gotabaya Rajapaksa pledged to set up an interim government in consultation with party leaders in parliament. However, he did not do so but appointed UNP leader Ranil Wickremesinghe as Prime Minister and thereby ended efforts of other parliamentarians to form a national unity government. The president’s pledge, made in the aftermath of the cataclysmic and unexpected violence that took place that day, was to reduce his presidential powers, transfer those powers to parliament and to appoint an all-party and interim government of no more than 15 ministers. These pledges remain unfulfilled and need to be implemented to be followed by elections as soon as the situation stabilises.
Kehelgamuwa’s football skills and President Premadasa’s political sagacity
By Hema Arachi
T.B. Kehelgamuwa, the cricketer who needs no plaudits from anyone, is well known. He represented then Ceylon and, later, Sri Lanka as a fearsome fast bowler during the pre-Test era. His contemporaries still talk about Kehel with great respect. Once S Skanda Kumar, the well-known cricketer, cricket commentator and former High Commissioner for Sri Lanka to Australia, proudly told me about his playing cricket with Kehelgamuwa. Bandu Samarasinghe, a Sri Lanka film star, on a TV programme vividly demonstrated how he faced Kehelgamuwa in a Sara Trophy game. That was the top-level tournament in the country.
This note is to share my watching Kehelgamuwa playing soccer when he was not so young. Then, though his grey hair was visible, he ran fast and played hard like a teenager. This was during President Ranasinghe Premadasa’s tenure. Returning from The Netherlands, after my postgraduate studies, I lived in Pelawatta, near the Sri Lanka Parliament and my workplace – International Irrigation Management Institute headquarters. I used to enjoy walking on Parliament grounds. That day was unique because the game between the President’s soccer team, comprising parliamentarians, and the Sri Lanka Police team, was played there.
President Premadasa was well known for his political sagacity, especially in manipulating any situation in his favour. For instance, the day Anura Bandaranayake became the Opposition Leader, Premadasa, praised Anura stating, “Anura is the best Opposition Leader we have.” He further requested that Anura join the ruling party and become a minister and also marry a girl from a prominent ruling party family. But within weeks, he was critical of Anura. One day an Opposition member asked him, “You said Anura was our best Opposition leader a few weeks ago but now criticise.” His reply was this: “Yes, I said so because Anura is the best Opposition leader for us, the ruling party, not for the Opposition. For the Opposition, the best leader is Sarath Muththetuwegama!”
A few weeks before the scheduled encounter between the Parliamentarians and the Police football team, there was a game between the Parliamentarians and the Colombo Municipality team. Premadasa captained the Parliamentarians and kicked the winning goal. I remember a cartoon in a newspaper where the Municipality team goalkeeper withdrew so that Premadasa could score the goal at his will.
During the game against the Police, Premadasa did not play but visibly played the role of the coach of the Parliamentarian team. Unlike the Municipality players, the Police played the game seriously. Kehelgamuwa represented the Police team that scored five goals by halftime, and the Parliamentarian team was nil. At halftime, Premadasa replaced the Parliamentarian goalkeeper with Jayawickerama Perera. Yet, the Police team recorded a sound victory.
I thought Premadasa was upset due to this defeat for his team. But no. Premadasa claimed victory: “I am happy that my team won the game by beating the Parliamentarians today! Being the Executive President, I do not belong to the Parliament. However, as the Commander-in-Chief, the Police come under my purview, so my team won today!”
PM: Sri Lanka negotiating with IMF as a bankrupt nation
Save us from our govt.!
Challenges, and need for an all-party govt.
‘Dates have the highest sugar content to fight Coronavirus’
U.S. Congress to probe assets fleecing by US citizens of Sri Lankan origin
Sunday Island 27 December – Headlines
Features3 days ago
When will the Gang of Four be held accountable for their irresponsible decisions?
Business2 days ago
Young apparel entrepreneur offers ‘winning deal’ to Sri Lankan nationals living abroad
News4 days ago
Fuel crisis: Key CPC facility opened for VIPs, friends as public transport shrinks
News5 days ago
HRCSL: No prisoners were used in 09 May attacks on protesters
News4 days ago
Resignation of Prez, PM prerequisite for resolution of current crisis – Direction Sri Lanka
News2 days ago
Dr. Godahewa warns govt. over its IMF strategy
Features3 days ago
The Estate Appus – a dead or dying species?
News3 days ago
Cardinal appeals to Pope to solicit aid for Sri Lanka