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For elderly women with breast cancer, surgery may not be the best option

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Health & Fitness

PHOTO | NEW YORK TIMES 

Annie Krause moved into a nursing home in Detroit in 2015, when she was 98 years old. She had grown frail. Arthritis, recurrent infections and hypertension had made it difficult for her to manage on her own.

When the facility’s doctor examined her, he found a mass in Krause’s breast and recommended a biopsy — standard procedure to determine what sort of tumour this was and, if it proved malignant, what treatment to pursue. Once diagnosed, breast cancer almost always leads to surgery, even in older women.

“If she were a passive person, she would have had a lumpectomy,” said Krause’s granddaughter, Dr Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston. “But my grandmother was very strong-willed. She said no, no, no, she didn’t want any procedure.”

That didn’t stop the doctor from recommending a biopsy, however.

Having spent years studying how best to inform older women about breast cancer, Schonberg said that patients’ decisions — about screenings and treatments — have proved stubbornly resistant to change.

She told me about her family’s situation in the wake of a recent study by researchers at the University of California San Francisco. Published in JAMA Surgery, it followed nearly 6,000 nursing home residents who underwent inpatient breast cancer surgery over a 10-year period.

It’s the most common cancer operation for nursing home residents, the researchers reported. Yet Medicare data showed that as a group, these women did not fare well.

“The trajectories for these patients tends to be poor to begin with,” said Dr Victoria Tang, a geriatrician and the study’s lead author. Almost by definition, women in nursing homes have serious health problems that already portend limited life expectancies.

The women in the study (average age 82) had high rates of diabetes, arthritis, heart failure and stroke. They needed considerable help with everyday tasks. Well over half were cognitively impaired.

Yet their surgeons tended to operate aggressively. Though about 11 per cent had a lumpectomy, more than a quarter underwent a mastectomy, removal of the entire breast. In more than 60 per cent, surgeons also removed underarm lymph nodes, a procedure usually conducted to help determine future treatment, but one that can cause pain and infection, with arm swelling that hampers mobility.

In younger and healthier groups, breast cancer surgery is considered low risk. “A lumpectomy is seen as routine, no big deal,” Tang said. “It can be done as an outpatient.”

But for these women, “the surgical treatment for breast cancer may have been worse than the breast cancer itself,” said Dr Rita Mukhtar, a breast cancer surgeon and a co-author of the study.

Within a month after surgery, 2 to 8 per cent of the patients in the study had died, a very high mortality rate. Those undergoing lumpectomy — perhaps, the authors hypothesize, because those women were sicker and deemed less likely to survive more invasive surgery — were most likely to die.

Surgeons and hospitals (and Medicare) pay close attention to the 30-day mortality rate, but most patients and families expect more, months or years of extended life in exchange for the rigors of surgery.

But within a year, 29 to 41 per cent of these patients had died, depending on the type of surgery they’d had — another very high mortality rate.

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Of those who survived a year, about 60 per cent experienced a decline in function. “A lymph node dissection might disable you and leave you in pain, so you’re less able to dress or bathe or even feed yourself, Tang said.

Of course, nursing home residents do decline and die, with or without surgery. But that, Mukhtar said, was the point.

“We’re taking people who are more likely to die of something else, and putting them through hospitalization and surgery, with all those risks,” she said, citing those including infection, falls and delirium. “By operating on them, we may be diminishing their quality of life for their remaining days.”

Given a clearer sense of the risks, patients and families might opt for less invasive treatments. Hormone therapy, like tamoxifen or aromatase inhibitors taken orally, slows the progression of certain kinds of tumors. Radiation may also control tumors, with fewer dangers than surgery.

In cases where a tumour grows through the skin and causes pain or bleeding, of course, surgery becomes a palliative response.

But it takes more than 10 years after screening to prevent a single breast cancer death for 1,000 patients screened, if they’re of average risk. So researchers say mammograms (and colon cancer screening, which involves a similar time lag) are most useful for those with life expectancies greater than a decade.

Few women in nursing homes will live that long. Many who develop breast cancer will experience no symptoms, and would never have known they had it without a physical exam or continuing mammograms.

Like any test or procedure, mammography involves risks: additional screenings, biopsies, complications of biopsies and treatment, and the anxiety the whole process creates.

The US Preventive Services Task Force doesn’t recommend mammograms for women over 75 because there’s insufficient evidence to assess benefits and harms. Older women have largely been excluded from clinical trials.

Since many older women have been dutifully having mammograms for decades anyway, Schonberg developed a brochure called “Should I Continue Getting Mammograms?”

It explains procedures, helps women assess relevant health factors and points out that over age 75, screening 1,000 women prevents only one breast cancer death over five years, while generating 100 false positives. (There’s also a version for women over 85.)

Distributing the brochure to 45 women, Schonberg determined that it had some impact. After using it, women were more knowledgeable and more likely to discuss the decision with their doctors. Yet 60 per cent still had another mammogram

She has since completed a broader study, being prepared for publication, involving 541 women over 75. Here, too, preliminary results show that the proportion who had another mammogram dropped only slightly after using the brochure, from 61 to 56 percent — a modest drop that demonstrates women’s reluctance to discontinue screening.

These subjects were not nursing home residents, and it might make sense for them to use other yardsticks besides age in their decision-making.

Mukhtar has performed breast cancer surgery on patients in their 50s and 60s, for instance, who had serious medical problems beforehand, leading to troubling complications afterward. But she also operated on healthy patients in their 80s who recovered well.

Nursing home residents are already in poor health, however. “It’s likely the surgery didn’t help them live longer, and certainly not better,” Schonberg said.

As for her grandmother, Annie Krause, she declined the biopsy and Schonberg supported her decision.

“In a 98-year-old, it probably is breast cancer,” Schonberg said. “But she didn’t want any more medical interventions. She was focused on optimizing her quality of life.”

Krause died two years later, after a stroke.



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BCCI: The bank ‘that would bribe God’

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Bank of Credit and Commerce International. August 1991. [File, Standard]

“This bank would bribe God.” These words of a former employee of the disgraced Bank of Credit and Commerce International (BCCI) sum up one of the most rotten global financial institutions.

BCCI pitched itself as a top bank for the Third World, but its spectacular collapse would reveal a web of transnational corruption and a playground for dictators, drug lords and terrorists.

It was one of the largest banks cutting across 69 countries and its aftermath would cause despair to innocent depositors, including Kenyans.

BCCI, which had $20 billion (Sh2.1 trillion in today’s exchange rate) assets globally, was revealed to have lost more than its entire capital.

The bank was founded in 1972 by the crafty Pakistani banker Agha Hasan Abedi.

He was loved in his homeland for his charitable acts but would go on to break every rule known to God and man.

In 1991, the Bank of England (BoE) froze its assets, citing large-scale fraud running for several years. This would see the bank cease operations in multiple countries. The Luxembourg-based BCCI was 77 per cent owned by the Gulf Emirate of Abu Dhabi.  

BoE investigations had unearthed laundering of drugs money, terrorism financing and the bank boasted of having high-profile customers such as Panama’s former strongman Manual Noriega as customers.

The Standard, quoting “highly placed” sources reported that Abu Dhabi ruler Sheikh Zayed Sultan would act as guarantor to protect the savings of Kenyan depositors.

The bank had five branches countrywide and panic had gripped depositors on the state of their money.

Central Bank of Kenya (CBK) would then move to appoint a manager to oversee the operations of the BCCI operations in Kenya.

It sent statements assuring depositors that their money was safe.

The Standard reported that the Sheikh would be approaching the Kenyan and other regional subsidiaries of the bank to urge them to maintain operations and assure them of his personal support.

It was said that contact between CBK and Abu Dhabi was “likely.”

This came as the British Ambassador to the UAE Graham Burton implored the gulf state to help compensate Britons, and the Indian government also took similar steps.

The collapse of BCCI was, however, not expect to badly hit the Kenyan banking system. This was during the sleazy 1990s when Kenya’s banking system was badly tested. It was the era of high graft and “political banks,” where the institutions fraudulently lent to firms belonging or connected to politicians, who were sometimes also shareholders.

And even though the impact was expected to be minimal, it was projected that a significant number of depositors would transfer funds from Asian and Arab banks to other local institutions.

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“Confidence in Arab banking has taken a serious knock,” the “highly placed” source told The Standard.

BCCI didn’t go down without a fight. It accused the British government of a conspiracy to bring down the Pakistani-run bank.  The Sheikh was said to be furious and would later engage in a protracted legal battle with the British.

“It looks to us like a Western plot to eliminate a successful Muslim-run Third World Bank. We know that it often acted unethically. But that is no excuse for putting it out of business, especially as the Sultan of Abu Dhabi had agreed to a restructuring plan,” said a spokesperson for British Asians.

A CBK statement signed by then-Deputy Governor Wanjohi Murithi said it was keenly monitoring affairs of the mother bank and would go to lengths to protect Kenyan depositors.

“In this respect, the CBK has sought and obtained the assurance of the branch’s management that the interests of depositors are not put at risk by the difficulties facing the parent company and that the bank will meet any withdrawal instructions by depositors in the normal course of business,” said Mr Murithi.

CBK added that it had maintained surveillance of the local branch and was satisfied with its solvency and liquidity.

This was meant to stop Kenyans from making panic withdrawals.

For instance, armed policemen would be deployed at the bank’s Nairobi branch on Koinange Street after the bank had announced it would shut its Kenyan operations.

In Britain, thousands of businesses owned by British Asians were on the verge of financial ruin following the closure of BCCI.

Their firms held almost half of the 120,000 bank accounts registered with BCCI in Britain. 

The African Development Bank was also not spared from this mess, with the bulk of its funds deposited and BCCI and stood to lose every coin.

Criminal culture

In Britain, local authorities from Scotland to the Channel Islands are said to have lost over £100 million (Sh15.2 billion in today’s exchange rate).

The biggest puzzle remained how BCCI was allowed by BoE and other monetary regulation authorities globally to reach such levels of fraudulence.

This was despite the bank being under tight watch owing to the conviction of some of its executives on narcotics laundering charges in the US.

Coast politician, the late Shariff Nassir, would claim that five primary schools in Mombasa lost nearly Sh1 million and appealed to then Education Minister George Saitoti to help recover the savings. Then BoE Governor Robin Leigh-Pemberton condemned it as so deeply immersed in fraud that rescue or recovery – at least in Britain – was out of the question.

“The culture of the bank is criminal,” he said. The bank was revealed to have targeted the Third World and had created several “institutional devices” to promote its operations in developing countries.

These included the Third World Foundation for Social and Economic Studies, a British-registered charity.

“It allowed it to cultivate high-level contacts among international statesmen,” reported The Observer, a British newspaper.

BCCI also arranged an annual Third World lecture and a Third World prize endowment fund of about $10 million (Sh1 billion in today’s exchange rate).

Winners of the annual prize had included Nelson Mandela (1985), sir Bob Geldof (1986) and Archbishop Desmond Tutu (1989).

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East Africa celebrates top women in banking and finance

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The Angaza Awards for Women to watch in Banking and Finance in East Africa took place Online via Zoom on 8th June 2021.

The event was set to celebrate the top 10 women shaping banking and finance across East Africa. The 2021 Angaza Awards, which will be a Pan-African Awards program, was also announced at the event.

Key speakers at this webinar were Dr Nancy Onyango, Director of Internal Audit and Inspection at the IMF; and Gail Evans, New York Times Best Selling Author of Play Like a Man, Win Like a Woman and former White House Aide and CNN Executive Vice President.

Dr Nancy Onyango advised women to deep expertise in their fields, spend time in forums and link with key players in that sector.
“Gain exposure with other cultures by seeking for employment overseas and use customized CV for each job application,” said Dr Onyango.

According to Gail Evans, women should show up and be fully present in meetings and not be preoccupied with other issues.
“Be simple and avoid jargon. Multi-tasking only means that you are mediocre Smart people ask good questions in a business meeting. Most women face drawbacks due to perfectionism, procrastination and fear of failure, said Evans.

She advised women to play like a man and win like a woman, be strategic, and intentionally make their moves to get to the top.

“For us to pull up businesses that have been affected by effects of COVID-19 pandemic, we need to re-invent business models, change the product offering and make more use of digital platforms,” said Mary Wamae Equity Group Executive Director.

Mary Wamae emerged top at the inaugural Angaza awards( East Africa) ahead of other finalists.

While women continue to excel in banking and finance, the number of that occupies top executive positions is still less.

“There is a gap for women occupying C suite level and it continues to widen in the finance sector. At entry level, there is still an experience gap for women,” said Nkirote Mworia, Group Secretary for UAP-Old Mutual Group.

She said that at the Middle Management level, women do not express their ambition. For this reason, UAP-Old Mutual has developed an executive sponsorship program to help women get to the next level.

Mworia added that most women hold the notion that top positions in management have politics and pressure.
“One needs leadership skills and not technical expertise to get to the top,” said Mworia.

According to Catherine Karimi, Chief Executive Officer and Principal Officer of APA Life Assurance Company, women need to focus on the strengths and natural abilities that they already have.

“Take risks and raise your hand to get to the high table. Find mentors along the way and develop your own brand and not compare yourself with others Focus on your strengths because it will make you move faster in the career ladder,” said Karimi.

Lina Mukashyaka Higiro, a Rwandan businesswoman and chief executive officer of the NCBA Bank Rwanda since July 2018, has three lessons for women who want to excel in banking and finance.
“Always spend at least 20 minutes each day reading, seeking genuine feedback from other staff members and widen your network,” Higiro told the webinar.

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Women picked for Angaza awards

Mary Wamae, Executive Director, led this year’s Top 10 Women in Angaza Awards, Equity Group (Kenya)(2)Catherine Karimi, Chief Executive Officer, APA Life Insurance Company (Kenya)(3)Lina Higiro, Chief Executive Officer, NCBA Bank (Rwanda)(4)Elizabeth Wasunna Ochwa, Business Banking Director, Absa Bank (Kenya)(5)Joanita Jaggwe, Country Head of Risk and Compliance, KCB Group (South Sudan)(6) Millicent Omukaga, Technical Assistance Expert on Inclusive Finance, African Development Bank (Kenya)(7)Emmanuella Nzahabonimana, Head of Information Technology, KCB Group (Rwanda)(8)Judith Sidi Odhiambo, Group Head of Corporate Affairs, KCB Group (Kenya)(9)Rosemary Ngure, ESG & Impact Manager, Catalyst Principal Partners (Kenya) and(10)Pooja Bhatt, Co-Founder, QuantaRisk and QuantaInsure (Kenya).

The Kenyan Wallstreet, a financial media firm, partnered with Kaleidoscope Consultants to raise awareness of seasoned women shaping and influencing the sector through their organizations.

The Angaza Award criteria included assessing the applicants’ area of responsibility and contribution to firm performance. Professionals in Banking, Capital Markets, Insurance, Investment Banking, Fintech, Fund Management, Microfinance, and SACCOs were invited to submit their applications or nominations via the Kenyan Wallstreet Award Web page.

ALSO READ: Angaza Awards Top Finalist; Mary Wangari Wamae

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IFC in New Partnership to Develop Affordable Housing in Mombasa County

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NAIROBI, Kenya, Jun 14 – International Finance Corporation, a member of the World Bank Group, has signed a new deal in support of affordable housing in Kenya.

The corporation has partnered with Belco Realty LLP, to develop a mixed use affordable living complex that will consist of 1,379 residential units and over 4,500 square meters of retail and commercial spaces in Kongowea, Mombasa County.

Together with the Kenyan firm, IFC says the partnership will help meet surging demand for housing in Kenya.

Under the agreement, IFC will help identify suitable international strategic partners to invest equity of up to $12 million, or Sh1.3 billion in Belco and to provide the company with the necessary technical support to develop the project.

The development, known as Kongowea Village, will be developed to foster inclusive and affordable community living within the city.

Jumoke Jagun-Dokunmu, IFC’s Regional Director for Eastern Africa says the project, which will be located on eight acres within the heart of Mombasa city, will aim to be a catalyst for wider city regeneration.

The project will be developed to meet IFC EDGE certification requirements and will incorporate the latest technologies in passive cooling, energy efficiency and water conservation to support sustainable urbanization.

 Kongowea Village is expected to create 1,160 jobs and business opportunities during the three-year construction period and many more after completion of the project within the themed retail arcade.

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 “Access to quality housing is a growing problem in Kenya and across Africa,” said Jumoke Jagun-Dokunmu, IFC’s Regional Director for Eastern Africa.

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“Developers often target the high end of the market, but this project is aimed squarely at the lower-income bracket. Helping Belco identify the right partners for this project is expected to attract more developers to Kenya and other parts of Africa to help meet rising demand for housing.”

 IFC‘s engagement with Belco will help Kenya support its rapidly growing and urbanizing population by increasing access to affordable housing. The problem is similar across most of Africa, where population growth and demand for quality housing are combining to outstrip supply.  We are pleased to partner with a company such as Belco that is committed to contributing to solving this challenge,” said Emmanuel Nyirinkindi, IFC‘s Director for Transaction Advisory Services.

 IFC’s partnership with Belco is part of its broader strategy to support better access to affordable housing in Kenya.

In 2020, IFC invested $2 million in equity in the Kenya Mortgage Refinance Company (KMRC) to help increase access to affordable mortgages and support home ownership in the country.

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