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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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Kenya listed among Sub-Saharan Africa countries with high potential for Islamic Banking

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NAIROBI, Kenya, May 8 – Kenya has been listed as one of the countries with a high potential for Sharia Finance, an Islamic banking model with several restrictions and principles that do not exist in conventional banking like interest fees.

Middle East, Africa, India, and Jersey Finance Director Faizal Bhana said Sub-Saharan Africa’s share of global Sukuk issuances is only a mere 2 percent, despite an Islamic population of more than 200 million people.

Sukuk are financial products whose terms and structures comply with Islamic law, with the intention of creating returns like those of conventional fixed-income instruments like bonds.

“When you are coming to Africa, the story is very different. Africa is home to 250 million Muslims in Sub-Saharan Africa. At the moment, the penetration for Sharia compliance finance across the continent is 21 countries providing Islamic Finance services,” he said.

Speaking to Capital Business, he revealed that the Islamic Finance industry has a compound annual growth of 11 percent since 2006, with assets worth multi-trillion shillings.

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“We need to look to all forms of financing. And Sharia compliance financing is one form and because of its links like sustainability and ethical, for government, it is an easy win,” he said.

He said there is a need for regulators to provide enabling legislation for Sharia finance services and more so for sovereign and corporate issuance of Sukuk.

The common practices of Islamic finance and banking came into existence along with the foundation of Islam.

However, the establishment of formal Islamic finance occurred only in the 20th century.

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Currently, the Islamic finance sector grows at 15-25 percent per year, while Islamic financial institutions oversee over $2 trillion.

Islamic finance strictly complies with Sharia law. Contemporary Islamic finance is based on a number of prohibitions that are not always illegal in the countries where Islamic financial institutions are operating like paying or charging interest, investing in businesses involved in prohibited activities like gambling.

Due to the number of prohibitions set by Sharia, many conventional investment vehicles such as bonds, options, and derivatives are forbidden in Islamic finance.

The two major investment vehicles in Islamic finance are equities and fixed income instruments.

 

 

 

 

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CMA okays Crown Paints’ rights issue to fund expansion

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Crown Paints head of sales Bhavesh Gandhi and CEO Rakesh Rao during the company’s launch of all-weather paints at the Trademark Hotel, March 1, 2020. [David Gichuru, Standard]

The Capital Markets Authority (CMA) has given the nod to Crown Paints Kenya Plc to raise Sh711.80 million from shareholders via purchase of additional shares.

The regulator, in a statement yesterday, said it had approved the firm’s bid to issue and list 71,181,000 new ordinary shares on the Nairobi Security Exchange (NSE).

“The rights will be issued on the basis of one new ordinary share for every one existing share,” noted CMA.

The additional funds raised will boost the company’s financial flexibility to navigate through a tough business environment brought about by the Covid-19 pandemic.

It would also boost the firm’s growth strategy according to the information memorandum.

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“The group’s management plans to use the rights issue funds to facilitate the development of new products, retiring of current facilities and funding regional expansion,” CMA said in a statement.

Wyckliffe Shamiah, the CMA chief executive observed that the disclosures made on the rights issue comply with the capital markets regulations and will enable investors to make an informed decision.

Mr Shamiah noted that the regulator had reviewed the application for exemptions from complying with Regulation 4 of the Capital Markets (Take Over and Mergers) Regulations, 2002 concerning the intention of the company’s major shareholders, who have undertaken to take up their full rights entitlements.

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“They are also willing to take more than their initial entitlements subject to availability during the rights issue,” said Shamiah.

Crown Paints is expected to make bi-annual updates to CMA on the use of the proceeds of the rights issue.

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Branch buys local micro finance bank

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The deal gives Century Microfinance Bank a much-needed lifeline. [Courtesy]

Branch International Ltd has acquired microfinance lender Century Microfinance Bank in a move that gives the financial technology (fintech) firm a stronger presence in the country’s financial sector.

According to regulatory filings published by the Competition Authority of Kenya (CAK), Branch has acquired 84.89 per cent of the issued share capital in the microfinance bank.

The deal has been approved by the market regulator.

“The Competition Authority has authorised the proposed transaction as set out herein on condition that the acquirer and the target will each maintain the terms agreed with the borrowers in respect of all loans existing in their loan books at the time of the acquisition,” explained CAK in a notice in the Kenya Gazette.

The deal will further give Century Microfinance Bank a much-needed lifeline, coming in the wake of depressed earnings due to disruption from digital lenders and recently, the Covid-19 pandemic.

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According to Central Bank of Kenya (CBK) data, the micro-lender recorded Sh348 million in assets as of the end of December 2019, a 19 per cent drop from Sh431 million in 2018.

The firm also recorded Sh326 million in liabilities for the year ended December 2019 with customer deposits sitting at Sh256 million during the period under review. The lender made Sh82 million in total income in 2019, the majority of it from interest on loans, fees and commissions.

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Brach International, one of the leading fintech players in the Kenyan market has over the years increased its user base across the region to more than three million.

The firm says it has disbursed more than Sh35 billion in loans, the majority of which it lent to users in its African markets in Kenya, Nigeria and Tanzania. In 2019, Branch secured Sh17 billion in the new financing and a partnership with Visa to issue virtual pre-paid debit cards to its users.

The acquisition of Century Microfinance Bank will allow the fintech firm to deploy more solutions to grow its digital and physical foothold in the Kenyan market.

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