Catching Cancer in Time

Women’s Personal Fight Against Cancer

A year ago, Astghik Zakaryan shared pictures of herself with no hair—after undergoing chemotherapy. She included the message, “I’m sharing something very personal for the first time… in the hopes that it might save someone else’s life, just like my life was saved by the example of another.

Several years ago, one of Zakaryan’s acquaintances discovered she had breast cancer. Fortunately, the treatment was successful and her life was saved, but barely. The ordeal scared Zakaryan. She diligently went for an annual mammogram for over ten years, bringing along her mother and sisters. Even though they felt healthy and did not have a history of cancer in their family, it was better to be safe than sorry. “It would only take ten minutes and would always result in, ‘You have no problem, goodbye,’” Zakaryan says. “That is, until the time came for a regular checkup in 2020.”

She remembers the date: July 22, 2020. It was the beginning of a very personal war. Tests confirmed that she had a malignant tumor, an aggressive type in the beginning stages, not yet metastasized.

After receiving 18 rounds of chemotherapy in six months, Zakaryan underwent surgery.

“They killed the tumor, then operated,” says Zakaryan, now 41. “I’m well now. I’m not even taking medication. I go for checkups every three months. I had cancer in one breast, and it was very small. But just to be sure that it won’t recur, they removed both my breasts and put in implants. I posted pictures after the surgery so that people can see my personal story and go in for regular checkups.”

Head of the Radiology Department at the Armenian-American Health Center Ani Hakobyan says that, even though women’s responsibilities leave little time to see a doctor, yearly examinations are necessary.

“Today’s modern technology allows us to see millimeter-level changes,” says Dr. Hakobyan, “It might be pre-cancerous or early-stage cancer, in which case chemotherapy and radiation can be avoided.”

She says that statistics from the early 2000s show that women went to the doctor quite late, in the third or fourth stages of cancer. Today, 40-50% of cancer cases in Armenia are diagnosed early on.

“In the initial stages, a minor surgery might be all that’s needed,” explains Dr. Hakobyan. “However, if it is allowed to grow, then the problems become more complex. Of course, treatments have advanced and improved outcomes, even during the third or fourth stages. But if it can be found in earlier stages, naturally the survival rate is higher.”

According to her, cancer is more commonly found in women over the age of 60, but mainly because they didn’t have a checkup earlier. The most vulnerable age group is actually 45-55. It is in this earlier age group that pre-cancerous and early-stage cancerous cells are most commonly found.

Gayane Arzumanyan, 40, found lumps under her arm in 2011. The doctor determined them to be cysts and not to worry about. Nevertheless, she consistently went in for annual checkups. In 2019, during her regular examination, they found a tumor in the pre-cancerous stage.

“I was both scared and hopeful at the same time,” Arzumanyan says. “I started reading books, Buddhist literature. I was trying to understand what death is. I was preparing myself by considering that everything doesn’t end with death. I even reached the notion that maybe the universe was giving me a chance to be born again and start anew. The next week, they did a biopsy, and I was waiting for the results. It was awful. Despair and hope were fighting within me.”

She says they found the tumor in November 2019 and operated on it the next month.

“It’s vital that you have faith in your doctor,” says Arzumanyan. “When I saw her, I felt inner confidence. After the surgery, I went through radiation treatment for four weeks. After the last round of chemoradiation [concurrent chemotherapy with radiation treatment], my doctor told me I was healthy. Now I go for an ultrasound every six months and a mammogram every year. Honestly, I don’t want to remember what I went through; I’m scared it might come back. At every checkup, you hope they won’t tell you that the results were positive again. If I hadn’t gone to the doctor as early as I did, I don’t know what would await me. There’s a type of woman who says ‘Don’t think about it, it will pass.’ But our body can’t always fight off every illness on its own.”

According to specialists, breast cancer is becoming more common in younger women. Dr. Ani Hakobyan explains that this is a global phenomenon:

“The breast is an organ that is regulated by hormones, and it is very susceptible to hormonal changes,” she says. “This is because women go through many hormonal ups and downs in their life. In this case, the breast is considered a target organ. These effects lead to prostate cancer in men and breast cancer in women.”

Breast cancer can be found in women who have had multiple children, women who have never given birth, and women who have breastfed. However, there are some factors that can contribute to the disease.

“It’s a welcome fact that women want to work, find their footing, and then get married. However, the fact remains that the risk for cancer increases if a woman does not give birth before the age of 30,” explains Dr. Hakobyan. “This means the risk drops if she gives birth for the first time before 30, or if she has several children before the age of 35.” She adds that women become more vulnerable when hormonal or contraceptive medication is not taken correctly, when they have abortions or miscarriages, or go through trauma and stress.

Dr. Hakobyan painfully states that, after the 2020 Artsakh War, many women who lost their sons discovered they had cancer. “Cases of mastopathy have suddenly increased,” she says. “We saw that immediately.”

A “Good” Cancer

In 2011, Armenia’s government approved a Strategic Plan for Tumor Prevention. Also, the Disease Prevention and Control Program, implemented jointly with the World Bank, has been in effect since January 2015. This program allows women to receive cervical screening tests for free at public polyclinics in order to catch cervical cancer early on and prevent it. The human papillomavirus (HPV) vaccine has also been available since December 2017 with the same goal. HPV infection is the main cause of cervical cancer.

Dr. Marina Voskanyan, Head of the Gynecology Department at the Armenian-American Health Center, states that cervical cancer is the fourth-most widespread type of cancer, after breast cancer, around the world. Despite the fact that cervical cancer can be easily diagnosed and treated, women in Armenia continue to die from it.

“Any oncological disease has its dormant period, when there are no symptoms. When the symptoms begin, it’s already in the developmental stage,” says Dr. Voskanyan. “You can prevent [cervical cancer] by giving a Pap smear. This test can detect any change within the cervix, from no change to the most aggressive stage of cancerous cells.”

According to her, if a woman gives nine Pap smears within her life, they can prevent cervical cancer from developing 99% of the time. She says that, during the past several years, the number of identified cervical pre-cancerous tumors has increased, which is actually a good indicator. It means that women are getting checkups before symptoms appear, during the pre-cancerous stage.

“I always say that cervical cancer is one of the ‘good’ cancers, which can be diagnosed at the pre-cancerous stage,” says Dr. Voskanyan. “The increase in diagnoses at this stage is connected to the increase in women going in for checkups. This culture is [i.e. social norms in Armenia are] changing quite a lot.”

Screening Programs are Saving Lives

In 2020, a free screening program was initiated for citizens over 45 at the Viktor Fanarjian National Center of Oncology. Of the 699 patients who were examined, 81 were diagnosed with colon cancer and 159 with benign tumors within the colon. According to the Center’s Director Dr. Narek Manukyan, in some cases, the tumors were removed with a colonoscopy.

“We also removed pre-cancerous tumors with endoscopic means, thus avoiding major surgeries and chemotherapy,” says Dr. Manukyan. “The Ministry of Health will be implementing a free screening program again, which will take place at our center and at another health institution. In general, screening programs are very important in modern oncology. Screening tests allow us to find the tumor when the patient has no symptoms.”

Dr. Manukyan emphasized the fact that, in terms of cost-effectiveness, screening tests are much cheaper for the state than further treatment for the disease.

A year ago, the state initiated a free screening program for breast cancer in the Lori region. Of the 770 women who had mammograms, 80 were diagnosed with cancer at a stage where surgery was necessary.

“The next is Syunik,” says Dr. Manukyan. “Screening tests save so many human lives.”

Armenians Don’t Like Going to the Doctor

Dr. Narek Manukyan says that going to the doctor for regular screening, even in the absence of symptoms, is normal practice around the world. Meanwhile, in Armenia, there is an aversion to going for a checkup, even during the initial stages of a health problem.

“A person might have pain in their abdomen for two years, stubbornly thinking that it will go away on its own. Then they discover they have stage 4 colon cancer,” he says. “In the first and second stages, the chances of being cured are definitely high. Even if they’re not completely cured, their life expectancy will be extended.”

Dr. Manukyan explains that the primary goal of modern oncology is to cure the cancer completely. However, if treatment results are not inadequate, then they try to at least extend the life. With stage 4 colon cancer, even that may not be possible.

Dr. Manukyan has noticed that, even though many women have started to go to the doctor earlier for screening, there is still more progress to be made.

“It’s positive that more people are going in for annual checkups,” he says. “More tumors are discovered during the early stages—first and second stage—and all our efforts are aimed at raising public awareness.”

According to 2020 data from Armenia’s National Institute of Health, there were 50,416 cancer patients in the country. In 2020, 6,934 people were diagnosed with cancer for the first time, most of them over the age of 50. The total number of deaths from cancer was 5,300. Data for 2021 is still being collected.

According to experts, the number of cancer diagnoses is rising sharply, especially for those over 35. While women are encountering higher levels of breast, cervical and ovarian cancer, men are being diagnosed more with tracheal, bronchial, lung, bladder and prostate cancer. Colorectal cancer has also risen significantly (including colon cancer, rectal cancer and bowel cancer), a trend connected to sedentary lifestyles and unhealthy eating habits.

The Root Cause of Prostate Cancer is Untreated Infections

Deputy Director of the Fanarjian National Center of Oncology Aleksandr Seinyan says the main reason behind the large number of prostate cancer cases is untreated infections.

“When people don’t take symptoms seriously, it can lead to cancer,” Dr. Seinyan explains. “An adenoma develops, which is a benign tumor that can later turn into cancer. We advise men to get an examination and a PSA [prostate-specific antigen] test at least once a year after the age of 45.”

Dr. Seinyan states that this type of cancer is often diagnosed during its second stage, but some elderly patients don’t see a doctor until they’re already in stage 4.

“At stage 3, the odds of beating it are quite good, especially if the prostate is completely removed,” he says. “We’re getting pretty good results.”

However, Dr. Seinyan says that the disease is appearing in younger patients, those aged 40-45. “Young people have started to pay more attention to themselves,” he explains. “They’re getting examined even for a small issue. It’s better that they come in, and we rule it out.”

Dr. Seinyan also specializes in soft tissue sarcoma and bone cancer. At the Center of Oncology, patients with both malignant and benign tumors of the bones and soft tissues are treated in the Bone Oncology Department. Every year, around 200 surgeries take place.

“Bone cancer makes up 2% of all cancer cases, while soft tissue sarcoma makes up 2-3%,” he says. “These pathologies make up about 5-5.5% of cancer cases in general. People get sick with malignant bone tumors before they turn 18 or 20. Last year, I had more than ten child patients. There have been times that we’ve had one to two patients within a year.”

Pediatric Oncology

Pediatric cancer is considered a rare pathology, both in Armenia and worldwide. Lilit Sargsyan is the Head of the Pediatric Oncology Department at the Pediatric Cancer and Blood Disorders Center of Armenia and a lecturer at the Oncology Department at Yerevan State Medical University. She says that Armenia’s statistics are in line with the rest of the world.

“In Armenia, every year, 80-100 children under 18 are diagnosed with cancer for the first time,” she explains. “Leukemia and solid tumors make up around 40% of these cases. The number of solid tumors in children is at 40-50 per year, the majority of which are tumors of the central nervous system, sarcomas and kidney tumors.”

Dr. Sargsyan states that recently they’ve had many children from Artsakh. Currently, they are preparing to study impacts of war on cancer.

“War induces prolonged chronic stress, which of course leaves its mark,” she says. “With our study, we are trying to figure out if the number of cancer cases has risen or not after the [2020] war. All around the world, it is well known that poor living conditions and chronic stress can deplete a person’s immune system, which can lead to the development of cancer.”

According to Dr. Sargsyan, it is not clear what causes pediatric cancer, and there aren’t any screening programs for predicting and preventing pediatric cancer. Their current patients include a two-week old infant who was diagnosed with cancer during gestation, a six-month-old, and a seventeen-year-old. Dr. Sargsyan says that pediatric oncologists should be assisted by primary care physicians who look out for warning signs.

“Let’s say a child has pain in the abdomen. They shouldn’t examine them for months, but instead send them immediately to our experts,” says Dr. Sargsyan. “The earlier we can diagnose, the better our treatment results will be. We’ve witnessed many incidents where we were too late, and this is the main reason [that a patient can’t be saved].”

She says the most important factor is getting an early diagnosis: “When a tumor is diagnosed in the ‘local’ stage—when it has not yet metastasized—there is a 70% chance of beating it. But if that same tumor was diagnosed at stage 3 or 4—when it has metastasized and spread—the odds drop to 7-10%, sometimes even less.”

According to Dr. Sargsyan, until 1995, only 3% of child cancer patients in Armenia were able to be cured. Today that figure is at 75-80%. She considers this an absolute revolution in pediatric oncology.

The State and the Private Sector are Helping Cover Treatment Costs

Costs for cancer surgery for patients from low-income families used to be partially covered by the state. However, in 2019, cancer surgery fell under a full state benefit package based on a patient’s social status.

Radiation therapy is partially covered. Those diagnosed with malignant tumors who are not considered socially vulnerable or part of special groups are treated with radiation therapy in which case they pay only half of the radiation treatment costs, while the other half is covered by the state. However, if the tumor is benign, then the patient has to pay the full radiation therapy costs, if they choose to go ahead with treatment. Meanwhile, those who are considered socially vulnerable or have another special classification can have their radiation therapy completely covered by the state, whether the tumor is benign or malignant.

There are also foundations that have made their own contribution to this expensive treatment process. The biggest one is the City of Smile Foundation. It supports the medical costs of children and adults under 25 who have cancer or a blood disease, starting from the first diagnosis.

“The state also provides great support, but it doesn’t have the resources, not even the richest states do,” says Dr. Sargsyan. “There are pathologies that are more low-cost, and there are pathologies, for example sarcomas, that require treatments that cost $1,000 per child.”

She states that pediatric oncology in Armenia has advanced to international standards. However, of course, there are still cases when parents consider treating their children abroad. Dr. Sargysan explains that their center’s expert group of doctors determines whether a child needs to go through a given stage of treatment abroad, if it is objectively not available in Armenia.

“We explain to the parents in detail if it’s possible to get that treatment in Armenia as well,” she says. “However, there are no legal levers that can be used to influence parents. They say, ‘We want our child to get treated abroad; we’ll raise money and take them’ But in reality, they are getting in the way. We are fighting for a just process so that those children who really need to can go, not those children that can receive the same treatment in Armenia without spending a penny.”

Dr. Sargsyan states that one or two children leave Armenia yearly and receive 99% of their treatment abroad. “The number of children that get cured is higher than those who don’t,” she says. “And this helps us work in this difficult field.”

Raw & Unfiltered 

Photo stories by Vaghinak Ghazaryan 

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