SIXTEEN years ago Nehmat Houssami wrote an article for the MJA about her journey as a child from Beirut in the late 1960s and early 1970s, to a burgeoning medical career in Australia as a breast clinician.
Today she is Professor of Public Health and a National Breast Cancer Foundation Research Leadership Fellow at the University of Sydney’s School of Public Health. She is also co-editor of The Breast.
Since 2003 Professor Houssami’s working life has progressively become less clinical and more focused on conducting research, though she maintains her breast cancer clinical work at the Royal Hospital for Women at Randwick.
“It keeps me close to what the clinical issues are, and what questions breast cancer patients are asking, and what women who are concerned about their risk of breast cancer are asking,” she tells the MJA.
Evidence gaps that she came across during her day-to-day practice sparked Professor Houssami’s initial interest in research.
“Sometimes good, relevant research isn't about doing the world's first study of this, or the world’s first study of that. It can be just looking at the evidence carefully and summarising conflicting evidence to be able to inform practice,” she says.
“For example, women who have early breast cancer will have the tumour removed … and then some will need a re-operation because when the cancer was excised, the tumour margins weren't clear, meaning there were tumour cells close to the surgical margin. The concern here is that if the margins aren’t adequately clear it could increase the likelihood of the cancer recurring in the breast.
“What both intrigued me and bothered me over the years, was that there was no agreement around the world about what would be an adequate or clear (“negative”) surgical margin. I have memories of sitting in congresses, listening to surgeons agree and disagree on whether 1mm, 2mm, 3mm, or 5mm wide clear margin was adequate,” she says.
“That bothered me because it meant that a woman had to go back for another operation. She had just got through one operation, and was already dealing with a lot of information about what additional treatments she might need.
“These seemingly little differences around tumour margin width were impacting women's treatments. And the reason there was such variability in surgical practice was because there was a lot of evidence accumulated over decades, but that evidence was heterogeneous, and no agreement could be reached.”
Professor Houssami saw the gap and, with funding from the NBCF, did a large meta-analysis of international studies which helped resolve the issue of surgical margins.
“In fact, several US clinical societies involved in breast cancer surgery invited me to work with them to develop consensus guidelines around surgical margins, and we have developed two guidelines on this issue since 2014,” she says.
“It's gratifying to see that there is now a level of consensus around the world on surgical margins. And certainly, there's some evidence now in the published literature that less women are having re-operations to obtain wider margins.”
These days Professor Houssami’s major research interest lies in diagnostics and imaging, particularly tomosynthesis. Her pilot study on digital breast tomosynthesis for population screening, done in collaboration with BreastScreen Victoria, is published in this issue of the MJA (insert page number here). She recently also established within the University’s Cancer Research Network, an Artificial Intelligence (AI) in cancer special interest group.
Professor Houssami was well into her medical training before she discovered that breast care was the direction in which she wanted to go.
“I had done some emergency medicine, even some orthopaedics. They didn’t leave me with a strong sense of what I really wanted to do,” she says. “When I was an intern, I had a brief time working on a ward with a small number of breast cancer patients. I thought maybe this was an area I could try to work in.”
She was still unsure when an opportunity came up to train at the Sydney Breast Clinic as a breast clinician.
“I didn’t necessarily have a clear idea about career directions, but I went with the opportunity to work in breast cancer diagnostic and screening. It was very engaging once I started.”
That idea of going where the opportunities lie is key, Professor Houssami says, to creating a satisfying career, “as long as you feel you can contribute through that opportunity”.
“Don't panic if you don't have that vision at the start of your career,” she tells the MJA.
“Having a medical degree is such a huge asset and can lead you in different directions. If you know what that direction is, follow your heart. But if you don't, go for the opportunities that come your way. Preferably draw on what interests you the most, but in addition to that, don't think that whatever career path you might choose at the beginning stays static.
“Things change. Adapt in response to new areas that are emerging, and that may be a new branch of medicine. It may be research, and it may be combinations of research and clinical work.”
Research is something Professor Houssami would encourage all students and junior doctors to think about taking on, or to explore at some point in their career.
“It’s not everyone’s cup of tea, and it’s very competitive,” she says. “But the point I'm making is that you don't have to do just one type of role. It can be hard juggling more than one role, or more than one area of work interest, but don't be afraid to take that on, or at least give it a try.”
From a childhood in Beirut, followed by migration at an early age to Australia, following her mother who came seeking medical treatment from renowned renal specialist Professor Priscilla Kincaid-Smith, Professor Houssami has never shied from taking big steps on tangential paths.
“I have been very fortunate,” she says. But it’s a fortune that comes from being willing to take her chances when they came.
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