Written by Jodi Grahl, Program Director

After a lengthy COVID-imposed hiatus, we resumed our in-person partnership with the Oncological Institute of Eastern Bolivia this month. The Institute’s mission is to treat the most challenging cancer illnesses in Bolivia’s low-income population, making them a perfect partner for us.

The goal of our trip was to support the advancement of the surgical capacities of the Institute’s physicians by providing specialized training and filling essential surgical equipment and supply needs. But we also traveled to the Cancer Institute to support our Bolivian partners and their patients in less-measurable but equally important ways—to share the burden, albeit for just one week, of the ups and downs of cancer care.

A patient’s mother and sister are all smiles with missioners Dr. Malcolm Bilimoria and P.A.. Allison Soward (in blue), and Bolivian surgeon Dr. Susan Aviles (in yellow), upon the news of a successful surgery.

Our methodology for expanding the capacity of local professionals involves working alongside them in the management of surgically treatable cases. While doing so, our visiting team members and their local counterparts each contribute their unique skills and knowledge, nurturing everyone’s professional growth. Given the specialty of our lead team surgeon, Dr. Malcolm Bilimoria, director of the Illinois Center for Pancreatic and Hepatobiliary Diseases at Northwest Community Hospital, our hosts had identified patients with suspected or confirmed gastric, liver, duodenal, gallbladder and pancreatic cancers to be part of the mission week. The U.S.-Bolivian team dedicated their first day together to reviewing each case. Chief Resident Dr. Cecilia Padilla walked us through each patient's history, including laboratory tests and images. None were “simple cases” – and none had a guaranteed good outcome. But in each case we had reason to hope that surgery could rid the patient of their cancerous tumors and/or relieve pain and extend their lives and wellbeing.

After attending to one emergency case on Monday, we developed tentative plans for seven additional patients. Our hosts had been unable to offer the needed operations largely because they did not have the optimal equipment and supplies, much of which we had carried with us. Or the procedures were especially complex, and none of the local surgeons had the experience to attempt them alone.

Over the following days, Dr. Bilimoria operated primarily with Dr. Susan Aviles, a young but highly-skilled surgeon. They were assisted by various residents including Dr. Alejandro Gutierrez, Dr. José Luis Quispe, and others. Other residents provided anesthesia and pain management care carefully overseen by U.S. anesthesiologist Dr. Nabeel Khan and his Bolivian counterpart Dr. Karoline Rocabado and others. In each case, medical students and residents stood on step stools around the O.R. table, craning to follow the painstaking process of resecting cancerous tissue. Our two U.S. Physician Assistants, Allison Soward and Stephanie Morup, assisted with the full spectrum of care while exchanging knowledge about specialized surgical supplies, patient care protocols, and other topics with the dozens of Bolivian doctors, nurses, techs, and students who assisted in and shadowed the week’s activities.

Four exceptionally challenging but ultimately successful surgeries on Tuesday and Wednesday boosted our morale as the week progressed. But we were quickly brought back to the reality of cancer care when Malcolm and Susan discovered Thursday’s case was inoperable. Although the patient had undergone CT imaging, the extensive spread of his cancerous tumors was only visible once the surgeons had begun. They used the opportunity to demonstrate the resulting protocols to implement in such cases, and then proceeded to close the incisions. Just a half hour earlier, I had reassured the family they could get breakfast since the surgery could take hours. They sensed something was off when we summoned them so soon and ushered them into a side room. Malcolm and Susan explained to the 54-year-old patient’s wife and daughter why they could not remove his tumors; attempting to do so would only hasten his death by destroying his vital organs. We stood with them in the mid-day Santa Cruz heat and humidity while they tried to make sense of what we were saying; although the doctors were able to take a sample of the tumors to identify potential chemotherapy treatment to slow the cancer, their husband and father likely had only months to live.

Upgraded imaging technology has improved cancer diagnosis at Santa Cruz’s Oncological Institute since our first visit in 2018. Unfortunately, tumors may elude even the best imaging, contributing to unexpected outcomes in some surgeries as in one of our mission trip cases.

After leaving the family with mission chaplain Ted Johnson and Puente de Solidaridad team members Carmen Salses and Marcela Canedo, we faced another grueling ordeal. Our next scheduled patient was a 49-year-old woman with liver cancer, but her pre-op labs that morning indicated her cancer was too advanced for surgery. Her doctor explained that, after she met with the pain management and palliative care teams, she could go home to spend her remaining time with her family. I was dumbstruck when she asked them to hurry her discharge paperwork so she could leave her bed for another patient; indeed, the hospital has a waiting list for its limited rooms. As we left the patient ward, Malcolm turned to the rest of us and reflected, “this is oncology,” referring to the roller coaster of high moments—like those over the previous three days of promising surgical outcomes—followed by Thursday’s devastating news.

Missioner Ted Johnson and Puente de Solidaridad staff Marcela Canedo and Carmen Salses maintained vigil outside the OR to accompany patients and families, both those operated by our joint team and other patients of the Oncological Institute.

After that difficult day, we began our final surgery on Friday knowing it could go either way. Our patient was another 54-year-old, this time a mother of six children. She had advanced stomach cancer, and on Monday we had not been sure she could withstand an operation given her severe anemia caused by internal bleeding. But a protocol of blood transfusions and high-protein supplements had improved her lab readings sufficiently to proceed. Malcolm explained to the family that her surgery would be challenging for any team operating anywhere in the world. But the patient was relatively young and determined to take the risk. We reserved the OR for the full day, assembled the best equipment and supplies available, and started early. Working methodically over five hours, Malcolm and Susan successfully removed the tumor and intricately reconstructed the patient’s digestive tract. Afterward, they told the family her surgery had gone as well as could possibly be hoped, and we were all delighted. The patient has a long recovery ahead of her, but ten days after her surgery she’s doing remarkably well in the very capable care of Dr. Aviles and the rest of the local professionals in Santa Cruz.

Through our Puente de Solidaridad team in Santa Cruz, we will continue to monitor the recovery and follow-up care of our mission trip patients. We are also planning continued training and mutually-educational exchanges through virtual encounters and case discussions over the coming months.

Thank you to all those who made this mission trip possible:

The Bolivian patients and families who not only entrusted us to participate in their care, but also allowed us to accompany them through their most difficult days,
the Puente de Solidaridad staff and volunteers who locally managed our mission trip from its earliest planning through to post-trip patient follow-up,
the administrative leadership and medical staff and volunteers at the Oncological Institute of Eastern Bolivia,
our medical supply and financial donors,
our U.S. mission team,
and the colleagues and families of our US team members who made it possible for them to step away from their busy practices and lives to make time for this transformative work.

The Ups and Downs of Cancer Care