It’s difficult, increasingly so, to find Pakistanis who haven’t witnessed someone close to them battle, or be defeated, by breast cancer. Everyone has a story to tell. Most of the time, the tragedies surround women’s mothers, aunts, great-aunts, older cousins, in general, older women; but some even told tales about their daughters and daughters-in-law discovering tumours in their breasts.

Apa Suraya, an 80-plus woman, who has mothered four daughters and two sons, suffered through two of her daughters being diagnosed with breast cancer. The elder daughter, Asma, married to a bank clerk, then in her late 40s, discovered the tumour too late, a mastectomy wouldn’t have helped its spread. Doctors were honest: they said chemotherapy may help but there would be no guarantee.

"Her husband didn’t exactly prohibit her from undergoing the radioactive therapy, but didn’t encourage or support her either. I don’t know what his reasons were. My guess is that he was ignorant and too upset to learn about how to fight the disease," says Apa Suraya. "I pleaded with her to sell her jewellery, receive the chemo, and buy herself time, but she decided to leave without a fight".

The younger daughter, Reema, was in her early 40s when she found a lump. Deeply affected by her elder sister’s death, she does a self-examination of her breasts at least once a month. "The doctors told me that my cancer was in very early stages and all I needed was a partial mastectomy, but I opted for a full one. They also told me that I didn’t need chemotherapy but I could get it done for good measure, so I underwent that horrible treatment as well," says Reema whose mastectomy and chemo was covered by her husband’s job’s health insurance.

Apa Suraya says that after Asma’s death, her family has become vocal about breast cancer; all the females in the family between the ages of 18 and 80 are regularly told by Apa Suraya to perform self-examinations and go for mammograms at the slightest suspicion.

In a breast cancer self-examination the women know they have to look for giltiyan (lumps). The general level of awareness is that the bigger and more painful the lump is, the more urgently they need to see a doctor. Women also know that breast cancer is especially prevalent in Pakistan. The third strand of knowledge many women have about breast cancer is that after crossing 40, if you have a family history of breast cancer, you should be going for regular mammograms. Whether they go or not, is a completely different story.

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Apa Suraya’s family derived a lesson from personal tragedy, but in other households people aren’t as keen to learn from each other. Sana, 38, lost her mother to breast cancer many years ago and now she worries about her mother-in-law whose sister died of breast cancer.

Whenever Sana, whose husband works as a telecommunication engineer, tells her mother-in-law that early detection is the best way to prevent the spread of breast cancer, the older woman tells her to "stop thinking about such scary and depressing things. Don’t you know sometimes things [diseases] happen just because we think and worry about them? If we want to be happy and healthy, we must only think about good things". Ignorance, after all, is bliss.

Others cite fatalism to explain why they don’t bother getting tested. Rehana, the 63-year-old wife of a retired senior army official, has easy, inexpensive access to reliable medical care, but she hasn’t gotten a mammogram in the last decade, despite there being family history of breast cancer. "My death is written. I can’t postpone what has already been decided, so why should I go to the hospital to get my breasts tested every six months?" says Rehana. What will be, will be, she seems to say, so why fight it?

Clearly, the memo about early detection being the best prevention hasn’t reached a lot of women. Fifty-two-year old Shamim who lives in Rawalpindi and is married to a retired government school teacher has never gone for a mammogram. Shamim knows what the lumps mean, but she doesn’t know what she would do if she were to find one. It’s not a conversation she has had with friends and family; nor does she want to. Shamim is not against the concept of modern medicine -- one of her more affluent grandchildren underwent plastic surgery recently in the hopes of an aesthetically appealing nose -- she simply doesn’t see the need to bother her husband to take her to a clinic until something is visibly wrong. "If I keep going for a mammogram every year, I will feel like a paranoid person who is waiting for the breast cancer".

There are also women who know in their hearts and minds that they should go for regular check-ups, but finances hold them back. Sumia, 63, lost her mother to breast cancer when she was 70. "I’m so close to her age now. I feel scared and I would like to go for mammograms, I know they will make me feel safer but I don’t have the heart to spend Rs2,000-3,000 twice a year, or even once a year to check for something that may not yet exist," says Sumia. She says if the service was free, she would be their most regular patient.

Public health campaigns and other forms of media do seem to have impacted younger women more successfully. This doesn’t only mean that women under 35 are performing self-examinations and encouraging their mothers and older aunts to go for mammograms, which they are; but also that they don’t consider breast cancer as a particularly fatal cancer.

Shazia, 29, who works at a Lahore-based development consultancy, believes that breast cancer is "probably the least scary cancer out there". She’s seen her paternal grandmother fight off breast cancer. "I don’t mean to downplay breast cancer, but if you compare it to stomach or liver cancer, the chances of recovery are higher. You can live without your breasts, but not without your stomach," says Shazia. She adds that she doesn’t mean to make the psychological impacts of a mastectomy invalid, but when it comes down to life or death, the value and worth of the breast changes.

Like any other health concern in Pakistan, finances and access to healthcare play a large part in availing treatment to breast cancer, which is closely linked to early detection. Hence, richer women do seem to have an upper hand in the battle against breast cancer, but even privileged women have to battle their own fear of finding the tumours, fatalism, and ignorance to detect the cancer at an early stage.

*All names have been changed to protect people’s identities