Breast cancer among Indian urban women is assuming epidemic proportion and is more aggressive than the west, with different tumour biology happening at a younger age, says RATNADEEP BANERJI.
Is India becoming the breast cancer capital of the world? 70,218 Indian women died in 2012, while in the US breast cancer deaths stood at 44000 and in China 48,000. In India 150000 women are diagnosed with breast cancer every year which is expected to rise to more than 200000 cases per year by 2030.
What happens in breast cancer? Cancer forms in the tissues of the breast, usually the ducts that are tubes that carry milk to the nipple and cancer forms in the lobules that are glands that make milk. It occurs in both men and women, although male breast cancer is rare.
Dr Subhojit Dey, Associate Professor with Indian Institute of Public Health, Delhi puts the risk factors – excess exposure to estrogen often through hormone therapy post-menopause, early menarche, late marriage and late pregnancy. Obesity makes post-menopausal women susceptible to breast cancer. Estrogen production in the ovaries as such stops post menopause but in overweight post-menopusal women androgen gets transformed into estrogen in the fat tissues. Therefore, obesity after breast cancer is a big risk.
In developing countries like India, the majority of women diagnosed with breast cancer do not survive because their cancer is too late. More than half of the breast cancer patients die of the disease because of limited access to early detection and treatment. Majority of women in the developing countries do not perform regular breast self-examination (BSE).
The perilous situation
70% women who may well be in their 40s or 50s reeling under breast cancer approach medical assistance in latestage such as stage 3 and 4 with large tumours that is more than 5 cms in size, of the size of a lemon. Only 46% women survive up to 5 years after diagnosis with breast cancer in India while up to 90% of women survive in the USA.
Breast cancer among Asians is more aggressive than many other races. It is happening at a much younger age even when they are in their reproductive stage. Breast cancer mainly affects and kills women in younger ages in India giving rise to ‘cancer orphans’, who have lost their mothers to breast cancer. Dr (Col) C S Pant, a radiologist and breast cancer screening expert vociferously puts the figures for 5-3 year survival rate: Stage I – 96%; Stage II – 81%; Stage III – 52%; Stage IV – 18%, Dr Pant attributes, ’Tumour biology of India is different’. The 5-year survival rate for patients of breast cancer in – India is 52%; China is 82% and USA is 89%.
Dealing with the psycho-social problems of a young patient is exceedingly difficult. Dr Kanchan Kaur expresses helplessness, ‘I sit before them knowing what physical distortion will leave behind and chemotherapy will leave them infertile. In the west there are established services to tackle these psycho-social issues.’ Cancer care is a glaring problem. Secondary and tertiary care hospitals are very expensive. Secondary and tertiary care hospitals are very expensive. Awareness about palliative care is abysmally low.
Breast cancer is up to 4 times in urban than rural women. In 2012, Indian Institute of Public Health, Delhi, a chapter of Public Health Foundation of India along with Indian Cancer Society initiated a community level survey on breast awareness of as many as 2017 women in Delhi. Dr Subhojit Dey, the principal investigator of SPARSH found, ‘ women hardly practice preventive behaviours such as breast-self examination (BSE).
The reasons for the low rate of BSE among these women include the fear of finding that they have breast cancer, inadequate knowledge regarding how to perform BSE, and the lack of awareness about what to do if a lump is found.
When should a woman start self-breast examination? A woman should start self-breast examination in her 20s especially if occurred in her family. Breast screening (mammography) should happen every 3 years after reaching an age of 50 years.
Lumps less than 2 cm go undetected during self-breast examination. Does mammography offer an astute option? Mammography is special x-ray done upon breasts. Mammography is often touted to cause false alarm with its over prediction. However Dr Subhojit Dey says, ‘During younger age breast is more dense and so often misleading results may appear. But mammography is certainly foolproof after 50 years. Again, these machines costing around a crore are present only in select locations in India. So mammography at large cannot be advised for Indian population at large when a place like Delhi has around 20 of them.
The stark reality is that for clinical breast examination, doctors are not trained. Dr Kanchan Kaur, specialist with Medanta Breast Service declares outright, ‘ We intend to control breast cancer but not cure it. In the west there is an organized national screening program. When I came to India from the UK, my first patient came up with four mammograms done every year and yet her breast was bleeding through skin. The mammograms were all wrongly interpreted as normal.’
Cancer Policy of India
India’s National Cancer Control Program began in 1975-76. While a lot of resources are devoted to prevent maternal deaths and anti-tobacco measures, hardly any resources are devoted for breast cancer control. Dr Preet Dhillon suggests,’ Cervical cancer screening has been taken up by many states. Similar screening tests for breast cancer mainly in urban areas need to happen. Again there are no population-wide programs for screening or clinical breast examination or mammography’.
The pink revolution
It is only 25% of women believing breast cancer to be curable. Rekha Gulbani, a breast cancer survivor recollects her initial horror on being detected, ‘Cancer means death. My first reaction was that I am not going to survive because I don’t have the money for treatment. Even if I go for treatment, I will die so why go through all that process’.
Manjit Singh Chawla lost ber battle against breast cancer at a rather early age. In her memory, her family launched MKC Roko Cancer Charitable Trust in India. They bring awareness of breast cancer and also provide early detection. In 2005, they launched a fully equipped mobile breast cancer detection unit for the semi urban and rural areas of Punjab. Roko started a campaign whereby NRIs sponsored camps in their villages. On the International Women’s Day in 2014, Roko started a cancer winner club called Le’ Flamingo at The Select City Walk Mall, Saket. This club is a network of cancer survivors under one roof to provide support and guidance to the newly diagnosed and the survivors put a role model in front of others. A speaker’s forum therein enables cancer winners to share their experiences. Roko achieved to accord bus concession to cancer patients in Punjab and Haryana.
Recently the Delhi chapter of Public Health Foundation of India released its policy brief towards containing breast cancer. India-specific guidelines need to be created for screening and early detection of breast cancer in India. Breast cancer has the highest burden and must be an important part of the cancer control strategy in urban areas under National Health Mission.
Files of Pictures and illustrations attached herewith bear the courtesy of Dr. (Col) C S Pant.