October is observed as the breast cancer awareness month. Breast cancer was the fourth most common cancer in India during the 1990s, but now it has become the most common. Studies suggest that the survival rate of patients with breast cancer is poor in India compared to the Western countries due to the earlier age of onset, late stage of disease at presentation, delayed initiation of definitive management and fragmented treatment.
Red flags of breast cancer
Any woman who notices the following signs must consult the doctor or visit a family physician or get an evaluation done by the oncologist to rule out breast cancer.
- Any swelling or lump in the breast or armpit.
- Any change in the appearance of skin over the breast
- Any change in nipple size, shape, symmetry, or nipple retraction
- Any puckering of the skin over the breast- could be an early sign of breast cancer and
- Any discharge from the nipple, which could even be blood tinged
Five things to prevent breast cancer
It is imperative to address that breast cancer is curable if detected early. It is also important to know that certain preventive measures as mentioned below can be adapted.
- Maintaining a healthy diet—that includes whole grain cereal, green leafy vegetables, fruits rich in antioxidants and avoiding processed food
- Maintaining a healthy lifestyle and body weight—there are various studies which show direct correlation between obesity and breast cancer, and therefore one must maintain their weight in the normal range. Furthermore, higher levels of physical activity have been associated with a decrease in risk of breast cancer
- Smoking and alcohol consumption are the leading non-genetic causes of breast cancer. Smoking in the form of cigarettes, e-cigarettes, vaping, etc are notorious and must be avoided to prevent breast cancer
- Pregnancy and breast feeding are known to be preventive factors- due to the reduced exposure to estrogen which is one of the hormones responsible for causing breast cancer
- Screening is important to detect breast cancer early- there are various screening guidelines that are followed in India. The American cancer society recommends that all women 40 years and above must get an annual mammogram and those with strong family history or mutations in BRCA gene must undergo an early screening. Screening modalities include mammogram, breast MRI.
Early detection and screening
According to the World Cancer Report 2020, the most efficient intervention for breast cancer control is early detection and rapid treatment. Screening for breast cancer can include different tests, of which clinical breast examination and mammography are commonly used. The screening modality which is of low cost is Breast Self-Examination. Although it does not affect diagnosis, it has been recommended by doctors as it makes one actively participate in their own health.
There are two types of mammograms- film and digital. Cancer detection rates are similar regardless of the type of mammogram used, but the digital one is more accurate in pre-menopausal women and in women with dense breast tissue.
In India, the risk factors must be assessed and incorporated into breast cancer screening program. Screening strategies must move towards a risk-based approach rather than the broader age-based and sex-based recommendations. Proper guidance manuals, development and usage of appropriate instruments and availability of adequate human resources can make a screening program successful.
Understanding India-specific differences by utilizing genomics may enable the identification of women at high risk of developing cancer, where targeted screening may be cost-effective. There is an urgent need to identify Indian-specific genetic/epigenetic biomarkers. These may have the potential to be used as biomarkers for early detection at the screening stage.
Challenges in breast cancer control
The initial manifestation of breast cancer, especially a lump, is generally not associated with pain, which adds to the delay in seeking treatment. In India, nearly 60% of breast cancer cases are diagnosed at stage III or IV of the disease. Most of the patients present to the healthcare facility only when there is a large palpable mass or secondary changes like local skin/chest wall changes are visible. Women tend to ignore the minor symptoms and do not show up at the hospital until it is unbearable, owing to their household responsibilities and lack of awareness about the disease. Other factors that influence the early detection and treatment are the presence of a diagnostic/treatment facility in the vicinity, patient’s preference and trust in the healthcare provider, amount of time required for travelling to the service centre and the costs and availability of finances to be spent on the treatment.
Although nearly 70% of the Indian population lives in rural areas, about 95% of cancer treatment centers are located in the urban areas of the country. The government facilities are inadequate in number to cater to many patients. Thus, patients are required to go for treatment in major cities along with their attendants, resulting in loss of livelihood of both the patient and attendants. There is an urgent need to establish a larger number of cancer care facilities accessible to those living in rural areas so that the gap between cancer detection and treatment services may be bridged. High attrition rates and out of pocket expenditures have led to loss of follow up in treatment, which is shown to be much higher in private inpatient cancer care.
The incidence of breast cancer is rising at a rate faster than a decade ago. Acknowledging that it is now one of the leading cancers in India, would be the first step towards making people aware of the disease. It is developing rampantly, and society’s discomfort to talk about women’s bodies has worsened the situation. In lieu of the challenges of breast cancer control, prioritizing the adoption of a preventive approach and early detection would take us a long way.