Breast cancer has ranked number one cancer among Indian females with age adjusted rate as high as 25.8 per 100,000 women and mortality 12.7 per 100,000 women. Aside from that, it has been shown that young age is a key risk factor for breast cancer in Indian women. The number of women diagnosed with breast cancer in India is expected to reach 1797900 by 2020, according to projections. A pleasant and encouraging clinical picture in the country would result from increased health awareness and the availability of breast cancer screening programmes and treatment facilities.
“To avoid dying from breast cancer, you must be diagnosed early. To avoid surgery, early diagnosis is also required. You don’t need to remove the entire breast if you have a 1 cm or 2 cm tumour in a 15 cm or 20 cm breast; you may only remove the 1 cm lump and perhaps radiate that region or the remainder of the area. The findings of a 20-year research that followed half of the patients who had mastectomy and half who had breast conservation indicated that those who had breast conservation fared better than those who had mastectomy,” said Dr Ramesh Sareen.
In an interview with Medically Speaking, a panel of experts discussed the treatment modalities and significance of early detection on the occasion of Breast Cancer Awareness Month. The panel included: Dr V Seenu, Head of Surgery, AIIMS; Dr Pramod Kumar Julka, Senior Director of Oncology, Max Hospital; Dr Ajay Gogia, Associate Professor, Oncology, AIIMS; Dr Ramesh Sareen, Surgical Oncologist, Indraprastha Apollo Hospital; Dr Shyam Aggarwal, Senior Consultant, Oncology, Sir Gangaram Hospital.
Here are a few excerpts from the interview:
What do we know about breast cancer in layman’s terms? We talk about a lump in our breast, which is the only indication that we have breast cancer. How can every woman, perhaps above 40, start diagnosing or even looking for breast cancer? How significant is it and why is it important to talk about it today?
Dr V Seenu: October is considered as a month for breast health awareness and pink is the colour that is being used by the WHO for the same. Most of these cancer registries are in India. The second important thing is that, unfortunately, unlike the rest, the majority of women with advanced breast cancer are present in India.
Awareness for breast cancer has certainly increased, but why is it that women are still reaching oncologists for the same at later stages?
Dr PK Julka: Awareness has increased, but not to that level in rural areas and even in urban areas. I am ashamed to tell you that even among doctors, awareness of a painless lump in the breast is not present. People wait for the pain to appear. Once the pain starts, they rush to the doctors. But, thanks to our media, people have begun to arrive earlier, and we have been putting on a lot of programs.I have done over 100 programmes on TV, radio and on daily news on early detection of breast cancer. So, if there is any lump in the breast, they must go see a doctor. All lumps are not cancerous. These lumps can appear anywhere, like in the axilla pit, neck, clavicle bone, or supra-clavicle node. Sometimes there is a discharge from the nipple as well, but that does not mean it is cancerous. One should definitely see a doctor.
What according to you, are the various signs which should ring the alarm bell and if they are not ringing alarm bells also is it important for the women who are above 40 to go for regular mammography considering we are seeing rise in breast cancer cases in the middle aged women as well?
Dr Shyam Aggarwal: Nearly 14 lakh new cases of cancer are diagnosed in our country each year, and almost one-and-a-half lakh of these cases are breast cancer in women. There are a huge number of cases of breast cancer that we get to see every year, and when it comes to the early diagnosis, women can not stay dependent on mammography. Hence, breast self examination is a very important test that women can do at home on a monthly basis, especially when they are on their menstrual days. They should look for any alteration in the size of the breast, drooping or any shape of the breast, and look out for changes in the nipple, retraction, size, or any type of bleeding etc. So they must go to a general surgeon for a checkup. So a breast self examination is a critical thing to be done every month after the age of 40. Awareness has to go to every woman in the country and all over the world. The second important thing to do is that they should go for a regular examination of the breasts at least once a year, but minimally twice a year. If someone can’t go for a mammogram since there is a lot of illiteracy, a lot of poverty, proper machines are not there in rural areas, but still all the primary health care workers can spread this message amongst women over the age of 40 years for breast self examination and a clinical examination by a doctor, so you can always pick up these cases early, so this is one. Secondly, if the lump persists beyond a month or two, then the woman should have a high index of suspicion and should go to a doctor for an immediate checkup and evaluation. Thirdly, cancer presents as a local disease with a painless lump, but women do come to us in advanced stages where the symptoms can be persistent in the form of cough, bone pain, brain involvement like headaches, etc. So, they should definitely visit the doctor if the persistency of symptoms is longer than one or two months and be suspicious about cancer.
How early detection of symptoms can help the patients increase their chances of survival and if they can reduce the chances of a full breast removal surgery?
Dr Ajay Gogia: This question has two aspects: No. 1, early stage cancer. The first stage cancer has a 90% chance of survival, and stage 3 survival is around 50%, so we can easily detect it at an early stage and improve the survival by so many means of awareness. And the second is breast conservation surgery, which is related to masctomy. It depends on which stage you are at. So it depends on your stage of breast cancer. People with stage 1, stage 2, and stage 3 can go for breast conservation surgery after chemotherapy.
What are the misgivings in the mind of the patient and if you could dispel fears around the complete removal of the breast and does that happen to every patient? Tell us a little about the breast conservation surgery.
Dr Ramesh Sareen: To avoid dying from breast cancer, you must be diagnosed early. To avoid surgery, early diagnosis is also required. You don’t need to remove the entire breast if you have a 1 cm or 2 cm tumour in a 15 cm or 20 cm breast; you may only remove the 1 cm lump and perhaps radiate that region or the remainder of the area. The findings of a 20-year research that followed half of the patients who had mastectomy and half who had breast conservation indicated that those who had breast conservation fared better than those who had mastectomy. In the last three or four years, we have had people do breast conservation even for stage 2 and early stage 3, depending on the size of the tumour and the size of the breast. Early detection gives you life and gives you life, breasts and money because you may not require chemotherapy. It also gives you calm and does not give you anxiety. Breast self-examination is very necessary in a country like ours, but trials have suggested that it’s the screening mammograms that can save your lives.
Every treatment for breast cancer may not require surgery, what would you tell the patients who have a lot of misgivings about the same?
Dr V Seenu: Surgery is the definitive treatment for breast cancer. If a patient presents early and if the size of the breast is good enough that I can remove the tumor, the patient will still have a good cosmesis. That is the time when we need to pick up. You cannot treat breast cancer without surgery. If it is a stage 4 disease, and the patient has metastasis elsewhere, then we may not do surgery, but for definitive treatment, surgery is the standard of care for local and regional control. The second thing is how the patient reacts. It all depends on the background of the patient. As you know, at AIIMS, we receive patients from different backgrounds, from very poor rural backgrounds to highly educated people. But it is extremely important to counsel these patients because losing a breast is like losing an image or femininity for some women. Counsel them, give them the options and then take the patients as per their chosen option.
What is the reason for rise in number of breast cancer cases in urban areas, in younger women and what are the lifestyle modifications that can help delay the same if not prevent at least?
Dr PK Julka: People are becoming lazier, and they are adopting sedentary habits. They are not doing exercise, travelling in AC cars, watching TV, so basically their diet is becoming poorer. Eating more junk leads to obesity, which can also lead to breast cancer. Talking about this, early menarche or late menopause can also lead to this because a person is more exposed to the female hormone, that is, estrogen. That is the culprit which causes cancer. We have modifiable factors and non-modifiable factors. Number one, if you’re a girl, you have more chances. It is not that men cannot have breast cancer, but there are only 1% of such cases. Second is early menarche-late menopause.
Modifiable factors include a change in lifestyle, which means you eat a well-balanced diet, avoid obesity via exercise, and modify your exercise routine such that you exercise regularly and avoid junk food. People avoid drinking and smoking, both of which can contribute to breast cancer. As a result, when all of the risk factors are combined, breast cancer is more likely to occur.
People who have mutations in certain genes come to us with breast cancer, even at an early stage. Only 5-10% are hereditary breast cancers. It is said that if mothers have breast cancer, children are liable to get it. Now you’ll be surprised to know that most of the patients I am treating today, I treated their mothers 20 or 30 years back.
What type of breast cancer is found in younger women? What happens if a women gets breast cancer in her late 30’s or early 40’s?
Dr Shyam Aggarwal: Breast cancer occurs about a decade earlier in India than it does in the West, according to research from around the world.For example, if the average age there is 50 years, in India it is 40 years. That is one very important difference, and it has been observed that young women getting breast cancer are supposed to be more aggressive and it is perhaps not dependent on oestrogen or hormones as suggested earlier, so the variety of triple negative breast cancer where the oestrogen receptor or the hormone receptors are negative and there is one more negative gene. All these three negatives give an aggressive nature to younger women who suffer from breast cancer. Secondly, the hereditary breast cancer also tends to occur at an earlier age, so this basically leads to a more aggressive disease and more women getting stage four disease, getting an advance cancer, where cure tends to illude them. If somebody gets cancer that has gone into the bones or into the lungs or liver, then cure is usually not possible. From stage one to stage three, a major proportion of patients can be cured. And when you have stage 2, 80% to 95% of women can be cured. These women have lived in society for a long period of time and have their own issues. They have been through the trauma of cancer and surgery, whether it is breast conserving surgery or total removal of the breast, which is needed for these women. Chemotherapy side effects, such as cognitive dysfunctions and other issues, can be prolonged, and the stigma of cancer can linger for months or years, not only in the family but also at work.They always have this fear of relapsing. There are so many issues in early breast cancer, when they are left after treatment for six months or so, which we need to address with extreme care, compassion, and a lot of psychological care is required for women to cope with the diagnosis and treatment of breast cancer.
After someone has recovered from breast cancer, what is the care which is required and is it possible to avoid a relapse or is it something which is totally out of the patients hand?
Dr Ajay Gogia: Around 60% to 70% of all cancers are hormone-positive cancers. After treatment, you have to continue around 5-10 years of hormone treatment post all the treatments, post surgery, post radiation or post chemotherapy. You need to continue all the treatment for 5-10 years to prevent a relapse.
Second, there are currently many advances in triple negative breast cancer, which is more aggressive and prone to relapse.In these cases, we try to maintain chemotherapy for 6 months to prevent the relapse. Thirdly, after all the treatment, we need to keep a check on weight, exercise, and lifestyle modifications to prevent future relapses.
Do people tell you that could you try treating me just by medication or just by radiation possibly avoid surgery?
Dr V Seenu: I think you’ve got me wrong. I didn’t say that surgery is the only treatment. The thing is, when you talk about breast cancer treatment, there is something called a multi-modal treatment, which means different modalities like surgery, Radiotherapy, chemotherapy, targeted therapy, and hormonal therapy. So these are all five methods used to treat breast cancer. And depending on the biology of the tumor, Based on certain receptors, we decide whether the patient should get only hormonal therapy or only chemotherapy or targeted therapy. It also depends on the age of the patient, their menopause status, etc. Unfortunately, we are not at the stage where after we diagnose breast cancer, some tablets will be able to cure it. The treatment is multimodal. For local and regional control, most often we use surgery and radio therapy. For early breast cancer, patients will have small cancer cells which have gone elsewhere inside the body, and to control that, we give chemotherapy, targeted therapy, or hormonal therapy, which is called adjuvant treatment. Surgery is not the only treatment, and it is not so that the patient will get away without having the surgery if needed.
Did you see any sort of delay in treatment due to the pandemic? Did you see people being hesitant or they are still hesitant to come to see the doctors or perhaps go for mammography?
Dr PK Julka: After joining Max, I found that everyone was getting treatment on time. Nobody got delayed treatment due to Covid and not even a single day we closed our center because of covid so. And we also gave them covid vaccine shots, and most of our patients were vaccinated as well, and they were getting regular treatment. You have to change their psyche because cancer cells does not see day and night.
What if someone who already has breast cancer gets covid?
Dr Shyam Aggarwal: COVID has a huge impact on cancer diagnosis. Patients who were coming in for screening stopped coming and getting out of their homes, and patients who had symptoms of stage one cancer, for example, a lump in the breast, never ventured out of their homes for six months all together, because there was a lock down. As a result, staged migration occurred, and women who were to be treated in stage 1 are now in stages 3 and 4, which has really led to a huge burden not only in India, but also across the world. If you look at the figures from the UK and the USA, you will see that staged migration has happened. So we are overburdened at this point in time, not with early stage breast cancer, but even with a larger load of late-stage breast cancer, stage 4 breast cancer. So I think that there is a huge, huge impact of COVID in general on cancer, including breast cancer. So we need to say to all our patients, there is no lockdown on cancer. The cancer cells are going to increase day by day, week by week, month by month. And if you are in stage one today, 4 months down the line, the possibility of stage 3, 4 is very, very high, so kindly don’t delay. And what has happened is that people who were coming from 200 kilometres or 400 kilometres have stopped coming to Delhi or stopped going to Mumbai, metropolitan cities. So now they’re getting treatment at their places, like Carnal, Dehradun, Meerut etc. So, you know, that facility has become a little stronger now because people can not travel as easily as before to these towns and big hospitals. Now, people are not travelling anymore. Finally, COVID has a direct impact on cancer. So, people who have covid and cancer, there is a slight increase in risk of mortality, and you don’t give chemotherapy. You wait for the covid to go away and only then you come in, but the increment in immortality is very small, there isn’t much difference. So cancer is usually a slow disease. Covid gets over in 15 days and after that women are fit for taking the treatment.
What difficulty does surgery in cancer in late stages pose for you?
Dr Ramesh Sareen: I agree that there is a stage migration and the people we see now, we see more of stage 3 and sometimes stage 4. So, I must tell you that out of a hundred cases, perhaps 30 to 40 percent of the patients can actually receive chemotherapy prior to surgery. The chemotherapy can be given to triple negative patients and the response to chemotherapy is pretty good. Cancer completely disappears in 50 to 60 per cent of the patients if proper chemotherapy is given in a proper center. So these patients who are coming in at stage 3 instead of stage 1, can have chemotherapy before and can possibly have equally good results as if they were in stage 2. Of course, you can’t replace stage 1 and stage 3 but can have a good chance of survival. But the rest, 40 to 50 percent of the patients where chemo doesn’t work well are the ones who will be disadvantageous. So, in short, early detection is a must. Even if they haven’t come and they are in an early late stage of triple positive, a triple negative stage, they still have a very good chance of survival. Hence, the positivity should not be taken away from women by saying that you come late and we can’t treat you. We can still treat a large percentage of patients that way and cure them.
Would you say that early detection has been a little illusive during this time? And now that the cases are low, what would be your message to the people?
Dr Ajay Gogia: The symptoms and signs of breast cancer do not depend on the pandemic. Stage migration has been done in stage one and stage 2 and here the primary modality is surgery.
At stage 3, the primary modality is chemotherapy followed by surgery, and at stage 4, when the cancer is at metastasis, chemotherapy is the only modality. Stage migration can lead to a treatment decision for all patients. Definitely covid has an impact on the diagnosis of breast cancer, and treatment decisions are based on the stage.
What would be your message to people on misgivings of early detection?
Dr V Seenu: The message for everyone is that any woman who has a lump or painless lump in the breast at about the age of 40 years, or any woman who is more than 30 years old, has some alteration in the breast, it is the duty of the spouse to bring that information to the doctor. The earlier the diagnosis, the better the treatment. The cost is less. The outcomes are much better.
Any messages to the men minority who may be at risk of breast cancer?
Dr PK Julka: A man should be aware of breast cancer, however it is very low, at about 1% of all female breast cancer instances. Men should not be illuded by the thought that they won’t get breast cancer at all. When we talk about breast cancer, generally, we talk of female breast cancer, We never talk of male breast cancer. Men should also check their breasts. We say self examination of the breast, they should also get mammograms done. They are treated just like female breasts. Early detection is the hallmark of a cure.
A large number of patients come from rural areas, any message from that point of view?
Dr Shyam Aggarwal: I can give you some statistics and some figures. For example, in Delhi, the incident of breast cancer is 40 per 100,000 people, in Kerala it is 135 per 100 per thousand. I said in India, you get one and a half lakh cases of breast cancer with a population of 1.4 billion people. In America, the stats are two and eight lakh per year. Look at the statistics suggesting that as you become more economically stable, you more of these issues related to women who become working class, late marriages, not having 2-3 children, and not breastfeeding. So, those are very important features. And that is the reason that the incidence of breast cancer is actually low in rural areas, but that doesn’t mean that the mammography machine and the message of breast cancer awareness should not reach the rural areas.
What would you like to tell young mothers who are lactating women?
Dr Ajay Gogia: Lactating women and the involvement of the breast with milk, all cases of pregnancy are usually early diagnosed or misdiagnosed. For pregnant ladies, any lump should be taken seriously. In the case of rural areas, you must conduct self-examinations and clinical breast examinations and in urban areas, one must definitely go for mammography and ultrasound.
What would be your side of the message to the people Dr Sareen?
Dr Ramesh Sareen: Early breast cancer detection saves your life, breasts, money, and saves you from the psychological upset. The surgery for breast conservation is one day in the hospital. You get admitted in the morning, you are out the next day, and you are okay in seven days’ time. So nobody should be scared of the surgery part, because if you’re scared and don’t come to the hospital, you make yourself worse. And thirdly, the incidence of cancer is rising in India, and younger women are getting it more, so be aware. Fourthly, mammographic screening, the opportunistic woman who can afford it must go for mammography because that’s the only modality which has been shown to reduce mortality as against medical examination or self-examination.