Breast Cancer - An alarming rise in morbidity and mortality of Indian women; Need for more awareness and screening programs.

Aswini B | 04 March 2020

Breast cancer - one of the common cancers in India is the leading cause of cancer-related death in women. Despite being a curable disease, 45-50% of the patients present the advanced stage. To tackle this worrying condition, increased awareness and screening programs among women are mandatory. The WEEK CONNECT conducted a conference jointly with CSIR- Institute of Genomics and Integrative Biology and Premas Life Science Pvt. Ltd., in Delhi, to expand breast cancer care for Indian women. More such programs may help us detect it early, and hence aiding better management and cure.

Cancer..!! The word that destroys hope in patients and peace in the family. It is considered as one of the most dreaded diseases. However, recent medical advancements have improved the survival of cancer patients dramatically. Breast cancer is one such disease that is curable when detected early. The tumour is generally found either in the cells lining the milk duct (called ductal cancer) or in the milk gland itself (called lobular cancer). Breast cancer may be sporadic or inherited. Inherited cancers are generally caused by mutations in BRCA1 and BRCA2 genes (2). Though they account for very few cases of breast cancer, they are highly penetrant in familial conditions (3). These genes are also a high-risk factor for ovarian cancer. In rare cases, mutations in CHD1, PTEN, TP53, STK11 genes may cause breast cancer as well. Hereditary cancers develop early in life compared to the sporadic ones and are inherited in an autosomal dominant pattern (2).

There are no noticeable symptoms or pain at the early stages. However, as cancer progresses, multiple signs and symptoms like a lump or a change in the size or shape of the breast, nipple discharge, tenderness, retraction (turning inward), skin irritation, dimpling or scaliness start to appear. Since these changes also occur as part of many different conditions, having one or more of these symptoms does not mean that a person has breast cancer (2).

To detect breast cancer, it is important to identify the early signs and symptoms and perform further screening. Currently, mammography is the only effective screening technique (3). Genetic testing is performed in the case of inherited cancer (2).

Multiple risk factors have been documented for breast cancer. The most important ones include reproductive factors like early menarche, late menopause, late age at first childbirth. Users of oral contraceptives and hormone replacement therapy are also at high risk. According to a study by Danaei et al in 2005, 21% of breast cancer deaths are associated with alcohol consumption, obesity and lack of physical activity. Hence, maintaining a healthy diet, proper physical activity, avoiding alcohol intake, having control of weight and obesity can prevent breast cancer in the long term. It is also observed that breastfeeding has a protective effect. Yet, these strategies do not eliminate the risk of breast cancer. Hence, to improve breast cancer outcome and survival, it is important to detect breast cancer early (3).

The global incidence of breast cancer varies widely ranging from 19.3 per 100,000 women in Eastern Africa to 89.7 per 100,000 women in Western Europe. Hence, it is considered to be a disease of the developed nations. Nevertheless, around 50% of all the breast cancer cases and 58% of deaths observed are in less developed countries (3). The global survival rate varies from 80% - 90% in North America, Sweden and Japan to around 60% in middle-income countries. the survival observed in low-income countries is less than 40%. The low survival rates are majorly due to lack of early detection programmes, resulting in a high burden of patients with late-stage disease and the lack of adequate diagnosis and treatment facilities (3).

The prevalence of breast cancer in India is 25.8 women per 100000 women. Considering our population it would be around 18,00,000 women in 2020. This has become the top cancers affecting Indian women, surpassing cervical cancer with 25 - 32% of all cancers affecting women. The highest prevalence of breast cancer in our country is recorded in Thiruvananthapuram, Chennai, Delhi and Mumbai (1).

The incidence of breast cancer in India has doubled since 1990. The mortality has increased by around 13% in the last 5 years. Almost 45-50 % of patients in India suffer from advanced stages. The reasons for the worrying statistics are lack of awareness and screening (1). This emphasized that we necessitate improving the detection and quality of treatment for breast cancer patients (1).

Cancer not only affects the patients but also their family, both emotionally and financially. The costs of treatment are high, ranging from 2.5 Lakhs to 20 Lakhs (6) and impose a severe financial constraint to the family (1). Early detection can drastically reduce the cost of treatment. (1). The government of India has multiple schemes and support systems that may help the affected family financially. This includes the Prime Minister’s National Relief Fund (PMNRF), Rashtriya Arogya Nidhi (RAN), Central Government Health Scheme (CGHS) (4) and Ayushman Bharat (7).

PMNRF meets the expenses of various medical treatments including cancer. The health minister’s cancer patient fund (HMCPF) under RAN, provides financial assistance up to Rs. 1,00,000 to cancer patients who are under the poverty line. CGHS provides cancer treatment facilities for retired central government employees and their dependents (4). Ayushman Bharat - PMJAY provides Rs. 5,00,000 to the patients (7).

Other amenities the government of India offers for cancer patients includes free railway travel from the nearest hometown station to cancer-treating hospital or institute and back, 50% off on economy class air tickets while travelling for treatment or medical checkup and income tax relief for cancer patients (4).

The WEEK CONNECT conference on Breast Cancer Awareness conducted jointly by The WEEK, CSIR-Institute of Genomics and Integrative Biology and Premas Life Sciences Pvt. Ltd.

Despite the support from the government, the survival rates for breast cancer remains low in our country and we require more awareness programs. Recently, THE WEEK along with CSIR- Institute of Genomics and Integrative Biology and Premas Life Science Pvt. Ltd., conducted a conference in Delhi which aimed to highlight preventive action against breast cancer and in turn to expand breast cancer care for Indian women. Distinguished personalities of the nation including Dr Shekhar Mande (the secretary of the Department of Scientific and Industrial Research, and director-general, Council for Scientific and Industrial Research), Preeti Sudan (secretary of the Union ministry of health and family welfare), Dr Balram Bhargava (secretary of the department of health research and director-general of Indian Council of Medical Research), Professor Ravi Mehrotra (CEO of India Cancer Research Consortium), Professor Rajiv Sarin (Tata Memorial Centre), Dr Anjali Agrawal (senior consultant and head at Teleradiology Solutions, Bengaluru, and general secretary, Society for Emergency Radiology, India), Dr Ramesh Sarin (surgical oncologist at Indraprastha Apollo Hospitals, Delhi), Dr Neeti Leekha Chhabra (founder and president of the NGO Yes to Life), Dr Anurag Agrawal, Director of the CSIR - Institute of Genomics and Integrative Biology, were part of the program. Top oncologists, researchers, medical students and cancer survivors had attended the program. The experts described the rising incidence and genetic aspects of breast cancer. Apart from explaining the experience and practical issues that the patient confronts, they also elaborated on the importance of screening for breast cancer, the relevance of genome sequencing and the latest treatment modalities (5).

Dr Balram Bhargava mentioned that the number of breast cancer patients diagnosed early is far lower in our country than that of the west. He emphasised the importance of self-examination (5). 20% of breast cancers can often be detected by physical examination. According to the Union Health Ministry, only 38% of women in India undergo routine self-examination (6). But self-examination does not work in younger women. Their breast tissue is dense and makes it difficult to detect a tumour that is smaller than one centimetre says professor H.S. Shukla who was a former dean of Banaras Hindu University and ex-president of World Federation of Surgical Oncology Societies). He also added that women can detect malignancy themselves only after they are 45 and that mammography works only after the age of 40. The mammography equipment requires high-quality maintenance and trained professionals to interpret the images. With a shortage of radiologists in India, Dr Anjali Agrawal suggested the usage of ultrasound which would be more affordable. She also mentioned the benefit of MRI, which is highly sensitive, for younger patients in the high-risk category (5).

According to Professor Chintamani (Department of Surgery, Vardhman Mahavir Medical College, Delhi), breast cancer in young women is aggressive and progresses fast as opposed to 80-year-old (5). To tackle this menace, it is important to acknowledge that breast cancer is one of the important health issues in the country. Next, there must be increasing awareness about the disease, especially in rural populations. All women above 40 years of age should be screened and educated about breast cancer. Women whose close relatives have had the disease should be screened earlier. Finally, implementations of proper screening programmes need to be ensured (1).

Preeti Sudan mentioned that the government of India had screened 92 lakh women for breast cancer at the health and wellness centres under Ayushman Bharat. Of these, 29,820 women were diagnosed with breast cancer, and 17,108 were already undergoing treatment. She added that the government had approved 20 tertiary care centres, 18 state cancer institutes for efficient treatment. Under the Ayushman Bharat-PMJAY, the government provides 150 oncology packages to the needy. She also stated that the newly set-up National Cancer Institute in Jhajjar has the most advanced equipment for cancer treatment (5).

Dr Anurag Agrawal explained that the way forward held in capitalising on the silver lining—the willingness of various sectors to collaborate on the problem, the scope of early intervention and in management of high-risk patients. He suggested that multiple partners from the clinics, research, technology, academia, government and young entrepreneurs need to be brought together for a mega programme (5).

More breast cancer awareness programs, screening programs and a better understanding of the tumour using novel technologies would help us fight the disease.

Reference:

Genomics in India

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Breast Cancer - An alarming rise in morbidity and mortality of Indian women; Need for more awareness and screening programs.