Nudging womankind, breast cancer incidence and mortality in India.

Shifali Talwar, 30 yr old ambitious and talented creative head of a leading media communication corporate kept postponing her appointment with the family physician since she had to keep traveling for client presentations. The nodule in her left breast that she had accidentally discovered while taking a bath was something that could always be attended to later. What finally forced her to a physician was the yellow tinge in her eyes that her colleague pointed out. After a few tests by the end of the day, the whole world had crumbled in front of her moist eyes, the cancer in her breast had traveled to her liver, she was told politely but matter of factly. It rendered her numb in mind and body, unable to think and make her decisions. Not only would she have to go through a prolonged course of chemotherapy, her chances were open to discovery and time only would tell. A la fait acompli a young productive life was cut short. After 4 agonizing months, when her cancer failed to get tamed and terminated in cardiac arrest. When will women comprehend and take necessary action to ward off their worst enemy – breast cancer. It certainly kills them more often than anyone or anything else. Globally more than 5 lakh women succumb to this new age Jack the Ripper every year and Indian women can hardly pretend it is happening to someone else i.e. their western counterpart. Urban and rural India writes off more than 39000 women every year to Breast Cancer within the 35-60 yrs age group. Agreed that United States, Belgium, Canada, Denmark and the United Kingdom lead the incidence charts that we fair better than china is no consolation. This is unacceptable since we are showing a steep upward trend whereas the incidence of Breast Cancer in the west is declining. Not only that our patients are a decade younger than theirs considering that 61% of our patients in India fall within 35-60 yrs of age. Our cancers are more aggressive, and discovered in advanced stages. Which is why 56% of our women have large sized, Grade III cancers and 42% have already spread to the armpit before they present to any physician.

‘Know your enemy’ is a logical first step for the just initiated survivor. Genetics and lifestyle cancer is a very oftenly quoted second name for this disease nowadays. 15% of breast cancers are hereditary and run in the family, in terms of increased risk for women who have one or more than one first degree maternal (mother, sister, daughter or aunt) relative having encountered this disease. Young ladies in this category can avail of BRCA1, BRCA2 gene testing to further elucidate their risk of actually suffering from this disease. A sample of blood dispatched to a laboratory equipped with FISH technology will predict or negate with 85% accuracy the subsequent development of breast cancer. Apart from this the ‘Cancer family syndrome’ is a loose association of breast, ovarian, uterine, stomach and pancreatic cancer in a cluster of distantly related families. Before anyone throws up their arms in helplessness, 85% of breast cancer arises sporadically perhaps because of factors well within human control. Hardly anyone these days would be prescribed radiation therapy in the chest area when they were children to suffer from breast cancer later in life only exception is children suffering from indolent lymphatic system cancers. It should not come as a surprise that community practices and individual lifestyles are potent yet malleable factors. Undoubtedly intracommunity or ethnic group attitudes to marriage, childbirth, inbreeding, must be held responsible for the highest breast cancer attack rates in Parsis followed by Sindhis, Christians and Moslems in that order. Late childbirth after the age of 35 yrs, intracommunity wedlock usually between the cousins amplifies the genetic risk many fold. Perhaps this our version of the same story that leads to high rates of breast cancer in Ashknazi Jews in United States of America. Changing lifestyles have brought in their wake a situation where young ladies begin menstruating averagely at 12 yrs rather than 14 yrs, plan marriage not before 30 yrs and usually do not contemplate pregnancy before 30 – 35 yrs. Uninhibited sexuality and aggressive lifestyles in metropolitan cities persist under the umbrella of long term oral contraceptive usage and unsupervised Hormone replacement therapy. Usage of estrogen alone oral contraceptive pills continuously for more than 4 years and estrogen alone hormone replacement therapy for more than 10 years are scientifically proven offenders. Normally annual checkups comprising Pap smear testing and Mammograms are a must so that development of a cancer from induced pre cancerous states can be inhibited in time by terminating hormonal medicine forthwith. Little reason why the bad female hormones namely estrone and 8- estradiol should not kick off carcinogenesis given enough time and a conducive environment. Obesity, apart from being a disease in itself predisposes women to breast and uterine cancer so does alcohol when consumed in excess of 3 to 7 drinks a week.

Tell tale signs are many like changes in the size or shape of breast, nipple discharge or even the nagging fear associated with the discovery of a lump in the breast. Ironic yet true that despite these being signs of relative advancement, women folk sit on it further for inane reasons like embarrassment, indifference or fear of the ominous. Why else would more than 50% of the women report advance stages when treatment options offer dismal outlook. . Does womankind have an option of continuous indifference to their own threatened extinction? Even when they learn that early detection straight away offers them an 80% chance of outright victory? At what cost? A simple three pronged strategy comprising of a monthly Breast Self Examination, Clinical examination every 3 yrs and mammography every year. Breast Self Examination is an opportunity for the woman to get to know her body and become psychologically comfortable with it.

Young ladies after they turn 20 need to feel their breasts and the respective armpits for not more than 20 minutes once every month, preferably a week after their periods in the privacy of their bedrooms or bathrooms. Women who have attained menopause can practice it any same day every month. It goes without saying any subtle changes deserve immediate reporting to a health provider. Every woman above the age of 35 must submit herself to a breast examination by a doctor or a trained nurse practitioner once every three years. If one happens to be at higher than normal risk by dint of factors elucidating earlier, this practice needs to be conducted annually. The third cardinal life saver is a special type of x-ray of the breast called mammography which is known to discover a lump 2 yrs before it is felt. Since mammography can detect 90% of breast cancer in older women, it is currently advocated for use once a year above 35 yrs of age. A word of caution! Subtle architectural distortions below the age of 35 yrs can play hide and seek with this modality. Breast ultrasound is the investigation of choice in this setting, if one is not to go wrong.

A little knowledge this is not and some time soon in future appropriate response is anticipated in the form of declining trends of breast cancer incidence and mortality in India.

Dr Sameer Kaul
Cancer Specialist