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Breast Cancer

Breast cancer….an impending epidemic

Incidence of breast cancer is increasing at an alarming rate, especially in urban India. Out of every two women diagnosed with breast cancer, one dies of it. This is due to late diagnosis and therefore ineffective treatment. We have to rise to this challenge NOW to see an effective decline, which itself would take years in our country.
The foremost contribution to breast cancer prevention is dissemination of awareness at an individual level as well as in the society.

Myths about breast cancer:

  1. Any lump felt in the breast is cancer.
  2. This is not true, all lumps are not cancers. However all lumps should be investigated to rule out cancer. The same is done by a pathologist by a simple procedure called `Fine needle aspiration cytology’. In this procedure, the pathologist inserts a fine guage needle into the lump and gets out a few cells which are spread out on a slide, stained and examined under the microscope to look for features of mailgnancy.

  3. Breast cancer lump is painful.
  4. Most cancerous lumps are painless. The pain starts only when the lump gets large enough & presses upon surrounding tissue. This is the reason we need to `look and feel’ for lumps as they can be deceptively lurking there.

  5. Breast cancer occurs only in females.
  6. Males can have breast cancer and it is more aggressive than that seen in females. However the incidence in males is lower than that seen in females. Any changes in the breast in males should be taken as seriously as those in females.

  7. Breast cancer occurs only in old age
  8. Not invariably. High risk cases can have breast cancer as early as in their twenties and thirties. This holds more true for cancers arising out of cells lining the glands. Cancers arising from the soft tissue surrounding the glands in the breast also do occur, although less commonly. These are the ones that can occur at a much younger age, even in the teens and in individuals in their twenties.

  9. Breast Cancer spares the nipple area.
  10. Not true again. Any change in the nipple contour should be taken seriously and medical advice sought. Please do not neglect itching, oozing from the nipple. If there is oozing from the nipple, a pathologist will take a sample of that fluid and see if there are cancerous / precancerous cells in the fluid.

  11. Breast cancer does not happen in pregnancy.
  12. Although most such lumps are benign or inflammatory, cancer does not spare a pregnant lady.

  13. Screening for breast cancer.
  14. Latest guidelines (October 2015) by the American Cancer Society have recommended mammography annually from the age of 45-54 yrs, every two years after the age of 55years

  15. A pathologist cannot be consulted directly or cannot examine patients.
  16. A pathologist is an MBBS doctor who has further specialised (MD) in tissue diagnosis. In fact with his/her experience and expertise, this doctor can examine, teach you self exam and tell you better if you need to rush into further tests or allay your anxiety. He/she can also further guide you regarding your treatment steps. Treatment for cancer cannot begin until a diagnosis of cancer is given on the tissue by a pathologist. Pathology is the engine room of medicine! Seventy percent of all medical diagnosis are made depending on his /her results. This is the person who can screen you for cancer, will eventually `type’ the cancer, will tell you if the surgeon has adequately removed the cancer with clear margins or if you need a revision surgery. They can also help to tell you if your cancer has spread.

  17. Breast cancer spreads rapidly.
  18. Not all breast cancers spread rapidly. Therefore the importance of early diagnosis and grading’ of the tumor by the pathologist. This doctor shall also do some special tests on the tissue and blood which will let the oncologist ( doctor specialised in medical treatment of cancer) know whether you would respond well to certain excellent drugs which are now available for cure.

  19. Breast cancers require removal of entire breast.

Again this is not always the case. Infact the emphasis now is on least amount of tissue removal. If we follow screening protocols diligently, many a times the radiologist will place a radiopaque marker/ a small metallic pin in the suspicious lesion not felt but seen on mammography. The same tissue is then precisley removed under guidance and given to the pathologist for confirmation. For better felt suspicious lumps an FNAC by a pathologist is done directly. If the suspicion is very strong at the first presentation, a trucut biopsy is done. The same is done by a larger core needle which provides more intact tissue for the pathologist to examine and further test.

India needs to wake up to the challenge of rising breast cancer incidence; one out of every eleven women shall suffer from breast cancer. Vigilant screening and early diagnosis is the only answer.

What the Unites States has achieved today (a decrease in mortality, even with an increase in numbers of women diagnosed with breast cancer) has taken several decades of untiring, persistent efforts

And they started that, when their death rate was not so high at all. So, for India, with a death rate of 70,000 and ever increasing, even if we start today, positive results will start showing not before the next 25 to 30 years at least, if not more.

Since more patients (in India) turn up in later stages, they do not survive long irrespective of the best treatment they may get, and hence the mortality is fairly high. There are lots of reasons for late presentations including lack of awareness, shyness on part of patients, social stigma, ignorance of doctors (patients present on time, but doctors are not aware and they delay treatment), and many other causes.

Aim of comparison

A comparison of breast cancer in India with western nations like the US and with our own neighbour, China, gives a good idea of the trends it is following. This comparison is obtained from the Globocan Project, the latest of which is for the year 2012. You can find it HERE.The following charts and tables are followed by a discussion on them.

COMPARISON 01: INDIA v/s US v/s CHINA

breast-cancer

international-agency

Collectively, US, India and China account for almost one third of the global breast cancer burden. Persistent efforts over last 40 to 50 years in the US have resulted in a large proportion of women presenting in early stages and there has been a consistent decrease in the death rates due to breast cancer, even though the incidence of breast caner is rising steadily. These statistics from IARC (WHO) reflect the same, and offer a good insight for developing nations like India, as to what can be done. The rate of rise of breast cancer in India (as you will see shortly below), is so rampant, that if we do not act now, we are in for a major shock in the next twenty years. India has a long way to go! See the images below and read the discussion below that and you will understand why.

The upper adjoining image gives an idea about Incidence and Mortality from breast cancer in India, US and China.

The lower adjoining image elaborates the numbers in more detail.

Both the above images essentially represent the same data. Please read the highlighted numbers. Concentrate on the following two points:

  • Incidence means the numbers of women detected with breast cancer in that particular year. The year in the above images is 2012. So the numbers in ‘Incidence’ represent the number of women who were newly detected with breast cancer for the year 2012. They are underlined with a red line in the column ‘count’ in the second chart.
  • Mortality means the numbers of women who died of breast cancer in that particular year. In the second chart above, the mortality numbers have been highlighted with red arrows in the column ‘count’

For the United States, for the year 2012:

  • 232,714 women were newly detected wth breast cancer
  • 43,909 women died of breast cancer
  • 232714 / 43909 = 5.29 = round it off to 5 or 6. So roughly, in the US, for every 5 or 6 women newly diagnosed with breast cancer, one lady is dying of it.

For China, for the year 2012:

  • 187,213 women were newly detected wth breast cancer
  • 47,984 women died of breast cancer
  • 187213 / 47984 = 3.90 = round it off to 4. So roughly, in China, for every 4 women newly diagnosed with breast cancer, one lady is dying of it.

For India, for the year 2012:

  • 144,937 women were newly detected wth breast cancer
  • 70,218 women died of breast cancer
  • 144937 / 70218 = 2.06 = round it off to 2. So roughly, in India, for every 2 women newly diagnosed with breast cancer, one lady is dying of it.

DISCUSSION

These ratios are not the best way of assessing the situation, but they definitely give a rough idea on how the country is coping up with breast cancer and what can be predicted for the future. If you compare these three countries, you can easily make out that India has the maximum number of women dying of breast cancer, and that number is huge (70,000!). What the Unites States has achieved today (a decrease in mortality, even with an increase in numbers of women diagnosed with breast cancer) has taken several decades of untiring, persistent efforts. And they started that, when their death rate was not so high at all. So, for India, with a death rate of 70,000 and ever increasing, even if we start today, positive results will start showing not before the next 25 to 30 years at least, if not more.

Since more patients (in India) turn up in later stages, they do not survive long irrespective of the best treatment they may get, and hence the mortality is fairly high. There are lots of reasons for late presentations including lack of awareness, shyness on part of patients, social stigma, ignorance of doctors (patients present on time, but doctors are not aware and they delay treatment), and many other causes.

In India, the overall incidence of breast cancer is less as comapred to the US. But if you see the actual number of cases, India is not far behind. In the year 2012, there were about 2,32,000 breast cancer cases reported in the US, whereas in India, 1,45,000 new cases were diagnosed. This implies that, though, because of India’s population, the percentage of total women affected seems less, the breast cancer burden in India has almost reached about 2/3rds of that of the US and is steadily rising.

COMPARISON 02: GLOBOCAN 2008 V/S GLOBOCAN 2012

globocan-2008
breast-cancer-2nd

NOTE: Globocan 2012 disclaimer states that, "The increasing availability of incidence data from cancer registries and mortality data from vital statistics offices, coupled with the fine-tuning of the estimation methods means that the current incidence and mortality estimates for 2012 cannot be directly compared to estimates from previous versions (e.g. GLOBOCAN 2008)." But for a rough comparison to see the trends, I believe, these data are good enough and give us a fair idea. The upper image below reflects data for the year 2008. The lower image below reflects data for the year 2012. A comparison between the rates recorded in Globocan 2008 and Globocan 2012, gives us an idea of rapidity with which breast cancer is rising in various countries and the death rates as well. Once again, we concentrate on US, China and India.

Compare the incidence and death rates of the three countries. For the year 2012 (as compared to the year 2008), United States reported 4000 more deaths, China reported 4000 more deaths, and India reported 17,000 more deaths! If we consider that the number of deaths reported in 2008 may have been lesser, still, 17000 is a huge number to comprehend with. You can very well judge, what India would face, if such trend continues.

COMPARISON 03: BREAST CANCER V/S CERVICAL CANCER IN INDIA

incidence-2008
incidence-2012
male-female-grafe

The following upper two images represent data from Globocan 2008 and Globocan 2012 and show the change in trend in India. In the coloured pie chart, the ‘pink’ colour represents numbers for breast cancer and the ‘ochre yellow’ colour represents the numbers for cervical cancer. You can yourself see the changes over just 4 years, where breast cancer is overtaking cervical cancer! The third image has a bar chart, which reflects the common cancers in males and females in India, for the year 2012, along with their numbers.

For decades together, cervical cancer was the most common cancer in women in India and more deaths in women in India were attributed to cervical cancer than any other cancer. This was the scene for almost 4 decades (or more). But over last ten years or so, breast cancer has been rising steadily, and for the first time now, breast cancer is the most common cancer in women in India, way ahead of cervical cancer. Both, the incidence, as well as deaths, due to breast cancer are more than cervical cancer. Part of it is due to an actual decrease in the incidence of cervical cancer. But most of it, will be because of rapid rise in the numbers of breast cancer cases.

WHO prediction for breast cancer in India

cancer-deaths1
new-cancers2

The upper image below shows the prediction of numbers of deaths due to breast caner in 2015 and the lower image shows the predictions of the numbers of newly detected cases of breast cancer.
For the years 2015, there will be an estimated 1,55,000 new cases of breast cancer and about 76000 women in India are expected to die of the disease. The gap only seems to be widening, which means, we need to work aggressively on early detection.

So what do we learn today?

India is experiencing an unprecedented rise in the number of breast cancer cases across all sections of society, as are also other countries. There is no way we can prevent breast cancer, but we can definitely detect it early and treat adequately. Only and ONLY with early detection, can we achieve a longer survival. And to make people aware of this early detection, it is going to need a lot of efforts, especially, since Indian society is so deep rooted in myths and alternative treatment and unusual illogical beliefs. It will take a lot of time to reverse this and get people on track. And the time is NOW. Presently, India already has one of the worst survivals from breast cancer, in the world (as you already saw from the numbers above); has the highest number of women dying from breast cancer in the world; and India ranks number one in the numbers of healthy life years lost (DALY – Disability Adjusted Life Years) due to breast cancer; and if this trend is not broken, I cant imagine how bad it will become.

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