Summary
Breast cancer is a leading cancer killer amongst Indian women. Its steadily rising incidence and young women getting affected with this, is alarming. We have to now move our focus in controlling it rather just treatment. The time has come to do screening of this disease on larger scale and more effectively. If we do screening properly and pick up cancer earlier treatment will be less expensive. This is possible with the support from the government.
Breast cancer is the most common cancer amongst women all over the world. In India our age adjusted rate is 25.8 per 100,000 women according to 2020 data. It was 32 in 2017 and in 2014 it was 35. These figures show that it is rapidly increasing. It is certainly less than western world. There are 29 population based cancer registries and 17 hospital based cancer registries in India. All these cancer registries show that it is the leading cancer in Indian women.
Among top 10 cancers which are common in India, incidence of breast cancer is found increasing steadily. The registries in the rural areas also show the same trend.[1] That means this is not the disease of not only affluent population but all sections of the society and also villages. This is a cause for concern.
It is also second most cause of deaths in Indian women. This is mainly because we are seeing lot of locally advanced cancers. Of all the breast cancers 60% of them are stage III and stage IV at the time of presentation. In these patients chemotherapy drugs don’t give good results as they would in early small cancers. The mortality rate in India is very high because of several other reasons like lack of screening, lack of medical facilities for cancer treatment and also because of mindset of our patients who seek medical help much later. That is why mortality rate in rural population is more as compared to urban population.
Of all breast cancer we diagnose 10% are genetic. In our country percentage of genetic cancer is more. These are by and large young patients of premenopausal age group and most of them present with advance cancer. Hence have poor prognosis. These young patients are our work force and we are losing our most important workforce because of this disease. This is because of lack of awareness and therefore advanced stage of cancer at the time of diagnosis. But screening of these patients for BRCA genes is very difficult because of the cost of testing. Genetic testing costs almost 30000 rupees.
There are very few cancer treatment facilities in our country. And most of them are in private hospitals. These facilities are in very few cities. So patient has to travel to another city away from her house. Therefore treatment of cancer becomes most expensive for them. And it is also prolong treatment. This is major hurdle and that’s why people opt out of the allopathic treatment and prefer other modes of treatment like ayurvedic or homeopathy and hope for the best.
This picture of breast cancer in India is alarming. There are several factors responsible for this increased incidence. In last few decades we have progressed significantly on our economic front. Hence our life style has changed. Our dietery habits have changed resulting in obesity. Our girls got good education and that’s why career has become their priority in the reproductive age. This resulted in late pregnancies.[3] This has now become way of life.
Most women don’t talk of breast problems. They feel shy and are also afraid of breast cancer. This is seen in all classes of society. Therefore they seek medical advice much later. Many times history of breast cancer is not disclosed to family members also because they feel it will affect their social life. Women in India don’t want to know about breast cancer. Because it is equated to mastectomy. And losing the breast to a lady is like losing her feminity. That’s why we must make them aware of breasts and breast problems. Teaching them breast self examination should be the next step which will help in diagnosing breast cancer early. And screening of breast cancer is the only way to reduce the mortality due to breast cancer.
There is no organized screening of breast cancer in India. It is only opportunistic screening. Our complex health system may be one of the reasons why we don’t have proper screening program. Almost 65% of Indian population lives in India where there are no medical facilities available. So screening is extremely difficult.
There are few NGOs like Helping hands of Dr. S.H. Advani. Their mammography van goes to housing societies, various Mahila Mandals in Mumbai for doing screening with mammography. ROKO Cancer charitable trust is another such NGO adopting different states like Meghalaya, Punjab, Delhi and doing breast cancer screening since 2005 till today. They are doing it in different companies like ONGC and Larsen Toubro etc. But this is not sufficient for our vast country of population of 140 crore. So government funded national level screening program is required. National Cancer Grid which consists of 180 cancer institutes in India is making guidelines which will be suitable for our health system so that the screening will be effectively implemented.
WHO has laid some guidelines for effective screening. According to that the disease being screened should be serious and prevalent. The test with which screening to be done should be sensitive and specific. It should be well tolerated. And should be less expensive. The test should change therapy and outcome.
Looking at present scenario of breast cancer in our society it is indeed a serious health issue and we have to have effective screening program. Developed countries like US, UK, Australia and Singapore clinical breast examination and mammography is used for screening. They have shown almost 30% reduction is the mortality rate. American cancer society and American College of radiology and several other bodies have shown that clinical breast examination alone is not enough. That’s why mammography should be integral part of the screening program. Digital breast tomosynthesis (DBT) is best way to do mammography to screen breast cancer. DBT is very good for dense breasts of young patients. It can pick up hidden cancers which are missed by 2 D mammography. In our country mammography is now available in smaller cities also. As there is increased demand of mammography equipment cost of these machines have also reduced. However there is almost 25% duty on this essential item which includes import duty and other duties. Hence it is not easily bought by radiologist. We still don’t have enough trained breast radiologists and technicians. With this in mind Breast Imaging society was formed in Aug 2012 to educate breast radiologists and standardizing breast imaging and thereby screen breast cancer accurately.
We have to do extensive screening of women above 40 as we find breast cancer in younger patients in our country. Then only we can reduce mortality significantly. And we have to do it annually as cancer burden in our society is increasing rapidly. Simultaneously in our rural areas where there is no facility to undergo mammography we must train our accredited social health activist-ASHA workers to teach breast self examination.[2] As these workers go door to door and know villagers very well acceptance is much better.
Treatment of advance breast cancer is very expensive and is available only at specialized centers. It is difficult for an average Indian to reach and spend so much money. Instead it is easy to spend on screening for breast cancer.
With Covid-19 all screening activities had come to standstill. So in near future we are going to see more advance cancers once again. Now that Covid cases have reduced we should start virtual breast cancer awareness program so that screening will get momentum and we can save lives.
References:
1. Badwe RA, Dikshit R, Laversanne M, Bray F. Cancer incidence trends in India. Jpn J Clin Oncol. 2014 May;44(5):401-7.
2. Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women. Asia Pac J Clin Oncol. 2017 Aug;13(4):289-295.
3. Singh S, Shrivastava JP, Dwivedi A. Breast cancer screening existence in India: A non-existing reality. Indian J Med Paediatr Oncol. 2015 Oct-Dec;36(4):207-9.
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