Breast cancer: Early detection is the key
Dr S.M .Bose

Breast cancer is the second common cancer affecting Indian females. It is rapidly increasing and has overtaken cancer of the cervix in metropolitan cities.

Indian data is not reliable; it is estimated that one in 20 Indian females is likely to develop breast cancer during their lifetime. Between 80,000 and 90,000 new patients are seen every year and add to the existing number of patients. The total breast cancer burden at any given time is between five and six lakhs. The complexity of multi-modality treatment makes it very difficult to look after this enormous number.

Breast cancer is a disease of the old age. Its prognosis is poorer in young patients. Breast cancer can also affect males. However, the incidence is very low; for every 100 females, we see one male patient. Males have poorer prognosis as cancer rapidly involves the underlying muscles.

Late presentation and outcome In India, we see very few patients of breast cancer in its early stage, whereas in America, those suffering from early breast cancer include only patients in whom the tumour is not felt from the surface but has been detected by mammography only. As many as 60 per cent of Indian patients commence their treatment when the disease is in advanced stages ( stage III and IV ). Contrary to this, in Western countries, 60 to 70 per cent patients come to doctors in stage I.

Long-term survival is directly related to the stage of the disease. Survival for 20 years is noticed in more than 90 per cent of the patients with a tumour diameter of 1 cm as compared to 50 per cent with 3 cm. This clearly signifies the importance of early detection and also explains the poor outcome of treatment in India. The quality of treatment and the histological type of cancer do have an effect on the ultimate outcome, but it is only a minor factor vis-a-vis the stage of the disease.

The onus of late presentation lies on (a) patients, who, because of lack of awareness and false modesty, do not consult surgeons early; (b) relations of patients who do not either have time or are reluctant to take their female family members to specialists; (c) doctors who do not suspect cancer and deny them rational treatment.

It is well known that the alternative systems of medicine — homeopathy, ayurveda and unani — cannot successfully treat cancer patients. The doctors belonging to these systems only waste precious time, energy and money without providing any relief. Quacks also easily misguide our patients.

The presence of a progressively increasing new swelling in the breast or the armpit is the commonest presenting feature of breast cancer, but our patients ignore this, as the swelling is always painless to start with.

Cause and effect

Why and how does breast cancer affect mostly a woman? Global research has been trying to find an answer to this question, but so far our knowledge is limited to hypothesis only. Breast cancer is supposed to be more common among affluent people, who are exposed to the modern environment. Modernisation is coming in a very big way in India and, therefore, the incidence of breast cancer will also rise further.

Statistically speaking, breast cancer is more common among spinsters; among women who have got married but have not born children; among those who have born children but have not breast-fed their babies. This is becoming more prevalent coming among the new generation, particularly those who are working and belong to the higher socio-economic class.

Literature does show correlation of smoking, alcohol and high fat intake to the causation of breast cancer. Environmental factors take time to bring about the required changes in the chromosomal level.

Genetic factor

Breast cancer has a genetic linkage. It is supposed to be more common among females whose first relatives had this problem. They are bracketed among " high risk patients". The identification of the abnormal chromosome and its repair by genetic engineering is likely to be made available in developed countries in the near future, but this may require a long time to be possible in India.

Screening and diagnosis

The disease can be detected in the asymptomatic stage (when there is no complaint) and this is possible by following regular screening protocols, to be started at the age of 35 years. These consist of mammography, a clinical examination by a specialist and self-examination of one's breasts.

Screening is supposed to decrease the number of people dying from breast cancer by almost 30 per cent. Breast screening is commonly practised in developed countries; but in India because of financial constraints, it has not yet become a common practice. Mammography costs only Rs 900 and it is a worthwhile investment for all those women who can afford it. Self-examination of breasts has to be learnt for details.

Mammography can detect a swelling as small as 0.5 cm in the depth of the breast which may not be felt from the surface. A biopsy of this lump requires to be taken for the confirmation of the diagnosis and this can be undertaken through the stereotaxis technique or by mammotome -— the former kind of facility is available at a few centres but the later is yet to come into practice.

PET scan and dedicated MRI mammography are the latest techniques and are supposed to give more reliable results than mammography, but these are costly and not widely available.

Fine Needle Aspiration Cytology ( FNAC ) is a commonly used technique for biopsy. It is 95 per cent reliable, but may also give false positive or negative results. Therefore, a surgeon has to use his clinical judgment for proper correlation. Experts in cytology are available only in major institutes.

Tissue for biopsy examination can also be obtained by inserting a wide bore needle, known as core needle biopsy. This is more reliable than FNAC, as the number of expert histopathologists far exceeds the number of cytologists.

Investigations

A breast cancer patient has to be thoroughly investigated for staging; to know the prognosis and also for judicious selection of the treatment protocol. The patient requires to be assessed for operation, chemotherapy and radiotherapy. It is possible to complete all investigations within 24 hours, and this delay does not affect the well-being of the patient.

Sophisticated and more reliable investigations like the PET scan, total bone scan for the detection of cancer and its staging are not readily available. In the whole of northern India, the PET scan facility is available only at the PGI, and that also for the last few months. The subsidized rate at the PGI is Rs 7000, but it can be at least Rs 25000 in the private sector.

Management

It has now been conclusively proved that a breast cancer patient has to be treated with multimodality treatment — surgery, chemotherapy, radiotherapy, hormone therapy and immunotherapy. A right combination with proper planning and sequencing is important. This treatment protocol depends upon the general condition and the menstrual status of the patient, the stage of the disease, the histopathological findings and the markers of the excised tumour — the most important factor being the expertise and experience of the treating surgeon.

Advances in surgery have proved that the total removal of breast is not required; tumour can be excised along with a rim of the normal breast tissue and the breast can be preserved, thus giving an excellent cosmetic look to the patient. This surgery has to be combined with the administration of radiotherapy and other forms of treatment modalities to give satisfactory results.

The cost of multimodality therapy is, however, quite high and beyond the reach of an average Indian.

Long-term results have clearly shown that the ultimate result following the proper application of breast conservation surgery remains equally good, if not better than total removal of the breast. Unfortunately, this form of breast conservation surgery is practised at a very few centres, and the main reason being the unavailability of expertise or

Lack of experience on the part of the surgeon.

Rehabilitation and support system

Breast cancer per se and the body image following surgery may leave behind a psychologically disturbed patient, who does not enjoy social life. Her sexual activity also suffers. These patients require psychological support from their near and dear ones. The body image can be improved tremendously by cosmetic surgery or even with the use of special brassieres.

Continued follow-up of the patient with the treating surgeon is very important not only for the rehabilitation of the patient but also for detecting the recurrence or distant metastasis. Recurrence can be effectively kept under control if it is detected early and proper treatment is available in time.

Another important fact that research has clearly brought out is the relationship of the treating doctor to the ultimate resul. It has been found that results are significantly better if the treating surgeon has special experience or expertise in this area, and treatment has been undertaken in specialized breast units. But, unfortunately, there are very few surgeons or units dedicated to the management of breast cancer.

The writer is a retired Senior Professor & Head of the Surgery Department, PGI, Chandigarh. He is also a former President, Association of the Surgeons of India, and has authored a book, " Cancer ".

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