Breast cancer in India is set to reach new heights in incidence in the next decade. It has already overtaken Cervical Cancer as the leading cancer in Indian women.
In India there are 1,55,000 breast cancers diagnosed yearly which results in 76,000 deaths from this disease.
Not only is the incidence of breast cancers alarming but the mortality from this cancer is 1:2, i.e. one in every two women diagnosed with breast cancer in India, succumb to it.
The take home message from the data available are the following:
- Rising numbers of cases of breast cancer in India
- Increasing incidence of BC in younger age groups
- Late presentation:This directly decreases long term survival of the patient
- Lack of awareness and Screening:Breast Awareness (Being aware about symptoms of BC, looking out for them regularly, and reporting them on time to a doctor) is the single most important factor responsible for better survival of patients in the west
- Aggressive cancers in young:Generally, many cancers in the younger age group tend to be aggressive
“It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.” – Sir Arthur Conan Doyle.
The solutions for this in the 5 yr plan set out by the Indian Government in 2012, is to set aside huge sums of money and set up big referral centres for Cancers by 2017. Cancer for the first time, especially breast cancer, is being treated on par with communicable disease in India.
Apollo Breast Centre:
This structure, namely Apollo Breast Centre, provides the infrastructure and expertise together, at a destined space in a specialist hospital, based on single organ based practise.
This comprehensive set up provides for a given patient with a breast problem – breast specialists in radiology, pathology, nuclear medicine, surgical, medical, radiation oncology and plastic surgery, all under one roof – Apollo Breast Centre.
What a comprehensive breast centre aims to fulfil is, a practise based on Evidence Based Medicine through a Multi-Disciplinary Team (MDT) approach, with the various specialist involved.
It is comprehensive, because it deals with benign and malignant breast diseases with the specialist trained to deal with all these pathology, in this organ based practice.
Frame work and pathways in Apollo Breast Centre:
The centre allows for patients to be referred from multiple sources to a given physician or to the centre itself.
The referral, if not in person, will be routed to the specific clinician and the patients progress will be seamless – breast surgeon, radiology, pathology, nuclear medicine, medical and radiation oncology and other specialities, all pitching in for wholesome care.
A one stop clinic in this set up will prioritise examination and investigation (mammogram +/_ ultrasound and biopsy) at one consult, the same day. The patient returns for a second consult for results and treatment advice, later in the same week.
Benign disease will be sorted from malignant disease, through given protocols.
The benign: malignant ratio in a given Breast Centre is: 80:20. This accounts for a high patient load which needs to be systematically and meticulously sorted with patient comfort and speed being the priority.
Benign breast disease which includes breast pain and different breast lumps, needs to be diagnosed, treated and specialist advice given as they are the major component of the work load (80%). This will involve patients from all age groups, more so in the younger population, who will need quick, accurate advice and treatment, being the productive workforce in the community.
Breast Cancer can present itself in well women as part of a screening protocol a) as screen detected or non-palpable cancer or b) as symptomatic or palpable cancers in women presenting with lumps and other signs in the breast.
The diagnostic and treatment pathways and expertise required in the two groups are different but with variable overlap, all within the scope of a comprehensive Breast Centre.
This is done with mammograms (X-Rays) and is advised in women without a breast problem, from age 40 years onwards, once a year and once in two years after age 50.
Early detection before a lump is felt, is the biggest advantage with screening mammograms, which makes even the resulting breast cancer treatment – minimal.
Screen detected or non – palpable lesions as a result of Breast Screening:
Breast screening, be it population based or individual health checks, has thrown up interesting pathology, which need different expertise to detect, diagnose and treat.
The pathology thus detected are benign, indeterminate, premalignant or malignant.
These lesions are not palpable, hence the diagnosis is based on tests done with mammogram/Ultrasound/MRI and biopsy done under ultrasound or mammogram guidance (stereotactic biopsy).
These are discussed in a MDT meeting and further biopsy, surgery or routine follow up is recommended.
Small, sub centimetre lesions detected through screening like cysts, fibroadenomas, duct ectasia, micro-calcifications, when proven benign and are asymptomatic, can be left alone without surgery.
Indeterminate lesions detected through biopsy like columnar cell hyperplasia, ADH, ALH, radial scar, papilloma, LCIS etc., will be discussed in the MDT meeting, and decision taken to proceed further for biopsy or leave alone.
Pre malignant lesions like ductal carcinoma in situ (DCIS), or frank invasive cancer will again be discussed in the MDT meeting and treatment pathway recommended.
10 Myths and Facts about Breast Cancer as seen in the general population:
1) Are all breast lumps cancerous and contagious?
Only 20 out of 100 (20%) breast lumps turn out to be cancerous after routine testing. Majority of breast lumps (80%) are benign (non – cancerous) after testing. These cancers do not spread by direct or indirect contact.
2) Breast cancer lumps tend to be painful?
Only 5-10 out of 100 (5-10%) breast lumps present with pain as a main symptom. Majority of breast cancer lumps are painless.
3) Am I more likely to get breast cancer if I am large breasted?
The size of the breasts does not determine the risk of getting breast cancer. Breast is made up of mainly fatty and glandular tissue. It is the amount of glandular tissue which determines the risk for breast cancer and this may be more than fatty tissue in some women, with small size breasts and vice versa.
4) Is Breast cancer is more common after menopause?
Breast cancer incidence starts to rise from age 50 and peaks in the 60’s and then the incidence tappers off, from 70 years of age onwards.
5) Having children and breastfeeding is good in preventing breast cancer?
Having children and breast feeding decreases the exposure of the breast to oestrogen/progesterone hormones by inhibiting the natural menstrual cycle, and hence the benefit.
6) I will get breast cancer if my mum had it?
Only 5-10% of breast cancers detected are inherited through a gene mutation. Majority of breast cancers detected (90-95%), are not inherited.
7) Mammograms are painful and dangerous?
Majority of women who had mammograms when questioned, described it as a discomfort, and felt that, the benefit outweighed the discomfort, especially with modern digital mammograms. The radiation received, is less than in a Chest X-Ray, so not dangerous.
8) A mammogram can diagnose breast cancer for sure in all patients?
About 10% of cancers can be missed on mammograms, but an examination and ultrasound by a specialist, can negate this effect.
9) I need to remove my breast (mastectomy), only choice, if I have breast cancer?
The size of the cancer in relation to breast size (more than 4 cms) and position of the cancer (less than 1cms from nipple), and the number of cancers detected, usually dictate the need for mastectomy or not. Mastectomy rate varies between 30-50%.
10) Breast cancer cannot be cured?
The outlook for all types / stages of breast cancer, is 85-90% – 10-year survival. This is one of the better cancers to treat, especially when complete treatment is effected with full compliance.
The above myths indicate that the doctors need to emphasize, reassure and educate the public on various issues, and that screening programme is essential in detecting breast cancer at a very early stage, to keep the side effects of treatment and death rate to the minimum.
What Apollo Breast Centre aims to accomplish is to, bring this disease and its diagnosis and treatment under one roof, and in doing so, helps the patient in making this complex journey with comfort, compassion and speed, as all specialists are easily available in Apollo Breast Centre.
Dr AP Subash Kumar MBBS, FRCSI, FRCS(Edin), FRCS(Gen)
Senior Consultant Surgeon,
Breast/Surgical Oncology, ASH, Teynampet, Chennai.