Are We Doing Enough To Fight Breast Cancer?
The covid pandemic and subsequent lockdown had a fallout on cancer diagnosis as patients delayed visiting hospitals due to fear of infection.
This was the case with Preeti (name changed), a 45-year-old housewife who felt a lump in her right breast when the lockdown had just begun. She put off visiting a doctor and it was only a year later as the world returned to a new normal that she went to the hospital and the slow-growing lump was diagnosed as breast cancer. Due to the delay in diagnosis, cancer had advanced to the third stage and required intensive treatment. She is still undergoing treatment and fortunately for her, the prognosis is good. But the same need not be the case with other patients who delay consulting a doctor.
Research suggests that a delay in beginning treatment of cancer by even one month results in an increase in the risk of dying by 6 to 13 per cent, and this keeps going up the longer the delay in starting treatment. Today, India faces an increasing burden of breast cancer with it being the number one cancer among women in the country.
Delay in diagnosis leads to a progression of the disease to an advanced stage and worsening of the disease. The high mortality results in nearly four out of ten women diagnosed with breast cancer dying of the dreaded disease. This is the reason that the major focus in the battle against breast cancer must be on promoting early detection when the disease is at an early stage and the prognosis for a cure and long-term survival is the best.
There are many reasons for the delayed detection of breast cancer in women with factors ranging from low awareness and health literacy, limited availability and access to cancer health services, and social stigma. The prime reason is that most women ignore initial symptoms as there is no pain or discomfort.
The level of public awareness about the disease is not as high as it should be. A survey carried out by Breast Cancer Care found that 5 per cent of women waited more than six months to report finding a symptom to their doctor. This is an issue that needs to be addressed on priority.
Creating awareness at the grassroots about the signs and symptoms and the importance of periodic screening for early detection of breast cancer is crucial. We must understand the nature of health beliefs related to breast cancer along with the attitudes of the female population to reduce the psychosocial risk factors.
Breast self-examination can serve as a useful adjunct to making the woman aware of her normal breast and any changes that occur. Education on these aspects must also include teaching women to help themselves and reduce cancer risks by following a healthy diet, not smoking, avoiding alcohol, staying physically active and exercising regularly, and keeping to a healthy weight.
Other reasons that lead to women delaying cancer screening include socioeconomic factors. A study has found that patients of rural background and low education status are more likely to be at an advanced stage of breast cancer at diagnosis than their urban counterparts.
Patients in urban areas are more likely to be diagnosed at stage 2 or earlier when the cancer is localised with palpable lumps, while in rural areas, breast cancer is usually diagnosed only after it has metastasised or spread to other organs in the body. Studies show that delayed diagnosis and higher mortality are linked to not just lower awareness but also poor access to healthcare facilities. Demographic factors such as lower education and literacy also play a major role.
Apart from increasing awareness and health education, periodic screening helps to catch the disease early with the onset of treatment at an early stage. Screening programmes should be organised for an identified target population based on the evaluation of risk factors with the optimal use of multidisciplinary healthcare teams.
Ultrasonography, though not typically used for routine screening can also be helpful in early diagnosis, especially in younger women aged 30 years and above. 50 per cent of women globally currently have no access to breast imaging.
Clinical breast examination (CBE) by a doctor or trained health worker has shown to be effective in detecting breast cancers in the early stage with survival benefit. In countries where access to mammography is not readily available, CBE is an effective method for early detection and can help overcome the limitations in low-resource settings.
Modern medical technology and innovation are leading to new methods such as Digital Breast Tomosynthesis and breast biopsy procedures. Digital mammography using computer-aided detection software can help in overcoming the limitations of lack of adequate mammography machines and trained manpower. Today, we also have several non-invasive prognostic bio-marker tests to diagnose breast cancer which are economical. Using the power of genomics, we are gaining insights into India-specific genetic biomarkers that can be used to identify women at high risk of developing cancer. The future will see genomics playing an increasing role in cost-effective targeted screening for breast cancer in a high-risk population and further enabling early detection and treatment of breast cancer.
Another key step is classifying cancer as a "notifiable disease" as recommended by the parliamentary standing committee on Health and Family Welfare. With cancer not recognised as a disease, cancer cases and deaths are underreported. With proper reporting of numbers, the correlation of data to the clinically proven fact that breast cancer is a completely curable type of cancer if detected at an early stage will get strengthened.
Finally, bringing together these facets into a successful strategy to combat breast cancer will require collaboration between private healthcare and the government. This will bring in multiple benefits. Breast cancers diagnosed at an early stage cost much less to treat than those diagnosed at a late stage.
The typical cost of treatment including radiation, surgery, and investigations costs less than Rs 3 lakh. Targeted and personalised chemotherapy costs more than Rs 20 lakh. Working together across initiatives for early detection, prompt diagnosis and treatment including training for front-line health workers who are often the initial point of contact for most women will help reduce system-level delays and save on costs.
Studies have shown that almost 99 per cent of women diagnosed with breast cancer at an early stage live for 5 years or more, compared to just 27 per cent of women diagnosed at an advanced stage. The target of at least two-thirds of breast cancer patients to be detected at an early stage must be achieved with a positive impact on population-level survival outcomes.
