Awareness is Key for Surviving

In a phase of Epidemiological Transition

The intriguing question is why is there an alarming increase in the incidence of cancer in India? There are various hypotheses and theories that are proposed such as, adoption of western lifestyle, changing dietary habits, evolving environmental factors. The exact reason remains unknown. But the fact of the matter is, India is in a phase of Epidemiological Transition (ET). 

Epidemiological transition is a phase of change that a society witnesses by increase in population growth rates brought by food security & innovation in public health & medicine. The results are, increase in life expectancy, replacement of infectious diseases by chronic diseases such as cancers and increase in cancers associated with lifestyle such as breast, colorectal & prostate. Similar results have been reported in Japan about 5 decades ago and in England in the latter half of the 19^th century.

Today, breast cancer is the most common cancer amongst urban Indian women. Although, the incidence is lower than in the United States of America (USA), the mortality rate is significantly higher. In USA, there are 234,087 new breast cancer cases annually with 41,904 (17.9%) deaths while in India there are 162,468 new cases annually with 87,090 (53.6%) deaths. If the disease is the same, why is there such a drastic difference in the outcome of the disease?

Why the abysmal outcomes in India?
One of the main reasons for the abysmal outcome amongst Indian women is the advanced stage of breast cancer at presentation. In India, more than 50% women present with stage 3 or locally advanced breast cancer (LABC) at diagnosis. Delayed diagnosis, increases cost of treatment by 1.5 to 2 times and reduces survival rate 3-17 times.

As opposed to this, in North America 5%-15% women have locally advanced breast cancer at diagnosis. Most women in North America are diagnosed at an early stage of breast cancer, typically stage 1 or stage 2. Therefore, North American women have a significant survival benefit. The key factors for early diagnosis are awareness about early signs of breast cancer and screening mammography. Because of the varying & diverse circumstances present in the Indian society, breast health awareness remains a challenge!

Breast Health Awareness – need of the hour

Breast cancer develops when breast cells multiply abnormally typically leading to formation of a lump or mass in the breast. There is a general assumption amongst women, “No pain, No problem”. However, many times, there is no pain in breast cancer. Therefore, if women are not aware of the signs and symptoms of breast cancer, they often do not notice them until it is too late!

Common presenting signs of breast cancer are painless palpable breast lump, skin thickening, crusting or scaling of the skin around the nipple areola complex, new onset nipple inversion & spontaneous bloody or watery unilateral nipple discharge. The symptoms may vary from patient to patient, but before the signs or symptoms develop, the cancer would have already been present for two to five years. This makes timely mammography screening at regular intervals a health priority.

Not every breast lump is cancerous. Nonetheless, every new onset palpable breast lump has to be evaluated by a physician. The doctor can then ask for a mammogram to be performed along with a supplemental breast ultrasound. If a suspicious abnormality is detected on imaging, it would lead to an image guided breast biopsy, which is a non-surgical biopsy with accuracy rates equivalent to a surgical biopsy.

Full Field Digital Mammography with 3D Tomosynthesis

Mammography is a powerful tool for timely detection of breast cancer. Mammograms do not prevent breast cancer, but they can save lives by early detection of breast cancers, even before the development of signs and symptoms of breast cancer. According to a report by the World Health Organisation, screening mammograms have shown to reduce breast cancer mortality by about 20%. Early detection of breast cancer has been further enhanced by newer innovations in mammography such as 3D Tomosynthesis.

3D Tomosynthesis is an advanced application of mammography, whereby instead of obtaining a single image of the breast, multiple slices are obtained and reconstructed such that small breast cancers do not hide in between the superimposed normal breast tissue. The Amulet Innovality from Fujifilm is one such application. 3D Tomosynthesis increases the detection rate of cancer by 25%-50% as compared to conventional mammography, facilitating identification of early stage breast cancer and reducing the need for additional tests and biopsies.

Most oncologists agree that breast screening mammography should start at the age of 40 and earlier in patients with high risks like genetic predisposition (BRCA 1 & BRCA 2 carriers) and those with a strong family history.

In conclusion, awareness about breast health and adoption of newer technologies such as 3D Tomosynthesis will enable us in early detection of breast cancer which is the key factor for saving lives.

About the author

Dr. Shilpa Lad is a Consultant-Breast Imaging & Interventions at NM Medical Center, Mumbai. She has also been the Assistant Professor & Radiologist at University of Ottawa, The Ottawa Hospital, Canada.