Breast cancer: A tranquil in potential turmoil is not an impossibility (Opinion)

MANORAMA BAKSHI

Breast cancer continues to be a major public health problem globally. India is no exception, breast cancer accounts 14 per cent of all cancers in Indian women, almost one in every four minutes, an Indian woman is being diagnosed with the breast cancer. In 2018, 1,62,468 new diagnosed cases and 87,090 reported deaths from the breast cancer were registered in India.

The majority (53 per cent) of new breast cancer cases are among women living in low-and-middle-income countries (LMICs). A shift towards more affluent lifestyles, particularly those linked to the dietary and reproductive risk factors, and changing fertility patterns attributable to fast urbanisation are found to be associated with an increasing burden of breast cancers in the LMICs.

Although inadequacy of early detection programmes and access to treatment are often blamed for placing the women in LMICs at a high mortality risk of breast cancer, poor awareness level, inadequate knowledge about signs and symptoms influencing the women's capability to understand the disease and its severity, and individuals' perceptions and beliefs about the symptoms, the disease and the health defining the women's ability to recognise and respond to their illness are found to be the cause of turmoil at the household level.

A lump in the breast or in underarm area and/or breast pain are the most common presenting symptoms [nipple discharge other than breast milk (including blood) is also not uncommon] but often, cognitive and emotional responses of the women are not the same and such differences emerge from the context of everyday lives and the knowledge of the women around breast cancer. The factors conditioning cognitive and emotional responses to the breast cancer are:

Socio-demographic factors
1. age,
2. level of education attainment,
3. hierarchical position of the household in the community,
4. relationship status,
5. living arrangements in the family and harmony in the relationships within the household,
6. occupation,
7. financial coverage for healthcare services.

Social factors
1. role obligations within the household and in the community,
2. practice/culture of symptom disclosure in the household and in the society.

Health seeking behaviour
1. self-examination of breasts,
2. mammography examination.

Emotional stability
1. fear,
2. threshold of anxiety and apprehensions,
3. level of stress and depression,
4. degree of optimism for life and practice of pragmatism in existence.

Perceived characteristics of Health System
1. accessibility,
2. responsiveness (including personal acquaintance with the healthcare service personnel),
3. appropriateness,
4. affordability (direct cost of healthcare service consumption at the point of service and incidental costs like travel, child care services, loss of wages, and so on�).

Early diagnosis of symptomatic cancer is linked to longer survival and more favourable outcomes for women. Studies have established that the delay in presenting to a healthcare service provider with a self-discovered breast symptoms varies between one to three months when an adequate knowledge (breast symptoms, breast changes associated with breast cancer, presence/absence of a family history of breast cancer) and beliefs (cause of symptoms, consequence from duration of symptoms,possibility of cure/control of symptoms and likely outcome from alternate help/therapy) exist in the society.

Longer delay is associated with a lower survival rate from breast cancer, more than three months delay in diagnosis is also not uncommon. Women's beliefs in the alternative help seeking behaviour of "ignoring the symptom and hoping that it would go away" are having the most common association with the increased likelihood to delay in diagnosis.

The whole month of October is now dedicated by International Agency for Research on Cancer to increase awareness worldwide with the knowledge of breast cancer. The first organised effort for bringing widespread attention to breast cancer has its origin as a week-long event in the United States in October 1985 with the message, "reduce the risk of having breast cancer by not smoking, limiting or avoiding alcohol and staying physically active."

The Government of India (GOI) did recognise this epidemiological transition from a predominance of infectious diseases, and has launched the National Program for Prevention and Control of Cancer, Diabetes, CVD and Stroke (NPCDCS) in 2011. Since then, most of the Indian states have initiated some activities under the programme, NPCDCS with technical and financial support from the federal government.

However, much more is needed to be done, since avoidable mortality continues to be high, and also years of life lived with disability due to poor coverage of screening programmes and access to the treatment for noncommunicable diseases (NCDs). Although regular screening has been initiated under the aegis of GOI, participation is low with only 5 per cent of the eligible women for breast cancer screening programme.

Science has progressed over the century from diagnosing early to preserve the pleasure of living life with interventions for different stages of breast cancer affecting different groups of population in different geographies. Each woman is different and so, is the treatment plan for the 'breast cancer', called 'personalised medicine' developed by the doctors specialising different areas of cancer treatment, like 'surgery', 'radiation oncology' and 'medical oncology' working together with radiologists and pathologists. The multidisciplinary team for care includes, in addition, physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, psychological counsellors, nutritionists, physiotherapists and rehabilitation therapists.

The common types of treatments used for early-stage and locally advanced breast cancer are:

1. Surgery - the removal of the tumour and some surrounding healthy tissue. The types of surgery for breast cancer include (a) lumpectomy i.e., the removal of the tumour and a small, cancer-free margin of healthy tissue around the tumour (here, most of the breast remains), and (b) mastectomy i.e., the surgical removal of the entire breast (variants: skin-sparing mastectomy and nipple-sparing mastectomy). Lumpectomy or partial mastectomy is generally followed by radiation therapy if the cancer is invasive. Mastectomy may also be with or without immediate reconstruction of the breast. Surgical intervention includes lymph node evaluation (lymph node biopsy and/or axillary lymph node dissection).

2. Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. Radiation therapy can cause side effects, including fatigue, swelling of the breast, redness and/or skin discoloration, and pain or burning in the skin where the radiation is directed, sometimes with blistering or peeling. Different types of such a therapy are (a) external-beam radiation therapy (b) intra-operative radiation therapy, (c) brachytherapy, (d) partial breast irradiation, (e) intensity-modulated radiation therapy, and (f) proton therapy.

3. Therapies using medication (medication through the bloodstream to reach cancer cells throughout the body) - (a) chemotherapy (use of drugs to destroy cancer cells, usually by preventing the cancer cells from growing, dividing, and making more cells), (b) hormonal therapy (also called endocrine therapy, an effective treatment for most tumours that test positive for either oestrogen or progesterone receptors), (c) targeted therapy (targets the cancer specific genes, proteins, or the tissue environment that contributes to cancer growth and survival, thus such treatment blocks the growth and spread of cancer cells and limits damage to healthy cells), and (d) immunotherapy (immune checkpoint inhibitor is used for the treatment of high-risk, early-stage, triple-negative breast cancer).

Managing physical, emotional, financial and social effects of breast cancer is understood as palliative care or supportive care. Supportive care treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, spiritual activities and family counselling.

Women who receive supportive care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with the treatment and overall quality of life during and after treatment. Supportive care intended to 'slow', 'stop', or 'eliminate' the breast cancer is to start with the diagnosis of the breast cancer/symptoms.

WHO describes adherence to breast cancer treatment as a multidimensional phenomenon which is determined by the interplay of factors from five dimensions i.e., (a) socioeconomic factors (e.g., socioeconomic position, level of education attainment, and cost of medications); (b) health system factors (e.g., ease of accessibility, responsiveness of healthcare service providers, and medication distribution systems); (c) disease condition factors (e.g., severity of symptoms, and level of disability); (d) therapy-related factors (e.g., the immediacy of beneficial effects, side effects, and duration of treatment); and (e) patient factors (e.g., self-efficacy, knowledge, treatment beliefs, and perceived barriers to adherence).

An early detection of breast cancer is having an estimated effect to reduce the mortality by 28-65 per cent. When the potential turmoil in the life and the existence caused by being late in getting diagnosed with the breast cancer is indisputable, the Clinical Breast Examination (CBE) offers the promise to preserve the tranquil of life. CBE (a breast examination performed by a healthcare service provider) prevents progress of an early-stage cancer to the advanced stage in the range between 17 to 47 per cent of cases. The results are promising and of interest for LMICs where a national screening programme based onmammography is not a realistic option. This reviewed evidence confirms greater effects of CBE on younger women and Asian women. Further, the probability to detect breast cancer with a sensitivity and specificity by CBEs is 54 per cent and 94 per cent, respectively.

Here, I conclude with the note that investment in 'technology' is not any panacea but CBE in conjunction with shift from the existing paternalistic style of communication between the vulnerable population and the healthcare service providers to participatory style of communication is having the promise to stop the present welfare loss (equivalent to 0.08 per cent of regional GDP, 2021) directly attributable to breast cancer in South Asia.

A limited health education programmes, particularly in rural and isolated areas, poor training of healthcare service providers and quality of information provided by the health systems are the obvious barriers to women's help seeking behaviour for an early detection of self-discovered breast symptoms.

(Manorama Bakshi is Director of Health & Advocacy Consocia Advisory. The views expressed are personal)