Dr. Sumeet Shah answers some of the common questions that overwhelm women, especially those living in areas where the rate of development breast cancer is high such as India.
Breast cancer is fast spreading in India and what stands more important than anything as a step to defy the odds is awareness about it. Below is all you must know about breast cancer to keep it from developing too much and too late, in the words of a breast cancer oncologist himself.
Since breast cancer is not as widespread in India as in the U.S, why must every woman in India be aware about it?
Breast cancer may not be as widespread in India as in the US, but it is showing a significant rise in both urban as well as rural areas. The rise in urban areas is very alarming. Besides the fact that it is occurring in younger age groups as well, most patients present in stage 2 and beyond, predominant reasons being their lack of awareness of this disease, undue waste of time in alternative therapies, and in many cases, even the lack of awareness of their first contact doctor, who treats the lump as a ‘normal’ causing a delay of a couple of months. A delay of even a month or two can upstage the disease. Higher the stage at presentation, the lower the survival.
What are the prominent signs of breast cancer that a patient must look out for?
The most common symptom is a painless, hard ‘knot’ or a ‘lump’ in the breast. Because it does not cause any pain, it is often ignored by the patient. (All cancerous lumps may not be painless, occasionally there may be pain as well).There can be other symptoms like a ‘bloody’ or ‘blood stained’ discharge from the nipple, in drawing of the nipple, changes in the skin of the nipple, dimple on the skin over the lump, changes in skin, which make it hard and look like an ‘orange peel’. In advanced cases, there may be ulceration. Also, along with these symptoms, there can be lumps or knots in the arm pit (axilla) as well.
Since breast cancer can develop at any age, at what age must a woman (aged +18 or +40) start getting herself checked for any symptoms of the disease and how often? Can a woman aged not more than 40 years undergo mammography? If not, what are the consequences?
‘Breast Awareness’ is the key word here. Following are the standard recommendations, as put down by the NCCN, for ladies with a ‘normal’ risk:
From age of 20 to 40 years:
- Breast Awareness: A lady must be ‘aware’ of the changes in her breast. She must perform a BSE (Breast Self Examination) once every month, around 5th day of the cycle. This will enable her to promptly detect any change or any ‘lumpish’ feel in the breast, or in the nipple, or arm pits and report to an ‘experienced’ health care provider
- CBE (Clinical Breast Examination): A lady must visit her health care provider, who is experienced in breast diseases, once every one to three years for a routine breast examination.
From age 40 years onwards:
- Breast Awareness
- Annual CBE (Clinical Breast Examination)
- Annual Mammography
To please note: The above guidelines are from the US, and after studying the trends in their population. It may not necessarily be matching for our population. They provide a good framework till the time we frame our own guidelines. It is essential that ladies do not go for screening mammography on their will, but consult their health care provider, and then do the mammography, else the findings of mammography can lead to a lot of undue confusion. Because in many instances, it may be possible to defer mammography till even 50 years (as is the protocol in European nations), let the doctor decide. However, in no instance, should a ‘screening’ mammography be done before 40 years of age because below 40 years of age, usually, the breast tissue is very dense, and mammography will not pick up smaller cancers and may be reported as normal even though there may be an underlying cancer. Hence, it is essential that women consult their health care provider, get a breast examination, and if there is any suspicious finding in women under 40, an ultrasound of the breast may be advised. If the ultrasound shows up something, then is the time that a mammography be done even in age less than 40 years, or it may be done if a lady presents with a hard lump, where there is a strong suspicion of cancer. Let your doctor decide, let your doctor assess and calculate your risk for developing breast cancer.
Apart from the above general guidelines for a normal risk lady, there are specific guidelines for ladies at high risk. You can find the details at http://www.breastcancerindia.net
Does the current trend of women marrying late or not marrying at all (in which case there is no breastfeeding); pursuing unhealthy habits, etc have anything to do with increasing breast cancer cases in India? What are the other lifestyle-related factors that may be increasing one’s risk?
It is generally believed that the more the exposure of breast tissue to the hormone estrogen, the more the chances of developing breast cancer. The hormone estrogen is produced in the female body, starting from menarche (the first menstrual period) to menopause (when the menstrual cycle gets over); it is produced in the first half of every menstrual cycle, and it circulates in the body, also having effect on cells of the breast. The only time, estrogen levels go down, is pregnancy. So early menarche, late first delivery (beyond 30 years of age), late menopause; all increase the time for estrogen to act on the breast and hence they are considered as risk factors for breast cancer. Life style related factors include food habits (more of junk food, fatty food), obesity, alcohol, improper sleeping hours (night shifts), lack of exercise etc. About 4 to 8% of breast cancers may be hereditary, due to certain genetic changes, which are carried down the generation, and these breast cancers (and ovarian cancers) tend to occur at very young ages.
What precautions must a breast cancer patient take after having been diagnosed with the disease? (Ensuring the surgeon is certified, quitting unhealthy habits, etc)
Specific precautions to be taken are those during chemotherapy (related to infections, hair fall etc.); apart from that, nothing more. A breast cancer patient is as normal as any other individual and can lead a normal life.
What is the most common type of treatment given to breast cancer patients? Can a patient choose to conserve her breast/s irrespective of the type/stage of cancer?
The treatments of breast cancer include surgery, chemotherapy, radiation therapy, hormonal therapy, targeted therapy, and most importantly, rehabilitation (both mental and physical). All the above treatments play an important role. Surgery is usually done first, so as to remove the cancer and the draining lymph nodes. The other treatments are then given, so as to reduce the chances of cancer coming back. However, quite commonly in Indian scenario, women present in advanced stages, where the tumour is not amenable for surgery. Here, chemotherapy may be given first, to reduce the size of tumour, and to make it ‘operable’ and then surgery may be performed. All breast cancer patients must be treated by multidisciplinary teams, consisting of all specialists of treatments mentioned above.
[Read: Types of Breast Cancer Treatment]
As for surgery, more than 70% tumours are amenable to breast conservation, and we can very well do that. All patients who undergo breast conservation surgery, compulsorily need radiation therapy, to decrease the chance of tumour coming back in the same breast. There is a common misconception in the minds on many patients that conserving the breast will cause the tumour to come back. It is not so! The chance of the disease coming back elsewhere in the body, after a breast conserving surgery is the same as where the breast is removed. There is only a slightly higher chance of tumour coming back in the breast which is conserved. But I must add here, it is essential that breast conservation surgery be done by a specialist in breast diseases, for two reasons, one, to achieve a good cosmetic outcome, which needs a proper understanding and planning of incisions and reconstructions; and second, to achieve a good cancer free margins. Those inexperienced in breast diseases, or those who do not do such surgeries frequently, may end up messing with both the above points, resulting in an inferior cosmetic outcome, or getting close margins which will increase chance of disease coming back.
What should a breast cancer patient expect in terms of changes in the body during/post treatment? Most breast cancer survivors report to have been nauseated and severely fatigued during the course of chemotherapy.
Most chemotherapy related side effects can be controlled by appropriate medications, which will improve the quality of life of the patient. This (side effects of chemotherapy), by itself, is a vast topic and it is not feasible to discuss here. Few things that help during chemotherapy, are positive attitude, Yoga, a good intake of water (3 to 4 litres daily), balanced food, adequate fruits and a good moral support from the family. If a lady feels fit during chemotherapy, she must continue working, which will help a lot.
[Read: Breast Cancer and Weight Changes]
Are there any limits to what a patient can do during or post treatment?
No there are no limits as such. It is very subjective, and depends upon the patient.
What changes must a breast cancer patient make in her lifestyle during and post treatment?
No changes. The only thing that matters is a positive attitude. A breast cancer patient undergoes a lot of depression during the treatment, many of them become very conscious about their image, the way they look, the way others look at them and perceive them. Many of the patients feel that they no longer look beautiful; they are not what they were earlier, especially with respect to their body image. This is the most important point that they must overcome. It is essential for a breast cancer patient to feel positive, strong and come out of this. And the most important role is that of the patient’s husband, children or immediate relatives. They must make that patient feel, that they are as beautiful as ever, that they love them as much as they always did; they are as much needed and as much important as they always were, and that the patient is not alone in this fight; they are all together, they must just hold the patient’s hand and tell, do not worry, soon all the treatment will be over, and good days will be here again!
Why are post-treatment follow-up sessions important?
Any cancer, at whatever stage at presentation, can always strike back. Hence, all cancer patients are given a follow up protocol, usually every three months for the first two years, every six months for the next three years, and yearly thereafter. A doctor performs a routine checkup to see if there is any chance that cancer has come back. But this is not the only reason for a follow up. It is the doctor’s duty to ensure a proper rehabilitation. A doctor must also see during the follow up, whether the lady is now back into her routine life or not, does she need any help, etc.
Dr Sumeet Shah is a Surgical Oncologist from Mumbai.
Read more articles on Breast Cancer.
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