Breast Cancer Prevention and Perspective

Kerala Cancer Crusade and Cancer Literacy Mission and IRIA Preventive Radiology National Program conducted a Webinar Series on “Breast Cancer Prevention and Perspectives of a Preventive Oncologist” in association with IRIA Kerala, Swasthi Foundation and Community Oncology, Regional Cancer Centre, Journo Med. The second-day webinar discussed “Breast Cancer Prevention and Perspectives of a Preventive Oncologist”. The event was held on 7th October 2022.

October month being “Cancer Awareness Month” and “National Breast Cancer Awareness Month” was introduced in the year 1985 as a campaign by the American Academy of Family Physicians, AstraZeneca Healthcare Foundation, Cancer care and other organizations. Also, “Male Breast Cancer Awareness Week” was celebrated in the third week of October. An annual campaign was conducted to educate people regarding Breast Cancer. Awareness is created to promote education, and to screen and early detect the risk of cancer among cancer patients. Positive promotions educate and support the campaign. 

Breast Cancer 

Breast Cancer is a disease where the breast cells grow without control. Cancer usually depends upon the cells that lie in the breast. Breast cancer being metastasized and spreads through blood vessels and lymph nodes. It rapidly spreads to other body parts. 

Commonly developed Breast Cancers:

Invasive lobular carcinoma: Cancer cells arise in the lobules and spread in the breast tissues which are closely located. Invasive cancer cells spread to other body parts. 

Invasive ductal carcinoma: These cancerous cells develop in the ducts and spread to other breast tissue parts. Invasive cells spread and metastasize to other parts of the body. 

Understanding the genetic and chemical makeover of cancers helps doctors in easy diagnosis, and they opt for the effective treatment for specific cancer. Not all breast cancers are malignant. 

The Significance of October month i.e., Cancer Awareness Month was well illustrated by Dr Gomathy Subramanian, President of IRIA Kerala. Today Breast Cancer is the most prevalent issue among women. Breast cancer awareness is being conducted at many institutions since October 1st, 2022, including various academic sessions. 

Mr A. Hemachandran, IPS, Former DGP, Kerala Police expressed his view on Cancer Significance, the detection of cancer in ancient times, and the establishment of a gap involving cancer care. The gap regarding cancer care is due to the lack of proper medical facilities, awareness and scientific temper. He revealed his agony regarding Cancer Care where people still follow the ancient treatment methodologies though there is an evolution of Modern Medicine. People are still in fear to use Modern Medicine and adapt to their traditional ways of treating cancers, where few traditional applications may deteriorate and aggravate the problem. He explained that Kerala is a state with abundant facilities and regional care centres for cancer care. 

Dr Kalavathy MC, Associate Professor, Division of Community Oncology, Regional Cancer Centre spoke about the Significance and Early Detection of Breast Cancers. 

The Burden of Breast Cancer Disease

The incidence of breast cancer is around 55 women/ 1,00,000 women. So, the prevalence must be around 150/1,00,000. But in the case of breast cancer, it is much higher. Around 10,000 new breast cancer cases are reported in Kerala annually. So, the number of prevalent breast cancer cases may be around 50,000. The incidence (the number of new cases detected in a year) is comparatively high in Kerala. 

Prevention 

If a single important risk factor is there, it is very easy to prevent the disease and just remove that factor. For example: In the case of lung cancer, smoking is an important risk factor. So, if one doesn’t smoke, the risk of getting lung cancer is very low. But in the case of breast cancer, it is a multifactorial disease, there is no proven single important risk factor. So, primary prevention is very difficult. 

Risk Factors 

The risk factors of breast cancer include

• Ageing 
• Nulliparity 
• Late age of first delivery
• No breastfeeding 
• Early Menarchy and Late Menopause
• BRCA 1 and 2 mutation in a family 
• First-degree and second-degree relatives with breast cancer
• Post-menopausal obesity 
• Surgery in the breast for benign diseases, some benign conditions of the breast 

How to tackle Breast Cancer?

Breast cancer is a very huge public health issue, and many women are suffering and living with this disease. The burden of this disease is very high. Then how to tackle such cancers. Survival is better for an early staged detected breast cancers which are treated properly. The maximum number of years for cancer survivors is 5 years. The condition of the patient is good in stage 1 and stage -2. When it comes to stage-3 and stage 4, the survival rate is very bad. That shows the importance of early detection. 

How to detect Breast Cancer early?

• Self-breast examination (BSE)
• Clinician breast examination 
• Breast ultrasonogram 
• Mammogram 
• Fine needle aspiration cytology (FNAC) is effective in easily palpable lumps, but good laboratory services needed
• Magnetic Resonance Imaging (MRI)

Cost-Effective Methodologies for Screening

• Breast self-examination is simple, with no cost involved but effective. The number of false positives is high and leads to more investigation load. 
• In the case of the physician’s breast examination, access is the problem. Many times, women doctors are unavailable for breast examination and many times, it leads to further investigations. 
• Ultrasonogram is comparatively cheaper, but many times again access is the major difficult issue.
  Mammograms, if need to be performed many times, mostly asymptomatic women are hesitant, it is a more expensive procedure in routine, even though, it is considered as “Gold Standard for Breast Cancer Screening.”
• Magnetic Resonance Imaging (MRI) is not routinely done as part of breast cancer screening unless, in specific conditions, it is also very expensive. 
• Genetic study screening: BRCA 1 and 2 mutation studies are not recommended for population screening. So many social and cultural issues arise during this screening. 
• Fine needle aspiration cytology is effective in easily palpable lumps, but if the lumps are not easily palpable, good access is a problem, the expense is a problem, and good laboratory services are recommended. 

Risk Stratification 

• Screening all women in the age group 30-65 years in Kerala is not feasible due to the limited infrastructure available
• Risk stratification of women and offering screening and investigative services to the high-risk category is the accepted strategy in breast cancer screening in countries with limited resources like India. 
• All know that in countries like the US, UK etc., all the women schedule their annual mammographic screening. They have to schedule mammography on a particular day. But in India, people don’t have that practice. Even in Kerala, though people are highly educated, health conscious etc., one can’t expect a normal woman, an asymptomatic woman who is having very good breasts and even if the woman doesn’t feel routine pain, women don’t recommend going for mammographic scanning alone. Here, the women are categorized under the high-risk category and the low-risk category groups based on their acceptance of mammographic tests. 
• Nulliparous women, women who had first childbirth at a later age, women with BRCA 1 and BRCA 2 mutation, women with a family history of breast cancer in the first-degree and second-degree relatives, women who have undergone surgery for benign breast conditions and women with sudden benign breast conditions (all these are non-modifiable risk factors etc.) can be included under the high-risk category.  
• Obesity, smoking, drinking and being sedentary etc. also have a risk-enhancing effect (these are modifiable risk factors). 
• All women who do not have the above-mentioned factors fall under the average risk category. 
• Various tools are available to calculate the risk of developing breast cancer based on the selected risk factors. 
• So, in any screening programme focus on women with the above-mentioned risk factors and women who currently have any swelling or lump in the breasts.
  

Methodology accepted 

• Women with average risk if attending the screening program can be palpated and if any lump is detected, can be subjected to imageological testing (with USG for younger women with dense breast tissue and mammogram (MMG) for elderly women with less breast tissue. May be followed by FNAC.
• If the women are in the high-risk group if the lump is palpable, can be subjected to USG/ MMG/ FNAC. But even in the absence of any palpable lump, women may be subjected to routine imageology. 
• MRI may be reserved for women with no palpable lump in the breast but who have a strong family history.
• For eg: A history of ovarian cancer in the family is also a risk factor, but the history of ovarian cancer is many times confused with cervical cancer. 

Preventive Oncologist/ Imageologist and Pathologist Role in Detection of Breast Cancers 

• All three professionals form an important trio in breast cancer early detection.
• The imageology results help in getting a diagnosis of cancer/pre-cancer (ductal carcinoma in situ)/ equivocal (BIRADS 1 Va, 1 Vb etc.)/ benign/ normal.
• In equivocal cases FNAC may be of great help in many cases, in others again depending on the background risk. MRI or follow-up or surgical consultation have to be done. 
• FNAC and biopsy act as factors helping in confirming the diagnosis. 

Prevention of Breast Cancer

• Concentrate on modifiable risk factors like physical activity. More vegetables, fruits and low calory food must be consumed
• Avoid being obese,
• Walk regularly as if the person’s health permits even if the individual has his/her vehicle,
• Women with high risks may concentrate on all these factors, but they should do the regular SBE, clinician examination, USG/ MMG etc. which helps in early cancer detection. 

Conclusion

• Having risk factors do not mean that one will develop breast cancer.
• Many women develop breast cancer with no identifiable risk factors.
• But women with a high-risk factor profile have a slightly higher risk of developing breast cancer.
• Self-breast examination is to be made mandatory for all women to detect breast cancers.
• Modifiable risk factors for breast are risk factors for many other cancers and other chronic diseases.
• All of us need to practice the measures to prevent breast cancer apart from involving in conversations regarding breast cancer.