IT city (Bangalore) is also India’s Breast Cancer Capital

Bangalore is India’s breast cancer capital – Dr. Anita Khokhar’s Blog

Bangalore now has the dubious distinction of being India’s Breast Cancer Capital. In a recently concluded population based study, the IT city has registered the highest incidence of Breast Cancer cases in the country (36.6 new cases for every one lakh population). (Source: PBCR data)

This data compiled from 11 cities across India revealed Thiruvananthapuram to have the second highest incidence of Breast Cancer at 35.1 followed by Chennai (32.6) and Nagpur (32.5).

Although the study has revealed these numbers, the actual incidence of Breast Cancer in these cities is much higher. This is due to the fact that many cases go un-reported.

The reasons for such a high incidence of breast cancer in Bangalore are quite obvious:

  • Increased incidence of smoking and alcohol consumption among women
  • Early menarche (age at which menstrual periods start) due to obesity and Western lifestyle habits
  • Late marriages and children
  • Lack of breastfeeding
  • Increased use of estrogen based contraceptives
  • Late menopause and the use of hormone replacement therapy following menopause

All these factors are known risk factors for breast cancer and are quite prevalent in Bangalore.

This study should serve as an eye opener for women not only in Bangalore but also other metropolitan cities of the country.

 

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Molecular sub-types of Breast Cancer

Molecular markers are the order of the day in most cancers and novel treatments are being developed against these molecular targets. In breast cancer also, these molecular markers not only help in deciding the management but also serve as prognostic markers.

Recently, breast cancer has been divided into four major sub-types:

  • Luminal A
  • Luminal B
  • Triple negative/ basal
  • HER 2 enriched

The following table depicts the molecular profile of these tumors:

Subtype These tumors tend to be

Prevalence (approximate)

Luminal A ER+ and/or PR+, HER2-, low Ki67

40%

Luminal B ER+ and/or PR+, HER2+ (or HER2- with high Ki67)

20%

Triple negative/basal-like

ER-, PR-, HER2-

15-20%

HER2 type ER-, PR-, HER2+

10-15%

ER – estrogen receptor, PR – progesterone receptor

Luminal A tumors:

Most breast cancers are luminal tumors. These tumors resemble the cells lining the mammary ducts and they tend to be:

  • Estrogen receptor-positive (ER+) and/or progesterone receptor-positive (PR+)
  • HER2/neu-negative (HER2-)
  • Low proliferation index (Ki67)
  • Tumor grade 1 or 2

Patients with these tumors express ER, PR receptors and thus are candidates for hormonal therapy (tamoxifen, anastrozole, etc.).

Out of all the four sub-types, luminal A tumors tend to have the best prognosis and low recurrence rates.

 

Luminal B tumors:

Luminal B tumors tend to be:

  • ER+ and/or PR+ (like luminal A tumors)
  • High proliferative index (Ki67) – high number of actively dividing cancer cells
  • Her2/neu positive or negative

Women with luminal  B tumors tend to have a poorer prognosis as compared to patients with luminal A tumors and the tumor characteristics in these patients include:

  • Poorer tumor grade 
  • Larger tumor size
  • Lymph node-positivity

 

Triple negative/basal-like:

Triple negative breast cancers are:

  • ER-
  • PR-
  • HER2-

Characteristic of triple negative tumors:

  • Occur in younger women
  • More common in African American women. Indian studies have also shows a very high rate of triple negative tumors among young Indian women.
  • Aggressive tumors with poor prognosis (worst prognosis among the four sub-types)
  • Increases chances of distant metastasis
  • As these patients are ER, PR negative, they are not candidates for hormonal treatment

These tumors are also referred to as a Basal like tumors and exhibit similar characteristics to tumors found in patients with BRCA 1 gene mutations.

 

HER2 enriched tumors:

HER2 type tumors tend to be:

  • ER-
  • PR-
  • Lymph node-positive
  • Poorer tumor grade
  • HER 2 positive (although 20-30% can be HER 2 negative as well)
  • 75 percent of HER2 type tumors contain p53 mutations
  • Poor prognosis

HER2/neu-positive tumors can be treated with the drug trastuzumab (Herceptin).

 

 

Goldilocks Mastectomy – Will it have a fairy tale ending?

Goldilocks mastectomy is a relatively new procedure developed by Dr. Grace Ma and Dr. Heather Richardson. This is a single stage procedure, which gives women facing mastectomy an option that takes the best features of having and not having reconstruction and combining them into a single procedure. This procedure has been a recent topic of debate at many scientific gatherings.

The first question which pops to the mind is that why was this surgery named as Goldilocks mastectomy? The following is the reply given by the surgeons who developed this surgery:

“Most of us are familiar with the story of the young girl faced with uncertainty in the woods and with a big, bad wolf nearby. She had many choices to make, and each time she face a choice, she evaluated the pros and cons; risks and benefits of each one.  Most involved extremes -too hot or too cold; too hard or too soft. But there was a third choice that had attributes of both and fell somewhere in the middle. This was considered “just right”.

We chose this name because this technique embodies the simplicity of not having reconstruction and only having a single surgery with as little as possible discomfort and down time. Yet it preserves as much of the patient as possible and avoids an amputated appearance.

For those who still aren’t quite as large as they would like to be and choose to wear a prosthesis, wearing a bra is much more comfortable and the cleavage much more natural appearing.  Redundant tissue under the arm is avoided and the final result very soft and supple.

When discussing the different choices and options pre-operatively, it is easy to remember what a “Goldilocks” is and how it differs from mastectomy with and without formal reconstruction.”

Not all patients are eligible for Goldilocks mastectomy. It is mainly suitable for patients with large breasts, who have enough tissue left behind after mastectomy, which can be used to reconstruct the breast. It is NOT suitable for patients with small breasts!!

The following are the advantages of this procedure, as highlighted by the surgeons on the website (www.goldilocksmastectomy.com)

  • Can be performed on one or both breasts
  • Can be performed for prophylaxis or treatment of disease
  • No additional surgeries are required
  • No implants or artificial devices are used
  • Decreased pain and shorter recovery time when compared to formal breast reconstruction
  • Surgical removal of breast gland under the skin means:
    • No screening mammograms required
    • Most patients do not require radiation (dependent on the stage of disease)
  • Excellent option for patients who don’t want reconstruction or are otherwise poor surgical candidates for formal reconstruction
  • Patients with extremely large breasts or sagging breasts have the best outcome from this procedure

In this procedure, all the breast tissue is removed and the remaining redundant skin and tissue is mobilized and used to reconstruct the breast, which is usually much smaller than the original size and also in some cases deformed.

As it is a relatively new procedure, long term data is yet to reveal the efficacy and safety of this procedure compared to the conventional mastectomy. Another point which I could gather after reviewing the limited data available on this surgery is that cosmetic results are far INFERIOR than a regular reconstruction (whether implant based or autologous). Another reason for its limited use is that it can only be used in patients with LARGE breasts and a point which has not been highlighted by the authors is the gross disparity in size of the two breasts after the surgery (which is a source of worry to the patient).

It is still early days for this procedure and only time will tell whether it will have a fairy tale ending or not!!

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Indian Cancer Congress

Cancer incidence is rising rapidly in India and in an attempt to find Indian solutions to Indian problems, the 1st Indian Cancer Congress was organised recently in Delhi. More than 2500 delegates attended this conference, making it a grand success. For the first time the surgical, medical and radiation oncologists organised a common conference with a single aim: to help tackle the growing problem of cancer in our country.

It was a great platform for Oncologists all over the country to showcase their work and I was fortunate to be awarded the Best Poster Prize for my work on Breast Cancer.

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The next Indian Cancer Congress will be organised in Bangalore in a few years time and I am eagerly looking forward to it.

Chemo curls – Some like them, some don’t

Curls

 

Hair loss is a common side effect of most of the chemotherapeutic drugs used in the management of Breast Cancer and this period is quite traumatic for patients. It takes them some time to adjust to their new appearance, but their problem does not stop there.

After chemotherapy, majority of the breast cancer survivors start curly hair and no one exactly knows the reason behind this. This trend is universal and not restricted only to India. There is a lot of information about this on the net but no one exactly knows the scientific explanation behind this phenomenon. After reading a lot of survivor stories, I could infer that the texture of the hair after chemo is certainly different from a patient’s original hair and although some patients experience slight improvement in the quality and texture of their hair over time, for majority, this problem is life long.

For some patients, hair growth after chemo is a morale booster and they welcome this hair growth, without being concerned about the texture and the quality of hair. But for some patients, managing these curls can be quite a problem. It takes them a long time to get used to their new appearance and new hairstyle.

The following websites provide more information about chemo curls and how to manage them

http://www.naturallycurly.com/curlreading/living/curls-after-chemo-hair-loss

http://www.naturallycurly.com/curlreading/living/chemo-curls-a-survivors-tale

http://www.nbcnews.com/health/chemo-curls-another-kink-cancer-recovery-1C9386921

Our Pink Crusader

Chemo curls

Breast cancer cases in India to double by 2030

Currently, one in 23 Indian women develop breast cancer, but a recently concluded study states that the numbers are going to double by 2030 –Breast cancer cases to double by 2030: Study – Times Of India.

India is on the brink of a breast cancer epidemic and the question is that is it really prepared to handle this epidemic?

This study highlights some important facts:

  1. 115,000 new cases of breast cancer are diagnosed each year and this number will double by 2030.
  2. Indian breast cancer presents a decade earlier than the Western world. This means Indian women in their thirties and forties will bear the brunt of this epidemic. As screening mammograms are not very useful in this age group, it cannot be used as an effective screening modality.
  3. Increasing longevity and lifestyle changes have been attributed to this sudden rise in the number of breast cancer cases.

There are some more shocking facts about Breast Cancer in India, which have been highlighted by other studies.

  1. Lack of awareness about this disease compounded by the lack of screening guidelines in the country, leads to majority of the patients presenting with locally advanced breast cancer. A study which I published in the Journal of Royal Society of Medicine, couple of years back, highlights this problem – Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study.
  2. The above mentioned study also highlights the lack of preparedness of the medical system to tackle with this epidemic. There are very few centres in India, which are providing dedicated Breast Cancer Services. These facts should trigger a positive change in the medical system and more emphasis should be paid to develop dedicated breast cancer units across the country.

As it is extremely difficult to develop screening guidelines for breast cancer in our country, I feel increasing awareness about this disease is the first thing which we should focus on, in addition to developing a more comprehensive breast cancer service in our country.

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