Breast Cancer Care During COVID19 – my experience at CK Birla Hospital, Gurgaon

The current COVID19 pandemic has affected the way all doctors practice and oncologists are no exception. Over the last 2-3 months, we have witnessed a lot of changes in treatment protocols, attitude of cancer patients towards their disease and the behavior of newly diagnosed breast cancer patients. Rather than going into technical details regarding the treatment protocols which we are following (which are an Indian modification of American/ European guidelines, most suited for our breast cancer patients at CK Birla Hospital), I will be discussing changes which we have made as doctors and how are our patients coping with the pandemic.

When the lock-down was announced in mid March, fear & panic is what prevailed amongst the patients and they were initially apprehensive in coming to the hospital for their surgery/ chemotherapy. But by early April, it was clear to patients that COVID will persist for a few months and although the world might be in lock-down but the cancer brewing inside their body would continue to grow and they would need to fight it out.

This change in patient attitude coupled with the proactive management at CK Birla Hospital (specially measures taken to improve patient and staff safety), we were able to carry out breast cancer treatment smoothly, even during the lock-down.

During the two months of lock-down, 94% of our breast cancer patients continued their chemotherapy. The ones who skipped some cycles were patients with metastatic disease, who wanted a ‘chemotherapy holiday’. In this period, my unit also operated 22 breast cancer patients. The number of benign (non cancerous) breast surgeries dipped dramatically during this period but we have seen a rebound increase in such cases since the lockdown norms have been eased.

After talking to a lot of friends & colleagues in UK/USA, I realised that I will only be able to take care of my patients if I stay healthy and disease free. To ensure that, in addition to the measures implemented by the hospital, I have also started using extra precaution in the form of a 3M 6200 mask with two p100 filters, which keeps the smoke plumes (thought to be a the leading case of infection in surgeons & anaesthetists) away. Of course, my OCD of hand washing has also served me well during this period 😊.

rk ppe

Our breast cancer patients have also adapted well over the course of the last 2 months. Our unit has a very active cancer support group known as ‘Vijay’ and all the members have devised new methods to keep in touch with each other during these tough times.

In the pre-covid times, old patients used to visit the new patients on the day of their surgery/ first chemotherapy. This is has been replaced by zoom group calls to support newly diagnosed patients. Even our treatment completion celebrations have undergone a lot of change. Earlier, these used to be elaborate affairs where the patient’s family & the treating team would participate actively, but now we have toned it down (but not stopped it, as it is a very important landmark in the patient’s life) to a simple cake cutting with everyone wearing masks.

pt celebration

To summarise, my biggest learnings during this period have been

  • Cancer care has to go on but we should be willing to adapt our treatment strategies after a thorough discussion with the patient
  • The safety of the treating team & patients is of paramount importance in order to deliver seamless breast cancer care during this outbreak

 

 

This article has been written by,

Dr. Rohan Khandelwal

Principal Consultant – Breast Cancer Surgery

CK Birla Hospital, Gurgaon

rohankhandelwal@gmail.com

Breast Cancer Care During COVID19 outbreak

At present, almost half the world is in lock-down due to the corona virus outbreak and it is difficult to predict for how long this situation might remain the same. In India, it is almost certain that the lock-down due to COVID 19 will be extended till at least end of April. Even though we are in a state of lock-down but our body is still functioning and that means diseases like cancer might still be growing inside our system. So how does one deal with a problem like breast cancer/ breast lump during this period.

Tips for existing breast cancer patients

  1. Remain in touch with your treating breast cancer surgeon/ breast cancer oncologist. They will outline the treatment protocol during this period
  2. If you have an early stage breast cancer which is curable, you should not defer your treatment during this period, as it can lead to progression of the cancer.
  3. If you are suffering from cancer which has spread to the body (metastatic breast cancer), then discuss with your doctor if the chemotherapy frequency can be reduced or if you can be shifted to hormonal therapy/ oral treatment for the time being.
  4. Corona virus infection is usually severe in patients who are suffering from pre-existing conditions like cancer, diabetes, hypertension. So, please take all precautions to prevent infections
  • Eat a healthy/ balanced diet. Avoid outside food.
  • Make sure you take your daily dose of  vitamin C. This can either be in the form of a supplement or just a glass of lemonade
  • If you are undergoing chemotherapy (which can lead to reduced immunity and white blood count), please monitor the blood counts and if they are low, consult your breast cancer doctor immediately
  • Wear a mask whenever you are venturing out of your home, especially, when you are going to the hospital
  • Maintain strict hand hygiene. Wash your hands multiple times a day and use a hand sanitizer liberally

 

 

 

 

Recently detected a breast lump – what should you do during this period?

During the lock-down, lot of ladies are taking out time to carry out breast self examination and they are picking up new breast lumps. If you are one of them, I would advise that you consult a breast lump surgeon immediately. This consultation can either be an online consultation or a physical visit to the hospital. In an online consultation, if the doctor feels the need to carry out a physical examination, he/she would call you to the hospital.

A breast lump should not be ignored because if it is cancerous, it can increase in size during this period. A mammography or an ultrasound should be done after physical examination and if the lump is suspicious, a biopsy/ needle test should be done to confirm the diagnosis. If the breast lump turns out to be non cancerous (benign), then the treatment can be deferred till the time COVI19 situation improves. Your doctor can provide you medicines during this period to deal with the problem/ breast pain associated with the lump.

If the lump turns out to be breast cancer, as I have highlighted above, please consult your doctor and make a treatment plan which is suitable to you.

These are testing times for everyone, including patients. One has to be cautious about not getting infected by the virus as well as make sure that their breast cancer/ breast lump treatment doesn’t suffer. If you follow the tips which I have highlighted above, you can tide over this phase without compromising your health.

 

 

This information has been provided by

Dr. Rohan Khandelwal

Breast Cancer Surgeon

CK Birla Hospital, Gurgaon

To book an online consultation with Dr. Rohan Khandelwal, click here

 

All breast fibroadenomas don’t require surgery

Breast fibroadenomas are the most common cause of breast lumps and they are commonly seen between 15-30 years of age group. We usually see a lot of anxious women presenting to the Breast Centre at CK Birla Hospital, Gurgaon with this complaint and all of them have two common questions:

  • can it turn into breast cancer?
  • does it require surgery?

I will address these two questions in the text below but before that I would just like to give you some information regarding breast fibroadenomas.

Clinical presentation  – Breast fibroadenomas usually present as painless (non painful) breast lumps which keep shifting their position within the breast. These lumps can remain the same size for long periods of time but sometimes they can present with pain, rapid increase in size. Approximately 10% women can have multiple fibroadenomas [read about the lady with 39 fibroadenomas in both breasts].

There is no known cause for fibroadenomas and no well defined risk factors.

On examination, these lumps are usually firm in consistency and mobile, which is why jokingly they are also known as a ‘breast mouse’.

Diagnosis of a fibroadenoma can be made out on an ultrasound of the breast (which is the preferred imaging technique in patients less than 40 years of age). If a mammogram is done, you can see a ‘popcorn appearance‘ of the lesion.

 

Calcified Fibroadenoma

Majority of the fibroadenomas can be clearly made out on an ultrasound but if a lesion is showing some atypical changes, then a tru-cut biopsy/ FNAC (needle test) is recommended to confirm the diagnosis. This is also indicated in patients with a family history of breast cancer.

Coming back to the two questions which all patients with breast fibroadenomas have running through their mind during their visit to a breast surgeon:

  • Can fibroadenomas turn into breast cancer?  —  Multiple studies have shown that the risk of a fibroadenoma changing into breast cancer is negligible (less than 2%). It is usually more in patients who have atypical fibroadenomas or an existing family history of breast cancer. Patients with a family history of breast cancer should not ignore these breast lumps and should get a biopsy to confirm the diagnosis.
  • Do all fibroadenomas require surgery? —- Well, not all of these breast lumps require surgery. There are certain indications to surgically remove these lumps:
  1. If the fibroadenoma is more than 5 cm in size. Such a fibroadenoma is known as a ‘giant breast fibroadenoma’.
  2. If there is a family history of breast cancer. In such cases, it is advisable to remove the lump.
  3. If there is rapid increase in size of the lump or it is associated with breast pain which is not getting controlled with medicines.

Surgical removal for fibroadenomas is usually a minor surgery which is done as a day care procedure. The incision for this surgery is usually made around the areola (peri-areolar) as this incision heals with minimal scarring. Sometimes the incision can be made in the skin fold under the breast (infra-mammary crease). Some patients can candidates for scar-less fibroadenoma surgery, in which the lump is removed via a 3-4 mm incision using a special machine.

Peri-areolar incision – scar is hardly visbile after a month

Those patients who are not candidate for surgical excision are asked to follow-up at regular intervals, usually 6 months to 1 year. In addition to this, they are asked to monitor the size of the lump. In case there is a rapid increase in size of the fibroadenoma, they are asked to return immediately. Unfortunately, there is no credible medical management of fibroadenomas.

 

Information provided by:

Dr. Rohan Khandelwal

Breast Cancer Surgeon in Gurgaon

CK Birla Hospital

Dr. Rohan Khandelwal also performs scar-less fibroadenoma surgery at CK Birla Hospital

All underarm lumps are not cancerous

Ladies commonly present to our Breast Cancer unit with complaints of lumps in the underarm region (axilla) and their first concern is always breast cancer, but not all axillary lumps are a sign of breast cancer. In this article, I will highlight the common causes of under-arm lumps/ swellings, which ladies can develop:

  • Axillary lymph node enlargement – this is the most common cause of underarm lumps. Lymph nodes are present all over the body and they serve as filters. Breast drains into armpit (axillary) lymph nodes. Therefore, if there is any cancer/ infection in the breast, it can lead to enlargement of these nodes. In such situations, we get an ultrasound of the breast and underarm region to confirm the enlargement. Diagnosis is confirmed by a needle test known as FNAC (fine needle aspiration cytology) or lymph node biopsy in some cases.

Another common cause of enlargement of these nodes is after shaving/ waxing of  underarm hair. This can lead to momentary enlargement of these nodes (reactive  lymphadenopathy), which usually settles down with time or with a course of antibiotics.

  • Accessory axillary tissue – ladies usually come with a large lump in the underarm region but give a history that it has been present over a long period of time or has increased in size post-pregnancy or after breast feeding. This is due to extra breast tissue present in the armpit region, which increases after pregnancy and lactation. For most ladies, it is a cosmetic problem because of which they are unable to wear cut sleeves clothes. Some ladies might complain of pain in the swelling as well. An ultrasound should be done to rule out any other condition and surgery can be done to get rid of this problem.

 

Accessory axillary tissue

Accessory axillary breast tissue

 

  • Sebaceous cyst in the underarm – This is a lump which forms due to a blocked hair follicle duct. It can remain painless till it becomes infected. It is a superficial lesion which can be managed with a simple removal of the lump. If the lump is infected, it can initially be managed with antibiotics before surgical removal

 

sebaceous cyst

Sebaceous cyst in underarm region

 

  • Breast cancer – Cancerous lumps can primarily develop in the underarm region or cancers can present as lymph nodes in the underarm region. In either case, an ultrasound/ mammogram is required, followed by a biopsy to confirm the diagnosis. Proper staging of the breast cancer is important before management

 

Primary & nodes

Malignant axillary lymph nodes on mammogram

 

  • Breast tuberculosis – is a common diagnosis in India. It will either present as an abscess in the underarm region or enlarged lymph nodes (covered earlier) in the axillary region. Diagnosis can be made by a needle test or lymph node biopsy. Treatment usually involves taking anti-tubercular drugs for a period of 6-9 months, depending on response.

 

As I have highlighted above that breast cancer is just one of the causes of axillary lumps. Having said that, it is best that you visit a breast unit whenever you notice a lump in the breast or underarm region. After taking a history and carrying out clinical examination, the breast surgeon will order an imaging test, which would either be a mammogram or ultrasound or both. This would be followed by a tru-cut biopsy/ FNAC to confirm the diagnosis. In some cases a lymph node biopsy might be required to clinch the diagnosis.

 

For further information or to book an appointment, please contact

Dr. Rohan Khandelwal

Breast Cancer Surgeon

CK Birla Hospital, Gurgaon

rohankhandelwal@gmail.com

 

What does BIRADS on your mammography/ ultrasound report mean?

Lot of times in my Breast Clinic at CK Birla Hospital, Gurgaon, I get patients who come and tell me that they are suffering from stage III breast cancer. When I ask them how do they know about that, the answer which I usually hear is that “my mammogram/ ultrasound report shows BIRADS III.” Not only patients but I have also seen some doctors getting confused with the BIRADS reporting.

BIRADS (Breast Imaging Reporting and Data Systems) is a standardized way of reporting breast radiology reports.  This helps radiologists categorize patients from a score of 0-6 and it helps breast cancer surgeons in taking decisions based on this score. Having a uniform reporting system is useful because patients might get their radiology and breast disease treatment done at different places.

The score doesn’t imply the stage of cancer and patients should be aware of this to avoid unnecessary anxiety after seeing the radiology report.

  • BIRADS 0 means an incomplete investigation – This usually occurs when a mammogram is done in a patient with a dense breast and it does not yield any meaningful information. In such a case, usually an ultrasound or MRI Breast is done

 

  • BIRADS 1 is a negative scan, which basically implies that there is no lesion in the breast and everything is normal. In these patients we advise them to follow up after 1 year

 

  • BIRADS 2 is suggestive of a benign lesion, which has essentially a 0% risk of cancer and these lumps don’t require a biopsy. They can be followed up in a year’s time. Simple cysts, most typical fibroadenomas fall under this category.

 

  • BIRADS 3 lesions are probably benign and these breast lesions/ lumps should be followed up every 6 months (short term follow-up). These lumps do not require a biopsy/ FNAC but if you have a family history of breast cancer, then the clinician might be inclined to do more tests/ biopsy at this stage rather than wait for 6 months.  Fibroadenomas, duct ectasias can fall under this category of lesions.

 

  • BIRADS 4 breast lumps/ lesions are suspicious lesions and they need to be biopsied to confirm the diagnosis. They are further sub-divided into 4a, 4b, 4c which implies low, medium and high risk for cancer. These patients should be counselled accordingly and a tru-cut/ core needle biopsy should be scheduled as soon as possible. Atypical fibroadenomas, suspicious microcalcifications, duct papillomas usually fall under this category of lesions

 

  • BIRADS 5 lesions are highly suggestive of malignancy and the risk of cancer in these breast lumps is more than 95%. All patients with these breast lumps should be subjected to the tru-cut biopsy, which is preferred over a FNAC (fine needle aspiration cytology)

 

  • BIARDS 6 lesions are when a radiological test is done after confirming the diagnosis of breast cancer.

 

The table below summarizes the BIRADS score and the action which needs to be taken in each category.

The Radiology Assistant : Bi-RADS for Mammography and Ultrasound 2013

 

So the next time you receive your mammography / breast ultrasound report, don’t be surprised to see the BIRADS score. Discuss the report with your radiologist and breast cancer surgeon and take action accordingly. Remember, that all breast lumps are not cancerous and all of them don’t even require a biopsy/ FNAC test.

 

This information has been provided by

Dr. Rohan Khandelwal

Principal Consultant,

The Breast Centre

CK Birla Hospital, Gurugram

Breast Cancer – Facts & Figures (Hindi Video)

Breast Cancer is now the most common cancer amongst Indian women. Approximately 1 in 22 Indian women suffer from this disease during their lifetime. A high incidence has also been noticed in parts of North India like Gurgaon, Delhi NCR, Punjab.

Breast cancer is curable if defected early. If breast cancer is detected at an early stage, another advantage is that mastectomy or full removal of the breast might not be required.

In this patient education video, Dr. Rohan Khandelwal (Breast Cancer Surgeon in Delhi NCR) talks about some common facts and figures regarding Breast cancer in India. In this Hindi video, he talks in detail about the risk factors and the best way to detect this disease at an early stage.

It is important to realise that the most common presentation of breast cancer is in the form of a painless lump in the breast (not painful).

If you have any further queries regarding breast cancer, please reach out to

Dr. Rohan Khandelwal

Breast Cancer Surgeon, CK Birla Hospital for Women

+91 79-88252759

Mastectomy for Breast Cancer Treatment – Things to Know

Mastectomy is one of the most common surgical approaches for breast cancer management.

Over the years, the technique of mastectomy has undergone a lot of change. This patient education video summarises the current role of mastectomy in treating breast cancer, along with the post- surgery care required by the patient.

This video also covers points to prevent lymphedema (swelling of the arm) following breast cancer surgery.

This information has been provided by Dr. Rohan Khandelwal, who is a Breast Cancer Surgeon with more than 8 years of experience. He is currently heading the department at CK Birla Hospital for Women, Gurugram.

CME on Best Practices in the management of Breast Cancer

The Breast Cancer Department of CK Birla headed by Dr. Rohan Khandelwal recently organised a CME on best practices in the management of Breast Cancer and Breast Lumps.

Dr. Rohan Khandelwal and his team discussed the latest surgeries in the management of breast cancer including breast Onco-plastic surgery and skin/ nipple sparing mastectomies with reconstruction.

Dr. Rohan Khandelwal

Breast Cancer/ Lump Surgeon is available at CK Birla Hospital, Gurugram everyday.

Lifestyle changes to manage cyclical breast pain (Mastalgia)

Breast pain is a common symptom with which patients come to the Breast Clinic. Although there are various causes of breast pain, the most common is fibrocystic diseases or fibroadenosis.

Fibroadenosis or fibrocystic disease leads to cyclical breast pain, which means that pain is maximum before the menstrual periods but reduces when the periods start. The intensity of pain can vary from patient to patient. In some patients the pain is so severe, that they need to take pain killers.

There are certain lifestyle changes and natural therapies which ladies can use to reduce their cyclical breast pain but they should only be tried once the doctor has confirmed the diagnosis and ruled out more serious conditions like inflammation and breast cancer. One should also maintain a pain diary to evaluate if the pain is reducing or increasing with time.

1. Weight reduction – this is specially useful for patients who have a high body mass index (BMI). A reduction or even 2-3 kg’s can lead to a dramatic improvement in breast pain

2. Cutting down on tea/ coffee – There is anecdotal evidence that reduction in caffeine intake, specially before the periods helps in the management of cyclical Mastalgia

3. Adequate breast support – wearing a well supported sports bra helps in reducing the pain, specially during walking/ running/ exercising. Underwired bra’s can sometimes aggravate the pain

4. Turmeric/ curcumin – many of my patients have benefitted with curcumin/ haldi/ turmeric for a period for 30-40 days. Patients have reported a 30-35% reduction in pain.

If your breast pain doesn’t settle down with these methods, please consult your doctor for further evaluation and treatment.

For further advise, please contact

Dr. Rohan Khandelwal

Breast Surgeon (Benign and Cancerous Breast Conditions)

Gurgaon

+91 79-88252759

The Breast Centre at CK Birla Hospital for Women

After successfully running a Breast Cancer unit for the last 5 years at Gurgaon, me and my team have taken up the challenge to set up another Breast Cancer unit at CK Birla Hospital for Women, Gurugram.

At the Breast Centre, we would be providing comprehensive breast services ranging from non cancerous to cancerous disorders. Everything from state of the art surgical facilities to an aesthetically designed chemotherapy lounge will be available under one roof.

For appointments, you can contact –

Shantanu – +91 79-88252759

or contact Dr. Rohan Khandelwal, Breast Cancer Surgeon in Gurgaon – rohankhandelwal@gmail.com