In my previous posts, I have highlighted the misery of poor Indian breast cancer patients who test positive for HER 2 neu. These cancers are usually aggressive and need to be treated with targeted agents like Herceptin. The problem is that each dose of Herceptin costs close to 50-60 thousand rupees in our country and this drug is not available in any government medical college.
Even with the introduction of bio-similars like CANMab, the cost of treatment remained to the tune to 40-45 thousand rupees per dose. I know many families, who sold their houses & jewelry to fund for their loved one’s Herceptin treatment. One such patient was Mrs. Laxmi (name changed), who had Stage III HER-2-neu positive breast cancer. She hailed from an average middle class family and the news of diagnosis of breast cancer was a huge shock for her. To add to her woes, she got to know that she would require close to 6 lakh rupees to fund for her Herceptin treatment. After a lot of deliberation with the family, she decided to fund her treatment by selling her wedding jewelry. Fortunately, things worked out well for her and she is still alive & healthy, 5 years after her cancer diagnosis. Other patients are not so lucky, as they do not possess such reserve money to fund for their HER treatment.
The Indian government’s new AMRIT scheme (Affordable Medicine & Reliable Implants for Treatment), might turn out to be a huge boon for these breast cancer patients. This scheme aims to bring down the cost of essential cancer medicines by 50-60%. The first AMRIT center was inaugurated recently at AIIMS and soon other centers would be started all across the country. Although the list of drugs which will be made available at these centers has not been released, I am hoping that Herceptin would be one of them. This would really help us in treating HER 2 positive patients, thereby leading to increased survival rates.
If this scheme is properly implemented, it will truly turn out to be an “AMRIT” for Indian cancer patients.
Breast conserving surgery (BCS) is fast becoming popular but one should be aware of the the contraindications of this procedure in order to avoid high recurrence rates & complications.
Breast conserving surgery in simple words is lumptectomy (removal of the tumor with a normal rim of tissue). All patients following BCS require radiotherapy. Some of the contraindications of this procedure are related to the surgical aspect whereas others are contraindications for radiotherapy.
- Pregnancy – is a contraindication for radiotherapy, as it can lead to teratogenic effects.
- Two or more primary tumors in separate quadrants (multicentric tumors). Patients with multifocal tumors (two or more primaries in the same quadrant) can undergo BCS. [Fig 1]
- Diffuse malignant-appearing calcifications on mammogram
- History of prior radiation to the breast area
- Persistent positive margins
- Inflammatory breast cancer
- History of collagen vascular disease – leads to increased radiotherapy associated complications
- Breast size to tumor size ratio [Fig 2] – Instead of the absolute size of the tumor, tumor/ breast ratio is a better indicator of whether the patient is eligible for BCS or not. Fig 2 – highlights two patients, both with identical tumor sizes but one patient has a large breast (leading to a small tumor/ breast ratio) whereas the other patient has a small breast (leading to a large tumor/ breast ratio). BCS is avoided in patients with large tumor to breast ratio as it leads to poor cosmetic outcome.
Following are NOT contraindications to BCS:
- Family history of breast cancer
- Positive lymph nodes
- Bilateral breast cancer
- Lobular histology
- Central quadrant tumor
Sometimes breast cancer tends to surprise us and present in an unusual manner. In India, due to lack to awareness and a stigma attached with breast cancer, females from the rural set-up tend to present with locally advanced breast cancers. I happened to encounter one such case couple of years back and managing this case turned out to be quite challenging. We managed to publish this case in the Breast Disease Journal and it generated quite a discussion in all the forums where it was discussed. [Breast cancer presenting in the midline without a lesion in the breast: a therapeutic dilemma. Khandelwal R, Poovamma CU, Shilpy C, et al. Breast Dis. 2013 Jan 1;34(2):57-9.]
A 48- year- old post-menopausal lady presented to the Breast Clinic with complaints of a rapidly enlarging chest swelling for the last 8 months. The lesion had ulcerated one month back and she complained of a foul smelling discharge from the growth. There were no complaints of any lumps in the breast or axillae.
On examination, a 14 x 10 cms ulcero-proliferative lesion was seen over the midline of the chest extending 4 cms on either side of the midline. The lump had restricted mobility over the underlying chest wall. In addition, the patient had multiple, enlarged lymph nodes in both the axillae. No enlarged lymph nodes were felt in the supraclavicular fossa. No organomegaly was palpable in the abdomen.
A provisional diagnosis of soft tissue sarcoma of the chest wall was made but the presence of bilateral, hard axillary lymph nodes raised a suspicion of a breast carcinoma. Patient was then subjected to a CECT of the chest, which revealed a fungating soft tissue mass over the chest with bilateral axillary lymphadenopathy. MRI of the breasts failed to pick up any lesions in the breast. CT abdomen was unremarkable. A PET-CT done to look for distant metastasis, revealed a mildly hyper-metabolic anterior chest wall mass [SUV max 4.8] with bilateral axillary lymphadenopathy [SUV max 5.1]. There was no evidence of involvement of supraclavicular or internal mammary lymph nodes. No distal metastasis was observed on PET.
Following the imaging tests, an incisional biopsy of the lesion was performed, which to our surprise revealed an invasive ductal carcinoma (grade II) with DCIS. Immunohistochemistry revealed the tumor to be ER and PR positive but HER2 negative.
The case was extensively discussed in the tumor board and a decision was taken to treat the patient with neo-adjuvant chemotherapy. Patient received weekly Paclitaxel for six weeks, which was associated with a good response and the tumor regressed in size. A PET scan done following NACT revealed a residual lesion in the midline with bilateral axillary lymph nodes. PET scan did not reveal any lesions in the breast.
Following a good response to NACT, the patient was taken up for a wide local excision of the tumor with bilateral axillary dissection. As none of the breasts had any lesions, they were not addressed during the surgical procedure. Patient had an uneventful post-operative period and three weeks later she was started on adjuvant chemotherapy, which was followed by radiotherapy to the chest wall.
Following completion of radiotherapy, the patient was started on Letrozole and was kept under regular follow-up. The patient remained symptom free for 1 year after surgery, after which she was lost to follow-up.
This was an extremely rare presentation of breast cancer and managing this patient was a therapeutic dilemma.