Changing trend of Breast Cancer incidence in India

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Breast Cancer and the age wise distribution in India

This graph depicts the changing trend in the age wise distribution of breast cancer in our country. Over the years, the incidence of breast cancer has increases dramatically and there has been a higher increase in the incidence between 30-40 years of age. This is mainly attributable to the lifestyle changes visible in the Indian society. Another major factor, which is difficult to quantify is the increase in pollution levels.
It is important we realise this change and encourage patients to take corrective measure to control the modifiable risk factors like smoking, alcohol consumption, obesity. Also increased awareness is required, so that these cancers can be detected early.

Mondor’s Disease

Mondor’s Disease
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1. Type of superficial thrombophlebitis (inflammation of the veins_  which involves the veins of the anterior chest wall & breast
2. Presents like a painful, cord like structure just below the breast (image)
3. Most commonly involved vein is the lateral thoracic vein. Other veins involved are – thoraco-epigastric & rarely superficial epigastric
4. Clinical features – pain along the lateral chest wall and below the breast. Patients may also complain of a cord like structure. Some patients present with just breast pain and the cord is detected by the breast surgeon
5. Benign, non cancerous lesion, which is self-limiting
6. Management – Consult a breast surgeon and get imaging done to rule out any other breast lump.
7. Treatment involves warm compresses and anti-inflammatory medicines. It usually resolves in 4-6 weeks. 
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Pic Courtesy: http://www.cosmeticsurgeryforums.com

Importance of maintaining a pain diary in Breast Pain

Breast pain (or mastalgia) is common problem faced by women at least once during their lifetime. It can range from mild pain to a chronic debilitating condition, which can even push a patient to the verge of depression. In fact, in the last one month, I have encountered two such patients, who have stopped socializing because of excruciating breast pain.

Mastalgia has varied causes and it can broadly be divided into cyclical & non cyclical causes. Cyclical mastalgia (breast pain) usually occurs because of hormonal fluctuations and the intensity of pain varies according to the menstrual cycle. On the other hand non-cyclical mastalgia usually occurs because of musculo-skeletal causes and the pain persists all throughout the month.

For the correct diagnosis and management of breast pain, it is important for the doctor to know certain points regarding the pain like:

  1. duration of pain
  2. location – restricted to one point or spread over the entire breast
  3. intensity of pain
  4. fluctuation in intensity of pain over a few days
  5. Radiation of the pain – is the pain running to some other site from the breast
  6. Is there a lump associated with the pain? Usually breast cancer does not lead to pain in the initial phases
  7. what makes the pain better
  8. what makes the pain worse

 

These facts along with clinical examination and an ultrasound/ mammography help the doctor in determining the cause of breast pain. The above mentioned points can easily be maintained in a “pain diary”, which is something which I ask all my patients to maintain.

Following is a format which I hand over to them and ask them to maintain it regularly for a period of 30-40 days.

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This information helps me in:

  • Assessing the cause of pain
  • Judging the response to therapy

So the next time you visit your doctor with complaints of breast pain, make sure you maintain a ‘pain diary’, so that your treatment can proceed smoothly.

 

Article by:

Dr. Rohan Khandelwal

Consultant, Department of Breast Diseases & Cancer Care

W- Pratiksha Hospital, Gurgaon

 

Girl Power 

Proud of you #SakshiMalik. The six minutes in the ring were just a small part of the fight, which started right from birth in a state where the incidence of female foeticide is extremely high and a girl child is looked down upon. Your grit and determination to overcome all odds and win this medal is really commendable. Hats off to you! #SaveTheGirlChild

From scratch to becoming one of the top 100 Oncology blogs in the world

After a hectic day of work in Bangalore, I was having a casual discussion with Dr. Sumer Sethi, who is one of the most influential doctors on the internet & a great motivator. During our discussion, he encouraged me to start writing a blog about my experiences as a Breast Surgeon. Breast Surgery was a relatively new branch at that time and Dr. Sethi was of the opinion that a blog would be a great medium to create awareness about Breast Cancer & my experiences as a Surgeon. That is when ‘Random Reflections of a Breast Surgeon‘ was born.

Initially, it was quite difficult for me to take out time to write blogs but gradually it became a habit and I started enjoying it. In due course of time, the blog became really popular among patients suffering from Breast diseases and medical students aspiring to become surgeons.

Every now and then, encouraging messages from patients, well-wishers and students have motivated me to keep on pushing the boundaries of my blog. The latest recognition by Feedspot of nominating my blog as one of the Top 100 Oncology Blogs in the World has just strengthened my resolve to continue spreading my experiences with the world.

In the last few months, I have started encouraging patients/ students/ doctors to share their experiences on my blog and if anyone is interested in highlighting their work, you can email it to me on rohankhandelwal@gmail.com. Also for patients, I have also launched by new website – http://www.breasthealth.in , which provides details about all Breast Diseases & their management.

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Olive Oil Cuts Breast Cancer Risk – PREDIMED Trial Data

A recent study has shown that the ammunition against breast cancer is stocked in a women’s kitchen. Data from a large randomized control trial has recently indicated that  women can dramatically reduce their risk by following a version of the Mediterranean diet that goes heavy on extra virgin olive oil.

Data from  a clinical trial known as PREDIMED, which was designed to assess the cardiovascular effects of Mediterranean diet, demonstrated that women who followed the diet were 62% less likely to be diagnosed with breast cancer compared with women who were only asked to reduce the overall fat content in their diets. The results were recently published in a reputed journal, JAMA.

Although the study’s main focus was cardiovascular disease, researchers also tracked the incidence of five types of cancer, including breast cancer. Patients in this trial were divided into three groups:

  1. Mediterranean diet supplemented with extra virgin olive oil
  2. Mediterranean diet supplemented with mixed nuts
  3. Regular low-fat diet.

Study analysis showed that the women in the extra virgin olive oil group were 62% less likely to be diagnosed with breast cancer during the course of the study as compared to women in the regular low-fat group.

Researchers wrote that the  women in the extra virgin olive oil-heavy Mediterranean diet group got 22% of their total calories from the oil. However, the researchers wrote that for olive oil to be beneficial, it should contribute at least 15% of the total calorie requirement.

There are many reasons why extra virgin olive oil is a potent cancer-fighter:

  • It is rich in oleic acid, a substance that helps in killing cancer cells
  • It’s also high in squalene, a compound that has antioxidant effects.
  • Polyphenols like oleocanthal & oleuropein have also shown to reduce the spread of breast cancer.

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 This is the first prospective randomized clinical trial to see whether a Mediterranean diet can offer protection against breast cancer. The data seems promising but there are certain points which need to be kept in mind:
  1. The study included white women between the age of 60-80 and they had Type II diabetes or at least three risk factors for cardiovascular disease, such as high blood pressure, too much “bad” cholesterol or a history of smoking. So, more studies are required in young patients to see if this diet benefits them as well.
  2. Also more studies are required to see if the same holds true for other racial groups as well

The good thing is that more and more Indian families are shifting to olive oil but what has to be clearly kept in mind is that this study was conducted for Extra Virgin Olive Oil and not routine olive oil. So next time you go to buy cooking oil, make sure you choose Extra virgin olive oil to cut your risk of breast cancer.

Role of a Breast Cancer Husband

Western statistics reveal that nearly seven out of ten marriages touched by breast cancer do not survive and ultimately lead to divorce. With the incidence of breast cancer increasing in young Indian women, this problem will soon be evident here as well. In fact, during my tenure in Bangalore, I did come across a few patients who were deserted by their families after their diagnosis of Breast Cancer.

Although there is no magic formula for a couple to weather this difficult period, but some of these points can help husbands support their wives during their Breast Cancer treatment.

  1. Stand by her during the treatment & tell her that you ‘love’ her

In a marriage or any intimate relationship, silence is not golden. The strong silent type need not apply for the position of husband, lover, best friend, confidante and supporter of a woman with breast cancer. Your bride, your wife, needs and wants to hear from you. Actions may speak louder than words, and you may take all the right actions, but speaking words brings comfort, reassurance and knowledge of your inner feelings. She cannot read your mind. Being there for her is more than physical or economic security. Words have meaning. And the three most important words in the English language at this time, at this moment, when together you are facing her mortality, are: “I love you.”

  1. Involve her in the decision making

It is not easy for a lady to deal with the diagnosis of breast cancer. Often it has been seen in India that husbands and family members make clinical and personal decisions on their behalf. Although these ladies appreciate some of the decisions but they would love to be part of others, which involve their future.

A simple example is deciding between a mastectomy & breast conservation surgery. Family members err towards the side of mastectomy but in reality a lot of young patients actually want breast conservation surgery. It always helps to consult them in private and then take a collective decision.

  1. Go to Her Appointments

It is not what you do when you accompany her to treatment, but rather the act itself that speaks volumes to her. It also gives you some sense of empowerment. You are more than a helpless spectator cursing the damned disease. You have joined the battle.

  1. Sometimes humor helps

Funny, it does. There’s even a study to prove it, by psychologist Sharon Manne of the Fox Chase Cancer Center in Philadelphia. Couples who laughed at cancer coped better with the stress of treatment. We know that the act of laughing is itself healing. It makes us feel better and helps us get better.

  1. Continue to enjoy as a couple – she is NOT invalid

Treatment can be grueling and tiring, but you both need to live your life as fully as possible. Continue to enjoy what you enjoy individually and as a couple, particularly the latter. Don’t let cancer put an end to your personal and social life.

 

If you follow these simple steps, you can also become a Proud Husband of a Breast Cancer Survivor

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Article By:

Dr. Rohan Khandelwal

Consultant, Breast Oncosurgeon

W Pratiksha Hospital

Talk on Women’s Cancer

W-Pratiksha Hospital had launched a Women’s Cancer Prevention Drive in October, in which they had pledged to screen 1000 ladies for Breast & Cervical cancer free of cost. In addition, regular camps and health talks were planned over a period of 6 months.

The latest health talk was organized at W Pratiksha Hospital and it featured talks on Breast & Cervical Cancer. Women of all age groups attended the talk in huge numbers. I had the privilege of talking about Breast Cancer and the reasons why India is seeing a boom in the incidence of this cancer. This was followed by a lively question and answer session, in which ladies addressed their concerns about Breast Cancer and their apprehensions to get screened.


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Similar talks are going to be organized at regular intervals at the hospital and in nearby schools & colleges.

AMRIT for Indian Breast Cancer Patients

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.

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Updated Breast Cancer Screening Guidelines

American Cancer Society has recently revised the breast cancer screening guidelines and they were featured in the a recent article in JAMA.

The most significant change has been the age of starting mammographic screening, which has been increased from 40 to 45 years. This change has been made after taking into account the lower incidence rate of breast cancer in this age group. Another factor which led to the delay in initiating screening was the higher number of false positive mammograms observed within this age group.

Recommendations:

  • Women with an average risk for breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation).
  • Women aged 45 to 54 years should be screened annually (qualified recommendation).
  • Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation).
  • Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation).
  • Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation).
  • The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation)

These guidelines are quite different from those of the US Preventive Services Task Force (USPSTF) and this is a cause of concern & confusion among patients. The following table highlights the differences between the two guidelines:

Mammography Screening Parameter ACS USPSTF
Starting age (y) 45 50
Screening frequency Annually to age 54 y, then biennially Biennially, beginning at age 50 y
Stopping age (y) For as long as a woman is in good health and has a life expectancy of at least 10 y 75
Total lifetime mammograms if screening continued to age 74 y (n) 20 13
Lifetime risk of dying of breast cancer (%) 1.8-1.9 2.0
Lifetime risk of dying of breast cancer with no screening is 2.7%.

Do these guidelines affect Indian patients?

Well, firstly India has no screening guidelines and only opportunistic screening is practiced by a very small segment of the population. Secondly, there are some studies which say that Indian breast cancer occurs at an earlier age and therefore screening should be initiated early.

These questions be answered if proper trials on this topic are carried out in the country. For the time being, we should lay more stress on creating awareness regarding breast cancer.

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