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Journalism of Courage
At 40, Lavanya Priya K, a Chennai-based strategic HR business partner, is back at the gym, does a few laps in the swimming pool, meets her friends and enjoys accompanying her 12-year-old daughter to her games in the neighbourhood. Yet two years ago, she had lost every motivation to step out of her home although she survived stage 2 breast cancer. “Although my left breast was removed, I was dealing with side effects of the seven cycles of chemotherapy to shrink the tumour before surgery and the 15 cycles of radiation therapy after it. Then there was the trauma of self-image as there were deformities in my torso. I just lost confidence in myself, became self-conscious, insecure and the will to step outside,” she says.
Today, she is not only cancer-free but thanks to a breast reconstruction surgery feels, in her words, “whole” and put together again. “Everybody talks about the side effects of therapy in terms of physical impact. Yet it is the impact on the mind that is more lasting. With your breast gone, you feel your femininity and by extension, your identity is gone. I just thought I needed to be there for my daughter, not for myself. That’s the greatest disservice I did to myself. Breast reconstruction gave me courage to look like my old self again,” she says.
“Most women experience feelings of grief and loss after a mastectomy or breast removal surgery. It impacts a woman’s sexual functioning and relationships. Changes in body image, loss of sensation and body confidence drain them of the little energy and courage they can muster,” says Dr Ramesh K Sarin, senior surgical oncologist at Indraprastha Apollo Hospital, Delhi.
“Breast reconstruction allows women to heal emotionally while recovering physically. Prosthetic bras often lead to postural problems and back pain. Studies worldwide show that women who undergo reconstruction experience better quality of life, improved body confidence, and lower rates of depression and anxiety after cancer treatment,” says Dr Venkat Ramakrishnan, lead, Breast Reconstructive Surgery, Apollo Athenaa Women’s Cancer Centre, New Delhi, who is fighting to make it an integral part of cancer therapy and extend insurance benefits to patients, like he did for Lavanya.
‘I HAD NO FAMILY HISTORY, WAS A FITNESS FREAK. TIMELY TESTS SAVED ME’
Lavanya was the first person in her family to be diagnosed with cancer and made conscious lifestyle choices, be it about her diet and fitness. “I felt a lump in the shower and without wasting time or attributing it to any other condition, got it tested the very next day. The scan was not very clear, so I had to get a biopsy (a process that extracts sample cells or tissues for diagnosis) and found the tumour to be malignant,” she says.
A rapidly growing lump makes for easy detection but a slow-growing lump or other symptoms could be less obvious. Sometimes, cancers are too small and may not be picked up by the mammogram. At other times, the dense breast tissue may hide them completely. “Some patients may be the first in their families to have cancer because of mutation of genes and normal cells in their body. That’s why we do extra tests as part of the early screening package at age 40. Other than routine mammography and clinical breast exam, we do ultrasound, which uses high-frequency sound waves to produce images of the breast tissue. It’s often used in addition to mammography to provide a more detailed image of the breast. MRI uses a strong magnetic field and radio waves to produce detailed images of the breast tissue. This is often recommended to women with a high risk of breast cancer or those with dense breast tissue,” says Dr Sarin.
WHY YOUNGER PEOPLE ARE DEVELOPING BREAST CANCERS?
Younger women who develop breast cancer are likely to have inherited mutations in BRCA1 or BRCA2 genes, which increase breast cancer risk. Such risks get aggravated by other triggers like lifestyle, improper diet, obesity, lack of exercise, smoking, overuse of birth control pills or hormone therapies. Endocrine disruptors from chemical pollutants are also being studied. “Eleven per cent of Indian women between 35 and 45 develop breast cancer compared to seven per cent in the West. Also patients may not show any symptoms in stages 1 and 2. That explains why you could get diagnosed in later stages. That’s why regular screening, whether you have symptoms or not, is mandatory. Early detection helps you recover completely,” says Dr Sarin.
“There has been an increase in triple negative cancers, accounting for nearly 40 per cent of cases. These don’t have any of the three receptors found in other breast cancers. So doctors have fewer treatment options. This type affects young women and are more aggressive,” adds Dr Sarin.
BATTLING THE PAIN IN THE BODY AND MIND
During her chemotherapy (where the anti-cancer drug is administered through an intravenous infusion or even a pill), and post-surgery radiotherapy, Lavanya battled side effects like diarrhoea, intense exhaustion, hair loss, nerve damage, skin scarring and brain haze. “In fact, breast reconstruction should be ideally done during mastectomy and additional therapies like radiation do not cause problems at the reconstruction site. Then you can even cover it under insurance. But I couldn’t as I had developed a chest infection and had to wait for it to completely heal over six to eight weeks before I could consider any other procedure,” says Lavanya.
During this time of recovery, the structural change in her chest turned her into a recluse. “I was scared about comments. Besides, I didn’t know that a delayed breast reconstruction procedure would not be covered under insurance as it would be re-categorised as a cosmetic procedure. Since the procedure costs anything between Rs 8 and Rs 15 lakh, I gave up the idea,” says Lavanya.
But Dr Ramakrishnan didn’t. He did a lot of to and fro with the insurance company to convince them that reconstruction is part of mainline cancer treatment and was needed so that Lavanya could function normally. He did two months of back and forth with pictorial representations and explanations before the insurer agreed to pay up. “In fact, the doctor even reduced my breast on the right side to match the reconstructed one on the left side,” says Lavanya.
WHICH BREAST CANCER SURVIVORS QUALIFY FOR RECONSTRUCTION, WHO DOESN’T?
“In the Western world, more than 60 per cent of women who undergo mastectomy choose to have their breasts reconstructed. In India, the figure is a mere 1%. This disparity is not due to lack of surgical capability but due to lack of awareness and the misconception that breast reconstruction is a cosmetic indulgence rather than a medical necessity. It is the correction of a deformity caused by life-saving cancer surgery,” says Dr Ramakrishnan.
He uses implants or the patient’s own tissue from the abdomen, back, or thighs. “Today, reconstruction techniques have advanced tremendously. Microsurgical reconstruction — performed using the patient’s own tissue, most commonly from the abdomen — has a success rate of over 99% when done by experienced surgeons. This procedure, called the DIEP flap, is performed simultaneously with breast removal and adds only about two hours to the surgery for one side. It is extremely safe and does not increase cancer risk at the local site or affect future treatment. None of my patients have reported anomalies. Studies show that reconstruction does not make breast cancer come back. If the cancer does come back, reconstructed breasts should not cause problems finding the cancer or treating it,” says Dr Ramakrishnan. In some cases, combined mastectomy and reconstruction may even reduce the need for post-surgery radiotherapy,” he explains.
But are there any caveats? “Young breast cancer survivors with very good prognosis should exercise this option. Those battling stage 3 or 4 cancer, with a poor prognosis and expected lifespan of five to 10 years can do without it, though this group does this in the West too. We do not do reconstruction in inflammatory cancers, which is less than two per cent, the obese and those with heart problems or hypertension,” says Dr Ramakrishnan.
As for Lavanya, the body transformation has made her patient. “I have now realised that no matter how life-threatening my circumstance, I deserve to smile,” she says.
