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Friday, July 20, 2018

Constant vigilance

Evidence suggests breast cancer hits Indians earlier,but lifestyle changes aren’t an option for many. The disease is curable,and regular checks are a must,say doctors

Written by Abantika Ghosh | Published: June 2, 2012 3:49:50 am

Breast cancer was among the first cancers to be pronounced ‘curable’. Its history though,is replete with some of the most gruesome instances of ‘treatment’ — from the medieval surgeons who attacked the disease with fire,acid and leather bindings to the late nineteenth century when students of William Stewart Halsted,the cocaine-addicted pioneer of radical mastectomy,at times removed not just the breast but also ribs,shoulder and collar bone to prevent its recurrence in the patient.

Evidently,breast cancer evokes strong sentiments in both patients and doctors.

It has speedily replaced cervical cancer as the most common cancer among Indian women,thanks to a host of reasons ranging from genetics to changing lifestyles,this unfortunately is one sentiment that more and more women — often at a younger age than their mothers and grandmothers — will have to learn to contend with.

According to figures from the National Cancer Registry,one in every 25 Indian women is likely to suffer from breast cancer at some point of time. Though the emotional implications of a diagnosis or even cure — especially if accompanied by mastectomy — are often very severe,breast cancer is regarded as one of the “good” cancers because it is possible to be cured of the disease without drastic changes to the patient’s quality of life. The only condition for this is early diagnosis and treatment.

However,as concerns of possible overdiagnosis of breast cancer have only just begun being raised in the West,often to serve business interests more than anything else,it is important to understand that any unnatural or sudden growth in the breast may not be cancer. But it is good to have the growth checked. Tumours in the fibrous tissue of the breast are very common and usually benign.

Breast cancer’s classical medical definition is cancer that starts in the tissues of the breast. It can be of two main types,ductal carcinoma and lobular carcinoma.

Ductal carcinoma starts in ducts which carry milk to the nipple,while cancerous growth in the lobules is called lobular carcinoma. Lobules are those parts of the breast which produce milk. Lobular carcinoma is the less common variant. Even more rare is cancer which starts in other parts of the breast.

A clear trend of rising incidence of breast cancer in urban India has re-fuelled the discussion about breast cancer risk factors. As Dr Ramesh Sarin,consultant oncologist at Indraprastha Apollo Hospital succinctly puts it: “Women,especially those growing old are at the biggest risk of suffering from breast cancer. Since we cannot change our sex or stop growing old,we might as well learn to live with the risk and take measures to ensure early diagnosis.”

Another alarming observation in India has been that breast cancer occurs at a younger age. “Our breast cancers happen ten years earlier. There is no simple answer to why that happens but it could be linked either to life expectancy or genes. That is why western modules of screening have been revised here to catch the disease more in younger women,” says Dr Ashok Vaid,consultant oncologist at Medanta Medicity.

About a week back,a study published in the journal Fertility and Sterility,said women who have undergone in vitro fertilisation at a young age are more prone to breast cancer. It did not state anything ground breaking,but merely restated what has been known for long. Women undergoing IVF are given the hormone estrogen in very high doses — to assist conception and pregnancy. Prolonged exposure of breast cells to estrogen has always been known to be associated with increased incidence of breast cancer. The same applies for the observation that post-menopausal women who have undergone hormone replacement therapy (estrogen again) are more likely to have breast cancer.

However,for a country like India,which is fighting a breast cancer deluge,the findings reinforced the reasons for its tryst with the disease. A rapidly urbanising population — and even rural India aspiring to embrace the urban lifestyle — has meant women marry late and postpone motherhood. On the other hand,as nutrition levels improve,young girls attain menarche earlier. To understand why all these things add up to breast cancer,it is important to look at the interplay of female sex hormones: estrogen and progesterone.

Estrogen starts circulating in the body from the time a girl has her first menstrual cycle. It continues to do that till the time the girl is pregnant. During that time,followed by the period of lactation,estrogen levels remain low. With young girls attaining puberty earlier (before they are 12 years old) their breast tissues are exposed to estrogen from an earlier age. Late motherhood means that exposure continues way beyond the early twenties,which used to be the normal age for first pregnancy in the earlier generation. Opting out of lactation introduces estrogen back into the female physiology as soon as the pregnancy ends. This cycle is further aggravated by the choice to have fewer babies. The bottomline of all these lifestyle patterns is that estrogen gets a far longer time to act on breast tissues. The result: an explosive increase in the disease which cannot really be contained because the lifestyle issues involved are largely non-negotiable.

However,there are strong genetic factors contributing to the disease too. Dr Sarin says genes BRCA1 and BRCA2 are associated with breast cancer,though only five per cent of women suffering from the disease answer to that genetic description. “If there is breast cancer in the family — or even ovarian cancer because the two are very closely linked — the risk doubles or even triples. In such cases,we often prescribe a drug called tamoxefen which is basically an estrogen-like compound competing with hormone receptors to block estrogen’s action. But it can cause brittle bones and increase the chances of uterine cancer,” she says.

What then is the secret of escaping the dangling sword of breast cancer? Vigilance and more vigilance is the doctor’s prescription.

Start early

* If there is a strong family history,screening should start at the age of 25

* Mammography does not work well in younger patients because it is X-ray based and often cannot penetrate the dense breast tissue

* A clinical examination,an ultrasound and in some cases an MRI is advised

* If nobody else in the family suffers from the disease,get a screening mammography done every two years after the age of 40

* Go to the doctor for an annual examination after you are 30 years old

* Breast self-examination is extraordinarily effective,provided you learn to do it correctly

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