I was sitting in my OPD a few months back when a patient was brought in. The frail woman in her seventies was accompanied by her husband and their grown-up daughter. When the door opened, there was a strong smell of pus emanating from somewhere around.
On evaluation, she was found to have an ulcerated mass in her left breast teeming with maggots. Most of her breast had already been eaten away by the aggressive looking ulcer, causing the malodour that filled the room.
More surprises were in store. This wasn't a person coming from some remote corner of the country with limited access to health care facilities. Her residence was right in the heart of the city, just a stone's throw from some of the leading cancer centres of the state. She was also highly educated, a teacher with fairly good knowledge about early detection of cancer and the need for frequent self-examination. She had noticed the lump when it was small, but chose to ignore it as it was not causing her any discomfort.
This situation brings to light some important deficiencies in healthcare delivery in our country. On the one hand, we have overtly anxious patients with heightened awareness leading to extreme fear or even paranoia for cancer; and on the other hand, most cancers in India are still diagnosed in advanced stages like in the above example. The need of the hour is to facilitate early detection of breast cancer and to refer in time to a treatment centre. But this is not as simple as it may sound.
Let's examine the issue in more detail to find out why. Most females of the menstruating age group have lumpiness of their breasts. Many even have swellings of various sizes and shapes. Majority of them suffer from breast pain, usually in the days preceding their monthly bleeding.
Nipple discharge is less common, but more distressing. When a woman has breast pain, or discharge from her nipple, she is alarmed and seeks medical advice. But the situation is not the same with a lump in her breast. Unless the lump is growing very fast, or is associated with pain, the general tendency is to ignore it as insignificant. Many such lumps are harmless. However, without a medical check-up, one can never be sure.
Mammographic screening
Many countries in the developed world adopt a strategy of mammography-based screening for early detection of breast cancer. Various studies have also proved that such screening is very effective in timely detection if done regularly after the age of 50. Unfortunately, these results cannot be extrapolated onto Indian population.
Available data point to the fact that Indian women develop breast cancer at least ten to fifteen years younger than their western counterparts. This, combined with the fact that mammography in younger females is more likely to miss many cancers due to the dense nature of their breasts makes it unsuitable for screening young persons with apparently normal breasts. And one must not forget that in India, more than 60 percent of all breast cancers are still diagnosed in advanced stages as compared to the less than 20 percent advanced diseases documented in most developed countries.
The guidelines also recommend breast self-examination as a tool for female education and empowerment. Examination of breasts by a clinician adds to the early detection in low-income countries where accessibility and affordability of mammograms are of much concern.
In conclusion, monthly breast self- examination by every adult female and timely medical consultation in case of any suspicious symptom is a more pragmatic approach to breast cancer early detection and treatment in our setting. This is the need of the hour and cannot be ignored if we want to bring down the cancer burden among our females to acceptable levels.
Mammography is useful, but affordability and accessibility limit its widespread use in the rural Indian context. Once we attain the target of detecting majority of cancers in early stages, further advancements may be considered in the form of more stringent application of screening mammography and genetic screening in selected cases.
(Dr Sandeep Pillai is surgical oncologist, KIMS Cancer Centre, Thiruvananthapuram).
