Dr Abhishek Shankar, Dr Pritanjali Singh
Globally, cancer has emerged as an important contributor to human health and burden is growing with each passing year. Cancer has emerged as an important health issue in last few decades. Carcinoma of breast, cervix, uterus, ovary, and lung accounts for nearly half of the cancer incidence among female. Breast cancer is one of the most common cancers in India and is rapidly rising among women. During this Breast Cancer Awareness month, this article is focused on the risk factors, sign and symptoms, screening and management of breast cancer. In India, although everyone is aware of different cancerous diseases, there’s a lack of detailed knowledge around it. From different risk factors, symptoms, diagnosis to treatments and prevention and screening, there’s a vast ocean of information that still fails to meet the common eye.
Health Promotion Approaches for Breast Cancer Prevention
Health promotion interventions can help to decrease the incidence, prevalence of Non-communicable Diseases (NCDs) including cancer. It also helps to decrease the morbidity and mortality associated with NCDs at national, state, and community levels. Health promotion activities as a preventive measure for cancer are focused on underlying risk factors like physical inactivity, overweight and obesity, dietary factors including fruit and vegetable intake, tobacco and alcohol use, infections, and environmental and occupational exposure.
Physical inactivity attributes to nearly 5% of all cancer deaths and many studies have reported that physical activity decreases the development of breast cancer. A study conducted on the female school teachers of California found that the rigorous physical activity for 5 hours per week or more decrease the chance of developing breast cancer with Relative Risk (RR) of 0.80.
Certain workplaces or occupation pose higher risk of breast cancer and flight attendants due to exposure to cosmic radiation and circadian rhythm disruption have increased risk for breast cancer.
In recent decade, increased level of environmental pollution is a major concern for public health. Many of the chemicals or components of environmental pollution i.e. asbestos, dioxins, nickel, chromium, arsenic, industrial emission and vehicular emission are probable or potential carcinogens. Environment smoke or second-hand smoke is associated with higher risk of breast cancer.
In recent years, advancement and improvement of research has given more insight about cancer biology. With the growing interest of scientists, chemoprevention is proven to be clinically beneficial in carcinoma of breast and many of the therapeutic agents for chemoprevention, currently under trails, are debatable. Tamoxifen have been reported to be useful in decreasing the breast cancer risk by half in asymptomatic breast cancer patients. Chemoprevention in breast cancer has been widely studied which resulted in approval of Tamoxifen and Raloxifene by Food and Drugs Administration, USA. Tamoxifen found effective in reducing breast cancer risk not only in healthy women but also in high risk women. Other therapeutic agents in chemoprevention of breast cancer are under research, which are raloxifene, exemestane, anastrozole, tibolone, retinoids and bisphosphonate ibandronate.
Risk Factors & signs and symptoms of Breast Cancer
Studies have shown that your risk for breast cancer is due to a combination of factors. There are risk factors like getting older, genetic mutations of BRCA 1 and BRCA 2, early menarche and late menopause, having dense breast, personal history of breast cancer, family history of breast or ovarian cancer and previous treatment using radiation therapy to chest or breasts before the age of 30 years, are non-modifiable. Risks like not being physically active, being overweight or obese after menopause, taking hormones, and drinking alcohol can be modified.
Prevention and screening of breast cancer focus on reducing the cancer incidence and mortality. It is an important step to make general population more aware about sign and symptoms of breast cancer. Prevention of breast cancer include change in lifestyle and eating habits, behaviour change and reduction in environmental and occupational carcinogen exposure, while screening aims at detecting the pre-malignant lesions or cancer at early stage where chances of cure are much higher. Effective screening can further reduce the cancer related deaths, which can be up to 20% in breast cancer.
|Breast Cancer signs and symptoms||§ Breast lump or thickening
§ Change in the size, shape or appearance of breast
§ Changes to the skin over breast
§ Redness or pitting of the skin over breast
§ Nipple discharge
§ Nipple retraction
In India, breast cancer burden is high and there is high cost of cancer treatment, less expenditure on public healthcare, high out of pocket health expenditure despite many government health schemes. To prevent the burden of rising number of NCDs, government of India launched National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), under which screening of breast, cervical and oral cancer is done at community level. These three cancers contribute a major burden of cancer in India and are easily preventable and treatable if detected early, can help to reduce mortality.
Breast Cancer Screening Recommendations
Carcinoma of breast is most frequently diagnosed cancer among women worldwide and contribute nearly one tenth of cancer incidence and 6.6% of all cancer deaths. Breast cancer burden is higher in developed countries but cases are also rising in developing world. Mammography is most widely recommended as screening modality for breast cancer. Breast Self-Examination is no more recommended for breast cancer screening as it has failed to decrease mortality from breast cancer in different studies. Clinical Breast Examination for Breast cancer screening also has limited data.
US Preventive Services Task Force (USPSTF), USA recommends mammography for breast cancer screening. Women aged 50 – 74 years should go for mammography every 2 years. It is an individual choice to start screening between 40 to 50 years of age. Mammography has no clinical benefit in women older than 74 year of age.
American Cancer Society (ACS) recommends annual mammography for women aged 45 – 54 year; every two year for women aged 55 year and older until their health condition is good with 10 or more year of survival chance. Women between ages 40 – 44 years may choose to screen them annually. Annual mammography with MRI is recommended for as early as age 30 among women with known BRCA gene mutation. Canadian task force recommends mammography for women aged 50 – 74 year, every two or three years. For women aged 40 – 49 years, no screening is recommended as evidence of benefit of screening is not of high certainty. Under NPCDCS and operational framework for management of common cancers in India, clinical breast examination by healthcare workers is recommended for women aged 30-65 years, every 5 years for breast cancer screening. Suspected case of breast cancer then further evaluate by mammography or ultrasonography (USG).
|Recommendation for prevention and screening of breast cancer|
|Cancer||Cancer Prevention/ Risk Reduction Strategies||Tool(s) for cancer screening||Recommended Age||Frequency|
|Breast||For High Risk Women*, use of chemoprevention Medicine, tamoxifen or raloxifene, is recommended;
Education & Awareness about breast cancer risk factors, signs & symptoms and recommended age for screening
|Clinical Breast Examination
(for high risk women*) (MoHFW, India)
|30 years onwards||Every 5 years|
|Mammography||50 – 74 Years||Every 2 Years|
|MoHFW: Ministry of Health & Family Welfare|
|*High risk women: Family H/o Breast, Ovarian or Colon Cancer, with H/o Chronic Benign Breast Diseases and with personal history of Breast Cancer in the same or opposite Breast|
Oncology societies and associations have expert members of various oncology specialties along with volunteers and breast cancer survivors who can educate masses about the breast cancer risk, signs & symptoms, prevention and screening methods. They can also encourage communities to adopt healthy lifestyles, food habits and to adopt breast cancer screening practices.
A multipronged strategy is needed to tackle the growing burden of breast cancer. In addition to it, an effective implementation of national framework for screening of common cancers, will be a boost in inciting an attack on these preventable cancers. Apart from government initiatives, advocacy by civil society and efforts of non-government organizations also needs to be promoted. In summary, the unique challenges of preventable cancer burden may be dealt with indigenous and country-specific approaches which may result in a sustainable long term control and cure of breast cancer.