Breast cancer is the most common malignancy among women worldwide. In India, it
has trumped cervical cancer as the most prevalent cancer among women, especially among
urban populace. As per World Health Organisation, about 1 .5 lac cases of breast cancer are
being diagnosed per year in India with 70,000 women succumbing to illness every year. The
overall mortality figure due to breast cancer is double in India compared to Western
countries. The incidence is further projected to increase from 0.1 5 million currently to 0.23
million per year by 2026, ballooning into a major health care problem. The oncogenic trigger
targets the epithelial cells lining the ‘milk ducts’, which behaves errantly due to mutation.
Either there is loss of checkpoint to combat uninterrupted proliferation or up-regulation of
genes which regulate cell turnover.
Breast cancer happens to be a compilation of multifaceted illness assorted under
one canopy with varied clinical presentation, behaviour and outcomes. Lots of key factor
affect the prognosis including age, menopausal status, stage, hormonal stage and treatment.
Lesser median age and higher stage at presentation partially due to lack of awareness,
meagre resource and aggressive biology mars the ultimate outcome of women with breast
cancer in India. Due to novel discovery in molecular genetics, every patient can be assigned
to a special discrete group which makes her assessable to receive maximum benefit to a
selected combination of therapy. Such approach of individualised tailored therapy improves
the probability of cure while minimising adverse effects and futile costs.
Screening general population helps in prompt detection of early pre symptomatic
stage breast cancer and reduces mortality. For women with average risk, monthly breast self
examination (BSE) along with 3 yearly clinical breast examination (CBE) after 25 years and
annual CBE with mammography yearly after the age of 40 years is recommended. Women
with increased risk determined with risk prediction model require early and more vigilant
screening with six monthly CBE beginning at 30 years of age. Select group of women with
familial pedigree suggestive of higher risk or genetic predisposition can undergo risk
reduction bilateral mastectomy with bilateral oophrectomy or follow up closely with
tamoxifen use. These screening protocols should be aided with mass breast cancer
awareness programme to augment the impact of benefit achieved.
Any diagnosed breast cancer merit systematic examination and pertinent
investigations to determine the stage, grade and hormonal status of the tumour. This is to
be followed by meticulous individualised planning by multidisciplinary team of doctors
comprising surgical, medical and radiation oncologists. Majority of early breast cancer
patients can preserve the affected breast after undergoing breast conservation surgery
provided they agree to receive subsequent radiotherapy. The sequencing of therapy
proceeds from surgery to chemotherapy followed by radiotherapy. Patients also receive
adjuvant hormonal therapy if deemed necessary for a period ranging from 5 to 1 0 years. For
locally advanced tumours, doctor could suggest chemotherapy before surgery to make
tumour optimally resectable. Patients presenting with metastasis unfortunately could not be
cured, however meaningful symptomatic palliation and prolonged survival could be achieved
with hormonal and chemotherapy in considerable number of patients.
Remarkable improvement in survival in localised and locally advanced breast cancer
over past two decades has been achieved. Credit for this feat is shared equitably between
effective population based screening strategies and individualised therapeutic options
including modern chemotherapeutic agents with customised radiotherapy. Even in patients
with metastatic disease, novel drugs such as transtuzumab, everolimus,fulvestrant and
lapatinib in selected cohorts of patients have prolonged survival effectively.
Breast cancer continues to be a major health care problem with deepening crisis due
to projected rise in incidence. Modifiable risk factors can be overcome by adopting well
balanced diet, adequate exercise to achieve optimum Body Mass Index (BMI) with
encouragement to breast feeding practices. Mass breast cancer awareness programme
with early detection and prompt referral can save many lives. Effective early individualised
therapy guided by trained multidisciplinary specialists can go a long way in reducing the
burden of this ‘Emperor of all Maladies’.
