By Dr. Kumardeep Dutta Choudhury
Cancers are caused by mutations that may be inherited or induced by environmental factors or result from DNA replication error. Ageing is the main risk factor for carcinogenesis. Breast Cancer like illness has been documented in Indian subcontinent since antiquity. The actual diagnosis began in 19th century and cancer burden started to increase in 20th century.
Cancer is the second and fourth most common cause of death in urban and rural India respectively. The mortality rate has doubled from 1990 to 2016. The reasons for the increase in cancer in general and breast cancer on particular are enigmatic. The popular media and lay public blame erosion of traditional Indian values and culture and westernization. The types of cancer which used to dominate in numbers are typically associated with infections, like cervical cancer are declining whereas cancer associated with lifestyle like breast cancer are increasing in both urban as well as rural areas.
In India although age adjusted incidence of breast cancer is lower than western countries, but mortality is at par. Over 26 years, the age standardized incidence rate of breast cancer in females increased by 39%. with an increased trend observed in every state of the country. As per 2012 Globocon data, in urban registries like Delhi, Mumbai and Thiruvananthapuram, breast cancer was the most common cancer in women and in registries such as Barshi, Aizwal and Guwahati, cervical cancer was most common in women. In 2020 more than one lakh seventy-eight thousand cases of breast cancer were diagnosed in India. Age standardised rate of breast cancer at present is 69 per 100000. as per the latest trends, a higher proportion of the disease is being diagnosed among the younger age group in India (median age 40-50) as compared to the west (median age more than 60yrs). The incidence of breast cancer is increasing in premenopausal women. The disparity is largely attributable to hereditary predisposition, social and cultural influences, late marriage and delayed childbirth, lack of breast feeding, fewer children, long term ocp use, hormone replacement therapy etc.
Furthermore, approximately 30% of breast cancer cases amplify her 2 neu as measured by ihc. Tumours not expressing er, pr and also not overexpressing her 2 neu, are termed triple negative breast cancer(tnbc). tnbc’s are aggressive tumour and are associated with higher metastasis and recurrence rates. The prevalence of tnbc is estimated to be 31% which is much higher than western prevalence of 12%. in India nearly 60% of cases are diagnosed at stage iii and iv of the disease which is also much higher than their western counterparts.
Safer and more effective management options have now evolved. we have come a long way from upfront surgery followed by chemotherapy to upfront neo-adjuvant chemotherapy, especially for locally advanced aggressive tumours. These approaches have resulted in higher proportion of breast conserving surgeries and onco-plastic surgeries at select tertiary care centres. sentinel lymph node biopsy is also done in tertiary care hospitals in metropolitan cities.
In hormone receptor positive disease, we are using indigenously developed gene expression profiling for prognostication and risk stratification.
With respect to adjuvant chemotherapy we have made a huge stride from classical cmf regimen of 1970’s and 1980’s to anthracycline based regimen of 1980’s and 1990’s to its modification of addition of taxanes and their newer forms in late 1990’s and 2000’s. in her 2 neu positive cancers we are using pertuzumab and trastuzumab based regimen with higher rates of complete response whereas in triple negative breast cancer immunotherapy and testing for germline brca testing and using of poly adp-ribose polymerase (parp) inhibitors have dramatically changed the outcome.
we are passing through an interesting era of the breast cancer journey, whereby the tough and uncertain times of the past have been left behind. we work in the present, with a myriad of options available to us. the future now rests on two pillars of personalised medicine and other of innovative adaptive clinical trial designs and participation to develop targeted or mutation specific therapies.
(The author is a Senior Consultant, Dept. of medical oncology, Action Cancer Hospital, Paschim Vihar, New Delhi. The article is for informational purposes only. Please consult medical experts and health professionals before starting any therapy, medication and/or remedy. Views expressed are personal and do not reflect the official position or policy of the FinancialExpress.com.)