We are unfortunately in the middle of what is amounting to an increasing disease burden in this country and if you were to look at the Indian Council of Medical Research rates there’s about a 4-5% increase per annum comparing annually with breast cancer. So much so that it was 218 on the cause of death list in 2003, it is now number 7 as a cause of death in our country if you take all the parameters into account and it is apparently the fastest rising disease amongst women which is not infectious in our country. So we see and operate about 500-600 cases a year just at my unit.
The age group is very different to that in the West in that the median age of occurrence is between 42 and 47. We’ve got cases spilling over which are in their thirties and, of course, as life expectancy increases over 70 as well which are very hard to manage because there’s very little research being done at either end.
Why do you think this increase is due to the westernisation of India?
It’s linked to westernisation because if you look at the western data as well it was the post-Second World War economic and industrial boom that occurred across Europe and America that suddenly led to the increase in the number of breast cancers. I think it’s also related to diet, it’s related to pollution which is very significantly present in our country. Unfortunately there isn’t enough work being done to see what’s the exact cause but it’s very hard to do that because unlike, say, lung cancer where the chief source is tobacco or cervical cancer where the chief source is a virus which is sexually transmitted, breast cancer is a multi-factorial disease so you don’t know that by stopping a particular thing you’d necessarily be able to prevent it. And every six months we get some new factor that’s added into the mix as causing breast cancer. The recent one was red wine; in the study that they did in the UK where they said that women who have x number of glasses of red wine a week are far more likely to get breast cancer than the ones that don’t and if you look at it against the cardiac background, that recommends that you have four glasses of red wine a week at least.
So it’s not just one thing that you’re looking at, it’s very hard to actually establish what is causing breast cancer in our country. The fact that we have it in a younger subset is, I think, just the demographic that exists in our population. We are a much younger country with a median age incidence of 26.3 years at the moment so if you’re looking at that then you’ve actually doubled your age almost limit for getting the cancer which is pretty similar to what was there in the West where a median age being about 62, 58 in the ‘80s and the average age of breast cancer was 55-57, so it was bang on. I think the age will increase as the pyramid reverses itself in our country but that’s some time to come.
Can you tell us about your session at ICC?
It was very interesting because we had three difficult cases of three women, one very young as I had mentioned earlier, in her thirties, one in her late seventies, where there was access potentially to all sorts of therapy but it was a question of what should be applied, how should you diagnose this patient, what is the need to apply all the current gizmos that we have at our disposal? Very often we find that patients have walked into our clinics with a whole host of investigations that you would never ever dream of recommending based on evidence-based medicine. I think that’s the challenge in India is we’re not necessarily a resource poor country, I think it’s just poorly managed resources as opposed to resource challenged. I think if you’ve put a lot of technology available to people, people want to fall back on technology as a fail-safe mechanism which is not always true because there is horses for courses and there is a definite evidence base to applying technology. Just trying to get things across as to who should have a mammogram, when should you have a mammogram, who should have a PET scan, what is the role of breast conserving surgery? Because one of the things in India is that we still believe if you’ve got a breast cancer it doesn’t matter whether it’s 1cm or 5cm, you must have the breast off because that means the cancer will go away. We know from years and years of trial and experience that that’s not always the case and that’s not the case. I think in our country it’s not looking as to whether we should do conservation or mastectomy but it’s actually getting the right patient or selecting the right patients in whom we can apply the conservation too. I think that brought it out and then you’ve got so much chemotherapy that is potentially being given to patients just because they’re presenting slightly later. We had a discussion about an 80 year old getting chemotherapy. Now I think anywhere in the West that wouldn’t even be a discussion for that but it was done and at the said institution at which this patient presented herself she had chemotherapy unfortunately which was toxic to her and she actually didn’t die of her breast cancer, she died because of the therapy that was given to her. So I think we need to streamline all the algorithms which are already there and they’re applicable in the West and we need to actually bring them in our country. We’ve got institutions like the Tata Memorial and the All India Institute of Medical Sciences that are making great steps to try and get all the centres to come on board and play ball together. I think we’re looking at potentially better patient care over the next decade.
