MBCC 12

Dr. Siddharth Ramesh Sahni - Artemis Health Institute, New Delhi, India

Issues affecting Indian breast cancer treatment

At the moment I am in New Delhi in the national capital region of India, in a hospital called the Artemis Health Institute. It’s a private facility, but it’s different in that it’s very site-specific oriented, and we have the Artemis Cancer Centre, of which I lead the Artemis Breast Unit. We just look after all the breast cancers that come in and the non-cancerous breast diseases as well. What’s alarming is that when I left India in ‘95, I don’t think anyone would have envisaged a separate breast institute within a facility, and today the numbers of breast cancers are increasing rapidly to allow that to happen. I don’t know whether that’s a good or a bad thing, but it’s certainly here to stay.

The raw data which was released by the Indian Council of Medical Research in 2007 hasn’t still been published, it actually showed about 150,000 new breast cancer cases, which is above the prediction of the World Health Organisation for India for 2015, which stated about 112,000 cases, so we’re already way ahead of that curve. Also the median age for breast cancer in India is being viewed at between 40 and 45, so if you compare that to the figure in the west it is actually coming ten years earlier as well.

Why is this?

Well there hasn’t actually been research to show why the disease is coming in a younger population, but you have to understand that 65% of all population amongst women in India is under the age of 50, so I think it’s more demographic associations rather than anything else. But also I think because breast cancer is multi-factorial, there has to be a role that stress or disadvantage or a changing lifestyle is playing amongst women. Because if you look at the theory and the risk of breast cancer, Indian women should not, as a group, be getting breast cancer, particularly in the numbers that we are getting it at the moment.

Do you have a screening programme?

No we actually don’t have a national screening programme for detection based on mammography particularly. As you are aware, one of my colleagues spoke to you about the National Cancer Control Programme, what that concentrates on is secondary prevention of breast cancer, which essentially allows for breast self-awareness. But the government has no national cancer screening programme for breast per se.

There are pockets, or efforts that are being made. The largest trial in that is actually being run out of Mumbai by the Tata Memorial Hospital, but that did not involve mammograms, it actually involved teaching the community breast self-examination. And there are papers to show that women who do practise breast self-awareness are far more likely to go and get a mammogram in any case. And it did show that over a ten to fifteen year period, the T-size of the cancers detected in women who are fairly proactive in breast self-examination was much lower, and that has increased the rate of early detection of breast cancer. Other than that there has been no major drive.

There are people who are trying to do mobile screening, but it’s not just the detection of the tumour which is important but it’s also the treatment thereof. And there are still some fallacies that exist amongst the population, both medical as well as the people who get the disease, about the fact that you have to do a mastectomy and the loss of the breast even though it’s not so prominent culturally in India, it’s still regarded as a huge loss. Women really don’t want to go and get themselves screened because the message that whether it’s a 1cm tumour or a 5cm or a 10cm, that you don’t need to lose your breast if it’s early breast cancer, has still not got through.

So that’s one of the reasons that we’re still seeing the disease in much more numbers now, but at a much later stage than it is in Europe. I’ll give you an example: the average tumour size across the board in New Delhi is 39mm. So that’s pretty big, and the stage is a stage 2b or 3a, so we have about 60-65% of all breast cancers presenting at this stage, so you’re already a bit behind the eight-ball.

You’re visiting the European Institute of Oncology working on a collaboration?

I was fortunate enough to actually have spent some time training at the European Institute of Oncology, in the Department of Sonology here with Professor Umberto Veronesi and Alberto Luini and all the others, and we have managed to collaborate based on our dialogues in the last few years, on the rising trends in breast cancer numbers in India as well as the lack of appropriate facilities. And I don’t mean just centres, but just the whole outlook towards the disease.

And what we’re doing with the European Institute is actually combining their experience with what we have in India, and looking at disseminating awareness to the general population and using the experience that Professor Veronesi has established all over these years in doing that so effectively. Also, to build up advocacy and get brand ambassadorships from both countries.

And then once you have that in the general population, to then simultaneously train the doctors in all aspects of breast cancer so including radiology, pathology, nuclear medicine, surgery; to be able to deal with the disease, because as you’re aware of Professor Veronesi’s maxim of changing from maximum tolerated therapy to minimum effective. So once you get that it sends out a very, very positive message from the person who has undergone that so-called tailored therapy and the feedback into society is huge. So we’re trying to fill a void that we think does exist. We know it exists and can be filled effectively.

We are very lucky that as partners in this programme in India we have two of the largest public cancer centres that are associated with it; the two being the Tata Memorial Hospital and the All India Institute for Medical Sciences, by virtue of the fact that the directors of these two institutes are board members and part of the steering committee as well. So we are really hopeful of this programme succeeding.

We’ve already undertaken some activities which have started in terms of awareness, particularly in New Delhi, and we hope that will continue at a fairly good clip six months down the line, and we’ll be able to share more with you by this time next year.