Breast cancer: Proper treatment after early detection must

“Early detection saves lives” is certainly the catch phrase when it comes to breast cancer. The central message of the popular, global breast cancer awareness campaign Pink Ribbon, this slogan has acquired a special relevance in India over the past decade.

That’s because breast cancer has become the most common kind of cancer among Indian women, accounting for 25-31 per cent of all cancers, according to the Breast Cancer India, an NGO. Younger women are falling prone to this disease - the average age of those developing is now 30-50, a significant drop from the earlier age group of 50-70, says data from the National Cancer Registry Programme. And that’s not all. Of the 1,44,937 women diagnosed with the disease in 2012, nearly 50 per cent didn’t survive, according to the Globocan (WHO) project.

These grim statistics reflect only part of the story. The other, untold bit, revolves around the lackadaisical attitude of women when it comes to their own health: Over 90 per cent of breast cancers in Indian women are diagnosed at stage II or later, largely because females don’t opt for regular preventive checkups and mammograms. Low awareness, shyness andfinancial constraints are the reasons cited for this negligence. Public health crusades are hell bent on persuading women from all strata of society to cultivate “breast awareness”- learn to examine themselves for lumps and get regular mammograms.

Breast cancer spells big business. There’s money in it at every stage- from diagnostics, to treatment and recovery. The past decade has seen the development of new anti-cancer drugs and targeted molecules that have radically transformed the outcome of breast cancer and made personalised medicine a reality, boosting the commerce linked to the disease.

Healthcare technology companies are in head-to-head competition to develop scanners that enable the quick and accurate detection of tumours, and radiation machines that promise targeted exposure; the oncology diagnostic sector is riding the wave of genetic medicine; and specialists are busy handing out expensive, tailor-made prescriptions for treatment.

Yet, mammography remains the thrust of all campaigns. The idea of ‘regular screening’ and ‘early detection’ being the best protection still prevails, despite the scant information on how many lives, exactly, are being “saved,” under what circumstances and at what cost? The assumption that early diagnosis is linked to higher survival rates comes from data in countries that provide women access to adequate and affordable healthcare.
 Early diagnosis certainly makes a difference between life and death, but only when high quality, advanced oncology treatment is available.

Whether early detection really improves survival rates of Indian women in the current context – where public health facilities are inundated with patients who can’t afford optimal cancer care and are on waiting lists for chemotherapy, surgery and radiation therapy that may be several weeks long – is questionable.

A diagnosis of breast cancer can spell financial doom. A mere 15-20 per cent of the women diagnosed with the disease can afford the complete spectrum of recommended oncology diagnostic and therapeutic treatment.

Early detection is only useful in settings that treat early stage cancers on priority. This isn’t the case here, where cancer treatment guidelines across different states and hospitals vary considerably.

Cancer care centres and specialists aren’t held accountable or compelled to deliver key outcome measures, making it impossible to collate data necessary to make inform policy. Though the average cost of chemotherapy is lower than it was a decade ago, specialised diagnostic tests and new drugs are hugely expensive. Newer targeted therapies are still out of reach for the majority.

Just four decades ago, cutting off the breast (radical mastectomy) was considered the only way to prolong the life of those diagnosed with breast cancer. Today, radical mastectomies are rare and the “one size fits all” approach is no longer applicable. No two tumors are alike, and breast cancer does not behave in a uniform way: Oncologists recommend the determination of tumor genomics, so that they can create a personalised treatment plan for each patient.

Tumour ‘markers’

Blood tests are done to determine tumour ‘markers’- these help in the planning and monitoring of treatment, and guide prognostic decisions too. If a woman tests positive for the hormone receptor estrogen (ER) for instance, she will need hormone therapy to help prevent recurrence of the disease, as estrogen stimulates some cancers to grow and needs to be counteracted.

A woman with receptors for HER2-neu protein called “HER2+” kind of cancer responds well to a drug called Herceptin, considered a wonder drug, which Roche has a monopoly over. But this is one of the most expensive drugs in the world, costing about Rs 75,000. A cheaper version called Canmab- made by India-based Biocon Ltd with US partner Mylan Inc- is priced 25 per cent less. According to industry estimates, however, only 15-20 per cent of the women who need the drug in India get it.

Clearly, tackling the menace of breast cancer among Indian women is much more complicated than promoting early diagnosis. Early detection without access to proper treatment doesn’t improve the prognosis: the lack of easily available and affordable treatment for breast cancer impacts survival rates as much as a late diagnosis. Many a times, ‘early’ cancer becomes ‘advanced’ if treatment is delayed.

So, let’s go beyond the notion that screening is the ultimate lifesaver for women. The only way we can make early diagnosis meaningful is by ensuring that cancer treatment is administered within two weeks of a positive test. Unless we demand accountability in the form of data regarding key outcome measures such as treatment-related deaths, survival rates after treatment and the like, breast cancer will continue to claim the lives of millions.

(The author is a microbiologist who writes on health issues)