A 45-year-old Adivasi woman reached the outpatient clinic of a rural secondary care hospital. There was an intense malodor as soon as she walked in, causing a sense of disgust among the other patients who were waiting to be seen. She said that she sustained an injury to her right breast a month back, which then became an ulcer.
The ulcer rapidly progressed in size to occupy most of her right breast and started discharging pus and blood. Her clothes would be soaked in this foul-smelling secretion. This led to the discontinuation of her work as a tea estate worker. Her husband and children had distanced themselves from her for over three weeks because of the foul odor. She then developed severe pain in the affected area and a fever and that is when she decided to visit the doctor.
“Did you notice any lump in your breast before the injury? Have you taken any oral contraceptive pills in the past? How many children do you have and when was the first child born? Have you breastfed them? Does anyone in your family have breast cancer?” - The doctor at the rural health center asked the lady.
The questions mentioned above help doctors in assessing the cause of a breast lump and a lady’s risk of developing a cancerous breast lump. She said that she had three children. She wasn’t sure of her age so she couldn’t say how old she was when her first child was born. She hadn’t taken any contraceptive pills and had breastfed all her children. She wasn’t aware of any cancers in her family. Having children early, and breastfeeding them protects a woman against breast cancer. Whereas, taking contraceptive pills for long durations and family history of cancer are considered risk factors for breast cancer.
The doctor went on to examine her. She was severely pale and emaciated. Her breathing was fast and so was her heart rate. The average hemoglobin of the Adivasis in the region is 8gm/dL (anything below 10gm/dL is classified as anemia) Most of them are malnourished and have low blood pressure. On examining the right breast, there was a large ulcer with a copious amount of foul-smelling pus discharge and multiple maggots creeping out of the wound. Yes! Maggots in the woman’s breast. The underlying breast was infiltrated by a large hard and painful mass that was fixed to the chest. The diagnosis was obvious- cancer of the breast in a very advanced stage. The doctor was upset that the patient presented so late.
“Why couldn’t you come earlier? I’m sure you had a lump in your breast much before all this developed. Why did you neglect it?” - the disappointed but frustrated doctor asked the lady.
“I noticed a lump 5 months ago, but it was painless. So I thought it was nothing to worry about. My village is deep inside the forest. There are no buses. I need to walk for over an hour to get to the road. There are elephants on the way.”
A painless breast lump is one of the most neglected symptoms. Unfortunately, it is one of the most common presenting symptoms of breast cancer. Studies have shown that up to 98% of women in low-income countries are unaware that a painless lump could be a warning sign of early breast cancer. This is one of the important factors for delayed presentation and advanced and inoperable stages.
Breast cancer is the most common cancer among women in urban India and the second most common cancer in rural women. The incidence of breast cancer in India has nearly doubled from 1983 to 2012. As per the Globocan data 2020, breast cancer accounted for 13.5% of all cancers and nearly 90,000 deaths in India. Thus becoming the leading cause of cancer and cancer-related deaths in India.
When detected early, breast cancer is almost always curable with surgery and sometimes with chemotherapy in addition to surgery in selected patients. Even in locally advanced cancers (when cancer spreads locally without spreading to distant organs) the treatment can be potentially curative. This consists of neoadjuvant chemotherapy (before the surgery) to shrink the tumor followed by modified radical mastectomy (removal of the entire breast tissue with the draining lymph nodes in the axilla). In eligible patients, breast conservation surgery can be performed which can give similar results as that of mastectomy. However, lack of awareness results in only one-third of the women getting diagnosed at an early stage. 1 in every 10 breast cancer patients is diagnosed at the last stage of cancer in India.
Our patient was admitted immediately as she had a significant infection in the bloodstream from the infected cancerous ulcer and required emergent treatment. She was administered antibiotics and pain medications. The wound was cleaned and dressed. Investigations showed that the cancer had spread to her lungs, bones, and liver. The poor outcome was discussed with the patient’s family who opted for comfort care. She succumbed to the disease 2 days later.
In our experience over the last 25 years in a tribal secondary care hospital, we have seen many such patients either unaware of the condition or not seeking care early in the disease. The scenario is similar in the rest of the country as well. The key to the successful treatment of breast cancer is early diagnosis. Breast examination performed by health workers for screening of breast cancer results in significantly early detection and helps in the early initiation of life-saving treatment.
When breast cancer is detected in stage 1, the chance of surviving more than 5-years is more than 95%. But this becomes only 21% in stage 4 breast cancer (once cancer spreads to other organs). With a considerable lack of awareness regarding the symptoms (painless breast lump which is hard, irregular, and less mobile, even at a young age) all efforts at screening become ineffective. Breast self-examination is one of the most efficient forms of screening.
The general bias towards the health of women in the predominantly patriarchal Indian society leads to further delays in the treatment. Women from rural areas face the burden of having to travel great distances to get evaluated and treated in tertiary care centers. Studies have shown that women’s health is often neglected in the family and in general access to healthcare is poorer for women. Stigma related to breast cancer, similar to what the lady mentioned above faced, is also a huge barrier to initiate early treatment. Thus, blaming the patient for delaying treatment serves no purpose as the problem at hand is much larger than just the patient being careless about her symptoms.
However, even equipped rural secondary care centers can competently manage patients with early and locally advanced breast cancers. Healthcare workers including village health nurses, ASHA (accredited social health activist) workers, and health professionals at primary health centers must strive hard to spread breast cancer awareness among the public. School curriculums should include symptoms and signs of breast cancer and emphasize the importance of breast-self examination. We need to prioritize the health of women by addressing gender inequality at the same time. Poor health is not just a problem of the body but that of society.
In conclusion, spreading awareness regarding measures to reduce breast cancer risk and how to detect breast cancer early is important. Regular breast-self examinations and frequent health checkups can help in detecting breast cancer at an early stage. Lastly, stigma related to breast cancer and gender disparity in healthcare in India needs to be addressed urgently in order to reduce the burden of breast cancer in India.
