In my first week of surgical rotation of internship, I had the privilege of caring for a woman with breast cancer. She had undergone chemotherapy and surgery and was planned for radiotherapy. Her son, a college student, had temporarily put his education on hold to be there for his mother.
Their financial situation and family circumstances were far from ideal, and the mother carried a heavy burden of worry, fearing that her illness might affect his education and life. Despite her circumstances, she seemed to have an undeniable grace.
She had noticed a small lump in her breast months ago but had ignored it. Being a working mother, she was not able to find time to get investigated until many months later when she developed pain and oozing of fluid from her nipples. By then, the lump had also significantly grown in size.
When she visited the doctor, the diagnosis of breast cancer was made. It was heartbreaking for her and the family. "I know that if I had just taken what I felt seriously, and confirmed it with a doctor earlier, I may have gotten treated sooner. Knowing this kills me on the inside," she says. It was then that I realized the difference it would have made in her life if only her breasts had been examined by a trained professional who would have been able to pick up what was happening and prescribed her mammography and biopsy.
A recent study by the Indian Council of Medical Research (ICMR) says that breast cancer is the most prevalent cancer among women in India, followed by cervical, ovarian, and lung cancer. It is projected that the number of women with breast cancer will continue to rise with an estimated 2.3 lakh women getting diagnosed with the disease by 2025. However, sheer large numbers are not the only cause of concern.
Nearly two out of every three patients with breast cancer are diagnosed at stage III or IV of the disease. As breast cancer in its later stages is associated with poorer outcomes, early detection remains our most potent weapon against this disease. If diagnosed at an earlier stage, breast cancer treatment is not only simpler and shorter but also cheaper as compared to its treatment at an advanced stage. This is not only associated with a better quality of life for the patient but also for the caregivers.
There are many screening recommendations for early detection of breast cancer and they vary based on age and risk factors. Younger women between 25 to 40 years of age at lower risk are suggested clinical breast examinations (CBE) by trained physicians every 1 to 3 years. Women above 40 years of age are recommended yearly clinical breast examinations and mammograms. In women with increased risk (risk factors explained here) an MRI of the breast may also be recommended alongside mammography. However, the difficulties in adhering to the ideal screening schedule are multifold in a resource-limited country like India.
Despite being widely talked about as a possible solution to this problem, self breast examination too, is riddled with problems. It is a method that can be easily practiced in one's leisure time and it also helps women to be aware of the characteristics of their breasts. However, evidence has shown that most women follow the wrong technique even after teaching programs and the number of women compliant with the practice is minimal. As getting investigations done in private centers often doesn’t require a doctor’s prescription, a self-breast examination can increase the possibility of unnecessary investigations like imaging and biopsies. It can also result in an increase in the identification of otherwise harmless lesions and unnecessary anxiety related to possible cancer diagnosis. There are also chances of missing some significant breast abnormalities, particularly small or deeply situated ones.
Clinical breast examination (CBE) is a more reliable option compared to self-breast examination. It is different from SBE since a healthcare provider does it and hence has a higher chance of correctly identifying any abnormality. Unlike mammograms, which are logistically challenging, CBEs can be conducted in all setups by trained healthcare providers without sophisticated equipment. A study among the 1.5 lakh population of women in Mumbai who underwent clinical breast examination revealed that it was able to effectively pick up breast cancer in its early stages and thus helped in saving lives by starting early treatment.
The lack of doctors in rural areas is a major roadblock in universalizing clinical breast examinations. To address this, the JPHIEGO (John Hopkins Program for International Education in Gynecology and Obstetrics) in 2018 launched the Breast Health Initiative (BHI) in selected rural and urban parts of Uttar Pradesh and Jharkhand. Using mannequins, they trained healthcare workers, not just doctors but also staff nurses and ANMs, in primary healthcare centers to pick up breast lumps. BHI combined breast health education, clinical breast examinations, and referral pathways to diagnostic centers in case of abnormal breast examination findings. A survey done later to assess the impact of BHI revealed that the intervention helped in identifying 24 women with breast cancer out of whom 72% were diagnosed at an early stage.
Lessons from the BHI experience suggest that comprehensive training at the primary care level for not only physicians but also nurses and ANMs in clinical breast examination is a possible way of boosting early detection of breast cancer. “The key is to make healthcare workers competent enough to do a good examination with the required privacy and confidentiality and guide the patient and act as a link in the referral pathway”, said Dr. Suranjeen Pallipamula, a public health specialist at JPHIEGO India.
The Indian Government has also taken measures to promote clinical breast examinations via Ayushman Bharat- Health and Wellness Centres. Further evaluation with mammograms is done only in suspected cases if required. This is carried out by Auxiliary Nurse Midwives (ANMs) and nurses trained by robust modules. However, the current number of women undergoing clinical breast examinations is abysmal. The National Family Health Survey-5 (NFHS-5), conducted from 2019 to 2021, revealed that only 0.9% of women between the ages of 30 and 49 underwent clinical breast examinations.
This poignant story of the woman's delayed breast cancer diagnosis sheds light on the pressing need for both increased awareness and accessible clinical breast examination facilities in India. There is an urgency for a paradigm shift toward practical solutions. We must bridge the awareness gap and champion the integration of clinical breast examination into routine healthcare practices. This could be done via collaborative efforts between the Indian government, non-governmental organizations, and healthcare providers. It is high time we ensure that every woman, regardless of her circumstances, has the opportunity for early breast cancer detection and treatment.
About the author:
Angelina Sony is a medical doctor with an interest in primary care
Edited by Christianez Ratna Kiruba.
Image by Janvi Bokoliya.
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