According to the World Health Organization, <a href="https://acsjournals.onlinelibrary.wiley.com/cms/asset/cda39a9d-7a4e-4d2d-99ca-28e7d1a12b34/caac21660-fig-0001-m.jpg">cancer</a> is one of the top two causes of death among people under the age of 70 years in most countries. <a href="https://pubmed.ncbi.nlm.nih.gov/26427363/">80% of the 15&middot;2 million</a> new cancer cases in 2015 needed one or more surgeries. In India, it is <a href="https://journals.lww.com/ijmr/fulltext/2022/10000/cancer_incidence_estimates_for_2022___projection.6.aspx">projected</a> that nearly 1.5 million new cancer cases will be diagnosed per year by 2025. Access to safe and affordable surgical care, therefore, is crucial for patient care in otherwise fatal but often curable cancers.

Healthcare disparities only become worse in <a href="https://hdl.handle.net/10161/23143">access to surgery</a> between rural and urban areas in India. Similarly, nearly over 65% of the Indian people reside in rural areas that have only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477376/">5%</a> of the country&rsquo;s cancer care facilities. The COVID pandemic further <a href="https://www.hindustantimes.com/ht-insight/public-health/impact-of-covid-on-cancer-care-unaddressed-problem-and-the-possible-solutions-101643631412106.html">worsened</a> the access to surgical cancer care. &ldquo;Because of the COVID lockdown, buses were not coming to our village. There was nobody to bring me to the hospital and I did not have the money to get a taxi,&rdquo; told a 45 years old lady from rural Tamil Nadu who presented to the hospital emergency room in 2021 with a large ulcerated mass in the breast that had started as a small nodule 9 months ago.&nbsp;

The occurrence of breast cancer in particular has been steadily increasing and it is currently the <a href="https://www.wcrf.org/cancer-trends/worldwide-cancer-data/">most common</a> cancer worldwide. Lack of awareness about cancer symptoms, the stigma associated with cancer, and poor family support are some of the barriers to care. Breast cancer, which ideally should be picked up early by women themselves, is still diagnosed at late stages in India. This coupled with the stigma associated with cancer further prevents people from seeking care as they try to hide the complaints as much as possible.&nbsp;

&ldquo;A young lady in her early thirties who was a mother of two children came to our outpatient clinic with a large breast mass. She had ignored it till now as it was not painful. She came to us now, as it had grown rapidly and was no longer conceivable. Although her husband was supportive, ill-treatment by the rest of the family caused significant mental and emotional stress in the patient who even contemplated suicide. By the time she presented to us removal of the entire breast was the only option as the tumor was very large. She underwent the surgery and received radiation therapy,&rdquo; told her surgeon working in a private tertiary hospital in south India. However, the story doesn&rsquo;t end here. Women often face stigma even after achieving a cancer cure due to body image distortion. Fortunately, in the case of this woman, she underwent a breast reconstruction surgery that helped in avoiding stigma.

Affordability is another <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956579/">significant barrier</a> to obtaining cancer surgery. People often are forced to migrate to far-off cities in search of good quality cancer care which worsens the financial toxicity for their households. &ldquo;I had to sell my house to raise funds for my surgery,&rdquo; told Mr. Abdul (name changed), a school teacher from Bangladesh who traveled 1800 km to Vellore to get treated for colon cancer. &ldquo;I had heard that the quality of treatment was better here which is why I traveled to India to get treated. I think that my chances of having a successful surgery and surviving are better here.&rdquo;&nbsp;

Oftentimes, despite presenting early with symptoms, some patients suffer delays in appropriate care due to misdiagnosis. This could be explained by a lack of expertise and infrastructure, especially in resource-limited hospitals. &ldquo;The doctor told me I had tuberculosis and so I started on tablets which I took for 6 months. However, my symptoms did not resolve and I kept getting worse,&rdquo; told a middle-aged man who was later diagnosed to have metastatic lung cancer.&nbsp;

Similarly, stomach cancer can often present as heartburn which can be treated using over-the-counter antacids. &ldquo;I developed acidity 12 months ago. Initially, I used to feel better after taking oral antacids. However, over the next few months, the acidity worsened and I felt tired all the time,&rdquo; told Mr Swami (name changed) from rural Tamil Nadu. As his initial ultrasound was normal, he was not advised to do any further investigations. Once his symptoms worsened, the only option he had was to go to a medical college and hospital that was 4 hours away. After multiple trips to that hospital and getting an endoscopy, he was diagnosed to have stomach cancer. The cancer had already spread to the nearby organs, deteriorating his chances of survival.

Dr. Nandakumar Menon, the director of <a href="http://ashwini.org/">ASHWINI Gudalur Adivasi Hospital</a> which caters to the tribal communities of the Nilgiris district in Tamil Nadu says that cancers of the esophagus and stomach are the leading cancers among the tribals of the town of Gudalur. &ldquo;The closest healthcare facility to perform upper GI endoscopy is 5 hours away and it is impractical to refer patients all the way just for an endoscopy test.&rdquo;&nbsp;

However, Gudalur Adivasi Hospital has successfully addressed this gap in the healthcare system.&ldquo;We set up an endoscopy suite in our 50-bedded secondary care hospital way back in 2011. For over 10 years, diagnostic upper GI endoscopies have been performed in our hospital by trained junior doctors and we have been able to diagnose a significant number of patients with cancers of the esophagus and stomach,&rdquo; told Dr Menon.&nbsp;

The overburdened healthcare systems further add to delays in treatment. Specialized cancer care in India has been centralized to only major cities like Chennai, Delhi, and Mumbai. Hospitals in these places have gained patients&rsquo; trust which makes them travel across the country to seek care. Dr. Rajat Raghunath, a colorectal surgeon at Christian Medical College, Vellore in India says that over 60% of the patients who arrive at his department travel over 1500 km to seek healthcare. &ldquo;The conditions range from minor ailments like hemorrhoids to advanced cancers. However, there is a long waiting list for surgeries, and unfortunately, some of the patient&rsquo;s disease worsens and becomes inoperable,&rdquo; told Dr Raghunath.&nbsp;

According to Dr. Neerav Aruldas, a general surgeon practicing in the remote parts of the hilly northern state of Himachal Pradesh for the past 2 years, the health system has to diagnose its problems first. &ldquo;As most cancers now require chemotherapy first, the operation is delayed as the overburdened public health systems are not able to provide timely chemotherapy. Often patients who were referred for chemotherapy return without receiving proper chemotherapy. The delay and incomplete treatment lead to progression of disease where only palliative care can be offered to the patient who possibly could have been cured of the disease&rdquo; told Dr. Aruldas.&nbsp;

Setting up multiple cancer institutes in the northeastern part of the country is a welcome move to reduce geographic disparities in access to cancer surgeries. However, building new infrastructure solves only a tiny part of the puzzle. &ldquo;We have to send biopsy samples to Delhi due to a shortage of pathologists in our area. It takes 3 weeks for us to receive the biopsy results&rdquo; told Dr Aruldas.&nbsp;

Cancer patients are among the most vulnerable patient groups that cannot seek surgical care when they need it due to unaffordability, delayed diagnosis or misdiagnosis, disparities in the ability to reach the hospital, and stigma among other issues. These stories tell us that the fight against cancer is impossible and incomplete without integrating surgical care at all levels of the health system.&nbsp;&nbsp;

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Edited by Parth Sharma and Siddhesh Zadey.

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Cancer is an undeclared epidemic in India. What role does surgical care play in cancer care?

cancer care

Cancer Care in India - Incomplete and Impossible without Surgery

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.&nbsp;

&ldquo;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?&rdquo; - 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&rsquo;s risk of developing a cancerous breast lump. She said that she had three children. She wasn&rsquo;t sure of her age so she couldn&rsquo;t say how old she was when her first child was born. She hadn&rsquo;t taken any contraceptive pills and had breastfed all her children. She wasn&rsquo;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 <a href="https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm">risk factors </a>&nbsp;for breast cancer.&nbsp;

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&rsquo;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.&nbsp;

&ldquo;Why couldn&rsquo;t you come earlier? I&rsquo;m sure you had a lump in your breast much before all this developed. Why did you neglect it?&rdquo; - the disappointed but frustrated doctor asked the lady.

&nbsp;&ldquo;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.&rdquo;&nbsp;

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 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896900/">98%</a> 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 <a href="https://www.researchgate.net/deref/https%3A%2F%2Fdoi.org%2F10.1159%2F000115288">advanced</a> and inoperable stages.&nbsp;

<img alt="" src="http://localhost:8000/images/1708088245.png" style="height:512px; width:400px" />

Breast cancer is the most common <a href="http://www.pharmabiz.com/NewsDetails.aspx?aid=97342&amp;sid=1">cancer</a> among women in urban India and the second most common cancer in rural women. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8966510/#B5">incidence</a> of breast cancer in India has nearly doubled from 1983 to 2012. As per the <a href="https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf">Globocan data 2020</a>, 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.&nbsp;

<img src="https://lh7-us.googleusercontent.com/QxmrXXkyLzOO545Oqge2q5Q6xL5GUd5qvThAQpcysx-fR3nj6bun84XXAVziuVTYAon7Fz5Bnm-K4r7MBr6F1B-QlBKtbNhvcl9hnJgcvdPa4JL0Tx15oAgTeJuSAAjzKwyd3Pbz5XYq" style="height:503px; width:602px" />

When detected early, <a href="https://www.indianjcancer.com/article.asp?issn=0019-509X;year=2012;volume=49;issue=3;spage=277;epage=282;aulast=Akram">breast cancer</a> 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, <a href="https://link.springer.com/article/10.1007/s13193-016-0535-z">breast conservation surgery</a> 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.

<img alt="" src="http://localhost:8000/images/1708088238.png" style="height:351px; width:512px" />

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&rsquo;s family who opted for comfort care. She succumbed to the disease 2 days later.&nbsp;

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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 <a href="https://www.bmj.com/content/372/bmj.n256">early detection</a> and helps in the early initiation of life-saving treatment.&nbsp;

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.&nbsp;

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. <a href="https://pubmed.ncbi.nlm.nih.gov/31998823/">Studies</a> have shown that women&rsquo;s health is often neglected in the family and in general access to healthcare is poorer for women. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541646/">Stigma</a> 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.&nbsp;

However, even equipped <a href="https://journal.cjgh.org/index.php/cjgh/article/view/539">rural secondary care centers</a> 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.&nbsp;

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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.

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Why Ignoring a Painless Breast Lump is a Huge Mistake

Royson Dsouza&nbsp;is a Global health associate editor- of BMJ case reports, a fellow in the Department of Colorectal Surgery, Christian Medical College, Vellore, and a writer for Nivarana.

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Royson Dsouza

Royson Dsouza

Cancer Care in India - Incomplete and Impossible without Surgery

Why Ignoring a Painless Breast Lump is a Huge Mistake

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