India is staring at a breast cancer epidemic. But do we have the awareness and tools to prevent one?

Dr K Pavithran sees an average of 25 cases of breast cancer every month. Pavithran is the head of medical oncology at Amrita Institute of Medical Sciences, which has hospitals in Delhi and Kochi. Dr Gopinath KS, a surgical oncologist at Bangalore Institute of Oncology, sees about 25 to 30 breast cancer patient in a week. Both doctors have observed that the number of breast cancer patients in India has increased. The lack of early detection and treatment is leading to thousands of deaths in India and that death toll is set to rise.

A study published in August this year, examining breast cancer awareness in the country, found that more than 70,000 Indian women died of breast cancer in 2012 and predicted that the number of deaths is likely to increase to 76,000 in 2020. Younger women are also more likely to develop breast cancer with the average age of incidence shifting from 50 years to 30 years.

The Indian Council of Medical Research finds that India is likely to have more than 17.3 lakh new cases of cancer and over 8.8 lakh deaths due to the disease by 2020. Breast cancer is the most common of the types of cancers occurring in India followed by lung cancer and cervical cancer. The Council estimates that there were 1.5 lakh new cases of breast cancer in 2016 – that is more than 10% all new cancer cases in 2016.

Pavithran finds that his observation of greater occurrence of breast cancer is borne out by national data. “Hospital based statistics may not be a real indicator as Amrita Hospital is a tertiary care hospital with a special breast unit, referrals are usually more,” he said, suggesting that the hospital sees more breast cancer patients because those who have already been diagnosed some there. There are likely to be many more undiagnosed cases.

“The age-adjusted incidence rate of breast cancer as per the population based cancer registry data of ICMR shows increasing incidence [among the general population],” Pavithran pointed out.

Age-adjustment is a measure that accounts for variation in the age distribution of populations and is considered to provide more accurate estimates.

Early detection of breast cancer is crucial to treatment and survival for a patient. Like all cancers, breast cancer if detected early can be cured by chemotherapy and through surgery.

More gene-linked breast cancer in India?

All cancers occur due to damage to a person’s DNA. That damage can occur due to both environmental factors, that may be avoided, and genetic factors that may not be avoided.

Globally, about 10% of breast cancer is genetic or due to an inherited DNA mutation. But a recent study suggests that there may be a greater occurrence of genetically-linked breast cancer among Indian women. Most inherited breast cancer cases are because of defective breast cancer genes called BRCA1 and BRCA2, where BRCA stands for breast cancer. Women with BRCA gene mutations also have a higher than average risk of developing ovarian cancer. The study by Strand Life Sciences, a company specialising in precision medicine, in collaboration with the Indian Institute of Science in Bengaluru and other institutions, published last year in the Journal of Human Genetics has shown that Indian women have more BRCA mutations than women in western countries. The study detected pathogenic mutations in about 36.2% cases of patients with breast and ovarian cancer.

Some of the increase in breast cancer incidence in India maybe due to the greater life expectancy of Indian women now as well as control of other communicable and non-communicable diseases. As women live longer, they develop a greater chance of getting breast cancer.

Lifestyle changes such as bearing a child late in life, lack of breastfeeding, medical use of hormones, menarche occurring in younger people and menopause being pushed to a later age may have contributed to an increase in breast cancer cases, suggested Dr Suraj Manjunath, consultant surgical oncologist at Vikram’s Hospital in Bangalore.

Both women and men have BRCA genes. BRCA genes repair cell damage and keep breast, ovarian and other cells growing in a normal way. Those who have defective genes may develop breast cancer or abnormal growth in the breast and/or ovary. “Approximately 55% to 65% of women who inherit a harmful BRCA1 mutation and around 45 percent of women who inherit a harmful BRCA2 mutation will develop breast cancer by the age of 70 years,” said Pavithran.

The trend indicates that women who have family histories of breast cancer should have access to the BRCA genetic test to gauge their predisposition to the disease.

Dr Ryan Jensen is an Associate professor of Therapeutic Radiology in the Yale University School of Medicine. He works on BRCA mutations and suggested the need for a wider study to gauge the actual occurrence of genetically-linked breast cancer in India. “The only real way to get at the risk number is to perform a large study (>1000 people) in an unbiased, representative cross section of the Indian population,” said Jensen in an email.

Pavithran said, “Another interesting point from that study was that 20% of them did not have a family history of breast or ovarian cancers. This needs to be validated by a larger study from different parts of the country to develop our own guidelines for genetic screening.”

However, if there is trend of a higher proportion of inherited breast cancer in India, then there needs to be better access across the country to tools help detect the disease early.

Detection

Based on their family histories and genetics, women might have a high risk of developing breast cancer in their life times. Having a risk factor, like the BRCA gene, does not necessarily mean that a woman will get the disease but her chances to developing it are higher. The group of people at high risk of getting breast cancer includes men whose family members have had breast cancer before the age of 50 years, with cancer of both breasts and the ovary, and those with multiple breast cancers.

One way to catch breast cancer early is to screen women with family histories of breast cancer for BRCA genes. A patient who knows his or her predisposition to breast cancer can choose how often to get tested for the disease and the choice of treatment if he or she develops the disease. Breast cancer survival has improved because of the recent developments in diagnosis, especially the shift from using mammograms to using blood tests since mammograms often throw up false positives for the disease.

“Mammogram is not the ultimate in screening as there are lot of issues associated with it,” said Pavithran. “More simple blood based tests are being developed as an alternative to mammogram screening.”

The guidelines used in India so far to screen for breast cancer are not adequate to deal with the growing burden of the disease, said Dr N Sundari, professor at M S Ramaiah Memorial Hospital in Bengaluru. “The protocol we follow for breast screening needs modification because we

follow protocols that were prescribed by other agencies such as American Congress of Obstetricians and Gynaecologists, the Royal College and so on,” she said. “Women under the age of fifty [who test positive for BRCA mutations] can go for sonography but preventive breast surgeries are rare in India. So are BRCA screening tests as costs are high.”

Such screening may now have to be performed on younger women as well, if more women closer to the age of 30 are developing breast cancer.

“We could send such high risk patients for genetic counselling and screening for BRCA1 in selected cases,” said Pavithran. “The factors that govern this are the cost of testing, unwillingness to know what lies in the future and so on.”

Manjunath and his team have studied patients with BRCA mutations. He said, “If the index patient[first woman to tested in a family] tests positive for a mutation in a BRCA gene, then other family members are offered genetic testing for the same mutation. This requires extensive pre-test counseling, as they should be able to psychologically handle the implications of a positive test, and also understand the options available to them to prevent developing cancer. “

“BRCA gene tests cost between Rs 15,000 to Rs 35,000,” said Dr Chirantan Bose, vice president of clinical sciences at Medgenome, a company that offers diagnostic services. “We get about 800 to 1,000 patients in a month out of which about 50-60% are cancer patients and a reasonable chunk is breast cancer patients.

Sundari gives talks about breast cancer at tech companies, women’s societies, government teachers associations and the Lions and Rotary Clubs. “Even now awareness about breast cancer is poor among the people,” she observed.

At the same time, even doctors need to become more attuned to looking for breast cancer, said Pavithran. “Clinicians should be more aware of this and should counsel their patients more often.”