BREAST CANCER

BREAST CANCER

October is WHO designated ‘Breast Cancer Awareness Month.’

INTRODUCTION

Breast cancer (BC) will kill 76,000 women in India in 2015. For every two women with BC, one will die. Many of these deaths are preventable: simply by early detection. But detection often is late and thus fatal.  Lack of awareness is the major reason for late detection.

Breast cancer is the most common cancer in women in India, 27% of all cancers, closely followed by cervical cancer at 22%. BC is rising at a rapid rate. By 2030, the number of BC cases will rise to about 200,000 a year and deaths to about 100,000 a year. India has the worst survival rate from BC, and the highest number of women dying from BC, in the world. Even if we start a cancer awareness program today, 20-30 years will pass before its effect becomes discernible.

Breast cancer cannot be prevented. But BC incidence can be reduced by a few simple lifestyle changes; and the survival rate can be improved by early detection.

WHAT IS CANCER

Our body is composed of many different types of cells. These cells grow and divide in a controlled manner to produce more cells as required by the body. Also, the older cells and the damaged cells die.

However, sometimes, the genetic material of one cell gets damaged or changed [mutation] and the cell becomes immortal: that is, it will not die. When this ancestor cell divides, its descendant cells are also immortal. This gives rise to a limitless number of immortal descendant cells. The number of cells is far in excess of what the body needs. The extra cells then form a mass that is called a tumour.

These immortal cells are called cancer cells. The cancer cells are: immortal; capable of limitless division, and thus of limitless growth in the number of cells; and capable of spreading [Metises] to other parts of the body through blood and lymph system.

There are more than 100 types of cancers. Not all cancers form tumours: cancers of the blood and the bone-marrow [leukaemia], for example, do not form tumours.

Most cancers are named for the body part in which they begin: colon cancer, prostate cancer, ovarian cancer, breast cancer and so on.

WHAT IS BREAST CANCER

Breast consists of lobules (milk producing glands), ducts (tiny tubes that carry the milk from lobules to the nipple) and blood and lymphatic vessels.

Breast cancer is a malignant tumour that starts in the cells of the breast. It begins in the ducts; sometimes in the lobules:  and rarely, in other cells of the breast.

It then spreads through the breast lymph vessels to lymph nodes under the arms and thence to other parts of the body

WHO IS AT RISK OF BREAST CANCER

Every woman is at risk of breast cancer. In India, one in 28 women will get breast cancer. Certain factors increase the risk of BC.

AGE. Cancer is a disease of old age: most cancers begin to strike at age 60 and above. But now cancer is also striking, though only rarely as yet, the teenagers. Risk of breast cancer, for example, is about 0.25% for a 30 year old woman but increases to about 11% in a seventy-year old. In different countries, breast cancer risk in a 70 year old is 54% to 154% higher than in a 30 year old. Thus, as longevity has increased, so has the cancer incidence.

HEREDITARY. If first degree relatives [mother/father/brother/sister] had cancer, the risk of cancer is increased.

GENETICS. A person can be genetically predisposed to get cancer. A woman who has a family history of breast cancer is statistically more likely to get breast cancer. However, only a small percentage, less than 0.3% of population, is genetically disposed to get cancer. And less than 3-10% of all cancers are because of genetic predisposition. In women with BRCA 1 and BRCA 2, the probability of getting breast and ovarian cancer is more than 75%. Mutations in a few other genes [PTEN, CDH 1, TP 53 etc.] also increase the risk though not as much.

OBESITY.  In obese postmenopausal women breast cancer risk is twice that of the non-obese women.

DIET. Diet contributes to up-to 80% of cancers of colon, prostate and breast; and also contributes to cancers of pancreas, lung, stomach and esophagus. Alcohol, red meat, sugar increase the risk of cancer.

Smoking, night work, no children or child born after age 30, recent use of oral contraceptives (reverts to normal on stopping), HRT, and Chemicals in environment – increase the cancer risk.

MENOPAUSE. Late menopause increases the risk.

REDUCING THE RISK

Healthy weight, physical activity – brisk walking, cycling, swimming - 45-60 minutes five or more days a week, Breast feeding, no red meat, less sugar and less alcohol lowers the risk.

Controversy about whether diet rich in whole grains, fruits, vegetables and legumes and low in total fat (butter, oil), more vitamins, Marine Omega 3 fatty acids (found in seafood (e.g. fish oils) and in walnut, seeds, flaxseed oil etc.), and antiperspirants and bras reduce the risk.  Abortion and Breast Implants have no effect.

Selective Estrogen Receptor Modulators such as tamofoxien reduce BC risk but increase the risk of thromboembolism and endometrial cancer.

So eat well and exercise and you would have done your bit to reduce your cancer risk.

EARLY DETECTION

Since cancer-prevention is not possible, the saying, “prevention is the cure” is amended to “early detection is the cure.”

Only about 10% of cancer deaths are because of primary tumour. Most of the deaths are because of metastasis - spreading of the cancer to other parts of the body. Once metastasis happens, it is very difficult to treat. Early detection of cancer is therefore of utmost importance.

Several ways of early detection:

I.                   SELF-EXAMINATION OF BREASTS

More than 80% cancers are detected by women doing self-examination of breasts. The examination should be done every month, 5-7 days after menorrhoea. Do the examination as shown in the three pictures. Look for the following:

1.     Lumps in breast (less than 20% are cancer) or in lymph nodes in armpits.

2.     Thickening of breasts

3.     One breast becoming larger than other

4.     A nipple changing position or shape or becoming inverted

5.     Discharge from nipple

6.     Constant pain in part of breast or armpit

7.     Swelling beneath the armpit or around the collarbone

In case of palpated anomaly, consult your gynecologist.

The limitations of self-examination are:

1.     Only 20% women do self-examination of breasts.

2.     The tumour/changes are large by the time they are felt and this delay in detection can adversely affect the treatment outcome.

II.               IMAGING TECHNIQUES

Early detection of cancer is required and is possible by using Imaging Techniques. Four Imaging Techniques are available:

1.     X-ray (Mammography)

2.     Ultra sound (Sonography)

3.      MRI

4.     Computer Assisted Detection (CAD)

i.                    CT-scan

ii.                  PET

A visual inspection by endoscopy can also be done.

MAMMOGRAPHY.

X-rays examination. Small neoplasmatic tissue formations can be seen.

SONOGRAPHY

Sonography is done in addition to Mammography to rule out possible cysts and to estimate the size of the tumour. However, tumours smaller than 5 mm cannot be detected.

MRI

MRI is used to find out if the breast has been affected by more than one tumour.

COMPUTER ASSISTED DETECTION (CAD)

CAD is used to point out possibly diseased regions. It is used mainly as a second opinion to the report of the doctor.

LIMITATIONS OF IMAGING

1.     Imaging techniques magnify the tumour much as the magnifying glass magnifies the letters in a book. Normal letter size, called font, is 12. If the font size is halved, that is made 6, you may still be able to identify the letter. But if the font is reduced still further, say to 3 or 4, you will not be able to identify the letter even with the magnifying glass. In a similar way, the imaging techniques cannot identify tumours that are small.

2.     The QUALITY of cancer is more important than the QUANTITY. A small tumour can be more dangerous than a large tumour.  Imaging can tell the quantity of the tumour, that is, its size, but cannot tell the quality of the tumour.

3.     Most of the time, Imaging cannot even tell whether a tumour is cancerous or not.  

CONFIRMING CANCER

The only absolute way to confirm cancer is by biopsy: a small tissue from the tumour is taken and microscopically examined to check for cancer.

            

TYPES OF BIOPSY

1.     Punching Biopsy. Done in a locally-sedated state.

2.     Needle Biopsy. Done with a syringe and a special needle. As painful as venepuncture.

3.     Advanced Breast Biopsy Instrumentation (ABBI). Done with X-ray to ensure localisation of target. Only a few doctors are experienced in this technique.

Microscopic examination of biopsy is sufficient; but in a few rare cases specialized lab tests are required.

 

CANCER TREATMENT

Even small localised tumours have the potential of metastasis and therefore need to be treated. The treatment is surgery, medications (hormonal therapy and chemotherapy), radiation and immunotherapy.

Surgery offers the single largest benefit. Used along with chemotherapy and radiation, the local relapse rate is reduced and the overall survival rate may increase.

SURGERY

1.     

Mastectomy:  remove whole breast.

2Quadrantectomy: remove quarter breast.

3Lumpectomy: remove small part of breast.

  Breast Reconstruction Surgery or breast prostheses: to simulate breast.

Neo-adjuvant, that is prior to surgery, and Adjuvant that is after and in addition to surgery, medication is used as part of treatment. For example, Neo-adjuvant use of aspirin may reduce the mortality from Breast Cancer.

Adjuvant Therapies are:  

1.    

Radiation (negative effect on normal cells) to kill cancer cells in tumour bed and regional lymph nodes that may have escaped surgery. It reduces the risk by 50 – 66 % (i.e., 1/2 to 2/3 reduction of risk). It is confined to region being treated. But only solid tumour can be treated.

2.     Therapies using drugs/agents etc.

i.                    Chemotherapy (negative effect on normal cells). Uses drugs, usually two or more drugs in combination, to destroy cancer cells.

ii.                  Targeted Therapy that became available in 1990s that uses drugs that inhibit enzymes.

iii.                Monoclonal Antibody Therapy in which the agent is an antibody

iv.               Immunotherapy that uses patient’s immune systems to fight cancer using drugs.

v.                 Hormone Blocking Therapy. Uses Estrogen Receptors (ER +) Tamoxifen and Progesterone Receptors (PR +) Anastrozole that block the receptors.

vi.               Experimental Cancer Treatment

a. Gene Therapy

b. Ultrasound Energy.

vii.             Alternative Medicine.

Patients with good prognosis are offered less invasive treatment – e.g. lumpectomy + radiation + hormone.

Patients with poor prognosis are offered more aggressive treatment – extensive mastectomy + radiation + chemotherapy + adjuvant medication.

TREATMENT SUCCESS RATE

If the cancer is detected early, that is at Stage 1, prognosis is excellent and usually chemotherapy is not required.

If detected in Stage 2 & 3 prognosis is progressively poorer with a greater risk of recurrence.  Surgery, chemotherapy, and radiation are required.

If detected in Stage 4, that is metastatic cancer (spread to distant sites), prognosis is poor.  Surgery, radiation, chemotherapy, and targeted therapies are used. But the 10-year survival rate is 5% without treatment and 10 % with optimal treatment.

In India, more than 60% of the BC’s are diagnosed at stage III or IV. Hence the low survival rate.

PSYCHOLOGICAL AND EMOTIONAL ASPECTS

Cancer patients need psychological and emotional support. Besides the family, such support can be provided by support groups who are trained and experienced in providing such support. ‘Cancer Sahyog’ is one such support group in India.

CONCLUSION

Cancer is a 3200 year old disease. It is endogenous, a part of life-process. So it can neither be eradicated, nor prevented, nor cured.

As yet.

Over the past 2000 years, the survival rate for many cancers has improved dramatically: life expectancy increased by 20-30 years. But for a few other cancers - metastatic pancreas cancer, metastatic breast cancer, inoperable gallbladder cancer – improvement has been marginal: life extended by just a few months.

Late detection of cancer is fatal. The causes for late detection are many but lack of awareness is the principal cause. Other main causes are: patient being shy, social stigma and doctors’ ignorance because of which the treatment is delayed. An awareness program will address all these issues

Present state of our knowledge makes us believe that cancer prevention or cure is not possible because cancer is a product of the processes essential to the life process.

Will some radical discovery in the future make cancer prevention and cure possible? We don’t know. But we can always hope.

Because as Richard Clauser, Director, NCI, USA, says about the future of cancer cure, “There are far more good historians than there are prophets.”

DILLI KI RAMLILA

The first Ramlila was staged some time in 1200-1500 CE. Today, the world’s oldest and most famous Ramlila is Chitrakut Ramlila of Varanasi, in its 468^th year now.

The oldest Dilli Ramlila is the Maha (Sanatan) Ramlila. It was started in 1830 by the last Mughal Emperor, Bahadur Shah Zafar. Every evening at six pm, the performance begins with a procession of “jhankis (tableau of costumed performers),” passing through the lanes of old Delhi, starting at Chandni Chowk and ending at Ramlila Ground for the night’s performance. At the end of the performance, the procession returns to Chandni Chowk on the same route but in reverse. In recent years the enthusiasm for this Ramlila has waned because of the several hi-tech Ramlilas now being staged in Dilli.

Of the 300-400 Ramlilas being staged in Dilli, the best known is the Luv Kush Ramlila staged at the Lal Quila Maidan (Red Fort Grounds). Started just 36 years ago, in 1979, it has become the most popular Ramlila of Delhi. The daily spectators are 10-15,000 but at the finalé the number exceeds 100,000.

The reasons for Luv Kush’s success are not hard to discern: vision, planning, hi-tech, professionalism and meticulous execution.

Planning for the Ramlila begins eight-nine months before the opening day. The theme and stage-designs are finalized. Professionals are engaged to give effect to the plans.

At this year’s Ramlila, Ganesha appeared in the night sky, and descended, as if from heaven, amidst psychedelic lights, live ‘bhajans,’ and the crowd on its feet chanting Ganesha Vandana. The hydraulic-lift that lowered the Ganesha could be seen and that detracted from the magic a bit. Perhaps in the years to come a solution to this will be found.

In the coming days, Ahilya will transform into a living-being from stone, Hanuman will fly over the audience, and Megnand will appear at different places in mid-air. Kumar Gowda, the stunts and special acts whizz of hit TV serial Mahabharata, choreographed the special effects. Professionals and equipment for these was brought from Mumbai.

Seventy actors, a few playing multiple roles, will enact the Lila. The cast includes several well-known Bollywood and TV actors, - Asrani. Upasana Singh, Surendra Pal, Raza Murad, Shankar Sahney, Gagan Malik (Rama),  Ravi Kishan (super star of Bhojpuri films) and Manoj Tiwari (BJP MP from NE Delhi). Fifteen dancers in shiny costumes do scintillating numbers each day.

Costumes and make up, the other vital ingredients of a show, are in good hands. Costume- designer of ‘Devon Ke Dev... Mahadev’ designed the costumes. Four tailors are in daily attendance to make last minute alterations. Four makeup artists give the looks: Rakshas to appear fearful: dark complexion, thick, arched eyebrows, blood red mouth; and gods to appear serene and benevolent, light shining faces.

As happens in our country, the venue has an enclosure next to the stage - separated from the public by a 50-feet wide strip of empty land – seating 70-80, for ‘special invitees.’  And the special ‘special’ invitation, which I managed to get hold of, also includes a sumptuous vegie dinner!

For those who cannot make it to the venue, the performance is telecast live every day.

A happening in Delhi is not a happening if the PM doesn’t visit it. So the PM, cabinet ministers, VVIP Babas – Ramdev and others – and other lesser dignitaries watch some part or other of the Lila.

PS: Despite Modi ji’s exhortations, no toilets are in sight. If you are perseverant, you may, with lots of help from the security staff, detect one hidden in a remote corner of the parking lot. A mobile toilet of ten tiny cubicles, mounted on a rickety platform about three feet above the ground. You are better advised not to climb the shaky ladders to the platform unless you have the balance of a Yogi. If you can stand the nauseating stench and human waste in the cubicle, you may use it.

But my advice to the ladies is to do it as was done in Bhagwan Rama’s time: in the nature.

 

OF THE JUDGES BY THE JUDGES FOR THE JUDGES

 OF THE JUDGES BY THE JUDGES FOR THE JUDGES

Constitution is what the Supreme Court says it is.

“In difficult times when political branches cannot be counted upon, neither can the judiciary.”

n  Justice Chelameswar, dissenting Judge in the five-Member SC Bench which struck down the NJAC Act as unconstitutional.

Since 26 January 1950 when our Constitution came into being, till 1993, the SC and the HC judges were appointed by the executive in “consultation “ – as mandated by the Constitution – with the CJI and the CJ of the concerned HC. The Constituent Assembly debate made it clear that “consultation” did not mean “concurrence.” During this period many eminent judges such as HR Khanna, VR Krishna Iyer, Jagmohanlal Sinha were appointed;  and many landmark judgments such as Kesavananda Bharati holding the basic structure of Constitution to be inviolate, and  H R Khanna’s  “right to life and liberty cannot be suspended by the executive” were delivered:

When Indira Gandhi appointed her nominees as CJI superseding eminent judges like HR Khanna in one instance and three other eminent judges in the second instance, the SC, in 1993, created a “Collegium” of the CJI and two – later extended to four - senior-most judges of the SC to be the sole arbiter of the appointment of judges. It is too early to say whether the judges that the Collegium appointed reached the level of eminence of the executive-appointed judges. But many of the Collegium appointees have brought disrepute to the judiciary: Soumitra Sen, Kolkata HC and V Ramaswamy of SC, the only two judges against whom impeachment proceedings were instituted; PD Dinakaran CJ, Sikkim HC, who resigned facing corruption charges; Shamit Mukherjee of Delhi HC arrested in a land scam case, to mention but a few; not counting judges against whom serious allegations have been made. And the latest, Justice C S Karnan of Madras HC who issued contempt notice to his own CJ! Also some interesting statistics: 99 judges in the SC and in 13 HC, ie 52% of direct appointments from among the lawyers, are from families of judges and senior lawyers; Justice Joseph of SC, “deserving persons have been ignored wholly for subjective reasons . . .”

The point being made is that collegium system is not the panacea it was, is being, made out to be.

SC could recast the Constitution to make the Collegium the sole authority in the appointment of judges because the executive had been weakened by Emergency and its aftermath, Babri Masjid, string of corruption scandals beginning with Narshima Rao govt’s time and peaking in UPA 2’s regime,   fractured mandate at the centre and at the states, multiplicity of political parties and opinions, and social and political upheavals that kept the political class engaged at the cost of everything else.

But populace was uncomfortable with the the judges being accountable to no one but themselves. Judges appointing judges was unheard of anywhere in the world: in the US, UK, Canada, Germany, France, South Africa, Brazil – judges were appointed by the executive.  Justics Venkatachaliah committee set up in 2002 recommended setting up of a NJAC. Political class, emboldened by the Committee’s report, and sensing the people’s restlessness, decided to setup the NJAC for the selection of SC and HC judges.  UPA 2 then prepared the NJAC bill but could not get it passed. When the present govt took over, it had the bill passed unanimously in the two Houses of Parliament and in twenty State Assemblies.  If the legislators are people’s voice, then vox populi wanted the judges’ selection system to change.

The NJAC was not about the judicial independence guaranteed by the Constitution. It was about the system of appointing SC and HC judges. Did India’s judiciary lack independence when judges were executive-appointed? Is the judiciary not independent in the US, UK, France, Germany and other countries where judges are appointed by the executive? Nixon, then President of the US, appointed the Prosecutor for Watergate. The Prosecutor’s investigations resulted in Nixon’s forced resignation.  Was the Prosecutor the less independent because he was appointed by Nixon?

The SC has struck down the NJAC Act. SC has also decided to make the Collegium more transparent, responsive and less secretive and has scheduled hearings to decide on the ways it can be done.

The debate on judges’ appointment has not ended with the SC’s judgement; it has just begun. Though the govt is not at present in a position to do anything about it, we don’t know what the future holds. What if govt with a very strong mandate at the centre and at many of the states emerges in the near future?

THE SAHITYA AWARD MARTYRS

The moment I heard “Nayantara Sahgal is like Gurudev Tagore,” I rushed out to dig out her ‘Gitanjali,’ her ‘Jana Gana Mana’,’ her ‘Rabindra Sangeet,’ her ‘Last Harvest,’ . . .

I was still digging furiously when the voice pulled me by the ear, “not as a romancier, you idiot, as a protester.”

Oh, that. Gurudev returned his Knighthood in protest against Jallianwala Bagh. Had Nayantara recently detected another “Bagh”? Well Nayantara ji, your ‘Rich Like Us’ does not apply to us commoners.

“And she is the niece of erstwhile PM of India,” the voice continued, “whose nephew was Gurudev?” asked the voice. That clinched it. Gurudev is no patch on Nayantara, or on Shobha De of ‘Small Betrayals,’ a strong votary for ‘returning’ who missed the Sahitya by a whisker, the voice says, and so is in no position to return that which she never got.

Frankly, though, the actions of these hi-bro intellectuals leave me as confused as their pretentious writing.

Where were these award returning romanciers, for example, when 2300+ Sikhs were massacred in Delhi in 1984 (the only incident that comes close to the ‘Bagh’ massacre), when the then PM said when a big tree falls the earth is bound to shake a bit, when Mujjafarnagar riots happened, when 'The Satanic Verse' was banned, when Taslima was physically assaulted in Hyderabad, when Pandits were externed, made refugees in their own country, their women raped, when emergency was imposed and basic rights suspended and Sanjay went on a rampage, when . . .

Were they right then or are they right now?

And why did their star, Nayantara, accept the Sahitya from her nephew, Rajiv G, two years after the Sikh massacre?

And what about the romanciers who have not handed-in their Sahitya. Are they traitors to the cause?

The romanciers have the right to return their Sahitya, their marriage certificate, their birth certificate, and all and sundry certificates. But let them not claim the moral high ground, the pulpit, from which to preach their ‘selective outrage,’ their ‘double standards’  camouflaged as high morality which they never practiced till this opportunity to be grand came about.

Fetal Medicine

Birth of a disabled baby is distressing to the parents. And the baby has to live a life of difficulty. Can such birth be avoided?

Yes, sometimes.

Maternal Fetal Medicine (MFM), a relatively new discipline in medicine, makes this possible. MFM treats the fetus as an individual patient. It uses 3D and 4DUltrasound, MRI, CAT, blood tests and other tests to monitor fetal health, growth, and wellbeing and to diagnose fetal metabolic, chromosomal, and anatomic defects; and to assess if the fetal abnormality is amenable to medical or surgical treatment. However the advisability of fetal therapy as compared to postnatal therapy has to be critically assessed: the benefits of treatment should outweigh the risks if the fetal is left untreated, and the risks of the procedure itself to the fetus and to the mother.

With improved and safer methods now available to deliver nutrients, hormones, and substrates to the fetus, and to bypass certain blocked metabolic pathways, thirteen types of fetal malformations, such as Neural Tube Defects (NDT), Lung Prematurity and Maternal HIV infection can be medically treated. Several medical therapies are now in use; and research in fetal gene and stem cell therapy may soon offer early treatment for genetic disorders. For example, the first ‘in womb’ stem cell therapy trial to lessen the effects of the incurable ‘brittle bone’ disease – which can be fatal for babies born with multiple fractures, and can cause up to 15 bone fractures a year in the living – is scheduled to begin in January 2016.

Nine types of lesions, such as Obstructive Uropathy, Congenital diaphragmatic hernia, congenital heart disease - need surgical intervention. Open surgery on the fetus was first done in 1981 for obstructive uropathy by Dr. Michael Harrison at the University of California, San Francisco (UCSF). In the 30 years since then, several endoscopic procedures have evolved. But intrauterine fetal surgery is complex. And though a few of the procedures are now accepted as standard, questions remain about the safety and efficacy of fetal surgical corrections. Fetal surgery is thus still in the research and experiment domain.

If the fetal malformations are incompatible with life, such as severe chromosomal abnormalities and certain metabolic conditions and anatomic defects, especially of the brain and kidneys, then termination of pregnancy (MTP) may be an option.

Preterm delivery is an option in cases where the risk of continued gestation on the viability of fetus, or on fetal/maternal mortality/morbidity is greater - because of a maternal or fetal disorder - than the risk of preterm delivery.

Planned cesarean section is yet another option. It is done when a known medical problem would make labour dangerous for the mother or the baby.

Certain conditions increase the risk of chromosomal anomaly, eg maternal age above 35, previous offspring with chromosomal anomalies or other birth defects, previous Preterm birth, spontaneous abortions, high blood pressure and so on.

Such pregnancies are termed ‘High Risk Pregnancy’ and these should be under the care of a ‘High Risk Pregnancy’ expert obstetrician and MFM experts.

MFM has given rise to several ethical and moral issues. The autonomy of the woman and the moral status of the fetus are central to this debate. But more on it in another write up.

Dr (Prof) Sadhana Kala, Chairing a Session of Fetal Medicine, SCOPE Complex, New Delhi