Forty five-year-old Ayesha (name changed), a resident of a small town in west Uttar Pradesh (UP), first spotted a tiny painless lump in her breast in April this year. However, the Coronavirus- induced lockdown and the fear of catching the infection in a healthcare setting prevented her from seeing a doctor. Even when the lockdown was eased, her family was too scared to travel to Delhi to seek medical consultation. By the time she reached an oncologist four months later, her aggressive cancer had already hit Stage III, diminishing the chances of her survival.
Unfortunately, Ayesha is not a lone case of a seriously-ill patient being deprived of timely treatment due to the ongoing contagion. While we will never be able to collate data of how many such patients suffered delayed diagnosis and treatment this year, it is evident that the number is significant. Patient attendance in oncology clinics fell significantly in the initial months of the pandemic. The number of new cases diagnosed continued to remain relatively low even several months after the total lockdown had been eased. Breast Cancer Now, a British charity organisation, estimated that due to the contagion almost a million British women had missed a screening appointment. This might have led to thousands of cancers going undetected. For a country like India, where a majority of breast cancer detections still happen in the later stages of the disease, the Coronavirus outbreak has further hampered diagnosis and treatment, and is likely to negatively impact survival rates from the disease.
Rising disease burden in India: Breast cancer is the most common form of the disease among Indian women and accounts for an estimated 28 per cent of all cancers. In fact, a woman is diagnosed with it every four minutes while another dies of this disease every 13 minutes in the country. In 2018, it is estimated to have claimed as many as 87,000 lives in India. The incidence of the disease has increased dramatically over the last 25 years due to multiple factors, including increasing urbanisation, adoption of unhealthy lifestyles (smoking, drinking, junk food consumption and so on), increased use of plastic utensils and microwave ovens, rise in obesity, drop in physical activity levels, delayed age of child-bearing and reduced breast-feeding.
India also has a high mortality rate because a majority of the patients are still diagnosed in the late stages of the disease and a significant proportion of them are not able to get appropriate treatment. Another worrying trend is an increasing incidence of the disease in younger women. Shockingly, nearly half of the patients in urban India are less than 50 years of age. Poor awareness about symptoms, lack of a universal and comprehensive screening programme, social taboos and embarrassment to discuss the issue are the main reasons behind delayed diagnosis as well as the resultant high mortality. Unfortunately, the prevailing situation due to a worldwide pandemic has impeded diagnosis and treatment of a number of non-Coronavirus diseases, including all types of cancers. Already a neglected subject, women’s health has further been relegated to the back-burner as families delay medical consultation and avoid visiting healthcare facilities or undergoing regular disease screening.
Pandemic or not, do not put health issues on the back-burner: The Coronavirus is a long-term problem, which is likely to stay with us in the near future. While containing the pandemic and ensuring treatment of all infected people must be a high priority, adequate policy measures need to be taken to ensure that other serious diseases are not neglected in the process. Governments as well as healthcare providers, both have a role to play in achieving this. It is important to educate people about the importance of not neglecting their health conditions and prevent interruptions in treatment modalities, too. It is equally important to ensure continuation of unimpeded non-Coronavirus services in hospitals while also instilling confidence among people about the safety of hospitals and clinics, especially outpatient departments (OPDs).
However, the silver lining in the dark cloud is that thanks to advanced diagnostic and treatment modalities, survival rates of breast cancer patients have increased significantly globally. While survival depends on a number of factors such as the type of cancer, stage at the time of diagnosis, the quality of treatment, in the US it is estimated that up to 90 per cent of women survive five years after diagnosis and 84 per cent manage to survive 10 years.
However, in India, the survival rates remain abysmally low for reasons mentioned above. Increased awareness and health literacy, regular screening after 40 years of age, adoption of a healthy and active lifestyle sans smoking or excessive drinking, timely and appropriate treatment can help improve survival rates in India too.
New-age technologies can help navigate the Coronavirus pandemic: The adoption of new-age technologically- advanced methods further helps improve the quality of life of patients. Now, surgical treatment does not mean removal of the whole breast in all patients. It is possible to offer a breast conservation surgery in nearly 60-70 per cent of the patients either upfront or after chemotherapy.
Similarly, complete removal of armpit nodes, a procedure done routinely in all patients until a couple of decades ago, has given way to sentinel lymph node biopsy in which only a few nodes need to be tested for the presence of the tumour.
If these sentinel nodes are not involved in the disease, one does not need to remove the remaining nodes, thus bringing down the rate of shoulder dysfunction as well as lymphedema (swelling of the arm) significantly. Similar to surgery, personalised systemic therapy (chemo, hormone, immune and targeted therapy) has enabled us to avoid more toxic treatment in patients with a good biology tumour. Two patients with the same size of tumour can have very different outcomes. New-age prognostic tests help predict the risk of cancer relapse in the early stage of breast cancer with a high degree of accuracy, stratifying patients into low and high-risk categories, based on their tumour biology. Those patients who fall in the low-risk category have very limited risk of relapse and may be able to avoid chemotherapy.
Cancer patients face a higher risk of catching the Coronavirus infection as well as suffering from its complications because of their immuno-suppressive state as a result of the disease itself and due to chemotherapy. These prognostic tests that can help them avoid chemotherapy, if used judiciously, can kill two birds with one stone — patients can avoid chemotherapy, which is immunosuppressive, and avoid visits to the hospital to undergo chemotherapy.
Radiation therapy has also undergone a complete metamorphosis over the decades and modern machines enable us to deliver more precise radiation (thus sparing adjacent organs like the lungs and the heart from a high dose of radiation) and in a shorter interval of time (as less as two weeks as compared to the usual five weeks in a select group of patients).
In more good news, researchers in Canada have developed a new, inexpensive technology that could save lives and money by routinely screening women for breast cancer without exposure to radiation. The system, developed by researchers at the University of Waterloo, uses harmless microwaves and Artificial Intelligence software to detect even small, early-stage tumours within minutes.
By comparing the tissue composition of one breast with the other, the system is sensitive enough to detect anomalies less than one centimetre in diameter. A negative result could quickly rule out cancer, while a positive result would trigger referral for more expensive tests using mammography or magnetic resonance imaging. In addition to reducing patient wait times and enabling earlier diagnosis, the device would eliminate radiation exposure, improve patient comfort and work on particularly dense breasts, a problem with mammograms. However, this technology will take a while to come to India as it is still at the nascent stage.
In the end, people have to realise that while the Coronavirus is a serious pandemic, they must not neglect their overall health, compromise on regular check-ups and doctor consultations or delay cancer treatment. However, all hospital visits must be undertaken with complete precautionary measures that are the new normal now.
(The writer is head, Department of Surgical Oncology, Manipal Hospitals, Dwarka)