A close friend in her late 40s was being treated for backache for over 3 months, but it was detected to be due to metastasis from a breast cancer. An overtly palpable breast lump had gone unnoticed all this while. How we all wished she could go back in time and diagnose it earlier by undergoing a screening mammography, or a visit to her doctor who could have examined her breasts. If nothing else, even self-breast examination could have probably detected this lump much earlier! Tens of thousands of women and their families must have gone through this exact same mental agony, wishing that their cancers were diagnosed earlier at a stage when they could be cured.
The October that just went by was observed as the Breast Cancer Awareness Month. It may have contributed in increasing some awareness. But when I checked with my otherwise well-informed relatives and friends, whether they had ever done breast self-examination or considered scheduling an appointment for cancer screening for themselves or their near and dear ones, the answer was almost always an embarrassed ‘No’! Each one was under the delusion that they were ‘too young and healthy’ to be hit by the disease.
Breast and cervical cancers are the two most common cancers among Indian women contributing 40% of all cancers in them, and are also the leading cause of cancer deaths in women. What is fortunate is that both breast and cervical cancer can be diagnosed very early through fairly inexpensive, non-invasive and sensitive screening tools- mammography and Pap smear respectively (explained below).
Another interesting fact is that cervical cancer is caused by a virus called Human Papilloma Virus (HPV) and in the generations to follow, it may actually be eliminated by HPV vaccination.
It is pitiful that India still contributes one third of the global deaths due to breast and cervical cancers despite robust screening tools now available. An important reason is that only an abysmal 6.8 per cent of the overall healthcare expenditure (which itself is just 1.1% of India’s GDP, effectively a meager 0.06% of GDP) is spent on preventive health. While we wait for the government to hopefully prioritize preventive health, preventive medicine can be successful through individual and community efforts.
One of the silver linings to the Covid-19 pandemic is that it has introduced every individual across socio-economic strata to the idea of preventive health that goes beyond clean water, healthy food and general hygiene. It has familiarized us to the otherwise alien concepts of ‘early diagnosis’, ‘prompt treatment’ and ‘adult vaccination’ as the fundamental preventive modalities to minimise morbidity and mortality. And the time is ripe to take this mindset of health consciousness forward and bridge the gap between what we know and what we do.
Here is a list of little steps we can each take for achieving this:
A. FOR EVERY WOMAN AND HER FAMILY:
1. DO NOT IGNORE: any breast lumps, new symptoms like nipple discharge or abnormal skin over the breast. Meet your doctor at the earliest for further examination and if required, the relevant investigations. If lump is not cancerous (which is more often the case), you will be at peace by not leaving this as a lingering doubt. And even if the lump turns out to be a cancer, early treatment may prevent any further damage to health or life.
2. MAMMOGRAPHY AND PAP SMEAR: Mammography is the process of using low-energy X-rays, with no radiation risk, to examine the human breast for catching cancer at an early stage. A Pap smear involves collecting cells from your cervix — the lower, narrow end of the uterus that is at the top of your vagina, to look for abnormal cells which indicate a pre-cancerous or cancerous change in the cervix.
Every Indian woman between the ages of 40-75 who has the means to get herself screened must get one screening mammogram every 1-2 years. For cervical cancer, the recent WHO guidelines states that all women ages of 21-65 should be screened every three years to detect any pre-cancerous lesions occurring. Most people who regularly go for their tests may have missed it over the last 2 years of the Covid pandemic- it is now time to schedule your next visit.
3. GENETIC TESTING: If you have a first or second generation relative with early breast or ovarian or 2 or more relatives with any of the cancers at a later age, please contact your doctor to check if you are one of those who should opt for a genetic testing for hereditary breast and ovarian cancers. Detailed risk categories are here.
4. DO HEALTH-GIFTS ON BIRTHDAYS: Here is a quirky way of gifting health. Instead (or probably in addition to!) a birthday present, gift your wife, mom, sister, relative or friend a Mammography and Pap smear coupon. I can tell you from my own experience that often accompanying them the first time takes care of any hesitancy and inertia. Such a birthday reminder or gift may have far more meaning than the other routine wishes.
5. SELF BREAST EXAMINATION: This is an easy technique to learn to regularly examine your own breasts (as against clinical breast examination by a trained health worker as described below). Although self breast examination cannot replace mammography, I would still suggest that you learn to do this properly to familiarize yourself with how your breasts normally look and feel. It is recommended to get into the habit of doing this once a month to give you the optimal benefit from this modality.
6. HPV VACCINATION: is one of the very few vaccines that can actually prevent a cancer! Giving this vaccine to adolescent girls can potentially help eliminate cervical cancer as a public health issue. HPV vaccines are administered as a two-dose series (0, 6-12 months) for most persons who initiate vaccination at ages 9-14 years, and a three-dose series (0, 1-2, 6 months) for persons who initiate at ages 15-45 years. Importantly, it has been proven to be as safe as any other approved vaccine.
FOR HEALTHCARE WORKERS:
1. TALK ABOUT IT: We are the first source of ‘authentic and uncluttered’ information for most individuals. After having addressed all concerns of the actual illness the patient is visiting us for, a minute of conversation about age appropriate screening for diseases like diabetes, blood pressure and cancer will help clear several doubts they never knew whom to ask. Many patients who visit the doctors have healthy young girls at home who otherwise do not need to visit healthcare facilities. This is therefore also an opportunity to inform and remind their parents about HPV vaccination.
2. CLINICAL BREAST EXAMINATION (CBE): Critics will say that screening tests are expensive approaches meant only for the rich. A big study on CBE conducted by Tata Memorial Hospital showed that CBE by a trained healthcare worker is almost as good as mammography. Compared to current trend of not examining the breast at all, CBE definitely saves lives and reduces mortality. Doctors should therefore add CBE to the other systemic examinations performed.
Even for cervical cancer, another important research by the same institute has proven that visual inspection of the cervix with acetic acid by a trained healthcare worker is an effective way of screening for cervical cancer, leading to almost one-third reduction in deaths. For a country like India, where there are no structured screening programs offered by the government or the insurers, these are much cheaper and implementable options, particularly across smaller towns and villages.
FOR COMMUNITIES AND GOVERNMENTS:
1. CBE TRAINING FOR HEALTH CARE WORKERS: While the government cannot currently afford to subsidize or offer screening mammography to everyone eligible in the country, it can at least train ASHA workers in villages and other health care workers in towns and cities to perform CBE and cervical examination with acetic acid.
2. USING SOCIAL MEDIA INFLUENCERS: The sudden cardiac death of actor Puneeth Rajkumar recently stirred up an epidemic of cardiac checks. We really do not need to wait for a well-known person to get cancer to create a similar momentum for cancer screening. Awareness campaigns and public appeals by film-stars, leaders and other social media influencers may strengthen the cancer prevention movement without any additional financial burden on the government.
3. BRINGING HPV VACCINE INTO THE NATIONAL IMMUNIZATION PROGRAM: Over 100 countries have introduced the HPV vaccine into their national schedules. While this ensures individuals get this vaccine for free, it also takes care of any vaccine hesitancy that may exist. India is the world’s biggest vaccine maker. With the kind of fervor and scientific excellence that India has shown with Covid-19 vaccines, getting HPV vaccine manufactured generically, either through voluntary license or a compulsory licensing mechanism and bringing HPV vaccine on the National Immunization Program is not going to be difficult if there is a political will and resolution to do so.
4. REDUCING VACCINE COSTS: The HPV vaccines for cervical cancer cost over Rs. 10000 for the three dose regimen. Very few would spend such an amount. The government needs to intervene and cap the prices of vaccines so as to make these more affordable and accessible. Newer vaccine players need to be encouraged and supported.
Had my friend known this, she might have got a few more years. No amount of regret can change the past but it does have the power of changing the future for so many women and their families. I believe with all these efforts together, we can really save many lives, and one of those could be yours!