| |
COVER
STORY: HEALTH
The
Enemy is Within
What
do all these perfectly personal decisions have to do with breast cancer?
Plenty, apparently. Although urbanisation provides the setting, the enemy,
as they say, is within. It's called estrogen, the vital female hormone
that governs a woman's menstrual cycle and gives her feminity. About a
week before a period, a sudden surge of estrogen causes breast cells to
multiply. An error may arise in this duplication and the new "daughter
cells" can mutate. These then multiply during successive estrogen
surges and eventually form a tumour. If unchecked, it can spread to surrounding
organs like the liver and lungs.
During pregnancy,
however, estrogen is superseded by another hormone called progesterone,
which stops estrogen surges and alters the entire physiology of the breast.
This continues during lactation. "Pregnancies and lactation tend
to rejuvenate the breast by providing a long respite from the monthly
onslaught of estrogen," explains Dr Mittra, who heads the surgical
breast unit at TMHRI. Thus women who have two or more kids before 30 and
breastfeed them for several months reduce their risk of getting breast
cancer by over 50 per cent.
Since the
number of menstrual cycles seem to have a direct correlation with the
incidence of the disease, other factors also come into play. "A generation
ago girls got their first period at the age of 14 or 15," explains
Dr Rajendra Badwe, chief clinical research officer at TMHRI. "Today,
with better nutrition in the cities, nine and 10-year-olds are beginning
to menstruate." The same is true of menopause. While our mothers
stopped ovulating in their 40s, today, women reach menopause only in their
mid-50s. Coupled with increasing lifespans, both early menarche and late
menopause greatly prolong the reign of estrogen during a woman's reproductive
years, making her more susceptible to breast cancer.
Ironically,
medicine has both emancipated and endangered the female species. Hormone
replacement therapy (HRT), which liberated women from the debilitating
symptoms of menopause, artificially supplies estrogen to post-menopausal
women after their natural stores have dwindled. Studies have shown that
women taking HRT have a 60 per cent higher risk of developing breast cancer.
Likewise, the contraceptive pill, which liberated women from the chains
of unplanned motherhood, contains low levels of estrogen, although its
link with breast cancer is more nebulous.
Finally,
genetics also plays a role. "Women who belong to families which show
clusters of the disease-that is, three or more direct relatives including
mother, sister, aunts or cousins-have a 50-fold risk compared to the normal
population," says Dr Mittra. Even a single afflicted relative increases
the risk two to five fold. However, heredity accounts for only 5 per cent
of all breast cancer cases. Now, thanks to the Human Genome Project, in
the coming century, scientists may actually be able to identify women
who are genetically predisposed to cancer and prevent the defaulting gene
from being passed on to their progeny.
In the 1990s,
the discovery of Breast Cancer Gene One (BRCA 1) and Breast Cancer Gene
Two (BRCA 2), which are believed to predispose women to the disease, unwittingly
fanned public hysteria. In the US-which is the only country where this
controversial genetic screening method is freely available-thousands of
women are getting themselves tested. Those who test positive often give
in to the prevailing fear psychosis and resort to prophylactic drug treatment
or surgical removal of breasts before the disease is even diagnosed.
While genetic
screening is still far too expensive and virtually unknown in India, most
experts agree that early detection can save innumerable lives. In the
West, where women are acutely aware of their risk, the majority of breast
cancer cases are detected in the first or second stage, when damage control
is relatively easy. In India, however, the reverse is true: nearly 90
per cent of cases are detected only in the third or fourth stages, when
the disease is dangerously advanced or imminently fatal. A study of cases
registered under the National Cancer Registry Programme between 1984-1993
found that most patients came to the hospital when the cancer had spread
to surrounding tissues.
The commonest
method of detection is breast self examination (BSE) and is recommended
for all women above 25 years of age. "However, if BSE is not practised
correctly, it's a poor method of detection," says Dr Rajiv Sarin,
a breast-cancer specialist at TMHRI. Yearly mammograms are routinely prescribed
for high-risk groups and older women, but it is a costly procedure beyond
the reach of the common Indian woman.
Generally,
a "suspicious" lump is surgically removed and biopsied to determine
if it is cancerous. Even though the majority of results are usually negative,
a biopsy is a traumatic procedure. In a US study, for instance, it was
found that only one of every 24 women identified with a potentially harmful
lump actually had breast cancer. And only one out of every eight biopsies
was clinically justified. A new method called fine needle aspiration cytology
is less invasive.
For these
reasons, experts like Badwe strongly advocate clinical breast examination
(CBE) as the most cost-effective method of screening and early detection
for developing countries. Conducted manually by an experienced cancer
specialist or health worker, CBE is about 95 per cent accurate, easier
to administer in mass campaigns and much cheaper than a mammogram. In
fact, one of the largest randomised clinical trials that measures the
efficacy of this method is being conducted by TMHRI with the help of the
US National Institute of Health. Currently, 1,50,000 women from suburban
Mumbai, aged between 35 and 60, have been selected. Over the next six
years half of them will receive routine CBE while the other half will
merely be counselled about the disease. The study hopes to prove that
CBE actually helps save lives and is the most effective method for third
world countries.
Meanwhile,
treatment methods are also changing from traditionally drastic ones like
mastectomy to those that are minimally invasive and cause the least trauma.
While radical mastectomy, or removal of the entire affected breast, was
the norm a few years ago, today the trend is towards breast conservation.
Here, only the tumour and surrounding affected glands are removed. "Unlike
mastectomy, where a woman feels insecure about losing her feminity, breast
conservation is cosmetically and psychologically less damaging,"
explains Sarin.
The growing
number of support groups also helps patients to cope with the psychological
effects of the disease. "In addition, we increase awareness about
preventive measures in the general population," says Dr Tarana Khubchandani,
a breast cancer survivor who recently set up a support group called Passages.
"Breast cancer is a very real threat for the liberal urban woman
of today," says Khubchandani. But the good news is that with caution
and foresight, she can have her cake and eat it too.
-with
Subhadra Menon
Pg.1
Top
|
|
The
Indian industry has increased its decibel level of whining. Instead, it
should get the government to deliver, says INDIA TODAY Associate Editor
V. Shankar Aiyar in 
