Introduction & Facts
More than one million women worldwide are newly diagnosed with breast cancer annually. Worldwide, a woman dies of breast cancer every minute. In India well over 100, 000 women are newly diagnosed with breast cancer every year; a staggering number that has overtaken cervical cancer to become the leading cause for cancer related death among women in metropolitan cities. The number of newly diagnosed breast cancers in India is expected to increase to 130, 000 per annum by 2020. This is only the tip of the iceberg, as many breast cancers are not reported to the Cancer Registry & many states do not have a robust Cancer Registry.
World over, more people die of cancer every year than malaria, TB and AIDS combined. According to World Health Organization (WHO) statistics, more than half of the global cancer burden is found in under developed and developing countries. The overall burden of cancer cases is shifting substantially to vulnerable populations in ill-prepared & resource constrained developing countries. Currently, only 5% of global spending on cancer is aimed at developing countries. India currently spends only 1.2 per cent of its GDP on publicly funded health care. This is considerably less than most other comparable countries.
More than 60% of breast cancers in India present in the advanced stage and hence death rate from breast cancer is also very high. Lack of awareness and absence of an organized National Breast cancer screening programme are the main reasons accounting for late presentation. Although breast cancers are managed by surgical oncologists, the vast proportion of both benign and malignant breast disease in India is largely managed by general surgeons. Currently, very little effort is directed at empowering people about the importance of early detection of breast cancer & counselling patients is not considered to be an important component of breast cancer care. Whilst few Cancer Centres offer care on par with the best centres across the world, by and large, cancer care in India is a ‘lottery’ - with some getting excellent care, whilst most not. That there is huge variation in the survival of patients with breast cancer across the Country is an understatement.
Although introduction of an organized population based breast screening programme using mammography is the best proven way of detecting cancers in the impalpable stage, it is not a viable option for mass screening in India due to the enormous costs involved, huge variation in mammographic reporting and issues relating to quality assurance. Moreover, more than 87% of India’s population is under the age of 50 years, where screening by way of mammography is not effective at detecting early impalpable breast cancer (sensitivity of mammography is best over the age of 40 years).
Solution and public-private partnership - Implementation of Andhra Pradesh’s first population based breast cancer screening programme
There is indeed an urgent need to find an ‘Indian solution to an Indian problem’. With a mission to detect breast cancer in the early stages and save more lives, Ushalakshmi Breast Cancer Foundation (UBF) & KIMS-Ushalakshmi Centre for Breast Diseases (Indian Subcontinent’s first free standing purpose built Breast Centre located at Krishna Institute of Medical Sciences - KIMS) has partnered with the Govt. of Andhra Pradesh to implement Andhra Pradesh’s first innovative population based breast cancer Screening Programme.
950 Community based Health Care Workers (ANMs and Community Resource Persons- CRPs based in Hyderabad District were trained to perform clinical breast examination (CBE), a screening tool to detect early breast cancer (Figure 1). Equally, they were educated through well established and well researched audio visual aids about the importance of breast awareness & early signs of breast cancer.
Figure 1: Health Care workers along with Trainers at the launch of Andhra Pradesh’s first population based Breast cancer screening programme (2012).
Some 28,437 underprivileged women in Hyderabad District underwent breast cancer screening from October 2012 to September 2013. Women diagnosed with breast cancers through this initiative were treated free of cost through the Rajiv Arogyasree Scheme.
Clinical breast examination (CBE), where trained healthcare workers examine the breasts of women is relatively simple and inexpensive, and equally, there is considerable circumstantial evidence to show that CBE may be a viable option for a country like India. By detecting breast cancers when they are small will also help reduce mortality from this disease. There is already an ongoing randomized controlled trial in Mumbai to address this issue.
Encouraged by the success of the pilot project in Hyderabad District, UBF & KIMS-Ushalakshmi Centre for Breast Diseases has now embarked upon conducting a similar community based breast cancer screening programme aiming to reach out to about 1, 00, 000 underprivileged women between the ages of 35-65 years in 16 Districts of Andhra Pradesh over a two year period between 2014-2016.
The Government of India must consider early detection of breast cancer as a national priority, and equally, there is an urgent need for similar evidence based coordinated pubic private partnerships to be implemented across the country in the fight against breast cancer.
Conflict of Interest
The author wish to express that he has no conflict of interest.