As the second most common cause of death in India, every conversation around cancer counts, especially when it comes to women’s cancer
Writer-director Tahira Kashyap recently took to Instagram to tell the world that she had just undergone a partial mastectomy on being diagnosed with Stage 0 (pre-invasive) breast cancer. In a long, spirited post, she also jokes that except for the fact that she cannot give the Kardashians competition any more, she is doing okay. Other celebrities such as Sonali Bendre, Irrfan Khan and Manisha Koirala have posted earlier about how they are dealing or have dealt with cancer, and these have helped make it a part of daily conversation. But Tahira’s post is especially relevant because it touches upon the singularly important aspect of cancer treatment and possible cure — early detection.
A study published last month in The Lancet Oncology shows that while globally there is nearly 25% higher incidence of cancer in men than women, curiously enough, India bucks the trend. More Indian women than men are diagnosed with the disease, although more men die of it.
Statistics are not the whole story
The Indian Council of Medical Research estimates that by 2020, India might be staring at over 17 lakh new cases of cancer and over 8 lakh deaths. The Lancet study reveals that the incidence of breast cancer increased by over 40% from 1990 to 2016, making it the most common cancer among women in India today.
What’s more, the average age of onset for breast and ovarian cancer in India is 45-50 years, a full decade earlier than the peak age (above 60) in higher-income countries.
What is worrying the medical community and cancer prevention agencies even more is that these figures might just be the proverbial tip of the iceberg; there are countless people out there whose cancers are neither diagnosed nor reported.
Hidden within these numbers are the real and complicated problems that Indians, especially women dealing with cancer, are facing. Apart from lifestyle and genetic factors, a woefully inadequate medical infrastructure, severe lack of awareness, and low chances of early diagnosis and screening, not to mention the high stigma associated with the disease, are some of the key reasons for the rise in women-specific cancers in India.
More awareness, less reluctance please
Dr Ravi Mehrotra, co-author of the Lancet study and director of the Noida-based NICPR (National Institute of Cancer Prevention and Research), writes that apart from access to the right treatment, the general reluctance of women to approach doctors is as much a factor as the lack of public conversation about reproductive sexual health that causes Indian women to develop (and often die from) the largely preventable cervical cancer. (See box)
Still, women do go to the doctor for routine gynaecological check-ups. Dr Santosh Gowda, Additional Director and Consultant Medical Oncology, Fortis Hospitals Bengaluru, says that the higher incidence of cancer in women could simply be a case of more women being checked by doctors (for other reasons such as menstrual problems, pregnancy and post-natal issues) and more often than men. “It is telling that the mortality rate is higher in men,” he says.
The ‘preventable’ cancer
- Cervical cancer can be significantly prevented by HPV vaccination, good personal hygiene, safe sexual practices and, of course, regular screening with the PAP smear, since it is caused by the Human Papillomavirus (HPV) infection. HPV infection is the root cause of genital warts and cancers of the cervix, vagina, vulva, and anus. Gardasil and Cervarix are the two currently approved vaccines available. Both protect against infections with HPV types 16 and 18 that are responsible for 70% of all cervical cancers. Gardasil also prevents infection with other HPV types that cause genital warts. The vaccines have been noticed to be most effective when administered before a woman begins engaging in any sexual activity.
- Source: Dr Santosh Gowda and Dr Sandeep Nayak
Oncologists believe that at least when it comes to breast cancer, there is a greater awareness amongst women: sustained campaigns by organisations such as Indian Cancer Society and NICPR seem to be making a difference, however slight. “I have noticed women approaching doctors at early stages of breast cancer — like even when they notice small and painless lumps. Early detection is really everything in breast cancer,” says Dr Anthony Pais, Oncoplastic Breast Surgeon, and Co-founder and Clinical Director at Cytecare Cancer Hospitals, in Bengaluru. What’s also heartening: breast, cervical, ovarian and uterine cancers, which account for more than 70% of cancers in Indian women, all allow for higher chances of survival with early detection and treatment.
Is cancer genetic or lifestyle-related?
The spike in cancer cases is a direct result of lifestyle and genetic factors. However, according to Dr Gowda, “Less than 10% of cancers can be attributed to genetics. The remaining risks are related to unhealthy diets, poor nutrition, lack of hygiene, exposure to carcinogens like tobacco, obesity and HPV infections.” Evidently, if a patient already has a family history of cancer or is genetically susceptible, an unhealthy lifestyle and poor diet only help to worsen the risk — these trigger the ‘switching on’ of genes. His colleague Dr Sandeep Nayak, a consultant surgical oncologist, adds that though ageing is an unavoidable risk of cancer, a healthy lifestyle is the key to cancer prevention. “A simple awareness of the body, especially when it comes to women, goes a long way. Women should not hesitate to examine their body and must be alert to any unusual changes,” he says. Dr Pais believes that while yearly health check-ups are a good practice, it is time Indians get regular cancer screenings done with organ-based oncologists.
The first sign of breast cancer is a painless lump in the breast or armpit. There won’t be any other symptoms associated with it in most of the cases. Rarely, patients may have a discharge from the nipple, an inverted nipple or itchiness as the first symptom. It is important to remember that screening with mammography is to identify breast cancer even before a lump is felt in the breast. It is generally recommended that every woman above 45 years of age undergo yearly mammography, but in cases where women are known to have other risk factors (such as a family history), other protocols such as genetic counselling and early screening will be followed.
The earliest symptom of cervical and uterine cancer is abnormal bleeding, especially after menopause. Cervical cancer can also cause bleeding after sexual intercourse. Cervical cancer can be detected in stage 0 by the PAP smear test. A simple ultrasound scan of the abdomen can detect uterine cancers to a great extent. Ovarian cancers do not cause any symptoms till very late. Heaviness and abdominal swelling are the most common early symptoms.
In fact, the narrative around cancer is so strongly negative and understandably so, that people often tend to look at it as a death sentence. This not only saps their will to survive, but also prevents them from leading a meaningful life after remission.
The sore lack of healing and support groups only adds to the problem. Promising surgical and technological advances are already here but, as Dr Gowda puts it, what Indian women need to do is to pull the big C out of the shame closet.