How Pink is the Pink ? Burgeoning burden of Breast Cancer & Women

October is here and everyone seems to be coloring it pink with the tagline “Keep her in the picture”. The slogan for Breast cancer awareness month of 2023. But, when we visualize her picture, we find there is nothing so pink about the pink, rather its blue making her picture look so depressing? Let me discuss a bit of the statics around the breast cancer monster killing, maiming and robbing the very women for whose sake we color the month of October pink.  Brest Cancer knows no castes, no color; - black, brown or white women, no economic status the Haves and Haves-not. It strikes you equally and is now a formidable global health challenge. In India, Roughly, 2 lakhs women are detected or rather sentenced with breast cancer every year, and 50% of them die within the year of detection. Sadly, the only reason for such a high mortality is the late-stage detection. In India, about 82% of the cancers are detected in stage 3 or 4! Only 8% of cancer is found at stage 1 wherein this monster can be tamed easily with more than 90% of curability and long-term survival amply seen in the countries with higher HDIs.

Women health in India is a wide subject riddled with overwhelming complexities of myriad nature. As little facts as the place of birth, family, society, caste and the education level make a huge difference to their nutrition, health and overall survival. Maternal mortality is still a leading indicator to follow. Women nutrition is still a social challenge.  Ask any ASHA workers, who are burdened with follow up registers, about how difficult it is for any women in the rural areas to go to a PHC center for routine pregnancy checkup forget about normal health checkups. Venturing out alone itself for women is still riskier even in the cities which are engines of economy where women empowerment is being blared out from every nook and corner. Talking about breasts is shameful and a big taboo. Detecting breast cancer is filled with the stifling social environment that discourages women from openly discussing their breast health and is often associated with moral judgment, damage to family reputation is a big letdown, particularly in rural and semi-urban societies. Myths and fears about the social and matrimonial impacts further perpetuate the stigma around breast cancer. Can women freely talk about their breast health in the society?

Awareness, Availability, Accessibility and Affordability are still major hurdles in driving healthcare in our country. However, awareness assumes quite a significant importance in cancer disease management. It directly impacts clinical outcomes unlike many other diseases.

Consider these staggering statistics about cancer, approximately 1.7 million cancer cases every year and shockingly, over 90% of these cases are detected accidentally or incidentally. Even what alarms more is the fact that that approximately 36% of these cases are women-specific cancers, with breast cancer accounting for 14% and gynaecological cancers for 22%.

 In urban India, breast cancer is rapidly becoming the most common cancer among women, and it's the second most common in rural areas with a new case going up from 24/lakhs to 30/lakhs in next 3 years only. To compound the issue, over 80% of these cases are diagnosed at stages 3 and 4, in stark contrast to developed nations like the USA and the UK, where this figure stands at a mere less than 10%.

India now contributes around 13% to the total new cases of breast cancer detected worldwide, with a 10% share of the disease's global mortality. While interventions like HPV vaccinations have made significant strides in combating gynaecological cancers, breast cancer remains a formidable challenge when detected at advanced stages.

To make matters worse, there is a lack of national or regional awareness and educational programs about breast health or self-breast examination in colleges, universities, corporate workplaces, and community centres in major metro cities. Indian women are left to fend for themselves for information and guidance, with Google and social media often adding to the confusion rather than providing credible information.

In a low and middle-income country like India, where healthcare is riddled with challenges related to availability, affordability, and accessibility, teaching women how to perform self-breast examinations could be a game-changer. This approach not only dispels unnecessary taboos but also reduces detection costs. It also challenges the prevalent narrative that India needs to invest heavily in medical detection infrastructure like mammograms and ultrasounds, which may have worked in the developed countries with abundant resources but are impractical in the Indian context.

One must not forget that breast cancer in India disproportionately affects younger, premenopausal women aged 35 to 50, as opposed to western countries where it's primarily a post-menopausal phenomenon (70% of cases are among women aged 60 to 70). Furthermore, the scarcity of machines, competent human resources, and the prohibitive cost of mammograms hinder scaling up it as a viable solution.

The complex battle against breast cancer involves multimodality integrative treatment, including surgery, chemotherapy, and radiation. Regrettably, more than 65% of Indian hospitals lack these crucial modalities, and skilled surgeons, medical oncologists, and radiation oncologists are in short supply. The WHO's recommendations suggest that India needs at least 5,000 evenly distributed radiation machines, and we fall woefully short of this target.

Adding to the challenge is the skewed geographic distribution of oncological infrastructure, with 90% of facilities concentrated in just 16 cities. This forces most Indians to travel long distances for availing treatment which directly increases cost and reduces compliance to the needed treatment.

The fear of detection is immense and its hardly communicated that that more than 80% of lumps or knots felt in breasts are non-cancerous. The soul  paralyzing fear isn't just about the disease but it's also about the social unacceptability, the journey to post treatment rehabilitation into normal life, and its implications on marriage and family life.

While we often crib about the poor participation of women in the economy, lack of job opportunities, and rising social atrocities, yet, we paradoxically pay so less attention to the cause of the health of women especially cancer, particularly breast cancer. I strongly feel, It's the time to acknowledge that the elephant in the room that the burden of breast cancer in India is mounting rapidly and the society's reticence, its patriarchal frame work and the policy makers negligence to discuss women's bodies has worsened the situation.

Some of the solutions lie well within the grasp.  A robust social awareness campaign, the effective inclusion of self-breast examination in public spaces, and widespread screening programs led by the trained community workers and volunteers are urgently needed. Policy interventions must correct healthcare facility distribution, address the shortage of skilled healthcare professionals, and prioritize the prevention and early detection of breast cancer. These steps will go a long way in conquering the monstrous challenge that breast cancer poses to Indian women.