Think pink

COVER STORY

If you’ve attempted to make a phone call from your landline at any point during the month of October, then you’re likely to have been jarred by the distracting pre-recorded voice of some random lady (who, she may not realize, is pretty much an introvert’s worst nightmare: someone who makes the task of placing a phone call even more daunting than it already is!)

“Chaati ka cancer aik jaan lewa marz hai,” she drones, “magar par waqt tashkhees sae qeemti jaanaen bachai ja sakti hain.”

Sure she isn’t letting you focus on whatever it was you picked up the phone to actually do, but the lady with the grating voice is right: breast cancer really is a deadly disease, and early diagnosis really can make a world of difference.

Awareness certainly helps.

Symptoms

Women – and men, for the disease can affect both genders, although it is significantly less common in gents – should, first and foremost, understand just how vital early detection really is.

“The five-year survival rate for Stage I is 98 percent,” Dr. Muhammad Nauman Siddique explains. He is a consultant medical oncologist and clinical haematologist at Evercare Hospital in Lahore and a visiting assistant professor of medicine at the University of North Dakota in the U.S.

As the disease progresses, treating it becomes trickier, and chances of survival fall. For Stage II and Stage III, the survival rates are 95 percent and 80 percent respectively, and by Stage IV, they fall steeply to 30 percent.

While the earliest stage may show no outward signs and is often detected through screening and monitoring, the disease starts exhibiting symptoms as it advances.

“Basically, what women could [look out for] is a change in the appearance of the breast: consistency, contour, shape of the nipple, especially if it becomes inverted – that’s a tell-tale sign for people who don’t have this naturally – bleeding from the nipple, or skin puckering, like something is pulling along the skin from the inside,” Dr. Nauman elaborates.

If you, in other words, notice any change in your breast, you’d be wise to consult a physician.

“Many of these lumps or tumours can be painless, but they could be painful too,” the oncologist says. “Most cases are not painful, but they can be, so you have to be careful and you should get it checked so that a physician can then see or order tests and reassure you that [the changes are not cancerous].”

In even more advanced cases, the disease can make a person feel sick overall and lead to weight loss, lack of appetite, or even malaise and lack of motivation.

Risk factors

In general, a woman has a 1 in 8 chance of being diagnosed with breast cancer at some time during her life.

The factors that increase the risk of developing breast cancer are, according to Dr. Nauman, divided into two categories: modifiable and non-modifiable. “There are non-modifiable things, like genetics, family history (which includes first or even second-degree relatives), increasing age, and race (with South Asians having a higher risk),” he details.

Even stature appears to have a link to the disease. “Girls who are taller have a bit higher risk,” he says. “If you are 5’9’’ or taller, then you have a higher risk,” he continues, explaining that he feels this might be related to hormonal status and a high surge in hormones during puberty.

Likewise, early menarche (when you start your periods) can play a role. “If the age is 13 or less, then you are destined to have a longer exposure to oestrogen or hormones that would then lead to a higher risk of breast cancer.” Even higher bone mineral density appears to be linked to a greater probability of developing the disease.

In modifiable factors, we have diet, physical activity, age at first birth (with it being deemed favourable if someone gives birth at age 20 or less), lactation, and body mass index. Weight, the doctor reveals, has an interesting link with breast cancer. “After menopause, higher weight equals higher risk for breast cancer. Before that, it’s the opposite; if you are very lean, then you are at a higher risk for the disease. But we don’t have any evidence that the higher risk linked to a lower body mass index can be negated by gaining weight, and thus maintaining a healthy weight remains the best policy.”

While a healthier lifestyle is likely to help us all, even those who feel like they have factors they cannot change can still benefit from more vigilance. “People who have certain non-modifiable factors – for example, they have a high height, genes, or family history, early menarche, these types of things – they probably can’t do a lot [to change that], but they could at least be more alert. So it still helps them to learn about these things.”

Treatment

The treatment options depend on the type and stage of the disease.

“Surgery is basically the mainstay of treatment,” Dr. Nauman says. The operation can take the form of either removing just the tumour (lumpectomy) or taking out the entire organ (mastectomy), with the decision coming down to the size of the tumour and the patient’s wishes.

Surgery can be both preceded and followed by other treatments. These include chemotherapy, which is medication that is toxic to rapidly growing cells like tumours; hormone therapy, which either reduces the production or blocks the attachment of hormones that are driving the growth of the cancer; radiation therapy, which can destroy cancer cells; and immunotherapy, which boosts the immunity against the cancer.

“At any given time, our body is probably producing a small amount of cancer cells which we are dealing with through our own immunity,” the oncologist elucidates. “But at times cancer cells can learn to evade this [defence mechanism] and [figure out] how to survive even against this kind of attack. So when that happens, then we develop different kinds of cancer. So immunotherapy is just to reverse that process – make our immune system strong so that it can become effective in taking care of the cancer cells again.”

Hormonal and chemo treatments can potentially cut down the risk of a recurrence by as much as 30 to 50 percent, depending on the type of the breast cancer, although their efficacy remains different for every individual.

Prevention and early detection

As with most ailments though, prevention remains the best cure. And early diagnosis makes a huge difference in the prognosis.

Start early screening for patients who have a high risk of breast cancer, Dr. Nauman recommends. “Usually the recommendation is to start screening at 40, but almost all women should actually see a physician for history and examination after 25, at least once every 3 years; that’s what most people say is the most cost effective method.”

Screening methods should be enhanced for those who are at very, very high risk, like those who have a high genetic risk factor, the BRCA gene mutation, or who got radiation treatment for a prior ailment. “Normally we are recommending mammograms, but high-risk individuals should get supplemental screenings, such as breast MRI to look for tiny lesions that a mammogram would miss.

“Those with the BRCA gene could consider preventive surgery – known as prophylactic mastectomy – and for some we even recommend doing ovarian removal, because the ovary is the source of oestrogen.”

Speaking of which, some people could qualify for hormonal medications – the ones used in cancer treatment can also be used in cancer prevention – to give them a break (usually 5 years) from oestrogen. “There was a U.S. study where they found that only 15 percent of the women who would qualify for hormonal treatment as a preventive strategy actually are on it, so 85 percent of the women who should be receiving the treatment are not on it. This is something that is practically non-existent in Pakistan. People – even physicians – don’t have any idea about this.”

Self-examination also remains essential for everyone. “It is important that we are looking for signs ourselves through breast self-exams,” Dr. Nauman says. “Look at the shape, contour, anatomy.” And it goes without saying that you should take care of your health. “Eat healthy. Your diet should include vegetables, fruits, nuts, and low-fat foods. Try to keep a lean weight. Exercise. Stay away from smoking and alcohol.”

So take Dr. Nauman’s advice – stay healthy, stay vigilant. And listen to that random PTCL/Ufone(/voices in my head?) lady as well; she may be irritating as heck, but she speaks the truth.