According to the Global Burden of Disease study, cancer caused 8.3 per cent of the total deaths in India in 2016, almost double of what it did in 1990. As per the WHO Global Cancer Observatory estimates, 1.32 million new cancer cases and 0.85 million cancer-related deaths occurred in India in 2020.
According to the National Cancer Registry Programme, the most number of women with cancers are found in west India followed by the south. Northeast India reports the lowest numbers. Breast cancer is the most common cancer in urban India, while it is cervical cancer in rural India. The average age for women for these cancers ranges between 45 and 60 years. One in nine people in India is likely to get cancer, with women outnumbering men.
For this column, we delve into the complexities of cancer in Indian women.
Dr Mandeep Singh Malhotra is an oncologist with more than 20 years of clinical experience. Currently working as director, surgical oncology at CK Birla Hospital, Delhi, he completed his senior residency in the speciality at the All India Institute of Medical Sciences (AIIMS), Delhi. He has done stints at Broomfield Hospital, Chelmsford, UK, and the University of Pennsylvania, US. His various awards include the Young Scientist Award in 1992.
Dr Mandeep Singh Malhotra
In layman terms: Cancer is a complex disease characterised by uncontrolled growth and division of abnormal cells. These cells originate within the body, not from external factors like bacteria, fungi, or viruses. Such growth disrupts normal cellular processes and can lead to the invasion of surrounding tissues and, in some cases, spread to other parts of the body through the bloodstream or the lymphatic system.
The speed of division: The development of cancer often occurs in cells that undergo frequent division, like the lining of the oral cavity, respiratory tract, gut (colon and stomach), and reproductive system (endometrium—the lining of the uterus). Additionally, blood cancers can arise from white blood cells and their precursor cells (cells that mature into functional forms). Frequent cell division increases the likelihood of mutations in the cell’s genetic code or DNA. These mutations can disrupt the normal control mechanisms that regulate cell growth and division, leading to uncontrolled proliferation and the development of cancer.
What causes mutations: Exposure to carcinogens (like tobacco smoke) and alcohol consumption can damage the DNA and increase the risk of mutations in cells lining the mouth, respiratory tract, and other organs.
Hormonal imbalances: long-term exposure to estrogen can contribute to breast and endometrial cancers.
Genetics: In some cases, cancer susceptibility is inherited from parents. However, most cancers are not directly inherited. Other factors are ultraviolet radiation, certain viruses, and chronic inflammation.
Most common cancers in Indian women: Breast cancer ranks as the most common, followed by cervical cancer. Both pose significant health risks, but ovarian cancer carries a notably higher mortality rate primarily due to late-stage diagnosis. Still, breast cancer remains the leading cause of cancer deaths as it accounts for more than a third of women’s cancer. Thus, while cancer-specific mortality (death rate) of ovarian cancer is more than breast cancer, the overall mortality of breast cancer is higher.
The age factor: For breast cancer, unlike in western countries, the average age for women in India is around 45 years, preceding menopause. This earlier age of presentation is a critical concern. Ovarian and endometrial cancers typically manifest after menopause, mostly beyond 50 years. However, younger cases are increasingly observed. Cervical cancer peaks in the 35 to 50 age bracket, particularly affecting women with multiple sexual partners, poor hygiene, and financial limitations. The nationwide HPV vaccination initiative promises a significant decrease in future cases.
The stages of breast cancer: It begins with stage zero which is detectable through screening methods like mammography, ultrasound, or MRI. Early-stage breast cancer is limited to the breast, with no involvement of the underlying chest wall or armpit nodes. Locally advanced breast cancer (stage 3) involves lymph node spread or larger tumour size, potentially with skin or chest wall involvement. Stage 4 breast cancer indicates spread of cancer cells (metastasis) to other organs like bones, lungs, liver, or brain. Treatment depends on hormone receptor status (whether or not cells have proteins that bind to a specific hormone). Hormone-positive cancers respond well to hormone therapy, while aggressive subtypes like HER2-positive (HER2 being a protein that promotes the growth of cancer cells) or triple-negative (which has neither estrogen nor progesterone or HER2, and thus gives doctors fewer treatment options) require targeted therapy or immunotherapy alongside chemotherapy. Treatment response significantly impacts cancer control, with favourable responses leading to better outcomes even in advanced cases.
The march of ovarian cancer: This may also begin as borderline ovarian lesions (damage) before progressing to cancer. Initial stages involve localised ovarian tumours, and then it progresses to adjacent structures like fallopian tubes or uterus, causing symptoms such as pain or urinary/bowel changes. Advanced stages spread throughout the abdominal cavity and potentially to distant organs like the liver or lungs. Treatment strategies involve upfront surgery for early stages and systemic therapy for advanced cases, with chemotherapy, targeted therapy, and immunotherapy showing promising results, especially in responsive patients. CA 125 (a kind of blood test) is a sensitive marker for monitoring response to treatment and detecting cancer recurrence post-surgery. Hyperthermic intraperitoneal chemotherapy (a two-step procedure where cancerous tumours are surgically removed, and then heated chemotherapy drugs applied directly inside the abdomen to eliminate the remaining cancerous cells) is a newer technique enhancing chemo effectiveness. It is particularly beneficial for aggressive cancers or those with good initial treatment response.
What to do before pain strikes: While pain often indicates advanced cancer, proactive measures and lifestyle changes can lead to earlier diagnoses. For breast cancer, Self-Breast Examination (SBE) is a valuable screening tool. Performing monthly SBE is crucial in India due to the younger onset age (45 years). Mammography may not be effective at this age. Additionally, schedule clinical breast exams by a health care professional every six to 12 months and enrol for screening mammography under the supervision of a family gynaecologist or physician. For cervical cancer, the HPV vaccine drastically reduces chances of getting it by 80 to 90 per cent. It also prevents oropharyngeal (head and neck) cancers in both men and women, and penile cancer in men. Women should also go for regular gynaecologist consultations and consider pap smears (that test cells from the cervix) every three to five years or HPV DNA testing. They should watch out for symptoms like post-coital bleeding and unusual discharge. Early symptoms of ovarian cancer are often vague, but watch for bloating, dyspepsia (indigestion), and increased abdominal girth. Advanced symptoms include urinary/bladder/bowel obstruction and pain. If there is a family history of ovarian cancer, consult your doctor for more personalised advice.
The rise of cancer kinds: Over the past few years, a significant shift has occurred. Cervical cancer, which once held the top spot, has been surpassed by breast cancer. Additionally, there has been a rise in both ovarian and endometrial cancers over the same period. However, a promising trend is emerging, with the increased uptake of HPV vaccination, cases of cervical cancer are falling by seven to 10 per cent.
Busting common cancer myths: Bras (underwired or otherwise) and/or deodorants do not cause cancer. Breast cancer risk factors are largely genetic and environmental, not related to clothing or hygiene products. The HPV vaccine might, like all vaccines, cause mild, temporary side effects like fever or soreness, but has no serious side effects. The benefits of the vaccine far outweigh any potential risks. Biopsy does not spread cancer, but is crucial for accurate diagnosis. It is a dangerous generalisation that any female problem requires a hysterectomy (removal of uterus). Treatment options vary depending on the specific condition and severity. Consult a qualified health care professional for an accurate diagnosis and appropriate treatment plan.
Mastectomy is not the answer: Modern surgical techniques allow for breast preservation while achieving excellent cancer control in many cases. It is now proven that women at early stage of breast cancer who survive the cancer with breast tend to live longer compared with those who have undergone complete breast removal (mastectomy). Talk to your doctor about the best option for your situation.
Chemotherapy not so unbearable: Modern chemotherapy has come a long way, with advancements in supportive care significantly reducing side effects. Hair loss and other effects are often temporary and reversible.
Immunotherapy not a replacement for chemotherapy: Immunotherapy plays a vital role in women's cancer treatment, but it typically enhances the effectiveness of chemotherapy, and does not replace it. Each therapy has its unique role and works best in combination with others.
Alternative medicines: While traditional therapies like ayurveda can offer benefits in managing side effects and promoting general well-being, they cannot cure established cancers. Standard treatments like surgery, radiation, and chemotherapy remain the cornerstone of cancer control.
The role of genetics and lifestyle: The dynamic nature of breasts which undergo constant changes from puberty through menopause, increases the likelihood of cellular abnormalities leading to cancer. Lifestyle and environmental factors—early puberty, delayed pregnancies, reduced lactation periods, stress, alcohol consumption, smoking, and exposure to pollutants play a substantial role in this surge. Obesity is associated with higher estrogen levels, which further increases the risk. Understanding the genetic aspect is crucial, as 15 to 20 per cent of breast cancers in India are hereditary.
Genomic alterations: Mutations in BRCA1 and BRCA2 genes (that protect against cancer) contribute significantly to cancer risk. Women with these mutations face a 70 per cent lifetime risk of breast cancer and a 45 per cent risk of ovarian cancer. Genetic counselling becomes imperative for those with a family history of breast, ovarian, prostate, colorectal, or other related cancers.
Prevention strategies: Focus on lifestyle modifications, stress reduction, exercise, a healthy diet, and timely family planning. Encouraging women to consider childbirth before the age of 35, prioritising fitness, and promoting adequate lactation can mitigate risk factors. The advent of assisted reproduction technologies, while aiding conception, introduces new considerations and trends, potentially impacting breast cancer incidence.
Family history: In families with a history of breast or other related cancers, consulting a genetic counsellor is a proactive step. Assessing risk through analysis and pedigree charts allows for personalised interventions, such as intensive screening or risk-reducing procedures like mastectomy, which can remarkably reduce the risk of breast cancer-related mortality by 95 per cent.
The (perceived) loss of looks and confidence: Hair loss is a side effect associated with chemotherapy used for various cancers, including those of the breast, ovary, cervix and endometrium. Counselling reassures patients that hair loss is temporary and hair will grow back. Depending on the patient's mental state and support system, the hospital may involve trained counsellors specialising in post-cancer support.
Because of advancements in oncoplastic breast conservation, 90 per cent of women undergoing breast cancer treatment can save their breasts. Robotic surgery allows for precise procedures with optimal functional breast preservation, including skin, nipple, and sensation. Traditional medicines like ayurveda and nutraceuticals can help reduce the side effects of chemotherapy and radiation. Medications like high-dose IV vitamin C may also be used to manage hair loss and other side effects. Modern chemotherapy regimens are optimised to minimise side effects while maximising effectiveness.
A matter of cost: It is a common misconception that cancer treatment is always expensive and unsuccessful. For cervical cancer, the HPV vaccine is more affordable due to government initiatives. Early detection of uterine cancers often only requires straightforward surgery, making it significantly less expensive than treating advanced stages requiring radiation, chemotherapy, and other interventions.
For hormone-positive breast cancer, the most common type in India, the basis of treatment is surgery and hormone therapy. Risk assessment can even identify patients who don’t require chemotherapy, further reducing costs. Hormone therapy itself is inexpensive. Only a specific type of breast cancer, HER2-positive, requires targeted therapy, which can be more expensive. However, the availability of biosimilars (medicines that are very similar to biologics, or drugs derived from living organisms or natural resources) in India has brought down the cost considerably. Even for triple-negative breast cancer, not every patient necessarily needs immunotherapy. While it can improve response rates, adding it increases the cost significantly. Standard chemotherapy alone delivers a 50 per cent response rate, and immunotherapy only increases that to 64 to 65 per cent. Therefore, most patients can be treated effectively with standard chemotherapy, with immunotherapy offering an additional benefit for those who can afford it. Early-stage cancer treatment promises an 80 to 90 per cent success rate, regardless of cost. The high expenses and disappointments typically arise when treating advanced stages, requiring multiple lines of treatment, expensive diagnostics, and advanced medications.
Family and Friends: Research has highlighted the important role of family and friends in supporting cancer patients. Studies show that patients with a strong support system and positive mindset tend to live longer compared with those lacking social support. Family support acts as a powerful boon in a patient’s fight against cancer. It not only provides emotional comfort, but also practical assistance with daily tasks and treatment adherence. Interestingly, research also suggests a link between stress levels and cancer risk. Patients lacking social support or experiencing loneliness and depression often exhibit higher stress levels. This chronic stress may be a potential factor in increased cancer risk.
Post-treatment life quality: Modern breakthroughs in science and technology have improved the quality of life for women undergoing cancer treatment, particularly breast cancer. Today, the mission is to ensure women remain as they were before treatment, both physically and emotionally. Techniques like oncoplastic surgery and robot-assisted procedures allow women to not just walk out cancer-free, but walk out with their breast shape, sensation, and function preserved, with restored normalcy and confidence. Researchers are working tirelessly to reduce the burden of treatment side effects like hair loss, pain, and skin changes. Innovative medications like targeted therapies and immunotherapies, alongside advancements in chemotherapy, have significantly increased response rates. Even during chemotherapy, doctors take precautions to ensure ovarian function and reproductive potential remain intact. Modern radiation therapy minimises undesirable effects like skin irritation and scarring, further enhancing quality of life. Early detection, coupled with these innovative technologies, ensures not just increased survival rates, but also an improvement in post-treatment quality of life.
Top cancer self-care tips: Embrace happiness. While I cannot say that happiness completely prevents or cures cancer, a positive outlook has a significant impact on your fight and recovery. Stay informed about symptoms and follow the doctor's instructions diligently. Attending all follow-up appointments is important. Recurrent thoughts of cancer can be overwhelming. Seek support and practise stress management techniques to keep anxiety at bay. While research on dietary specifics is ongoing, consider potential triggers and incorporate nutritious elements to support overall health. Consult a registered dietitian for personalised guidance. Shifting the perspective can be empowering. Instead of dwelling on the negative, view the journey as an opportunity for growth and self-discovery.