IF SHE DISCOVERS A BREAST LUMP?

The discovery of a breast lump usually causes anxiety bordering on panic among many women. Most rush to the nearest doctor and plunge into a morass of illogical investigations and treatment, including surgery. Needless to say, many a woman regrets th is headlong rush at a later point of time.

Incomplete assessment and treatment, a false perception of cancer risk, a lifelong commitment to intensive and needless breast cancer screening, emotional and economic exhaustion are but a few fall outs that result from all this.
Lack of awareness

There are other women who in contrast are blissfully oblivious to the presence of a breast lump. A lack of breast awareness is often engendered by cultural inhibition and a conviction that once breast feeding is complete, the breasts are of no importance. Yet others do note the presence of a lump but assume rightly or wrongly that it will "go away". Often it requires a friend or family member to coax these women into seeing a doctor.

It is important to note that breast lumps are a common problem and the majority are benign. Lumps are usually discovered by the woman herself and only occasionally by doctors. A woman who is breast-aware tends to discover them early and obviously a painful lump is noted early in contrast to a painless lump.

What should a woman do if she discovers a breast lump? It is important not to panic. Approach a healthcare provider without loss of time. It is prudent at this stage to ask for a referral to a breast specialist (invariably a surgeon). This trend has become established in the developed countries after research showed significant benefits in outcome when a woman with breast disease is treated by a breast specialist.
Thorough examination

Next the patient will be subjected to a thorough examination by the surgeon to determine whether the woman truly has a lump. Often prominent breast tissue is mistaken to be a "lump". Breast imaging follows: mammogram in women over 35 years and an ultrasound scan in younger women. This is followed in the same sitting, if warranted, by an image guided needle biopsy of various levels of sophistication. On no account should a woman agree to bypass these steps and go straight for an open surgical biopsy. This can lead to serious repercussions in breast cancer management.

After comprehensive evaluation, (which may take four to five days) the treatment options can be discussed. With the dramatic and ongoing advances in the field of breast diseases, the emphasis is on individualised treatment. This may be in the form of clinical surveillance, medication or surgery according to the need. By and large there is no need for "emergency" surgery and even for cancers, a delay of a few days or even one or two weeks is of no medical consequence.
Don’t be short changed ?

The late 20th century saw a paradigm shift in the management of breast diseases, both benign disease and cancer. This came about due to two powerful influences: the women’s movement and mounting research evidence on the best methods to treat breast disease.

The First European Breast Cancer Conference held in 1998 issued the famous Florence statement: that all women (at least in western Europe) should have access to multidisciplinary breast clinics and that all breast related health services should have mandatory quality assurance. An important ground level consequence is that national guidelines were created in countries like the U.S., Canada, New Zealand, Australia to improve breast cancer outcomes. The impact was a fall in breast cancer death rates in these countries.

A powerful message of these guidelines is that only surgeons with a special interest in breast disease should treat patients with breast cancer and breast disease. The benefits are greater accuracy of diagnosis, better quality of treatment and a reduction in morbidity and mortality.
Indian situation

By contrast India is seeing rising incidence of breast cancer, high incidence of advanced breast cancer and shameful death rates. Indeed there are no national guidelines on how services should be organised, delivered and monitored within our socio economic constraints.

It is up to Indian women’s groups to push the medical profession and the Government to look at breast disease as a national issue.

Our women must assert their rights to get the best possible treatment and refuse to be short-changed as their western counterparts did nearly 50 years ago.

Spiralling costs

The advances in breast cancer medicine and surgery have been progressing at a prodigious rate. The crunch is that the best methods of diagnosis and treatment come at a cost.

In a highly specialised and evolving field such as breast cancer treatment, even diagnosis is an expensive business. A few thousand rupees need to be set aside just for assessment of the cancer. If in addition, genetic tests are required, the bill for this alone is about Rs. 50,000. But this elaborate evaluation helps individualise breast cancer treatment and enhances efficacy of treatment. Surviving a few years more without cancer is the direct result of this individualisation. It is indeed a balance between money and life.
Financial implications

Treatment in the form of surgery, chemotherapy and radiotherapy follows and is financially crippling. Families need a few lakhs of rupees to get the best in terms of the latest chemotherapy drugs of added efficacy or the latest machines for better and safer delivery of radiation.

Today we have special drugs such as anti-breast cancer antibodies, which can be given to selected patients to control the cancer remarkably well. The cost of these injections is approximately Rs.1,00,000 per dose. These drugs need to be given every three weeks for close to a year. To meet the bills, families have been known to reduce themselves to penury. The tragedy is that many do not survive.

Whom does one blame for this financial juggernaut: The government, the private sector or the multinational companies? Or the patient for asking to live in peace for a few more years?
Why see a specialist

• It gives better local control of cancer.

• It improves the survival of the patient significantly.

• The patient has greater satisfaction with the treatment.

• The patients receive greater psychosocial support.

• The patients have improved quality of life after treatment.

• It is cost effective to be treated by breast specialists in the long run.
If you discover a lump

• Ask to be referred to a breast specialist.

• Undertake investigations as per specialist advice.

• Wait for the full evaluation.

• Heed the specialist’s advice.

• Do not seek multiple medical opinions, particularly from "non specialists".

• Be reassured that the majority of breast lumps are benign.

• Even if you have a cancer, do not lose heart. It can be controlled effectively.
Tips to contain costs

• Ask to be referred to a breast specialist early.

• Do not undertake investigations without professional guidance.

• Adhering to international treatment guidelines contains costs in the long run.

• Be part of a breast cancer support group, on going information helps contain costs.