As with many non-communicable diseases (NCDs), breast cancer also took a backseat due to the global pandemic. However, health authorities have put forth strategies to curb the negative effects of the pandemic on the diagnosis and treatment of breast cancer patients.
To discuss this topic in detail, a webinar was organised by Healthnet in collaboration with the Indira Cancer Trust (ICT) and the National Cancer Control Programme of the Ministry of Health.
The panellists included National Cancer Control Programme Director Dr. Janaki Vidanapathirana, consultant oncologist Dr. Sachini Rasnayake, ICT Chairperson/Trustee Dr. Lanka Jayasuriya-Dissanayake, and breast cancer survivor and ICT volunteer co-ordinator Chitrika De Mel.
According to the Global Cancer Observatory (GCO) of the World Health Organisation (WHO), breast cancer is the most prevalent cancer in Sri Lanka with more than 3,000 new cases reported in 2018 alone, reflecting a higher rate locally (26%) when compared to the global estimate (24%). Even though it’s seen among both males and females, females are at increased risk by 100-fold. However, many get diagnosed at a later stage of the disease. Thus their quality of life and the survival rates are much lower. Pragmatic actions are now being taken at the national level to increase awareness and promote early detection. If detected early, the prognosis is extremely favourable with even a complete cure being achievable. Currently, only 59% of females with breast cancer are detected early (stage 1 and stage 2 of the disease).
Dr. Vidanapathirana mentioned the urgent need to increase the early detection rate to at least 80%, which will not only reduce the mortality rate but will also lessen the economic burden on the healthcare system.
The risk factors for breast cancer can be categorised as modifiable and non-modifiable. Among them, obesity, unhealthy diet, lack of physical exercise, tobacco, and alcohol use are considered modifiable risk factors. Being a female, age (with over 80% of cases in those 50 years and older), presence of inherited breast cancer-causing genes such as BRACA1 and BRACA2, and family history are considered major non-modifiable risk factors that make females more predisposed to getting breast cancer. Some of the other risk factors include radiation exposure to the chest and exposure to oestrogen and progesterone for a longer period during your lifetime. This could be due to early menarche (before 12 years of age), late menopause (after 55 years), not having children (nulliparity), and long-term exposure to hormone replacement therapy (HRT). There are two known protective factors which are breastfeeding and regular physical activity.
Look for these signs and symptoms during a breast self-examination
Look for an abnormality in size, colour, shape, a rash or dimpling of skin (orange peel appearance), inverted nipple, swelling, or any discharge from the nipple. Palpate the breast to feel for any thickening, lumps, and lymph nodes under the armpit, and note that pain is not always present.
Impact of Covid on early detection of breast cancer
Once there is a clinical suspicion of breast cancer, one needs to investigate quite early, and the best treatment modality should be selected with the help of a cancer specialist. However, the uncertainty regarding the outbreak and lockdowns have effects on early detection strategies which are conventionally followed.
“If only a single patient who routinely undergoes screening misses a single mammography, the consequences are limited; if we miss hundreds of thousands of mammograms, the impact is extremely severe in terms of lost lives, costs, and the burden on the healthcare system” (Frontiers in Oncology Journal, 2020). Hence, promoting self-examination is critical especially in a time like this where access to screening programmes might be limited to avoid the spread of Covid-19.
Dr. Rasnayake pointed out the importance of diagnosing breast cancer early as the treatment modality will change depending on the stage of cancer. For example, in the early stages, only surgery can render a complete cure in some, but in the late stages, surgery will be more extensive which will include taking out the lymph nodes.
Chemotherapy and radiotherapy will also be employed depending on the need. Hence even during a pandemic, we should be mindful and proactive to detect cancerous changes early. Due to the rapid advancements in treatment, the currently available options are less daunting unlike what was available decades ago. She pointed out that even with a diagnosis of breast cancer, the outcome need not be feared as treatment can be targeted and personalised.
Key national guidelines for early detection and management of breast cancer symptoms
- A breast self-examination should be performed by all women who are 20 years old and more at least once a month
- Clinical breast examinations (CBE) are recommended once every three years for all women from the age of 20 to 40
- For women aged 40 or over, clinical breast examinations are recommended annually
- For women whose relatives developed breast or ovarian cancer under the age of 40 years, annual clinical breast examinations should be started five years before the age at which the said relative developed cancer
- For women aged 50-69 years, a screening mammography is offered once every two years if the woman requests it
- Screening mammography or ultrasound scans every 12 months from 35 years can be offered for women with a strong family history of breast and ovarian cancers
- For women younger than 35 years, an ultrasound scan should be offered instead of a mammography
- Any male with breast cancer symptoms should be seen at a surgical clinic or by a surgeon
- The diagnosis of breast cancer is done at a tertiary care hospital by employing the triple assessment method. The triple assessment method refers to three diagnostic components;
- Medical history and clinical breast examination
- Imaging – mammography and/or ultrasound scan
- Non-excision biopsy – fine needle aspiration cytology (FNAC) and/or cone biopsy
This method is recommended as the sensitivity of the triple assessment is greater than any of the individual components alone. If the triple assessment results in a positive diagnosis, specialist care will be needed.
It’s no doubt that all NCDs have had major setbacks due to the current pandemic. This has also proven to be an opportune moment to spread awareness as more people are in tune with their health and wellbeing at present. Owing to the major shift in how breast cancer screening services are being utilised and managed during the pandemic, the time has come to be aware of preventive measures and work towards a healthier nation. While minimising face-to-face patient contact, it is crucial to provide other methods for patients to receive care safely; the need for standard practices to be modified to achieve this is evident. Having a portal of communication between all involved parties has become one of the key aspects in the current strategy with the involvement of social media and initiatives such as “Aayu Plus” which was recently implemented by the National Cancer Control Programme.
There is a dire need to establish a “new normal”, balancing breast cancer care and the risk of Covid-19 transmission. However, as we face the second wave of infection, the long-term effects of the Covid-19 pandemic on early breast cancer care are difficult to predict.