Dr. Shalini Mukherjee, Ph.D:
Breast Cancer: Beneath the Scar !
Over the past decade breast cancer has emerged as the most common cancer among women in India accounting for 27% of all cancers (IARC, 2018). What is still alarming is that the average age-incidence of breast cancer in India is 45-50 years, a good ten years lower than that in most Western countries (Leong et al, 2010). Several high-risk factors for cancer include genetic predisposition, tobacco and alcohol consumption, diet and life style choices and more defined causes for specific cancers.
In addition to heritable factors, women’s health is heavily affected by psycho-social and environmental ‘stress’. DNA damage in breast cancer has been linked to such factors in several studies (Flint et al, 2012). The lifestyles of Indian women- urban or rural, affluent or under-privileged, have undergone a drastic change over the last two decades, majorly driven by socio-economic factors. There has been major reorientation in the role traditionally played by women in society (Bhatt et al, 2015). In the complex matrix of balancing professional and domestic commitments, her health is often compromised. Unfortunately, very few actually pause to evaluate their stress load.
Psychological counselling and stress management are less pronounced words in Indian families. In this backdrop, a woman diagnosed with breast cancer faces a maelstrom of emotions when she stands at the threshold of a life changing decision. The only chance to live a cancer-free future is sacrificing an integral part of her body that makes her a woman! ‘Mastectomy’ (a surgery to remove all breast tissue from the breast as a way to treat breast cancer) is perceived more psychologically than clinically by most women. Most women simply believe it is the safest option available to protect themselves from future recurrence of the disease and to stall death, without entirely understanding the complexities of a single or double mastectomy.
There are many women who feel diminished and find it difficult to come to terms with their transformed bodies after a mastectomy. While an aggressive and potentially life-threatening breast cancer may not have much window for treatment other than mastectomy, an early diagnosed carcinoma may have other options. The mortality rates due to breast cancer in India are clearly on the higher side owing to the most common stage of detection which stands at stages II and III (Leong et al, 2010). Such an advanced stage of detection also makes chances of breast conservation surgeries less likely owing to the invasiveness of the disease. India does not have any standard screening system unlike many less populated countries. Women are ignorant about the importance of clinical breast examination. Treatment and detection standards vary from world-class to inadequate, depending on the socio-economic condition of the patient (Leong et al, 2010). Fine needle aspiration cytology (FNAC) is underutilized, and the diagnosis prior to a mastectomy is based largely on mammograms and biopsy (Tewari et al, 2006). Mammograms with their limitations related to age, breast tissue composition and other factors, lack precision (Cho et al, 2016). A person who has taken home a prescription as challenging as losing her breast(s), surely deserves to be made aware of treatment plans and offered psychological help.
Breasts are not only an integral part of a woman’s sexuality, but they emotionally weave the bond between a mother and her child. However, nobody wants to talk about it openly. Why? Terms such as “implants” (silicone structures filled with silicone gel or salt water), “Dorsi Flap” (a flap of skin, fat, muscle and blood vessels from the upper are back used for breast reconstruction ) , “TRAM” (a flap of skin, fat and all/part of the underlying “6-pack” muscle are used for breast reconstruction), “nipple reconstruction” (reconstructing a tissue mass into a projection mimicking the natural nipple), “DIEP”(blood vessels called deep inferior epigastric perforators, along with the connected fat and skin are removed from the lower abdomen and transferred to the chest for breast reconstruction) are almost non-existent in India and hardly discussed with patients. Options to help a woman feel ‘nearly intact’ after a breast removal surgery are as important as discussing the effectiveness of treatment plans and both are done lackadaisically, if at all. Adverse changes in body posture of women post-mastectomy mainly manifest in the asymmetry of trunk and shoulder girdle resulting in greater forward leaning of the trunk. There is a significant correlation between mastectomy and the asymmetry of the position of the “scapula”- the bone connecting the upper arm to the collar bone (Rostkowska et al, 2006). Breast reconstruction as well as post-mastectomy exercises often address these posture defects improving functional imbalance, which is important for rehabilitating patients (Rostkowska et al, 2006; Rangel et al, 2019).
Reconstruction surgery options need to be reliable with minimal donor site morbidity. They should be aimed at improving the patient’s quality of life without posing additional health risks. In India, these options are extremely limited. Breast reconstruction surgeries are expensive and require microsurgical skills which are also not available everywhere. More importantly, public health insurance policies do not cover such surgeries which cost above 1 lakh rupees for a single breast reconstruction. Misgivings arising from the lack of correct information and counselling (Mazumdar, 2013) stop several patients and their families from opting for breast reconstruction surgeries. A lion’s share of diagnosed patients either do not have access to silicone breast prosthetics or cannot afford them (at least 5000 rupees per piece). The private health insurance giants also do not provide coverage when it comes to such surgeries and prostheses.
Hence the numbers we see on the statistics for breast cancer patients do not provide a comprehensive picture. It is not just a cancer we have at hand to address; we also have the agonizing situation of partly or completely removing a woman’s breast(s). A scar that not only extends across her chest up to her abdomen, but cuts much deeper into her mind affecting her self-esteem, her relationships and her lifestyle. Some do move on in life leaving behind the crucial decision that changed their life forever but many simply hide the agony by keeping themselves engaged otherwise and avoiding any discourse about the trauma in public. If breast-feeding can be promoted all across the nation so openly, why can a woman not be encouraged to talk about her feelings about a mastectomy equally open-mindedly?
Dr. Shalini Mukherjee, Ph.D (Molecular Biology), University of Manitoba, Winnipeg, Manitoba, Canada.
October 1, 2020
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