The greatest rise in the incidence of breast cancer has been noted in developing nations, particularly in India. The rising incidence of breast cancer in India is likely due to further changes in lifestyle factors such as childbearing and dietary habits. Although it is lower than in the west, mortality is higher in India. This may be due to the late presentation stage and disparities in cancer care.
Regional cancer institutes and hospital-based tumor registries still report a large percentage of locally advanced breast cancer in our country. In urban India, with a slight socioeconomic advantage, there is an increase in breast cancer awareness. However, there is not much data on screen-detected breast cancers in India. Although there is no population-based breast cancer screening, opportunistic screening has gained popularity in urban metros among women's upper and middle socioeconomic groups in the last decade.
Most of our patients are symptomatic breast cancers, with only 9 % being screen-detected in urban well-educated upper socioeconomic class women. While mammography-screening debates are still ongoing, population-based mammography is not a viable and cost-effective proposition in India. The health care system is very heterogeneous in India. Although it is not cost-effective and probably not beneficial to do population-based mammography, opportunistic and high-risk mammography should continue in our country.
The last decade has seen several practice-changing developments in breast cancer care, leading to improved survival outcomes and quality of life.
Advanced Technology in Breast Cancer
Technology advancements in breast imaging with digital tomosynthesis have reduced mammography's false negatives and false positives. In addition, continuous improvements in technology have made interventional procedures like stereotactic biopsy easy for radiologists and patients.
From mutilating radical mastectomies, we have moved on to more breast-conserving procedures with attention to cosmetic outcomes and quality of life. As a result, oncoplastic surgery has become a defined specialty in many centres across the world. From volume displacement in the breast to volume replacement from donor sites, various options allow wide excisions with good cosmetic outcomes. In addition, the safety of oncoplastic procedures concerning survival outcomes has been established.
More patients achieve a complete pathological response with the increasing use of neoadjuvant chemotherapy and targeted therapy. This has also increased breast conservation rates, with consequent improvement in quality of life.
De-escalation of axillary surgery is also one of the major milestones achieved in breast surgery. Axillary sentinel lymph node biopsy is now the standard of care for stage 1 and 2 clinical and radiological node-negative breast cancer. Furthermore, studies have looked at the safety and accuracy of sentinel lymph node biopsy in node-positive patients who have responded to neoadjuvant chemotherapy.
Extensive use of breast MRI has opened up the possibility of doing vacuum-assisted bed biopsies in good responders after neoadjuvant chemo and targeted treatment. As a result, a subset of patients may avoid surgery altogether. Preliminary reports show promise in that direction.
Targeted Therapy for Breast Cancer
The biggest success with targeted therapy for breast cancer is with Trastuzumab. Two decades of experience and newer her 2 blocking agents later, we are now looking at a subset of responders who need escalation (Katherine trial) and a subset where de-escalation of anti-treatment can be equally effective.
Triple-negative breast cancers continue to cause concern with no path-breaking advances in therapy. Triple-negative breast cancers with a significant residual primary tumor and axillary nodes did worse, and in this subset, further extension of oral chemotherapy with capecitabine may improve outcomes. In addition, a subset of patients with a germline BRCA mutation will benefit from Olaparib in the metastatic setting. Finally, results from studies looking at the role of Olaparib in adjuvant therapy will soon be available, which might improve survival outcomes.
The last two decades also saw several genomic prognostic signatures in breast cancer. Validated studies using these signatures have opened up the possibility of personalizing chemotherapy. In addition, risk stratification and avoiding chemotherapy in low-risk patients have contributed to a better quality of life.
Radiotherapy for Breast Cancer
Radiotherapy has been a challenge in our country as there is a lack of facilities in tier two and three cities. In addition, the long duration of treatment deterred women from having breast-conserving surgery. With hypofractionation, the treatment time has been reduced to 3 weeks without compromising survival and quality of life outcomes. With improved survival, survivorship and quality of life have also been addressed, emphasizing diet, exercise, yoga, and other alternative and complementary therapies.
While we are looking at exciting times in breast cancer management, it is still a challenge to achieve a uniform standard of care across India. However, private-public partnerships, patient education and awareness, continuing medical education for medical personnel, and making technology and medical treatments affordable will help achieve better outcomes in our country.