DOI:http://dx.doi.org/10.7314/APJCP.2012.13.10.

4861
Breast Cancer in India: Where Do We Stand and Where Do We Go?

MINI-REVIEW

Breast Cancer in India: Where Do We Stand and Where Do

We Go?
Anita Khokhar
Abstract
This is a review article which looks into details what the actual scenario of the problem of breast cancer in our
country is. As the problem is on the rise, what is the level of the preparedness at our end to tackle the problem.
The articles reviews the epidemiology of breast, high risk factors, detection, diagnosis and treatment facilities
also along with that screening facilities and their ground reality, awareness of the women from different walks
regarding various issues of breast cancer and what intervention can be made to combat the disease.
Keywords: Breast cancer - challenges - India

Asian Pacific J Cancer Prev, 13 (10), 4861-4866

Introduction School of Public Health revealed that 1.35 million cases

of breast cancer would be diagnosed worldwide in 2009
India with a population of 1.2 billion is the most accounting for 10.5% of new cancers, second only to lung
populous democracy in the world. India is a pluralistic, cancer. Breast cancer cases are expected to increase by
multilingual, and multiethnic society. It includes over 15 26% by 2020 and most of these will be seen in developing
native languages with more than 70 dialects (Government countries (Anonymous, 2009).
of India: Office of Registrar General, 2010). Although Data from the International Agency for Research
the focus of public health has been mostly on infectious on Cancer (IARC) registry suggest that 45% of newly
diseases in the developing countries, non communicable diagnosed cases of breast cancer and 55% of breast cancer-
disease like cancer also take an increased toll on resources related mortality currently occur in low- and middle-
(Parkin et al., 2001). Unlike other cancers, breast cancer is income countries. IARC trends also show a 20-30%
eminently treatable if detected at an early stage. However, increase in the incidence of breast cancer in developing
there is a need for culturally appropriate breast cancer countries during the past decade (Curado et al., 2009). As
education and intervention strategies. With the Rs-10 per the ICMR-PBCR data, breast cancer is the commonest
billion Indian oncology market expected to grow at a cancer among women in urban registries of Delhi,
rate of 21 per cent for the coming five years, dedicated Mumbai, Ahmedabad, Kolkata, and Trivandrum where
oncology setups within hospitals are still in the pipeline it constitutes >30% of all cancers in females ( National
to cater for 2.5 million cancer patients (Shukla, 2010). Cancer Registry Programme, 2001). In the rural PBCR
of Barshi, breast cancer is the second commonest cancer
Epidemiology of Breast Cancer in India in women after cancer of the uterine cervix (National
Cancer Registry Programme, 2001). The age standardized
Although the incidence of breast cancer has increased incidence rates (AARs) range from 6.2-39.5 per 100,000
globally over the last several decades (Hortobagyi, 2005; Indian women. The AARs vary from region, ethnicity,
Anderson, 2008; Porter, 2008). the greatest increase has religion, with the highest incidence reported at 48.3 per
been in Asian countries (Green et al., 2008). In Asia, 100,000 women in the Parsi community of Mumbai
breast cancer incidence peaks among women in their (National Cancer Registry Programme, 2001).
forties (Agarwal et al., 2007), whereas in the United States The incidence of this disease has been consistently
and Europe, it peaks among women in their sixties. In increasing, and it is estimated it has risen by 50% between
India premenopausal patients constituting about 50% of 1965 and 1985 (Saxena et al., 2002). The rise in incidence
all patients (Agarwal et al., 2007). It is expected that in of 0.5-2% per annum has been seen across all regions of
the coming decades, these countries would account for India and in all age groups but more so in the younger age
majority of new breast cancer patients diagnosed globally. groups (<45 years) (Murthy et al., 2007). More than 80%
Over 100,000 new breast cancer patients are estimated of Indian patients are younger than 60 years of age. The
to be diagnosed annually in India (Nandakumar, 1995; average age of patients in 6 hospital-based cancer registries
Agarwal et al., 2007). A study conducted by the Harvard ranged from 44.2 years in Dibrugarh, 46.8 years in Delhi,

Community Medicine, Professor, Vardhman Mahavir Medical College And Safdarjung Hospital, New Delhi, India *For
correspondence: anitakh1@yahoo.com
Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 4861
Anita Khokhar
47 years in Jaipur, to 49.6 years in Bangalore and Chennai. and Christians and lowest among Jains and Buddhists.
The average age of breast cancer patients has been reported The possible reasons for high breast cancer incidence
to be 50-53years in various population-based studies done in the Parsi community are their westernized lifestyle,
in different parts of the country (National Cancer Registry consanguineous marriages, and late age of marriage and
Programme, 2001). A significant proportion of Indian childbirth (Paymaster et al., 1970). In another study in
breast cancer patients are younger than 35 years of age. Chennai, rates were highest in Christians followed by
This proportion varies between 11% at Tata Memorial Hindus and Muslims (Nair et al., 1993). Similar results
Hospital, Mumbai (Dinshaw, 2006) to 26% at SGPGIMS, have been reported from a study performed in the South
Luck now (Agarwal et al., 2007). Young age has been Indian city of Thiruvananthapuram (Nair et al., 1993).
associated with larger tumour size, higher number of In an Indian study on 226 breast cancer patients, 20.7%
metastatic lymph nodes, poorer tumour grade, low rates had a positive family history (Saxena et al., 2005). On
of hormone receptor-positive status, earlier and more the contrary, numerous other studies have reported a low
frequent loco regional recurrences, and poorer overall rate of familial pattern of breast cancer in Indian patients.
survival (Shavers, 2003; Mathew et al., 2004). There is This is particularly interesting given the relatively young
a significant difference in the survival rates in developed age of Indian breast cancer patients. At SGPGIMS Luck
and developing countries mainly because of a lack of now, only about 5% of all patients managed had a definite
early detection programmes and inadequate resources for family history of breast and/or ovarian cancer in first
treatment. Coleman reported >80% survival from breast degree relatives, similar to the figures available from
cancer in North America and Europe compared with other Indian centres (Agarwal, 2008). Genetic screening/
60% in middle-income countries and 40% in low-income diagnosis is not routinely performed in most Indian centre
countries (Coleman et al., 2008). due to paucity of funds and facilities. As a result, there
is scarce data on the genetic composition and BRCA1/2
High risk factors: Much of the increase of breast cancer mutations in Indian patients. Thus, the results of this initial
in India has been associated with greater urbanization and study suggest that the mutation spectrum and prevalence of
changing life styles. In a study on risk factors for breast BRCA1 and BRCA2 in the Indian population may differ
cancer among women attending a tertiary care hospital in from what has been observed in other populations. Earlier
southern India, the population was predominantly from age at menarche i.e. at or before 12 years and the women
a rural background which sustained on agriculture. This who had first full term delivery after 25 years of age were
revealed the fact that this disease is no longer confined to found to be at higher risk than women who had first child
an urban setting. However, despite the rural status, women before 20 years of age. Nulliparous women were at higher
in this study were literate and nearly 25% were employed risk than parous women. The risk decreases as parity
which probably explains the increased risk (Prince et al., increases. A case-control study carried out in Chennai
2010). Higher education level and income are shown showed that single women compared to married women
to be significant reasons for an increased risk (Singh had 4-5 fold higher risk for development of breast cancer
et al., 1999; Tavani, 1999). This is because economic in the age group of 40-54 years and 55 and above.
independence may encourage women to remain single Breast-feeding is a common practice In India. The risk
or marry late thereby increasing their risk of getting the was found to be more among nulliparous because of lack
disease (15.9%). There was no difference between cases of breast-feeding practices. In a multicenter case control
and controls with respect to physical activity in terms of study by Gajalakshmi et al. on breast feeding and breast
regular fitness regimen as only 3% in both the groups were cancer risk in India revealed that lifetime duration of breast
involved in it. However, 96.4% of the controls engaged feeding was inversely associated with breast cancer risk
in rigorous household activity whereas only 84% of the among premenopausal women and no such protective
cases did so. This suggests that the controls had a more effect was demonstrated in the post menopausal women
physically active life when we consider rigorous house (Gajalakshmi et al., 2009).In another case control study
work to be a form of physical activity. It was observed conducted at a government medical college at Nagpur,
that urban women were more obese and had relatively lack of or less duration of breast feeding was associated
larger body size in the early years of life. A positive with the risk of breast cancer (Meshram et al., 2009).
association was observed between breast cancer risk and Mothers who did not breastfeed in their lifetime were at
augmented anthropometric factors for both pre- and post- higher risk than those who had breast-fed their children.
menopausal rural and urban women. The study supports (O.R.=1.71, CI=0.54-5.35, P<0.001). Total duration of
the hypotheses that increased anthropometric measures breast-feeding is also important. As the total duration of
are important determinants of breast cancer in India, breast-feeding increases, risk of breast cancer decreases.
although they do not appear to contribute appreciably In the same study it was observed that the risk of breast
to the urban–rural breast cancer differences (Mathew et cancer was more for women who had menopause after 50
al., 2008). A case control study conducted in Mumbai years compared to women who had menopause before 45
indicated that compared to married women, single women years of age (Meshram et al., 2009).
had a 4-5-fold higher risk for developing breast cancer in
the age group of 40-54 and above (Paymaster et al., 1972). Receptor Status
In another study, nulliparous women had a 2.2-fold higher
risk than parous women (Rao et al., 1994). In Mumbai, Recent reports from India and Pakistan suggest an
breast cancer incidence rates are highest among Parsis important increase in the incidence of breast cancer and
4862 Asian Pacific Journal of Cancer Prevention, Vol 13, 2012
 DOI:http://dx.doi.org/10.7314/APJCP.2012.13.10.4861
Breast Cancer in India: Where Do We Stand and Where Do We Go?
specifically ER, PR negative breast cancer among these few patients actually opt for reconstructive surgery for the
populations. ER, PR negative breast cancer, of which 50% breast and that is a skill with which breast surgeons need
is also Her2Neu receptor negative (triple negative), is to get familiar.
biologically aggressive, resistant to conventional cytotoxic
chemotherapy treatment, and is associated with reduced Radiotherapy
survival compared to other subtypes of breast cancer This has an important role in the treatment of breast
(Kakarala et al., 2010). Estrogen (ER) and progesterone cancer at every stage. With appropriate treatment, many
receptors (PR) are found positive in only 20-45% of Indian women are cured of breast cancer, while many others live
patients. ER-positive rates were reported to be lower in longer with the disease and have a better quality of life.
Indian patients than those in western countries. Not all International guidelines recommend one megavoltage
patients in India undergo hormonal receptor testing as therapy equipment for every 120,000 population
evident from the study in Delhi which showed only 35.5% (Ravichandran, 2009). However, the current radiation
of patients had receptor testing (Raina et al., 2005). At oncology infrastructure in most developing countries
TMH Mumbai, the ER+ status was found in 33%, and remains grossly inadequate. In India for a population
PR+ in 46% of patients (Desai et al., 2000). According to of about 1100 million, 1155 radiotherapy machines are
some, the low ER+ and PR+ status in Indian patients may required to cater to all cancer patients but at present there
actually be due to improper immune staining techniques are only about 400 teletherapy machines, located in large
used. A study from a major hospital in Mumbai reported cities only. drrajiv sarin,actrec,mumbai (Rajiv, 2009).
that the ER–/PR+ reported on IHC were actually due to
suboptimal manual assays, and when the same tumors Chemotherapy
were evaluated using well standardized international kits, It is estimated that presently around 160 Government
they were found ER+/PR+ (Navani et al., 2005). hospitals and more than 350 private hospitals in India are
providing specialized oncology treatment. A very small
Detection, Diagnosis and Treatment percentage amongst these hospitals provides all three
areas of oncology namely surgical, medical and radiation
Although breast cancer can be detected at earlier oncology. Close to 25 regional cancer centers (RCC)
stages by simple breast examination, maximum (>90%) have been established in the country for the ongoing care
cases are diagnosed in advance stages i.e. stage II, III and and early detection of the disease. More than 35 major
stage IV (Meshram et al., 2009). In Africa and Asia the players are operating in the Indian cancer treatment
treatment of breast cancer in stages I, II or III costs less market and close to 15 MNCs are already present and
than U$ 390 per Disability Adjusted Life Years (DALY) more are planning to enter the market. Still, there are
averted. If the cancer progresses to stage IV treatment will very few exclusive hospitals dedicated to cancer care.
cost more than 3,500U$ per DALY averted (Groot et al., Apart from the regional cancer centers, which are owned
2006). Breast cancer treatment in India varies from non by the Government of India, the number of providers in
existent, to the most updated at power with the developed the private sector is small. There are numerous private
world. Breast cancer is treated using 3 main modalities: clinics operated by oncologists for chemotherapy, which
surgery, systemic therapy and radiotherapy. is a very fragmented sector due to the size of the country
and the preference for localized treatment because of cost
Surgery considerations (Sonal, 2010).
The majority of patients with breast cancer in Presently, more than 90% of patients with breast
developing countries are managed by general surgeons. cancer require either chemotherapy or hormonal therapy.
Surgical subspecialties dealing with breast cancer such Most of the recently launched anti breast cancer agents
as surgical oncology and breast surgery are still evolving. are expensive and beyond the reach of most patients with
Inappropriate surgical management of breast cancer is breast cancer in developing countries (WHO, 2008). It has
common at the community level. This takes the form been found by the WHO that in low and middle income
of indiscriminate diagnostic lumpectomy, incomplete countries up to 90% of the population pay for medicine
mastectomy and omission of or suboptimal axillary out of their own pocket due to lack of social insurance
lymph node clearance. All these factors can adversely and inadequately publicly subsidized services (WHO,
affect the prognosis of these patients (Deo, 2010). A large 2008). The Essential Drug List in India does not have
proportion of Indian patients are treated with inadequate/ even a single life saving cancer drug on its list, despite
inappropriate initial surgical procedures before they cancer being a part of national disease control programme.
are seen and managed by specialists. In a study from a Epirubicine hydrochloride used for the treatment of breast
major North Indian teaching hospital, almost 75% of the cancer is sold for Rs 2,000 for 50 mg vial. The required
patients referred for management of operable early breast dosage in patients is usually about 100-120 mg every 21
cancers (EBC) had had an incision or excision biopsy days for 6 cycles. The cost of treatment for the patient
not intended for treatment of breast cancer (Tewari et al., would be minimum of about Rs24,000. Another medicine,
2006). At SGPGIMS Lucknow,the picture is more or less docetaxel, is required to be taken in about 75 mg dose.
the same, and about 40% patients with EBC or locally However it costs about Rs11,915 to about Rs7,500/ for
advanced breast cancers present after some sort of surgical an 80 mg vial. The difference in the price is more than
procedure which was either not intended to be a breast Rs4,400/- between generic manufacturer with the lowest
cancer treatment procedure or was inadequate. Here very rate and the one with the highest price. Another drug,
Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 4863
Anita Khokhar
letrozole used for treatment of advanced breast cancer study already shows a good compliance-to screening rate
in post menopausal women is being sold at Rs5,445 for (70%) and down staging is already evident. The principal
2.5 mg 30 tabs, whereas the other generic manufacturer objectives of the study i.e. demonstration of a reduction
are selling it at Rs540/-.The treatment requires one tab to in incidence and mortality will however become evident
be taken every day for 5 years. The treatment would cost only after another 10-15 years (Dinshaw et al., 2005).
the patient about Rs326,700/-, whereas at the price sold Awareness: In developing countries lack of public
by the generic manufacturers it would cost a patient only awareness about breast cancer means that patients ignore
Rs32,400.Trastuzumab is being imported and is priced their symptoms till the very late stage. Only 36% of the
at Rs1,35,200 per vial of 450 mg which is required to be teachers had heard the term breast self examination.
taken for 52 weeks, which is clearly out of the reach of Teachers knew little about when and how to perform
most patients. Reasons for high prices of cancer treatment a breast self exam. Only 13.37% knew that the correct
medicine are primarily due to lack generic competition, frequency of doing it was once a month. Some 7.2% knew
or that the suppliers of generic medicines place the prices about the position in which it should be done and only
slightly below the brand medicine prices, or that there is 1.36% participants were aware of the right time of doing it
high profit margins in manufacturing, or high government i.e. for those women who menstruate, a week from the start
taxes and duties, or inefficient supply or high wholesale or of periods and for those women who do not menstruate
retail mark-ups (WHO, 2008). According to Kingsbury, one a fixed date every month. This dismal awareness
half of Indian women with breast cancer go entirely level was reflected in practice as none had ever practiced
without treatment (Kingsbury, 2008). BSE (Khokhar, 2009). Also none of the participants
went for regular Clinical Breast Examination (CBE) and
Screening mammogram. In another study on working women, out of
424 participants only 2 had ever done a breast self exam
Estimate of the cost-effectiveness of breast cancer and others had never attempted doing it. However with
screening in India compares favourably with estimates of the sending of sms reminders and conducting training
cost-effectiveness of breast cancer screening in Western programme the compliance improved (Khokhar, 2010). In
countries. It is estimated that in India it costs Int.$1341 another study conducted in urban area of Delhi, only 56%
per life year gained to screen women aged 40-60 with women were aware of breast cancer; among them, 51%
biennial CBE and Int.$3468 per life year gained with knew about at least one of the signs/symptoms, 53% were
biennial mammography (Quirine et al., 2003). In India, aware that breast cancer can be detected early, and only
screening from age 40-60 was more cost-effective than 35% mentioned about risk factors (Somdatta et al., 2008).
screening from age 50-70 due to the young age of the Interestingly of the low proportion of women 56/342
population, the low life expectancy (62 years), and (16.4%), who claimed to be familiar with BSE none of
the young age at which the peak incidence is reached. them had ever practiced it; 6/342 (11%) had received
Results indicate that every-5-year, biennial, and annual some form of training from a local NGO and the rest had
CBE for women aged 40-60 all lead to considerable sourced their knowledge from either the television or the
reductions in mortality and high numbers of life years print media (Rao, 2005). In rural Kashmir only 4% of
gained. Biennial screening with mammography led to the women had received any training or education about
higher reductions in mortality in simulation study and the purpose and technique of breast self exam (Dallas et
saved more life years, but at high incremental costs. The al., 2011).Since self detection remains a key method of
choice of the most appropriate screening policy for India breast cancer through the world even now, it is logical that
will depend largely on the amount that health authorities the women in India should be made breast aware (Mara,
are willing or able to pay. Although it is established that 2010).
screening by Mammography can substantially reduce
mortality from breast cancer, especially in women over Interventions for the Future
the age of 50 years. Breast cancer screening programs
involving imaging techniques are expensive and for this 1) Government agencies, non government organizations
reason cannot be adopted in developing countries as a and the media can play a major role in increasing
routine public heath measure. Economic constraints of awareness about breast cancer among the general public.
Mammography apart, compared to the west, a relatively It should be ensured that awareness campaigns are in
large proportion of breast cancers in India occur in younger regional languages to have a better penetration. Awareness
women (reflecting not only a younger age structure of the about breast feeding and its protective effects also needs to
Indian population but also the observation of lower risk in be imparted to decrease the risk of breast cancer. If local
post-menopausal women as compared to that in western celebrities can be involved to promote the cause it will
women). Published studies suggest that Mammographic further strengthen the awareness activities.
Tata Memorial Hospital has been involved in a randomized 2) There is also a need to strengthen the cancer-
controlled trial (n=150,000) which compares the efficacy related curriculum in medical schools, focusing on
of health education and clinical breast examination (CBE) breast awareness and screening methods. Also breast
provided by trained primary health care workers with just lump protocols made management will go a long way
health education provided by the same workers in women in avoiding mismanagement of patients with cancer at
aged 30-6 years living in the slums of Mumbai. This study primary and secondary healthcare facilities.
has now entered its 6th year and 3rd round of screening. The 3) Women in late thirties should be the target for the
4864 Asian Pacific Journal of Cancer Prevention, Vol 13, 2012
 DOI:http://dx.doi.org/10.7314/APJCP.2012.13.10.4861
Breast Cancer in India: Where Do We Stand and Where Do We Go?
purpose of screening in India as breast cancer is occurring Government of India, Ministry of Home Affairs, Office of the
in younger age group over here. Registrar General and Census Commissioner, India http://
4) Public health workers can be trained in Clinical www.censusindia.gov.in/.(accessed 01.17.10).
Breast Examination to reach out to the length and width Green M, Raina V (2008). Epidemiology, screening and
diagnosis of breast cancer in the Asia–Pacific region: current
of this huge country.
perspectives and important considerations. Asia Pac J Clin
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referral. Continued medical education can help in training Hortobágyi GN (2006). Costs and health effects of
the general surgeons in basic skills of breast surgery. breastcancer interventions in epidemiologically different
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developed for the developed countries.India is a limited 90.
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many cultural, social and health infrastructure differences breast cancer burden: variations in epidemiology and
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therefore we should form our own management guidelines
Kakarala M, Rozek L, Cote M, Liyanage S, Brenner DE (2010).
which are feasible and practical. Breast cancer histology and receptor status characterization
7) Regulation of the cost of chemotherapy drugs by the in Asian Indian and Pakistani women in the U.S.-a SEER
regulatory agencies is of utmost relevance in providing analysis. BMC Cancer, 10, 191.
complete treatment to the patients. Kingsbury K (2007). Global breast cancer: the changing face
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