Prevalence Of Breast Cancer In Kerala

Breast cancer starts when the breast cells begin to grow out of control. Breast cancer cells usually form as a tumor that can be seen on an x-ray or sensed as a lump. If these cells can grow into surrounding tissues (invade), and if it spreads to distant areas (metastasize) of the body the tumor is malignant (cancer). Breast cancer happens mostly in women, but men can also acquire breast cancer, too.

Breast cancer was found to be the most common female cancer globally, representing nearly a quarter (25%) of all cancers with an estimated 1.67 million new cancer cases identified in 2012. Compared to more developed (794 000) regions, women from less developed regions (883 000 cases) were more prone to breast cancer. ICMR’s National Cancer Registry launched PBCR in RCC in 2012 and it was one among the other 27 PBCR’s in India. A decade ago from 2012, in Kerala, the average annual incidence was 100 per one lakh population. 2012 data from Cancer registry revealed that the incidence rate had shoot up to 150 per one lakh population. Data collected by PBCR in 2014 revealed that the estimated crude cancer incidence in Kerala was 172.2 for males and 166.5 for females per one lakh population. WHO reports that every year in Kerala 50,000 new cancer cases were reported among which breast, thyroid and cervical cancers were reported more among women.In Kerala, associated to other states in India, tobacco associated cancer in females’ are uncommon but a huge group of women population has broadly affected Breast cancer is really a matter of concern. Breast cancer is assessed in every third women in the female population. Death rate of breast cancer was not great but the cancer provides a worrying condition and is considered to be weaker. As per the latest statistics, the cases of cancer, particularly breast cancer, are increasing fast in an extremely urbanised state like Kerala. In Kerala, annually, 1700 new breast cancer cases are detected. Fast growing breast cancer cases are a matter of severe concern.

Among Indian females with age adjusted rate as high as 25.8 per 100,000 womenfolk and mortality 12.7 per 100,000 womenfolk, breast cancer has graded number one cancer. Latest National cancer registries has reported that the age adjusted incidence rate of carcinoma of the breast was found as high as 41 per 100,000 women for Delhi, followed by Chennai (37.9), Bangalore (34.4) and Thiruvananthapuram District (33.7), the capital of Kerala. But, breast cancer crude rate displayed top rate in Thiruvananthapuram 43.9 (per 100 000) followed by Chennai (40.6), New Delhi (34.8) and Mumbai (33.6).

Breast cancer occurrence rate in the rural areas was only 60% of the frequency seen in Trivandrum city area. The prevalence rate was found to be 19.8 per 100,000 in rural area, while in the urban areas, it was 30.5 per 100,000. Kerala, which is assumed to possess an urban lifestyle even in rural locations, comes under the urban belt with cases of breast cancer being more common than cervical cancers. Regional cancer centre, Trivandrum conducted a study on breast cancer which revealed that BC accounts for 31% of all female cancers in Trivandrum and 35% patients were less than 50 years old. In 2016, a hike in Crude Rate of breast cancer was noted from 39 to 55.4 per lakh women. Also age specific rates were also increased from 35.2 to 43.4. It was also predicted that by 2019-20, CR would be 80 in Trivandrum.

Deccan Chronicle (2016) reported that in India, breast cancer was found to be the second most common malignancy next to cervix cancer with annual incidence of 20 per 1 lakh population in the country and in Kerala, 40 per 1 lakh population. The Hindu (2016) reported that about 50 percent of breast cancer cases were diagnosed among those less than 50 years of age. A major percentage of Indian breast cancer patients were found to be younger than 35 years of age.

In India healthcare is low on priority for breast cancer so that the early diagnosis or screening programme was found to be less so that mortality increased.In the earlier stage, disease is absolutely asymptomatic with a painless lump, mostly. Women from low socioeconomic levels, having less education and low-income might not pursue attention upon feeling a breast lump. This is usually due to their ignorance about what the lump represent, disgrace of being rejected by the community and partner, possible anxiety of losing the breast, the usual taboo of not discussing breast cancer subject openly and no information of presence of any effective treatment for the disease. People usually or mostly realize when symptomatic, and on an average, at stage 2B and beyond.

RCC (Trivandrum) studies shows that only 9% women present with Stage I disease of Breast Cancer including the health care workers since the Screening Practice was very low. Jayalekshmi et al., (2006) states that even in states like Kerala with advanced literacy and awareness status, medical support was pursued by only 15% of cancer patients in the localised stage of disease. Reluctance, lack of time and laziness among health care providers and lack of awareness concerning the significance of screening at regular intervals were mainly found to be the common obstacles for screening practice. Augustine et al., (2014) studies concluded that age and parity play a leading role in the incidence of breast cancer in Kerala. It also shows that past history of breast symptoms demanding biopsy was also associated with high risk of breast cancer. Longer period of breast feeding was found to be caring against breast cancer.

The desirable behavioural change among women could bring about by a community oriented educational intervention programme, emphasizing on appropriate techniques. A study conducted at Arpookkara Panchayat at Kottayam shows that knowledge about symptoms of breast cancer and self examination of the breast were lacking among Keralites, despite their high literacy rates. A screening programme conducted at Kasargod, in Kerala studied that among the women who attended the camp, 94% had heard of breast cancer and 34% thought it was common for a woman to get breast cancer. 73% had heard of BSE (Breast Self-Examination) and 43% knew the right technique of BSE. The camp observed that the trained nonmedical community personnel such as ASHA, Anganwadi workers and Kudumbashree workers could easily create a rapport with the beneficiaries and could overcome a number of cultural problems and custom barricades tackled by women from isolated or remote areas such as feeling of shyness during examination. The International Association for Research on Cancer, France, conducted a multi-institutional study during 2002-05 and is the major breast cancer study to be conducted in India. In Kerala, Regional Cancer Centre took over the study at Thiruvananthapuram where 1,200 females with breast cancer and an equal number of females were taken as control for the study.

Among breast cancer reported females 50% of them were almost less than 50 years, whereas in the West, almost 75 per cent of breast cancers reported in women were in the post-menopausal stage. Consumption of fatty food and sedentary lifestyles were the risk factors found in urban women under 35 years of age which constitute about 20 per cent of the reported cases. The study observed the short duration of breast feeding practices among urban women, who were forced to cut short the period as they have to go back to their job. The study revealed that compared to women who have breast-fed their children for one year in their lifespan, the risk of breast cancer is decreased by nearly 50 per cent in women who have breast fed their children about five years or more during their lifespan. A case-control study was conducted to examine the lifestyle factors related to breast cancer risk in Karunagappally, Kerala. Results showed that, among premenopausal women, intake of tapioca which is a frequently used food item in South India, predominantly in Kerala, decreased the risk of evolving breast cancer (Por =1 per woman) imaged in 1990-2003 to judge percent mammographic density (PD). No significant modification of the density change with age was seen with parity/age at first birth, oral contraceptive use, family history of breast or ovarian cancer in a first- or second-degree relative, age at menarche, smoking status or alcohol intake and educational level were observed. The observations recommend that postmenopausal hormone usage; baseline PD, menopause and body mass index forecast variations in mammographic density trends during adult life.Compared with Caucasians and Latinas, mammographic breast density was lower in African American women. The inconsistency may be a basic racial difference due to undetermined causes. Kavanagh et al., (2008) studies that radiologists today use earlier mammograms to compare with the present one for variations that could specify the beginning of a cancer. Though this improves finding rates for cancer, screening programs could probably increase their efficiency even more by including mammographic density as a principle for selecting women who want extra assessments. Mammographic density has a strong genetic component. A study of twins to determine the proportion of the residual variation in the percentage of density measured by mammography explained by unmeasured additive genetic factors (heritability), a study (Stone et al., 2006) on two twin studies comprising 571 monozygous and 380 dizygous twin pairs recruited from Australia and North America, and another study by measuring percent and absolute mammographic density using mammograms from 257 monozygotic and 296 dizygotic twin pairs, shows that that a great percent of the alteration is due to genetic factors. Douglas et al., (2008) proposed that the genetic constituent that regulates mammographic density may not be that altered from the genetic constituents that describe breast cancer risk factors. El-Bastawissi et al., (2000) determined the link of certain hormonal and reproductive factors with breast density over decades of lifetime. The association of nulliparity with density was obvious for women at all ages. Compared with younger women, older age at first birth was more powerfully allied with density among women > 55. When compared to not ever users of HRT, the relationship of present use of HRT with density, but not of previous usage, increased with age. Titus-Ernstoff et al., (2006) inspected aspects in relation to breast density in 144,018 New Hampshire women with at least one mammogram documented in a state-wide mammography registry. First analyses displayed a strong inverse association of body mass index (BMI) and age on breast density. Also, women with late age at first birth, late age at menarche, premenopausal women, and those currently using hormone therapies (HT) have a tendency to have increased breast density, while those with higher parity had chances to have less dense breasts.

The positive association of age at first birth and age at menarche and the inverse effect of parity were less obvious in women with low BMI than in those with high BMI. Among postmenopausal women, it was also observed that a strong positive association for age at first birth and breast density. Mammographic breast density varies during the menstrual cycle. It has been recommended that during the luteal phase of the menstrual cycle the sensitivity of mammograms could be lesser in mammograms acquired. Study was conducted among 11 women to observe the variation in mammographic density from the follicular to the luteal phase of the menstrual cycle. Though the mean increase in densities was rather small (1.2%; P = 0.08), six women had clinically substantial increases (1.4-7.8%), proposing that premenopausal women should undertake mammographic inspections in the follicular part of the menstrual cycle. Breast tissue is less radiographically dense in the follicular phase than in the luteal phase. These judgments are reliable with earlier observations suggesting that a woman's mammogramplanned during the follicular phase (first and second week) of her menstrual cycle instead of during the luteal phase (third and fourth week) could increase the correctness of mammography for premenopausal women in their forties. An inverse association between dietary Vitamin D intake and percent breast density (p = 0.009) was reported by Colangelo et al. 2006 through a small study in 99 Hispanic women from Chicago Breast Health Project Phase II Pilot Study.

A cross-sectional analysis study in 808 members of the Mammogram Density Ancillary Study of the Women's Health Initiative, did not find any relation between vitamin D or calcium intake and mammographic density after adjustment for BMI, age, regional solar irradiance, and other factors. Bérubé et al., (2005) studies that total ingestions of calcium and vitamin D were inversely related to breast density among premenopausal women. In multivariate linear regression, simultaneous additions in daily total consumptions of 1,000 mg calcium and 400 IU vitamin D were related with an 8.5% lesser average breast density. The negative relationship between breast density and dietary vitamin D intake inclined to be stronger at high consumption of calcium and vice versa. Consumption of calcium and vitamin D were not associated with breast density, among postmenopausal women. Among asymptomatic premenopausal women in Pakistan a study was conducted by Wasim, Khan & Samad, (2016) to determine the relationship between percent breast density s and serum 25 hydroxyvitamin D levels. The percent VBD was not found significantly correlated with the serum Vitamin D and calcium levels (p-value > 0.05). Vachonet al., 2000, in a historical cohort study of breast cancer families in Minnesota, evaluates the association of dietary factors and breast density in 1508 women. There was a suggestive positive trend between daily alcohol consumption and breast density in both postmenopausal and premenopausal women. After adjustment for other sources of alcohol, only wine consumption among postmenopausal women was important such that red wine exhibited an inverse association and white wine a positive association with percent breast density. There was no relationship with other inspected dietary factors. The cross-sectional variations in breast density across levels of nutritional factors were minor in extent but may have inferences for breast cancer risk. Brisson et al., 2007 in a cross-sectional study among 741 premenopausal women were enrolled in a screening mammography. In premenopausal women, with a lag time of about 4 months, changes in blood vitamin D seem to be inversely associated to variations in breast density. Season was strongly connected with 25(OH)D (P < 0.0001). The maximum smoothed average 25(OH)D levels were seen at the last of July (81.5 nmol/L) and the lowest in mid-April (52.4 nmol/L). Breast density exhibited uncertain seasonal differences (P = 0.028). The lowermost smoothed average breast density was detected in early December (38.5%) and the maximum at the commencement of April (44.3%). A study was conducted to assess the relationship of calcium and vitamin D from food and/or supplements, to breast density among a total of 783 post-menopausal women and 777 premenopausal enrolled in two different radiology clinics in Quebec City, Canada, in 2001 to 2002. The results show that among premenopausal women, increased consumption of vitamin D and calcium from food and supplements are associated to lower levels of breast density. It was proposed that higher intakes of vitamin D and calcium may signify an inexpensive and a safe strategy for breast cancer inhibition.

In the Minnesota Breast Cancer Family Study, Knight et al., 2006 inspected a possible relationship between quantitative mammographic density and circulating 25-hydroxyvitamin D (25OHD) which is the best indicator of vitamin D status.No evidence was seen for a relation between 25OHD and either total dense area or percent density. When the data were stratified by season of sample (winter and summer) or menopause, there was also no indication for any relationship. Yet, both dense area and percent breast density were lowest among those in the maximum vitamin D quartile with calcium consumption above the average. Study also reveals that in this cohort, vitamin D did not seem to be associated or related with mammographic density.