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Why are we doing more mastectomies for breast cancer in our country?

Breast cancer is the most common cancer affecting women in India. About 1 lakh new cases are being diagnosed every year in India. Majority of them present at a very advanced stage and consequent to this the morality is also very high.

Lack of awareness, reluctance to see medical professionals, fear of diagnosis, fear of losing the breast, fear of treatments like chemotherapy or radiotherapy are some of the reasons why women do not seek medical attention early.

Western world amidst debates about the benefit of screening, started screening program in the 80’s and 90’s. A significant stage migration has been observed in countries where screening is done. Besides breast surgery has developed as a specialty in its own right in most parts of the western world. It is no longer a situation of where a surgeon is a jack of all trades operating from head to foot . Organ based super specialization has lead to better outcomes in patient care.

Cancer care and its outcome in India is a lottery. About 50% of breast cancers that we see in the Metros are stage 1 and 2 breast cancers that are suitable to have their breast preserved. Nearly half of this group will have a mastectomy rather than breast preservation surgery for various reasons. . An unconvinced surgeon about breast preservation is not likely to offer this procedure to his or her patients. There are myths among medical fraternity that ,

  • Indian patients are not suitable for breast preservation and reconstruction.
  • That the preservation surgery is associated with increased recurrence.
  • That Indian women are not concerned about the body image as much as western women do.
  • Fear in the surgeons mind that the woman may not come for regular check ups after the procedure.

Surgeon’s awareness , and developing a specialty training in breast surgery is crucial to dispense with these myths . Positive versus negative counseling by a surgeon is an important factor in improving breast preservation rates.

Besides the surgeon factor, socioeconomic factors influence the decision for having a mastectomy rather than a breast preserving operation. Breast preservation entails radiotherapy subsequently and this involves time and money. Most patients in tier 2 and 3 cities do not have access to these treatments and cannot afford to stay in Metros for prolonged periods ( 5-6 weeks) for radiotherapy. This factor sways the decision in favor of mastectomy over breast preservation.

Another major influence in the treatment process is that , the women rarely participate in the decision making process in most families. It the husband or the near and dear who decide for the patient and it is often as case of mute acceptance of her fate and undergo a mastectomy.

Breast reconstruction after a mastectomy again is largely ignored by both the oncosurgeon and the patient. Factors like availability of plastic surgeon with adequate training and multi specialty involvement in the management influence the reconstruction rates after the mastectomy. Another major hurdle is our medical insurance procedures. Medical insurance companies consider breast reconstruction after a mastectomy as a cosmetic procedure and hence will not reimburse the same.

After a mastectomy there is very little support or help given to a woman to cope with a loss of her breast, Many are not aware of the availability of prosthesis that can be used to improve body image. Faced wth the deformity that occurs from a mastectomy, many women withdraw from social life and have a very poor quality of life after breast cancer surgery.

Improvements in public and surgeon awareness are likely to reverse the trend in the stage at presentation of the disease as well as the outcomes of the treatment.

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