Promising success rate after treatment at National Cancer Institute:

Breast cancer is preventable

Early detection and treatment, the key :

By Carol Aloysius

The prevalence of cancer especially breast cancer is now reaching epidemic proportions.The estimated number of new cases of cancer patients is said to be around 4,000 today, double the number in 2007.

The disease, however, is preventable and could be controlled with early detection and treatment. Sri Lanka’s premier hospital for Cancer at Maharagama has all the modern technologies and treatment facilities as well as screening facilities to monitor the progress of the disease, says an eminent oncologist at the hospital.

Consultant Oncologist, National Cancer Hospital, Maharagama, Dr LAKSHMAN OBEYSEKERA gives us fresh insights into the disease that is currently taking a heavy toll on the lives of women in Sri Lanka, and emphasises that the disease could be prevented with a mammogram on the doctor’s advice, and detected early so as to initiate early treatment and prevent its progress leading to complications.

Excerpts…

Q. Breast cancer is the most common cancer among women in Sri Lanka.Compared to a decade or more ago, do you see an increase in the number of women with breast cancer?

A. Yes. According to the National Cancer Control Program statistics it is in a rising trend. If you go by the figures in 2007 it was over 2000 new cases. The projected figure should be over 4,000 new cases by now. At Maharagama Cancer Hospital in 2010 we treated 1,237 new breast cancer patients. Of them 1,133 patients survived after four years. In 2011 there were 1,309 patients and out of them 1,240 patients survived after successful treatment given at National Cancer Institute, Maharagama. These figures highlight the fact that taking proper, timely treatment will cure them.

Q. Are there any islandwide surveys or national data to indicate the approximate number of women with breast cancer and those who have diedof it?

A. The National Cancer Control Program maintains a cancer register. The statistics are collected from each of the cancer units in Sri Lanka. Maharagama is the main centre and the rest are from provincial hospitals.

Q. Can a woman get breast cancer at any age?

A. Breast cancer incidence is more among the age group 40-60 years. However, there are reported cases of those less than 40 years or even in their early 20s who have got breast cancer. Most have been successfully treated. We recently treated a woman of 99 years and I’m happy to say that she is doing well. Remember, the disease can emerge at any age. So one has to be vigilant about one’s health especially if one has a strong family history of cancer such as breast, ovary endometirum and colon cancer.

Q. Elaborate

A. There are specific cancer causing genes running in families such as BRACA-1, BRACA-2, P 53. According to the research 65 percent of BRACA1 mutations and 45 percent of BRACA2 mutations will develop breast cancer by age 70 years.

Q. Can men get breast cancer?

A. Yes. Although the male breast is a rudimentary organ there is a chance of getting a cancer. We have about 50 -80 new male breast cancer cases per year. These cancers are aggressive compared to female breast cancer. So patients need to be treated promptly with a radical approach. If a male has a unilateral enlarged breast, unless proven otherwise it is a breast cancer.

Q. Who is most at risk of breast cancer in the case of women-adolescents? Middle aged women? Elderly women?

A. Middle age group carries the highest risk. Second is the elderly and the adolescent group which rarely affects. I would say the incidence is rising among the 30- 40 age group according to our experience.

Q. Does breast cancer occur suddenly or over a period of time? How long will it take to show symptoms?

A. It is not a disease that occurs or is visible overnight like an infection. It is a moderately progressing disease. That means it will be there as a pre clinical stage for 12 -36 months and show symptoms such as a “palpable lump". Before it the lump is palpable it can be detected in ultra sound scan, MR scan or in a xray - mammogram. There are some innocent lumps that appear in early stages, but they can carry a risk of changing to a cancer at later stages.

Q. What causes breast cancer? Is it a single factor or a combination of several factors?

A. The causes of breast cancer aren't fully understood. However, there are risk factors that are known to affect your likelihood of developing breast cancer. Some of these you can't do anything about, but there are some you can change. Factors influencing breast cancer are as follows: 1) Prior History of Breast Disease. If there is a family history of breast cancer especially if it occurs in first degree relatives we must be careful, and keep in mind that we carry the risk.

2) Age: Reproductive and Menstrual History. If a woman delivers her first baby after 30 years of age the risk of breast cancer is high. That means early pregnancy protects from breast cancer in the future. Early menarche and late menopause also gives more chance to breast tissues to be exposed to hormones such as oestrogen which will increase the risk of hormone dependent breast cancer.

5) Radiation exposure: If one is exposed to radiation the risk of cancer is high.

6) Dietary factors: Overcooked Meats: Heterocyclic amines are chemicals formed in the cooking process of meat products such as fish, beef, pork, and chicken. Exposure to high amounts of these chemicals, caused by a dietrich in broiled, grilled, or fried meat, has been correlated with increased risk of breast cancer. High intake of fat, fast food, taking alcohol also double the risk.

7) Hormone replacement therapy (HRT) is often prescribed to control menopausal symptoms that include decreased bone density, sexual dysfunction, fatigue, and mood swings. HRT may include treatment with oestrogen alone or a combination of both oestrogen and progesterone. Studies indicate that use of menopausal hormone therapy, currently or within the past five years, is associated with an increased risk of developing breast cancer. Several studies have shown that individuals who have stopped using HRT for more than five years are not at a significantly greater risk. What is important is to understand what causes are multi factorial. If one can identify any one of those risk factors they should change their lifestyles and be more careful about their health.

Q. Is it true that the body's natural immune system if high can block the cancer cells?

A. In our immune system there are two categories: humoral and cellularimunity. The cellular immunity has the ability to protect us from developing cancer. Thinking on this line researchers are looking for vaccines against cancer.

In the future we will have many more vaccines against cancer including breast cancer. Even today we have three FDA approved vaccines against cancer, those are cervical cancer, liver cancer and prostate cancer.

Q. Can factors such as food contaminants lower this immunity?

A. Contaminated food is harmful to the human in different ways. It has direct effects that causes cancer. Stomach cancer, Gall bladder cancers, Pancreatic cancers can occur due to contaminated food with organisms and carcinogenic chemicals.

Likewise this can also affect indirectly by impairing the immune response. Studies has revealed that contaminated food exposure was clearly associated with lower antibody responses to immunisations and an increased risk of antibody levels in children.

More worryingly the immune responses were lower than levels needed to provide long-term protection against the diseases.

Q. What about stress, lack of physical activity, poor nutrition - can they lower one's immune status?

A. Stress, lack of physical exercise and poor nutrition goes hand in hand with ill health. This is due to the lowered immunity. People who do mediation having good regular physical exercise and consuming healthy food will develop high immunity to counteract any harmful externalagents, which can lead to cancer. Attitude is also important. Studies have shown such patients can overcome the burden of cancer after treatment and survive long years without the risk of recurrence of cancer. We have noticed people who have hardships in their day-to-day life perhaps at work or in their personal life with stressful situations are more likely to get chronic disorders such as cancer, hypertension, diabetes and nerve system diseases.

Q. Do unhealthy lifestyles such as smoking, consuming alcohol, eating fatty high starch foods, and foods with a lot of salt and sugar lead to breast cancer?

A. Use of alcohol has a direct relationship with breast cancer. High fat diet also increases the risk of obesity and ultimately breast cancer. Using high salt diet doesn’t cause breast cancer but may be other illnesses such as hypertension and renal impairments.

Q. What are the early symptoms of the onset of breast cancer?

A. Common symptom is a palpable lump in the breast. Women who do regular self examinations of breast will detect the lump in early stages, but unfortunately our community is still not geared for such practice, maybe due to unawareness of the value of SEB [self examination of breast].

Other than that nipple discharge, inverted nipple, unusual unilateral enlargement, overlying skin changes such as orange peel appearance are some of other symptoms of breast cancer.

When it spreads to other areas such as lymph nodes, lung, liver, brain, or bone they get symptoms related to the particular organ.

For example when it spreads to lymph nodes, you can feel an enlarged gland in the armpit.

When the liver is affected patients complain of poor appetite. Generalised arches and pain may be due to bone involvement. Long-standing headaches, fits, blurring of vision are some of the symptoms of brain involvement.

Q. If detected early can it be treated and controlled? Can it be cured?

A. Definitely if one detects breast cancer early it can be cured. Breast cancer survivors will bear witness to this. Whatever the stage of the disease it is treatable and can achieve a reasonable survivorship even in the late stages of cancer. That is because there are several methods of treatment. According to the new studies it is an individualised treatment. The disease behaviour varies from person to person. The important thing is to get medical attention as early as possible and continue to have it.

Q. At present I understand there are three established forms of treatment, namely, surgery, radio therapy and chemotherapy. Can you tell us in detail of these procedures?

A. Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Five types of standard treatment are used. Patients with breast cancer undergo surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out. Breast-conserving surgery is an operation to remove the cancer but not the breast itself: Lumpectomy means Surgery to remove a tumor (lump). Partial mastectomy is Surgery to remove the part of the breast that has cancer and some normal tissue around it. Other types of surgery include the following: Total mastectomy - Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. After a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at a future time.

The reconstructed breast may be made with the patient’s own (nonbreast) tissue or by using implants filled with saline orsilicone. Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing.

This method is also frequently used in breast cancer. Here we give radiation to the chest wall or partially operated breast. By doing this we expect to reduce the risk of recurrence in the same breast or nearby chest wall.

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.

Chemotherapy is taken by mouth or injected into a vein. In breast cancer it is being used very frequently by oncologists. Doing this can prevent the spreading of the cancer cells to other organs and improve overall survival of the patient.

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer and those with metastatic breast cancer (cancer that has spread to other parts of the body).

Hormone therapy with an aromatase inhibitor is given to some postmenopausal women who have hormone-dependent breast cancer. This treatment is given in the seven to 10 years period.

New method of treatment is Targeted therapy, a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

The treatment is costly but the results are promising. So policy makers have to weigh the benefits and failures when deciding on the financial support given to government hospitals for this type of new treatment.

But I must emphasise, unless we use those new methods we cannot move forward in this long journey of cancer cure.

Q. Are they freely available in the state hospitals? Where can a person get this treatment?

A. Yes, most of the treatment are available in the state sector with some occasional hiccups. The main centre is at Maharagama followed by Kandy, Galle, Anuradhapura, Jaffna, Badulla, Batticaloa, Ratnapura, and Kurunegala.

The last three places will provide all treatment except radiotherapy because Radiotherapy machines are expensive and the facility is limited, but we plan to bring new radiotherapy machines called LINAC to each and every centre in the island by 2016 as a policy decision taken by the Ministry of Health.

Q. In recent times there have been new breakthroughs in breast cancer with new scientific discoveries regarding its origin in the cells and formation etc. Your comments?

A. Researchers are now concentrating on Molecular level that means not on the cancer cells but about the genetic patterns and it's mutations. Recently they introduced a gene mapping technique.

By this we can predict the outcome of the cancer also making it easy to take decisions about treatment on an individual basis. Taking a blood sample from a vein can tell us a presence of remaining cancer cells in the system and when to discontinue the treatment.

Q. What in your opinion is the most exciting aspect of such breakthroughs?

A. If you have an infection we take a blood sample and identify the bacteria and decide on an antibiotic.

Laboratory will give us a prediction about the sensitivity to chemotherapy or hormone therapy.

Q. Do you foresee a near future where women in our country too can benefit from these new methods?

A Yes, we are updating ourselves and taking measures to introduce new methods of treatment to Sri Lanka.

We as Sri Lankans are fortunate to have the free health system where most of the new treatments are otherwise expensive. With the help of the tax payers it is the government that will bear the cost and give the benefit to our patients.

Q. What can women do to prevent breast cancer?

A. Be aware of breast cancer, do self-examination of breast regularly, have a balance diet, do regular exercise get medical checkups at the correct time.

Q. The palliative approach to breast cancer patients is now being adopted in some hospitals in Sri Lanka to improve the quality of life of breast cancer survivors and patients. Your comments?

A. Palliative care means giving a patient maximum comfort to live with the incurable stages of a cancer. Here we give them pain killers, good nutrition and home based or institute based nursing care.

In this regard we have to go a long way. Keeping this in mind we are going to introduce palliative care units in the future for our patients under qualified Palliative care physicians.

Q. What is your message to women in general with regard to breast cancer?

A. Early detection can cure breast cancer. Do self examinations of the breast regularly. Do a mammogram if you are over 40 years.

And seek medical advice if you feel a suspicious palpable lump in your breast.

Mindfulness meditation and group therapy protect breast cancer survivors' cells

Study uncovers new evidence of a mind-body connection

Mindfulness meditation, yoga and group therapy have a positive physical impact within the cells of distressed breast cancer survivors, a new study has revealed.

Certain protective and stabilising components of chromosomes, known as telomeres, remain intact in survivors who practise meditation and yoga or attend support group meetings, whereas telomere length decreases for those who don’t receive such help. This new finding provides support for the theory that the workings of the mind impact on physical wellbeing.

“We already know that psychosocial interventions such as mindfulness meditation will help you feel better mentally, but now for the first time we have evidence that they can also influence key aspects of your biology,” says Dr Linda E. Carlson, director of research at the Tom Baker Cancer Centre in Calgary, Canada, and lead author of the study.

The shortening of telomeres is known to be connected to DNA damage or cell death, and has been linked to earlier mortality in patients suffering from a variety of diseases, including breast cancer.

More recently, research has indicated that psychological stress impacts on telomere length; suggesting that interventions which decrease stress may have positive physical effects on a cellular level.In an attempt to examine this possibility, Dr Carlson and her team recruited 88 breast cancer survivors who were experiencing a significant level of distress.

These women were divided into one of three groups; those who followed an eight-week mindfulness-based treatment programme, those who attended eight weekly group therapy sessions, and a control group who participated in a single stress management seminar.

The mindfulness program consisted of meditation instruction and Hatha yoga exercises aimed at cultivating non-judgmental awareness of the present moment. The group therapy focused on encouraging openness and emotional expression, and was designed to help build the patients’ social support systems.

The researchers believe that their findings demonstrate the potential for stress-reducing measures to positively influence the outcome of serious diseases.

For some of the research subjects, participating in the group interventions has already been “life-changing”.

- The Independent