Health Wise

With medical restoration easy to come by:

Removal of breast, no social unease

Suharshi PERERA

Breast cancer, the most prevalent cancer among women in the world and in Sri Lanka needs wider awareness to combat it at the earliest stage of growth. Consultant Oncological Surgeon of Apollo Hospital, Colombo, Dr. Naomal Perera says if diagnosed at a very early stage, the possibility in curing the patient could be almost 90 per cent.

Although it is very difficult to identify as to why certain women develop breast cancer while others do not, the root of the breast cancer is linked with hormonal influence on the breast cell, says the Surgeon.

Risk factors

Dr. Perera says there are certain risk factors that make women prone to develop breast cancer. A risk factor is something that may increase the chance of developing a disease. Women with one or more risk factors are at a greater risk in developing the disease, he says.

Age: Women who attain early puberty face an increased risk of breast cancer. Since hormonal influence may damage the gene of a cell in the breasts altering it, the women who had their first menstrual period at the early age and reach menopause late, experience more menstrual cycles in their lives.

In other words, the breast cells of those women are subjected to prolong stimulation by hormones which could result in damage to the genes of a cell leading towards breast cancer.

Family history: Family history is another important risk factor in developing breast cancer. If your immediate family member/s or relatives have had a history of breast cancer then you might be at a risk.

Those women with a family history of breast cancer should screen and examine themselves regularly for breast cancer to identify a cancer at an early stage, the doctor advised.

However, in Sri Lanka unlike in the West familial cancers are not very common though proper studies have not been done.

Delay in pregnancy: Pregnancy reduces the risk of breast cancer. During pregnancy the menstrual cycles stops and the absence of hormonal influence in the breasts keep the risk of breast cancer at bay.

The women who delay pregnancy through contraceptives and hormone pills for long (more than five years) are in danger.

HRT - The women on Hormone Replacement Therapy (HRT) for a long period to delay menopause are at a high risk of getting breast cancer, the Surgeon says.

Delaying the menopause means your body experience more menstrual cycles and the number of times the hormones attack the breasts will also be more.

If you have one or more risk factors it is advisable to consult a specialist to prevent future mishaps, the doctor said. However, a direct link of food habits, smoking and consuming alcohol with breast cancer is not confirmed.

Formation of cancer

Breast cancer forms with one genetically altered cell in the breast. The bad cell multiplies during a course of time and the doubling of bad cells takes around 90 days. The cancer cells which have certain immortal behaviour spread in the breast destroying the normal cells.

Once it forms a substantial number, enough nutrients will not travel into the centre of the cell mass which ultimately makes blood vessels growing into the tumour to supply the nutrients for the cells to grow.

Dissemination through these newer blood vessels and lymphatics results in spreading of the cancer cells into other organs such as lymph nodes, bone, liver, lungs and brain.

The cancer cells proliferate harming the entire system and it disseminates initially to armpits. Later it spreads to the liver, brain, bones and lungs.

Examination and diagnosis

If diagnosed early breast cancer can be treated successfully, he said. It takes at least six to seven years to form a tumour of 0.5 to one centimetre size. If the tumour is less than five centimetres it is considered as the early stage.

If it was two to three centimetres the chances of saving the life is very high, he said.

However, if it grows to over five centimetres or disseminated to other organs it has reached the advanced stage. The chances of survival is very low (5 year survival is less than 30 per cent.)

How to identify?

* Self examination of breasts

* Screening mammogram

* Self examination of breasts (Courtesy: Infobreastcancer.ca)

* Stand in front of a mirror and look at each breast separately. Note the size, shape, colour, contour and direction of your breasts and nipples.

* Raise your arms over your head and look at your breasts, as you turn slowly from side to side.

* Press your hands on your hips and push your shoulders forward. Look at each breast separately.

* Use the left hand for the right breast. Moisten the pads of your three middle fingertips with body lotion. Apply firm pressure and make small circles as you go back or forth (up or down, circular or spoke style) in a pattern covering all the breast area including the nipple.

* Extend the examination to the breast tissue in the underarm.

* Change your hand and repeat it on the opposite breast.

* Lie down and raise one arm above your head. Examine your breasts as before, omitting the underarm.

* Change your arm and repeat it on the opposite breast.

* According to Dr. Perera the self examination of breasts should be conducted once a month just after menstruation.

This method is very popular in the West but Sri Lanka lacks facilities and funding to apply this. In developed countries all women above 55 years undergo mammographic screening.

Symptoms

Feeling a lump in the breast or a blood stained nipple discharge could be symptoms of breast cancer. In addition if the breast is getting bigger than the normal size with redness of the skin over the breast like the skin of an orange and persistent pain in the breast could be a possible sign.

Itchy feeling in the nipple could be another sign which is not very common. This type of breast cancer is known as Paget’s disease and indicates an underlying cancer of the breast.

Treatment

Once diagnosed it can be treated according to the stage of the disease. If it is at a very early stage, a portion of the breast (Breast conservation surgery) can be removed through a surgery.

If it has reached the advanced stage then the patient has to undergo mastectomy (the total breast with the lymph nodes of the arm pit had to be surgically removed).

Other than that chemotherapy, radiotherapy and hormonal therapy are used to treat breast cancer. After surgery, depending on the pathology report, radiotherapy will be carried out for about a month and chemotherapy for six months.

After seven months the patient should go for regular checkups, which are done to identify possible recurrence on the side of the disease, occurrence of a new cancer on the opposite breast, and possible occurrence of deposits in other organs.

Ultra Sound scanning of the abdomen, chest X-ray, bone scans are done to identify any possible spread to other organs. These tests should be performed once in six months or annually and mammography every year, he said.

Breast reconstruction

The breasts can be reconstructed even after its entire removal avoiding social embarrassment. The breast can be reconstructed with silicon implants and by replacing the skin with skin from the abdomen or upper back.

The Maharagama Cancer Hospital and Badulla Teaching Hospital have carried out breast reconstruction procedures successfully, he said.

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At a glance

* Nearly 60 to 70 per cent cases of breast cancer in Sri Lanka is identified at the early stage due to the growing public awareness on the disease, Oncological Surgeon, Dr. Naomal Perera says. “Early diagnosis raises the possibility of curing the disease,” he said.

* Breast cancer is the most prevalent type of cancer in Sri Lanka and in the world. However, compared to the West, in Sri Lanka breast cancer prevalence is 10 times less.

Western cultural patterns, food habits and birth control have significant impact in the high prevalence of the disease in these countries but even Sri Lanka is treading the same path as the West exposing them to a greater danger of deadly diseases, he said.

* According to the Health Ministry, 7,374 newer cancer patients are diagnosed among the females of which 1,846 suffer from breast cancer. It is 25 per cent of the total cancer patients.

The Ministry jointly with UNFPA has launched a cancer prevention program through which all women will be screened for cancer, free of charge.

* As the first step, female school teachers will be screened for breast and cervical cancer, it said.

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Dr. Naomal M.A. Perera - MBBS, MS, FRCS (Edin)
Consultant Oncological Surgeon
Consultant General Surgeon
Trained at Cancer Hospital Maharagama and the Breast Unit at Royal Marsden NHS, (London), UK
Specially trained in oncoplastic surgeries of the breast .
Consultant Oncological Surgeon, Teaching Hospital, Badulla
Breast Surgeon/ Oncological Surgeon, Apollo Hospital, Colombo
Introduced breast reconstruction to Sri Lanka at the Maharagama Cancer Hospital in 2002, with over 300 cases of breast reconstructions done on breast cancer patients.

Pic: Ruwan de SILVA

Beware of that endless cough!

Harshini PERERA

Tuberculosis, is an air-borne disease, which dates back to 3000 BC, when it was first found in Egyptian mummies. It is a deadly infectious disease caused by a mycobacteria mainly Mycobacterium tuberculosis.

One of its special features is that whenever a person’s immune system is weak, he is easily susceptible to the disease. It being air-borne, anyone with diabetes or HIV/AIDS can easily become a victim of tuberculosis.

Dr. Sunil de Alwis, Director of National Program for Tuberculosis, said that this has become a threat to eight million patients around the globe while two million out of that die annually.

Further he said that there are 17, 000 Sri Lankans suffering from the disease whereas 1,500 patients die and 8,000 to 9,000 cases were being diagnosed each year.

Most of the patients suffer from tuberculosis are found living in congested areas like Urban slums, prisons and IDP camps in newly liberated areas.

Persistent cough for over three weeks, mild fever and sweating during nights, lifelessness and weight loss can be few of the symptoms. Tuberculosis can damage the lungs, central nervous system and the circulatory system. A patient should undergo treatment continuously for six months.

According to Dr. De Alwis, patients who have a non-stop cough should get their sputum examined at the nearest chest clinic for they are diagnosed with tuberculosis.

They will be called for treatment, Directly Observed Treatment (DOT). During this period the patient has to visit the clinic and take the drugs daily.

The system of treatment has been very successful in Sri Lanka as well as in a country like India, whereby Sri Lanka could reduce the mortality rate upto 80% a year.

“We use this method because some of the patients default to complete their course of treatment. When they default, the result is that healthy people can also be infected by the patient. Specially HIV/AIDS positive patients, might co-infect TB due to weak immune system in them.

When patients default in taking their medicine regularly, they may develop a different type of TB, called the Multi Drugs Resistant Tuberculosis (MDRTB). These patients will show resistance to drugs and in turn will spread disease to others.

There are Microscopy Centres in every district and in base hospitals around the country. A TB medical Officer is assigned to identify patients and treat them duly.

Pic: Vipula AMERASINGHE

Cause for increase in non-communicable diseases:

Lifestyle main culprit

L.S. Ananda WEDAARACHCHI

The latest World Health Organisation (WHO) report reveals that more people in Sri Lanka died from lifestyle related diseases such as heart diseases, cancer and diabetes than from infectious diseases.

Dr. Hiroshi Kobayashi, Director General Sapporo Cancer Seminar Foundation, Japan, and Professor Emeritus Hokkaido university said that the cause of death pattern in Sri Lanka is different from that in most developing countries which still show the number one cause of death as life style related diseases.

In an exclusive interview with the Sunday Observer he said that Sri Lanka will be able to cope with this problem by making the right lifestyle choices knowing what leads to the onset of such diseases.

“Cardiovascular diseases easily emerge as the leading cause of mortality with a total of 47,700 deaths, 16,300 in ischaemic heart disease, followed by the cerebrovascular diseases, with 13,000 deaths.

The total number of deaths from cardiovascular diseases is significantly higher than deaths from malignant neoplasms (Cancer) where the death rate was 19,100 while diabetes mellitus was the cause of death in 6,100 cases he said.

“Cancer, diabetes and heart diseases which are the most prevalent causes of death in Sri Lanka are basically noncommunicable diseases. All of them are closely related to the lifestyle led by the victims. The main causes of cancer are diet, tobacco, smoking and infection.

These three etiological categories represent 75 per cent of all the factors. Lung cancer is the most common cancer in the world and the main cause of lung cancer is tobacco. Unhealthy diet and infections are the causes for stomach cancer, he said.

Dr. Kobayashi said that the causes of lifestyle related diseases are neither individually specific nor do they differ according to the different diseases. Physical exercise, non use of tobacco, balanced non fat and salt diet with vegetable and fruits prevent lifestyle related diseases, he said.

Professor Hiroshi Kobayashi and Dr. Tetsuya Mizooue, Director Department of Epidemiology and International Health, Research Institute, International Medical Centre of Japan were in the island recently to evaluate the school based project for the prevention of lifestyle related diseases in Sri Lanka.

The project led by Dr. Kobayashi was implemented as a pilot project in four schools in Walasmulla and Beliatta in the Southern Province during the last three years with the assistance of Sapporo Cancer Seminar Foundation, JICA and the health promotion foundation.

He said that the Minister of Healthcare and Nutrition Nimal Siripala De Silva instructed that a national program in this regard be complemented.

“Few years ago communicable diseases such as Malaria, Diarrhoea were considered the main fatal illnesses. A Scientists, medical professionals and their medical innovations successfully controlled the situation, he said.

Dr. Panapitiya said that Sri Lanka has a well organised National and Provincial health network. That can be utilised to implement the national policy and the National Strategic Plan against the increasing non-communicable diseases.

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* A national policy with a national strategic plan will be implemented by the government as a preventive measure to meet the increasing non-communicable diseases which are the main causes of death in Sri Lanka.

* Dr. Lal Panapitiya, Director, Ministry of Health Care and Nutrition said that a national policy and a national strategic plan was vital since the non-communicable diseases such as heart diseases, diabetes, and cancer become the major cause of death in Sri Lanka mainly due to the change of lifestyle and unhealthy diet.

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Estimated No. of deaths by causes in Sri Lanka 

1. Infectious disease			9,000
   STDs excluding HIV			  100
   HIV/AIDS	    	   		    0	
   Diarrhoeal diseases	  		  700
   Malaria				1,000

2. Malignant neoplasms (cancer)		19,100
   Mouth and oropharynx cancers 	 1,500
   Stomach cancer			 1,400
   Lung Cancer			 	 1,400
   Lymphomas				   500
   Leukaemia				   900
	

3.Diabetes mellitus			 6,100

4. Cardiovascular diseases		47,700
   Hypertensive heart disease	 	 9,600
   Ischaemic heart disease		16,300
   Cerebrovascular disease		13,300 

WHO December 2004