Indian Journal of Cancer, Vol. 48, No. 4, October-December, 2011, pp. 403-405
Breast - Original Article
Is locally advanced breast cancer a neglected disease?
M Akhtar, V Akulwar, D Gandhi, K Chandak
Department of Surgery, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Digdoh Hills, Hingna, Nagpur, India
Code Number: cn11116
Background and Aims: Breast cancer is the second most common malignancy in India, and majority of patients present as a locally advanced breast carcinoma (LABC). Evaluating the prevalence of LABC and assessing the causes of local advancement and delayed presentation is the aim of the present study.
Keywords: Breast cancer, locally advanced breast carcinoma, neglected carcinoma
Breast cancer accounts for 5-8% of all cancer in India,  and the incidence is on the rise.  It is the most common cancer of urban Indian women, and the second most common in rural women.  Locally advanced breast cancer (LABC) accounts for 50% of all breast cancers.  This incidence is quite high when compared with the western statistics. The reason for this advancement is either patient neglect or health system failure or tumor biology. The present study aims at finding the cause of local advancement, which in turn will be helpful in planning health care intervention, which will help in reducing the incidence of LABC and improving the overall prognosis.
Materials and Methods
This prospective study was carried out from 2008 to 2011 at a rural-based tertiary care hospital located in Central India. All cytologically and histopathologically confirmed cases of carcinoma breast were included, while breast sarcomas and lymphomas were excluded. All breast cancers were staged as operable breast cancer (OBC), LABC and advanced or metastatic breast cancers (ABC or MBC). The subjects for study were LABC patients who included clinical stage T3N0, T3N1, T4 and/or N2-3. 
The prevalence of LABC was calculated by dividing the number of LABC patients by the total number of patients of breast carcinoma enrolled in the study. LABC patients were assessed by using a locally developed, pilot-tested and validated questionnaire for the cause of delay and advancement, with special stress on system factors, patient factors and biological factors. There was no such questionnaire available in the literature and hence a questionnaire was developed locally. The system factors for delay included nonreferral by general practitioner, treatment by alternative therapy, etc., while patient factors for delay included lack of awareness regarding breast cancer, economic reasons, shyness to show to doctor, fear of surgery/fear of losing breast, family noncooperation, etc. Biological factors meant aggressive tumor biology, which included all patients in whom local advancement occurred in less than 3 months from the time of first detection of tumor.
A total of 71 patients of breast carcinoma were enrolled in the study. All patients were females. The mean age of presentation was 48.3 years, with a range between 25 years and 72 years. Of the 71 patients, 36 (50.7%) patients had LABC, while 27 (38%) patients presented with OBC and another eight (11.3%) patients as MBC [Table - 1].
The cause of delayed presentation was analyzed in all patients who had LABC [Table - 2]. Patient factor (69.8%) was the most common cause for advancement, followed by system factor (23.6%) and biological factors (6.6%). In patient factor, the most common cause was lack of awareness of breast cancer (75%), followed by financial difficulties (52.8%). Among the system factors, trial of alternate therapy and delay in referring the patients to the tertiary care hospital were important factors. It was also found that many patients had more than one cause for delay in presentation [Table - 2].
LABC accounts for a sizeable number of breast cancer cases in the present series, which is a common clinical scenario in developing countries.  The treatment of LABC has evolved from single-modality treatment, consisting of radical mutilating surgery or higher doses of radiotherapy, to multimodality management in search of offering better disease control and survival, but prognosis continues to remain grim. Unfortunately, a large load of LABC in the Indian population means poor prognosis and increasing cost of multimodality treatment.
Finding out the cause of local advancement of disease and taking remedial community-based intervention to reduce the incidence of LABC by detecting causes of local advancement is a rational approach and, with intention of improving prognosis, the present study was an effort in this direction. A locally developed questionnaire, pilot-tested and duly validated, was an instrument used to assess the causes of advancement. The need to develop this instrument arose as no standard questionnaire was available in the literature. Also, the local population perspective was taken into consideration in the local questionnaire.
Patient factor was the major cause of delay, and it was lack of awareness about disease compounded with financial difficulty, i.e. inability to afford cost of treatment, which led to neglect of disease by the patient herself and also by the relatives. Therefore, we termed LABC as neglected disease. Similarly, system factors, the next common cause of advancement, was treating doctors showing neglect by not referring the patient for treatment to a specialized center and trying to treat LABC with alternative pathies present in India. These two human factors are amenable to rectification by community-based intervention. Prompt reporting by the patient for treatment and early referral by the treating doctor can take care of neglect and reduce the occurrence of LABC. Delay in taking treatment is not only observed in India but this was also seen in Thailand, where need to improve the referral system was emphasized.  Delay in standard treatment in carcinoma breast is associated with advancement of disease; a strong association between delay and stage of disease at diagnosis was observed in a population-based study in Germany.  A systematic review of 87 studies suggest that advancement of disease is due to a delay in seeking treatment.  Arguments of the present study are similar, which correlate delay with LABC and looking for causes of delay. The observations from the present study offer a strong case for community intervention in rural masses to improve the awareness of breast cancer and financially support those patients for treatment of breast cancer at government cost by extending Jeevandai Yojna (a social security scheme of the Government of India). Educating medical practitioners in rural areas and need for early referral is another strategy to reduce the occurrence of LABC.
The present study is a small effort and a hypothesis-generating exercise. The major drawback for such a study is inconstant definition of delay across the literature, making the comparison between the various studies difficult.  No study in the literature looked at LABC as a core group, and no such study is reported in the literature on the Indian population. A large multicentric epidemiological study assessing the social causes for advancement will go a long way in framing guidelines for a community intervention of education and screening programs to reduce the incidence of LABC in the rural Indian population.
Copyright 2011 - Indian Journal of Cancer
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