Samarpan

The environmental and lifestyle factors can be modified. Few examples are:

• # Exercise regularly
• # Eat a healthy diet rich in fruits, vegetables and eat cooked food
• # Deleterious habits like consuming alcohol and smoking cigarettes should be given up
• # Annual health check-up including screening of common cancers by your doctor

First of all, the person diagnosed with breast cancer should undergo a gene test. Especially, family members who are below 50 years of age should go for a gene test. If the gene test is positive, then all the family members should undergo genetic counselling and genetic testing. In such a case of strong family history, precautions that need to be taken include a mammography every year with adjunct ultrasound and a clinical breast examination (CBE) to be done once every 6 months to detect early breast cancer. If the gene test is positive, they should undergo genetic counselling for more directed (focused) preventive measures such as prophylactic surgery, etc. They should also incorporate lifestyle changes with a healthy diet and exercise.

Most menopausal symptoms are treated without HRT. However, in few cases, where the symptoms are extreme, HRT can be given for short time periods. Extended duration of HRT, for more than 5 years, increases the risk of breast cancer.

Bra or underwired bra does not cause breast cancer. It is a myth.

• Eat lots of raw fruits and vegetables as they are high in vitamins and minerals, although cooking some vegetables can make the vitamins more available for our body to use.
• When cooking vegetables, steam until just tender. This preserves more of the vitamins. Overcooking vegetables removes many of the vitamins and minerals. If you do boil vegetables, use the cooking water in a soup or a similar recipe to ensure your intake includes those vitamins.
• Wash all the fruits and vegetables. Washing does not eliminate all pesticide residues, but will reduce it. Choose organic products if possible, grown without the use of pesticides or GMOs (genetically modified organisms).
• Flavor food with immune-boosting herbs and spices. Garlic, ginger and curry powder not only add flavor, but they add a cancer-fighting punch of valuable nutrients. Other good choices include turmeric, basil, rosemary and coriander. Use them in soups, salads, casseroles or any other dish.
• Limit alcohol. In countries where alcohol consumption is high (more than 2 drinks a day), there are more cases of esophageal and oral cancers. Moderate drinking is associated with better vascular health, however there are many ways to improve vascular health that does not include alcohol intake, such as maintenance of a healthy weight and regular physical activity.
• Avoid processed foods. Packaged cookies, chips and other snacks are filled with unhealthy fats, maida (wheat) and preservatives, which do not nourish the body.
• Be physically active. It can help in preventing and recovery from certain cancers. It also helps with healthy bowel function. Aim for 30 minutes of activity everyday. A brisk walk is an excellent form of activity.
• Maintain a healthy weight. Research indicates there is a direct link between obesity and many types of cancers. For breast cancer, it is seen more often in post-menopausal women. If you are overweight, then maintain your weight with healthy habits including diet and regular exercise.

You need to eat nutritional foods that are palatable while experiencing side effects of chemo and radiation. There are many ways to keep your body healthy common symptoms and ways you can address them through your diet: Nausea:

• Drink lemon tea. You can also make a mixture of lemon, sugar and ginger and keep having a taste of it before meals. Ginger helps with nausea, but do not have too much as it may cause the stomach to burn.
• Eat small meals.
• Eat dry foods such as khakra, toast or plain roti.
• Avoid spicy and oily foods.
• Cooling foods such as curds, curd rice, lassi, etc. are helpful sometimes.
• Eat foods that do not have a strong smell.
• Eat food cold or at room temperature and not hot, to reduce its smell and taste.
• Loss or change in taste:
• Try eating or seasoning foods with sour flavors such as pomegranates, citrus fruits, apples and ginger.
• Try using spices such as mint, oregano and rosemary.
• Try different foods including the ones you may not have liked before.
• Eat with a plastic spoon if foods taste metallic.
• Do not wait until you are hungry to eat. Try and eat at certain time intervals.
• Have portable snacks handy, especially if you’re having trouble eating enough because of lack of appetite.
• Keep high-protein snacks ready so you can eat when you feel like it. Try cheese and crackers, peanuts, almonds, boiled eggs or roasted channa, peanut butter and some dry fruit.

Mouth sores:

• Eat soft foods, drink milkshakes and lassi.
• Avoid spicy or acidic foods.
• Eat lukewarm soups and dals. You can eat watery dal as soup.
• Avoid sharp or rough foods such as toast and chakli.

Constipation:

• Take adequate fluids to help move the bowels.
• Get enough fibre from whole grains and vegetables.
• Drink warm liquids like herbal and green tea.
• Eating dry fruits like jardaloo (dried apricot) with warm water at night also helps.

Diarrhea:

• Eat small, frequent meals and snacks.
• Make sure you are adequately hydrated with electrolyte-rich fluids like clear soups and coconut water.
• Avoid high fat, high fibre and high sugar foods.
• Potassium is often lost through diarrhea. Eat foods that have a lot of potassium, such as coconut water, potatoes and bananas for replenishment.
• Eat foods that are high in sodium, such as soups, crackers and pickles. Salt helps you retain water so you don’t become dehydrated.
• Avoid high-fat, fried, greasy and rich foods. They can promote diarrhea.
• Avoid foods that cause gas and bloating such as chewing gum and carbonated beverages.
• They can irritate your digestive tract.
• Limit milk and milk products. They may be hard to digest and promote diarrhea.

Fatigue: Fatigue is the most common side effect of cancer treatment. Many factors cause fatigue, and fatigue may even linger after breast cancer treatment is completed. Nausea, hot flashes, stress and depression may all contribute to fatigue. Not getting enough food and nutrients because of treatment side effects can add to your fatigue.

• Make sure you’re getting enough proteins, vitamins and minerals, and hydration.
• Eat often throughout the day in small amounts. Try to get in some light physical activity.
• Try to eat a healthy protein food with every meal/snack. Dahi, paneer, pulses, dals, cheese and nuts are all good sources of vegetarian protein.
• Protein helps heal and rebuild tissues. During treatment, eat one gram of protein for each kilo you weigh. So if you weight 60 kilos, try to get 60 grams of protein in your diet each day. Here is a chart for reference:
  • One egg- 6 grams
  • 100g cooked chicken- 28 grams
  • 100g cooked fish- 25 grams
  • Dal/pulses- 12-15 grams per cup
  • One cup milk- 8 grams
  • One cup dahi- 11 grams
  • 25g cheese (1/4th cup of cubed cheese)- 7 grams
  • 10-12 nuts (almonds, peanuts, cashews)- 3 grams

Getting these nutrients from foods rather than from supplements is ideal, however, if you aren't eating very much because of treatment side effects, ask your doctor about taking multivitamins.

• Prepare the biggest meal of the day when the patient is the hungriest. Each individual will be different.
• Offer favourite foods any time of the day. Upma for dinner or roti-sabji for breakfast is fine.
• Add dals to sabjis or make some snacks with channa for extra protein.
• Spicy and oily foods may not be well tolerated, so learn to cook with less spice.
• Make food softer as it is easy on the tongue and to swallow.
• If the patientis sensitive to smell, then close the kitchen door when cooking and burn an agarbatti to mask the smells.
• Drinking is many times easier than eating. Milkshakes, smoothies and lassi are good options. Limit tea and coffee to 1-2 cups per day as they tend to upset the lining of the stomach. Hot cocoa or herbal tea is an option if hot drinks are preferred.
• Eat a sensible diet during treatment without too much fat and little or no sugar.

• Women should examine themselves (self breast examination) every month after their periods, because that is when the breasts are very soft and easy to palpate. They should look for signs such as dimpling, ulceration of the nipple or some colour changes on the breast.
• They should palpate the left breast with the right hand and vice versa with the flat surface of the palm to examine the breast and see how the breast feels every month. If there is the slightest of change or a lump felt with the flat of the hand (and not the fingers), they should report this to their physician. All women over the age of 40 should have an annual mammogram where a low dose radiograph (x-ray) of the breast is done which detects early or even precancerous lesions. They should also undergo Ultra-sonography (USG) of the breast along with their mammogram.

• When a woman presents with a lump, surgery should not be the first step, which has unfortunately become the norm in the country.
• A woman who comes with a lump should have a mammography done (if above 35 years of age) or an ultrasound done (if she is below 35 years of age).
• After the mammogram, if the lesion is benign-looking, it may require a regular annual follow-up. But if there is any suspicion, a USG guided needle biopsy is performed. The needle takes out a small piece of the lump which is sent to the laboratory for diagnosis. This is a painless 5-10 minutes OPD procedure, without any need to go to the hospital and the results are obtained within two days. If the lump is reported as benign, no further procedure may be required. If the benign lump is more than 3 cm, a simple needle excision may be required. If it is a cancerous lump, then further treatment may have to be planned.

Digital mammography with tomosynthesis is by far the most efficient way to diagnose breast cancer. The conventional analogue mammogram, which is found in most clinics, has only 29% sensitivity and is more painful. A digital mammogram is 30% more sensitive than an analogue mammogram, but with an adjunct tomosynthesis, the sensitivity is as high as 75-80%. By additionally performing an ultrasound, the sensitivity increases to nearly 90-95%. Therefore, the imaging of choice is a digital mammography with tomosynthesis along with an adjunct ultrasound.

This is a painless investigation because the compression of a digital mammography is digitized (done by the machine) and so, very even pressure is provided. Also, the paddles are so designed to give least amount of pressure to the patient.

A woman should undergo mammography when she is around 40 years, as is the recommendation everywhere, and continue to get a mammography done once every year after the age of 40. If there is a strong family history, then the mammogram should be done annually and ultrasound and clinical examination should be done once in every 6 months. In India, most breast cancers happen at a very early age, around 40-45 years, and it is therefore considered ideal for a woman in India to undergo screening with an ultrasound after 35 years of age.

The exact cause of breast cancer is not known. It has not been understood why one woman develops breast cancer and another doesn’t; and when a woman develops breast cancer, it is hard to pinpoint an exact cause. However, breast cancer is always caused by a damage to the cell’s DNA.

• It is not advisable to do a mammogram if you are below the age of 30. In some instances where there is a very strong indication of a malignancy or a genetic breast cancer, the mammography may start at the age of 30.
• Mammography should not be done in the women who may have missed their periods and are pregnant.
• It is not performed on lactating women.
• It is also not performed on women who have extremely tender painful lumps.

Yes, it can be done during your periods. But, it is probably better to do it after the periods are over as the breasts become less lumpy and are more amenable to good mammographic diagnosis.

A woman should do a self-breast examination every month and get herself examined clinically by a doctor who is trained to perform a breast examination.

• A lump can be classified into three categories- completely benign lump, very suspicious lump and some lumps which are undetermined in nature- which could be benign or cancerous. The next step after mammography is ultrasound, where the lump will be classified.
• If the lump is benign (very small and like a cyst, or a small fibroid), then no further treatment will be required. If it is a complex cyst or a fibroid or if the lump is suggestive of a papilloma (benign tumours in the ducts of the breast) then a needle biopsy/vacuum assisted biopsy will be considered.
• If the tumour is diagnosed as a cancerous tumour on ultrasound and a mammogram, then the woman will undergo a needle or a trucut biopsy (needle biopsy under local anaesthesia), which is painless. This biopsy will give us both the diagnosis as well as characteristics of the tumour. The biopsy will take around 5 minutes with no stitches and hence, no scars/marks.

CBE should be performed by a doctor or a trained personnel only. Women in their 20’s and 30’s should get CBE done at least once in 3 years. Women above 30 years of age should get CBE done once in a year. If a lump is detected, an Ultrasound would be advisable to investigate further.

No, all lumps are not always cancerous. Only 5% to 10% of the lumps can be cancerous. A lump could be a fibroid, a cyst or just a normal breast tissue, which is very lumpy just before the menstrual periods.

Granulomatous mastitis is a very common finding. We see about 4-5 patients every month with granulomatous mastitis and it is a very challenging condition to treat; but in at least 90% of patients, we get excellent results with just medication.

Very rarely can a benign lesion become cancerous. A fibroid or a simple cyst never becomes cancerous. A papilloma (benign condition of the breast) is the only condition of the breast, which is known to be a precancerous lesion.

Tuberculosis (Tb) of the breast is seen very rarely. Granulomatous mastitis mimics tuberculosis but it is not treated as Tb. Tb diagnosis is made when there is a chronic abscess (pus collection) and the pus, which is removed with a needle, actually shows tuberculi bacilli in it.

A fibroid is a benign tumour of the breast, that is, non-cancerous tumour of the breast, and is very similar to the fibroid found in the uterus. It is a very common occurrence among young and middle-aged women. If the fibroid is small, then no further treatment will be required. If it is a complex fibroid, then a needle biopsy/vacuum assisted biopsy will be considered.

Yes. Breast cancers are in fact classified based on anatomical origin of the cancer or on the basis of molecular origins of the cancer. The cancers can be low grade or high grade and since not all cancers are the same, the treatment and the prognosis for each type of breast cancer differs from one another.

A change in lifestyle can go a long way in reducing your risk of having breast cancer. Some risk factors of cancer can be reduced. Avoid a sedentary lifestyle and get involved in physical activities. Make an effort to consume a healthy diet. Be aware of the changes in your breast by doing a self-breast examination every month and go to a doctor for an annual check-up/mammography. If you are in the higher risk category, consider genetic testing or prophylactic surgery.

Prophylactic surgery is done is done in a few selective cases that have a very high chance of acquiring breast cancer in their lifetime (for example, women with BRCA1/BRCA2 gene mutations with familial history of breast cancer), that is more than 85-90% lifetime risk. The surgery could be in the form of surgical removal of one or both the breasts with immediate reconstruction and removal of both the ovaries and the fallopian tubes (if advised) or it could be just mastectomies (surgical removal of breast) with immediate reconstruction.

Breast cancer can be treated alone or in combination by surgery, chemotherapy (administering drugs) and radiotherapy. Since no two breast cancers are similar, the treatment modality will not be uniform for all women and will depend on various factors like age, family history, characteristics of the lesion etc.

If breast cancer occurs, then there is 80% chance that your breast will not be removed.

• Most women will have single cancerous lump in the breast and that breast can always be saved by a very well planned and cosmetic breast surgery. In such a surgery, there will hardly be any scars because the scars will be hidden and the breast shape will be maintained as normal or may be even enhances with the surgery.
• Mastectomy or breast removal surgery is done in very few percentage of patients, may be 20% where there are multiple tumours. Also, in the case of a single lump in a very small breast, a breast removal surgery may be necessary.

No. For cancerous lumps, an open excision of the breast lump may be necessary.

When you are going through chemotherapy and/or radiation the body’s immune system is depressed and cannot fight infections as before.

Avoid:

• Raw salads - Unwashed vegetables, especially leafy vegetables that can hide dirt and other contaminants
• Raw sprouts - It is better to sprout them at home and steam them slightly rather than eat them raw.
• Certain fruits - Avoid most other thin-skinned fruits especially berries & guava.

You can eat bananas since they have a thick protective skin. Apples, pears washed well and skin peeled can also be consumed.

• Fruit juices - No fresh juice bought at a restaurant is recommended.

Homemade orange, sweet lime and watermelon are allowed if made with utmost hygiene.

• Raw or undercooked fish, seafood, or meat of any kind.
• Unpasteurized milk
• Soft cheeses made from unpasteurized milk, such as Brie, Camembert, feta, and goat cheese. Processed cheeses such as Amul and Britannia can be consumed.
• Undercooked eggs, such as soft boiled, over easy, and poached or foods made with raw egg, such as homemade raw cookie dough and homemade mayonnaise.
• Frozen foods

It is generally advisable to avoid public places during treatment. Please refrain from going to the market or the movies.

The most common type of simple breast surgery is the breast conservation surgery (BCS), which does not require reconstruction. The patient comes in the morning and goes by evening. There are no drains required in the early stage of breast cancer and the surgery is virtually painless because an extremely good local anaesthesia is given which covers the pain for 24 hours. Later the pain is dulled and is taken care of by just minor painkillers. The patient will require a day’s rest at home before she is back to her routine work. So, she can start going out within two to three days of the surgery.

Women, who require minor breast surgeries with breast conservation, can come in the morning, have the surgery and go home by evening. They can have liquids 4 hours after their surgery, and can start having their snacks in another 6 hours, and by evening they can have a normal regular meal. There is virtually no pain and the size and shape of the breasts are maintained. The patient will require a day’s rest at home before she can go back to her routine work. On the third day after surgery, the patient can actually start moving out of the house for small errands and small walks, etc. The patient can have a bath very next morning and they can resume work in about 5-6 days. Some patients of ours have also started to work after third day of surgery.

As such, there are not many restrictions after a breast surgery apart from those of a regular surgery elsewhere in the body. Some of the 'Do's' are: eat healthy, exercise regularly, especially the shoulder exercises as prescribed to you, wear a full support bra at least for a month. Few 'Dont's' are: refrain from lifting heavy weights, you may not be allowed to take a bath for 2 days immediately post-surgery.

After a breast conservation surgery, which is the most common surgery, the sensations are always maintained.

The woman will not be able to breastfeed from the breast from where the lump was excised because the breast will undergo radiation after surgery. She can breast feed from the other breast.

Removal of lymph node during surgery may cause accumulation of watery fluids associated with the lymphatic system. Due to the absence of adequate drainage, this watery fluid can accumulate in the upper arm thereby causing prolonged swelling. There are recommended physiotherapy exercises to minimize the swelling. In addition, breast clinics may be equipped with an automated limb compression machine, which can provide transient relief to the swollen arm if used on a regular basis.

One of the main improvements in the field of breast surgery has been the fact that axilla (armpit) is dealt with very differently today. This is apart from the fact that we are able to save the breast. To understand its importance, a little background knowledge may be useful. Once breast cancer occurs, it can spread from the breast tissue through lymph vessels and spread to structures called lymph nodes which are present in the axilla. For example, when one has tonsillitis, we can feel nodes in the neck. These nodes are the lymph nodes which are part of our immune system and are present in many parts of the body. These nodes are like check points which will try to prevent the disease from spreading to other parts of the body. So, there us a probability of the tumour in the breast spreading to the axillary nodes.

In the past, women not only had to undergo mutilating breast surgeries or total mastectomies but also had to endure mutilating radical surgeries to remove all the nodes from the axilla. As of today, there has been a sea of change in the recommendations for handling the axilla. There have been major studies to identify even a single node in the axilla, which is known as a sentinel node or the node which is the watchman of the axilla. So if that node is not affected by the tumour, it may be safely understood that the rest of the nodes will not be affected by the tumour. Therefore, we have a procedure named as the sentinel node biopsy which is done during the same surgery on the breast. If the node is diagnosed as negative, it would mean that it has no disease and so the rest of the nodes will not have to be removed. Thus, this saves the woman from extensive surgery.

Yes, reconstruction of breast during mastectomy is done keeping in mind shape, size, symmetry and minimal scarring.

Yes. Chemotherapy may be given before the surgery when the size of the tumour is quite big to be operated upon. This is know as Neo-adjuvant chemotherapy (NACT). Chemotherapy reduces the size of the tumour and thus makes it easy to operate and remove.

Hair loss is a possible side effect. In about 50-60% of the patients, there is complete hair loss. But in the rest of the patients there might be just thinning of the hair or partial hair loss. This is the only side effect that we have not really been able to combat. But the positive aspect of the side effect is that within three months, after completion of chemotherapy, the hair grows back thicker.

The only side effect of chemotherapy as of today is the hair loss. Earlier, the known side effects of chemotherapy were nausea, vomiting, reduction of blood counts, infections and hair loss. However, currently, chemotherapy has improved and is extremely safe and so, the side effects have reduced. Nausea and vomiting are non-existent side effects in the present day scenario due to the availability of better drugs which combat vomiting. In the past, burning pain, prostration, feeling weak, etc., were all side effects of chemotherapy. Today, these symptoms do not exist, making women very comfortable. There are a lot of myths about chemotherapy. Chemotherapy has improved leaps and bounds and the drugs are much easier to tolerate. They are better tolerated as the drugs are targeted (it only affects the cancer cells and not the normal cells).

Patients don’t need hospitalization for chemotherapy or Herceptin or hormone therapy. Internationally, it is recommended that chemotherapy be administered in a day care facility. Day care should be away from the major hospitals, which handle a lot of general elements such as infections, etc. Therefore, a stand-alone day care is probably one of the best ways to provide for chemotherapy because the risk of developing hospital-acquired infections is lesser. Proficient Day Care facilities will provide chemotherapy within 5 hours. Most of the regimes discussed here will require less than 5 hours.

Tamoxifen is an anti-oestrogen drug taken twice a day and it helps to combat breast cancer which is hormone positive. The side effects of Tamoxifen are:

• Women who are pre-menopausal suffer from hot flushes.
• They may become amenorrheic or their periods may reduce or thin out.
• There is a very small possibility that in less than 3 out of 1000 women, Tamoxifen may cause low-grade uterine cancer. The woman needs to be examined every year with an ultrasound to prevent such a possibility. In our experience, we have never actually seen a breast cancer turning into a uterine cancer after taking Tamoxifen.
• In a very small percentage of patients, Tamoxifen might cause eyesight problems which are reversible.
• If there is change in the thickness of the lining of the uterine cavity, Tamoxifen needs to be withdrawn and other drug needs to be given.

HER2 enriched breast cancer or HER2 positive breast cancer is a type of breast cancer. HER2 is another antigen or a special protein in the tumour cells and scientists have been able to find out antibodies against this antigen which is known as Herceptin.

• Herceptin is a very effective drug. It has reduced the mortality of breast cancer by more than 50% in the patients who have HER2 positive disease.
• Herceptin is administered in a day care facility. It requires half an hour to one hour to administer it intravenously and is painless.
• This drug is extremely safe, has virtually no side effects like nausea, vomiting, hair loss, etc., and is extremely safe in women. But it needs to be given under the supervision of a trained medical oncologist.
• The only side effect of Herceptin can be a very minor allergic reaction to the drug which needs to be ascertained before administering the drug.

Typically, the radiation regimes are given over 5 days, 15 days or 25 days. It takes only a few seconds to give radiotherapy. However, in a busy radiation department, the waiting time may be about 15 minutes to half an hour. The patient does not need hospitalization for radiation therapy. Radiation therapy today is extremely safe with no side effects.

There are no side effects of radiotherapy if done by well-trained radiologists.

The role of counselling and support groups is very important. Since the 1970s, there has been enough data and work by McGuire to suggest that support groups and counselling improve the survival as well as the effect of the treatment.

At Samarpan, we have a very active support group of patients and breast cancer survivors. For more information, contact your clinician or staff at Samarpan.

Caregivers can be parents, partners or spouses, adult children, friends or neighbors. Being a caregiver can be enriching and also a difficult experience for the giver and the receiver. Cancer can affect the quality of life of caregivers, causing psychological distress. Some caregivers set aside their own needs to help the other person. They may think it’s selfish to pay attention to their own wellbeing. But ignoring self-care can cause stress or burnout, which may trigger guilt, anger, resentment or depression. Patient and caregiver emotional distress is evident in each phase of illness, but is greater in some phases (diagnosis) than others (survivorship). An important first step is to assess the needs of family caregivers to assist them in reducing their emotional distress. The ultimate goal is for caregivers to continue to be effective caregivers without compromising their own health and wellbeing. At Samarpan, we have counselors that offer counselling and engagement with patients and their caregivers, ensuring healthier patients and their caregivers.