Breast Cancer Explained: What Every Woman Needs To Know

Breast cancer is now the most common cancer affecting people worldwide, with 2.3 million new cases and around 700,000 deaths each year. In India, someone is diagnosed every four minutes, and someone loses her life to breast cancer every eight minutes.

But behind these numbers is a question every woman and every family needs to ask: how do we understand breast cancer without fear taking over?

To make sense of all this, in this episode of The Wellness Algorithm, I’m joined by Dr P. Raghu Ram,  OBE, Founder Director of KIMS-Ushalakshmi Centre for Breast Diseases and one of India’s most respected breast cancer surgeons. Dr Raghu Ram has spent decades advancing breast cancer awareness, early detection and specialist care in India.

Together, we talk about lumps, breast pain, nipple discharge, screening after 40, family history, BRCA testing, HRT and the major advances in treatment.

🎧 Tune in to explore what every woman needs to know about breast awareness, early detection and the medical guidance that can help save lives.

For a transcript of this show, go to https://wellnesscurated.life/breast-cancer-explained-what-every-woman-needs-to-know-2/

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Transcript

Anshu Bahanda: For a number of women, the moment they hear words like lump, nipple discharge or abnormality in the shape of the breast, the fear just rushes in before the facts do. And yet, the truth is more nuanced than that. Not every change is breast cancer and not every symptom means the worst. But some signs do need attention. And knowing the difference can make all the difference to your peace of mind. This is Anshu Bahanda, and today on Wellness Curated, we're talking about Breast Cancer Explained: What Every Woman Needs To Know. To help us explore this, I'm joined by Dr. P. Raghu Ram. He's one of India's most respected breast cancer surgeons. He's also been honored with the Padma Shri, one of the highest in Indian civilian awards, in recognition of his contribution to this field. Before we begin, a small request. Please subscribe to the podcast. It's free and it supports our mission to bring you meaningful, well-researched, science-backed conversations. And if today's episode resonates, share it with someone who might need this information. So, let's begin. Thank you for being here with us today, Dr. Raghu. We're really delighted you made the time to do this. 

P Raghu Ram: Thank you very much. 

AB: You're welcome. Now, I'm going to jump right into questions. Tell me, how big a problem is breast cancer globally? And is India, in any way, different from the global scenario? 

PRR: Yes, breast cancer has overtaken lung cancer to become the commonest cancer affecting both men and women combined. I'm talking about statistics. Breast cancer is the most common cancer affecting people worldwide with 2.3 million new cases being diagnosed and some 700,000 deaths per annum. It is a tsunami. And it is expected that by 2050, the number of new cases of breast cancer being diagnosed every year would jump from 2.3 million to 3.5 million. And the number of deaths from 700,000 to 1.4 million. 

AB: Oh my goodness. 

PRR:  So it is a huge problem. Yeah, not only worldwide, but also in India with 200,000 new cases being diagnosed and 100,000 women succumbing to breast cancer every year. It's a huge problem and it is the commonest cancer affecting women in India as well. And, to put it simply, every four minutes, someone somewhere in India is being diagnosed with breast cancer. And every eight minutes, someone somewhere in the country loses her life to breast cancer. And, the startling statistics also show that because of lack of awareness and absence of an organized population based screening program, more than 60% present in the advanced stages. And, unlike in the western world where breast cancer is more common after the age of 50. The peak incidence of breast cancer in India is between 40 to 50. 

AB: Oh, wow. Okay. Now, from what you said, I have lots of questions swimming in my head, but I'm going to try and be organized about this. So tell me, you're saying that one of the main reasons is lack of awareness, that, you know, by the time people go for their screenings or by the time they're diagnosed, it's very late. Now, there's a very fine line between raising awareness and creating fear. So how do we talk about breast cancer in a way that will encourage early action without causing panic? 

PRR: That's a good question. Breast cancer does not just affect the body. It affects the mind and the soul. So therefore, it is very important that we don't scare people, but we should initiate conversations around awareness, creating awareness and reassuring people in a sensitive manner. 

AB: So what I want to do today is go through all the symptoms one by one, and if you can, explain to us what is alarming, what should be, where people should get attention. So let's first talk about lumps. Lumps in the breast. Can you help us understand the difference between common, benign breast changes and the signs that need urgent attention? 

PRR: Yes. So the first point to make is the vast majority of breast lumps are benign. 9 out of 10 breast lumps are benign. So in a centre like ours, which is called the KIMS - USHALAKSHMI Centre for Breast Diseases, which is a dedicated, comprehensive centre for breast health, when 10 women present to us, nine out of 10 are reassured because they have benign problems and not cancer. And one out of 10 is managed in a multidisciplinary setting. So essentially, the common benign lumps that occur, particularly in younger women. It is something called a fibroadenoma. 

AB: Yes.
 
PRR: Which is a very small lump which can also turn bigger. Then as women age, they develop what are called cysts, and also they develop dilatation or dilatation of the ducts, which is called duct ectasia, and infections relating to that as well. And there is a benign cross condition called Phyllodes, which can also be malignant. One out of ten lumps can cause cancer. And the symptoms to look out for are, that if someone notices a lump, particularly a painless lump in the breast, or a recent change in the size of the breast or color of the breast, recent indrawing of the nipple, eczema around the nipple areolar region, or a blood stain discharge from the nipple or puckering of the skin, overlying the breast, then one must not ignore and they must go to their doctor. So when I say that these are some of the signs of breast cancer, it doesn't mean that it is breast cancer. But when these signs are noticed, one must not ignore them. So it's very important to seek early attention.

AB: I want to repeat something very, very, very important that you've said here, which is that nine out of 10 lumps are benign. So for all the people who go into complete panic, and I don't blame them, but this is a very important point that you're making, that 9 out of 10 lumps are benign and it's not like it's going to be breast cancer for sure. But please, please have it checked. And then you gave a number of other symptoms like nipple discharge, skin dimpling, eczema around the nipples, change in shape. Please go to the doctor if something like this happens. Please carry on. 

PRR: Yeah, so that's basically it. And so essentially when someone presents with pain, it usually means it's, usually means it's not a cancer because pain is although, you know, associated with cancer, it is very rare. So when someone has a painful lump or pain in the breast, one can be reassured that it's unlikely to be cancer, but they must go and refer themselves to a specialist. 

AB: I have a question for you about age here. So you were saying that in countries like India most of the women are, the majority of the women are between 40 and 50 and in a lot of places they're over 50. But I'm also hearing cases of much younger women being diagnosed with breast cancer. What would you say here? What age should people start screening?

PRR: Women of all ages must be breast aware because breasts change throughout the month and it's important that whilst having a shower or applying a cream, it's important to notice any new changes in the breast. This is called breast awareness. A concept very different from breast self examination. Breast self examination means a woman is asked to examine her breasts at a particular time during the month. And that makes women paranoid. And so the concept now world over is changing from breast self examination to breast awareness where they are encouraged to look for any new changes in the breasts on a daily basis, not to a set method, but whilst applying a cream or having a shower so that any new changes are there, they must report to a doctor. So the first component is breast awareness. So women must be aware of their breasts. Breast cancer can occur at any age and as discussed, it is more common in younger women in India. So breast cancer can occur in 30s as well, and even in 20s, although it's uncommon. But we must not. The peak incidence as we discussed is from 40 to 50. And obviously the incidence of breast cancer increases as women age, so there's no specific age. So, particularly in a country like India. Any new changes as we discussed, particularly a painless lump in the breast, as I repeat, recent indrawing of the nipple or retraction of the nipple, blood stained discharge eczema in and around the nipple areolar region or puckering of the skin overlying the breast, or recent increase in size of the breast or color of the breast. One mustn't ignore. 

AB: Okay, thank you for that. And for women over 40, how often should they go for screening? 

PRR: So as women age, particularly 40 years is a benchmark because the incidence of breast cancer significantly increases after the age of 40. And that's the reason screening mammograms are recommended annually, every year. Women over the age of 40 and also under the age of 40. Screening mammograms, which is an X ray of the breast, is not recommended because the breast is very dense. In younger women, when the breast is very dense, when mammogram is done, it appears white and a cancer also appears white and it's very difficult to detect a very small tiny cancer. And that's the reason the recommendation is for all women to have an annual screening mammogram and an ultrasound scan of the breast. Because mammograms are not 100% accurate, they're about 85 to 90% accurate. And therefore combining an ultrasound scan, ultrasound scan of the breasts alongside a mammogram helps to make the breast imaging more accurate.

AB: Thank you. Is there anything else you think people should do in terms of screening or mammogram and ultrasound once a year and being breast aware, those things are enough? 

PRR: Yes. 

AB: Okay, thank you. I want to ask you about what we can do about reducing the risk of breast cancer. So firstly, there are a number of people, I was just talking to someone before we started the podcast where they have breast cancer in their family. And this whole topic was made quite famous by Angelina Jolie who said that she had a particular gene and to have those genes taken out, you know, she had to have her breasts removed. Can you just elaborate on that for me a little bit? 

PRR: Yeah. So any factor that increases the exposure of the hormone estrogen for a prolonged duration on the breast can potentially cause breast cancer. So those highest at risk are women. Because breast cancer can also occur in men also, but it is very rare. So being a woman and a previous history of breast cancer are the biggest risk factors. In addition to this, early menarche, late menopause, and lifestyle changes, like late marriages, not having children, having the first child after 30, not breastfeeding. So all these factors increase the prolonged exposure of the hormone estrogen on the breast. In addition to this, smoking, alcohol are big risk factors and therefore lifestyle changes like lifestyle factors, particularly physical inactivity, obesity, particularly after menopause, because after menopause, fat cells also can produce estrogen, which in turn can potentially cause breast cancer. So unhealthy diet, red meat, particularly not eating adequate vegetables and fruit. So all these lifestyle changes also contribute to developing breast cancer.

AB: Okay, and would you say, just coming back to my question a little bit, would you say there's a particular way that someone can check if they have breast cancer in the family, that they do or don't have that gene?

PRR: Yes. So family history is, actually, misconstrued in the sense that, say, for example, if my mother had breast cancer, it doesn't mean my children would get breast cancer. So significant family history refers to as, someone whose close relatives who have had breast cancer under the age of 40 or two or more close relatives who have had breast cancer at any age, close relatives who have had breast cancer and ovarian cancer in the family, and close relative who has had male breast cancer in the family. So when these criteria are there, their risk of developing hereditary breast cancer, that is significant family history is possible. And as we were discussing earlier, Angelina Jolie comes into this group because her mother, her grandmother, her aunts, her sister had breast cancer and ovarian cancer, and therefore she got the BRCA testing done. That is to assess whether there was an abnormality in the BRCA genes, which can potentially cause hereditary breast and ovarian cancer. And her initiative of getting the BRCA test done has created a lot of awareness that women with a significant family history should consider getting this done. But it has caused a lot of panic in a country like India, where we don't have genetic counseling services. Because when someone has a significant family history, they must not rush to a diagnostic center to get a BRCA testing or a genetic test done. 

They must first visit their doctor, who should refer to a genetic counselor or a specialist who should counsel the person, the lady, about the implications of having this test done before it is done. So it should not be done willy-nilly and just a sporadic member in the family getting breast cancer over the 40, there's nothing to be concerned about. So only when there is significant family history, that is when, you know, genetic testing is considered. And that too, after genetic counseling. 

AB: So you're saying that if there is significant history, then first get genetic counseling done, then go for genetic testing. Is that something which is easy for people to get to? Is genetic counseling easily available? 

PRR: Not very easy in a country like India. So here in India, in a country like India, they must go to a specialist who deals with breast disease and get themselves counseled. And only when the doctor or the specialist says that, yes, you have a significant family history. After hearing about the implications of getting the test done and the options that one has to, options that one has if the genetic test was to be positive, many women say, okay, I am at an increased risk. I'm okay, I would closely get followed up through an annual mammogram alternating with an MRI, which is one of the options when someone has a very significant family history. In addition to the surgical option of getting the breast removed prophylactically and the ovaries also removed prophylactically, which is called prophylactic bilateral mastectomy and salpingo oophorectomy. That's quite a radical option. And the third option in someone who has a very high risk is to be given a five year course of tamoxifen, which is a drug used for breast cancer treatment. So there are various options of treating women who have a significant family history and who have brca. BRCA positivity. And therefore, before the test is done, it is the duty of the person counseling to explain the implications. And then if the patient agrees to get the test done, fantastic.

AB: Thank you for that. That is going to help a lot of people. The other thing I wanted to ask is that you mentioned that women, you know, you were talking about the risk of breast cancer and you said it's reduced when women have children. Is that because of breastfeeding?

PRR: Yeah. So anything that interrupts the prolonged action of estrogen on the breast is protective. So when someone becomes pregnant and when someone breastfeeds, the uninterrupted action of estrogen is curtailed to a certain extent for a considerable period of time, and that is therefore protective.

AB: Now, a lot of people I know are on HRT and, you know, on estrogen as well. So please give us your opinion of that. And also about oral contraceptives. Should women be worried about these two?

PRR: In this day and age, there is no danger of oral Contraceptive pills causing breast cancer. In fact, the risk is very minimal. In the past, the oral contraceptive pills contained high doses of estrogen which could cause breast cancer. But in this day and age, the dose of estrogen within the pill is very tiny. So the benefits far outweigh any risks. But coming to hormone replacement therapy which is given after menopause, there is a modest increase in risk to, for women who take the HRT for a prolonged period of time. Say if someone is taking HRT for over five years, and if there are 100 women, there may be one additional extra breast cancer that is diagnosed. So the risk is modest and therefore, they must weigh the options of taking long term HRT versus not taking in consultation with the gynecologist and the specialist if required. Dealing with breast disease, and particularly those who have had breast cancer in the past, and those who have a very strong, as we discussed, strong family history of breast cancer must not take HRT. 

AB: What are the major advances that you're hearing or for your seeing relating to breast cancer surgery and relating to breast cancer as a disease that you have noticed in the last two decades? 

PRR: Yes, so in fact the major advance in breast cancer was several decades ago. In fact, the multidisciplinary approach to managing breast cancer, where a surgeon, radiologist, the pathologist, the medical oncologist, the radiation oncologist, the, the plastic surgeon, the palliative care specialist and the breast care nurse together decide on the treatment. So treatment is very individualized through a multidisciplinary approach. And breast cancer was the first cancer where multidisciplinary team decision making was introduced a long time ago. But in recent times the exciting changes have been to doing less. So in fact, the number of breast conserving surgeries have significantly increased worldwide. And previously breast conserving surgeries used to be done when the tumor was small. But in this day and age, even if someone presents with a locally advanced breast cancer, that is a large breast cancer, even over 5 cm, with advances in treatment, particularly chemotherapy being given prior to surgery, which is referred to as neoadjuvant therapy, we are able to shrink the tumor and make it small so that breast conserving surgery is possible. Another major surgical advance has been minimally invasive surgery to the armpit. Because when breast cancer occurs, the first site for cancer to spread is the lymph nodes in the armpit, which we call axilla. Traditionally, the surgical treatment to the axilla involved removing most of the lymph nodes, which is referred to as axillary node clearance. This can cause significant morbidity in terms of altered sensation in the inner aspect of the arm, tingling sensation.

And particularly some women, about 10 to 20% can develop swelling of the arm, which is referred to as lymphedema, which can be very difficult to manage. So the advance is that when someone has an early breast cancer, and at the time of assessment, if the ultrasound does not show that there is any abnormal lymph node, we're able to remove selectively one or two or three nodes, which is referred to as sentinel node biopsy, whereby we would know at the time of operation through a frozen section whether or not that lymph node is abnormal. If the lymph node is not abnormal on the frozen section, then we can safely exclude removing all the lymph nodes, thus sparing the woman of all the morbidities that we just. Which, I just highlighted. So sentinel node biopsy is a big boon. So whether it is the breast, breast conserving surgery, doing less is more. Similarly in the armpit as well, doing less in terms of, performing sentinel node biopsy rather than axillary node clearance is actually what is happening now. And women are spared of excessive surgeries, and morbidity associated with the surgery is significantly reduced. 

AB: Thank you so much for that. It's good to know that treatment and surgery is now very personalised. And with all these advances, I think the surgeons are trying as much as possible to save the breasts and to save the lymph nodes. Now, I want to ask you, post the chemo being done, can you talk to me a little bit about how you ensure that the breast cancer doesn't come back? I know some of my friends were on the tablets that were given to them. 

PRR: So breast cancer treatment, as I mentioned earlier, is not delivered just by a surgeon. It's always a multidisciplinary setting. A multidisciplinary team decides on what treatment needs to be given based on the age of the patient, the size of the tumor, the type of the tumor, the grade of the tumor, the estrogen receptor, progesterone receptor, and HER2 status, the lymph node status in the armpit, and whether or not the cancer has spread, spread anywhere else. So based on all these factors, the team that comprises the surgeon, radiologist, pathologist, medical oncologist, and radiation oncologist decides on what treatment needs to be given. Essentially, there are five modalities of treatment. One is surgery, which I have just mentioned, the other is chemotherapy. The third is radiotherapy. The fourth is hormone therapy, which is the tablet therapy which you were just talking about. And the fifth is targeted therapy. Which treatment is given to whom? We need to take the advice of the multidisciplinary team, and that decision is discussed with the patient and the patient's family before initiating that particular treatment strategy.

AB: Okay, thank you for that. And Dr. Ram, tell me, of all the research that's being done in the field of breast cancer, what are you most excited about? 

PRR: There are advances in every aspect of breast cancer treatment. Whether it is surgery, the chemotherapy drugs that are given, the radiation techniques that are given, targeted therapy that is given. So there are advances in every field of breast cancer care. And, basically, in the future, we expect that we are able to detect breast cancer through just a blood test. And there is research going on worldwide to see whether it is possible. And in the fullness of time, the first port of call would not be a mammogram, it would be a blood test. And if there is an abnormality in the blood test, that is when women would be referred for a mammogram, which is the gold standard. And when someone has a lump. The other point I wish to make is that as we already discussed, 9 out of 10 breast lumps are benign and only 1 out of 10 is cancer. So when someone notices a breast lump, when they go to the doctor, it is very important to have what's called a triple assessment. That is, the doctor takes history and examines. That's the first component. The second component is mammogram and ultrasound scan. And the third component is under ultrasound guidance, you have an ultrasound guided core needle biopsy.

There are two types of needle biopsies. One is a FNAC, which is called fine needle aspiration cytology, which is very commonly done in our country, which has been given up and which should not be done because it gives false positives and inadequate results. So if there is a solid lump, one must have a core needle biopsy under ultrasound guidance. So with these three ways, that is clinical examination, breast imaging, and a, needle biopsy, we're able to confidently tell whether or not someone has cancer or a benign problem without the need for the lady to go under the knife. So just because someone has a lump, they should not undergo surgery. It's easily possible to get the triple assessment done, all of which can be done within an hour's time. 

AB: Fantastic. And tell me lastly, if there's one thing that you want every woman to understand about breast cancer, what would that be?

PRR: So breast cancer cannot be prevented, strictly speaking, there are only two ways to fight breast cancer. Women of all ages must be breast aware, and any new changes which they notice must be reported to a doctor. That's the first. The second, women 40 years and over must have an annual screening mammogram alongside ultrasound scan of the breast. This way we're able to pick up breast cancer many, many years before the lady or the doctor can feel the lump. And when you pick up cancer that early, we can confidently say that we expect such women to succumb to old age and not breast cancer. And the final message is it is the duty of the men in the house. So when someone's mother or wife or sister, a lady, the woman is the nerve center for the family. If she is well, the family will be well. So it is the duty of the man to ensure that his mother, spouse, sister, grandmother gets an annual screening mammogram.

In India, we have many festivals. So in addition to buying a saree and sweets, it's very important to ensure that the women in our lives are cared for. And the best way is to detect cancer early. And when cancer is detected early, we can win the war on cancer and scores of lives can be saved through early detection. 

AB: Actually, I love what you just said. Don't forget, more than the presents, it's important that you look after the medical health and the breast health of the women of the family. I'm going to very quickly do, ask, give you some questions and you tell me whether it's myth or fact. We're going to do a rapid fire round. You've answered all these questions in our chats, but we'll go through this very quickly. Yes, every lump is cancer. 

PRR: It's a myth. 

AB: Only older women get breast cancer. 

PRR: That's a myth. 

AB: Breast pain usually means cancer. 

PRR: It's a myth. 

PRR: Breastfeeding lowers risk. Yes, it's a fact. 

AB: No family history means no risk.

PRR: It's a myth. 

AB: Thank you, thank you. Thank you so much, Dr. Ram. 

PRR: Very grateful. And every opportunity to, to empower is an opportunity to save lives. 

AB: Today's discussion reminds us that awareness does not have to feel alarming. It can be calm, it can be informed, and it can be empowering. Knowing what to look out for, understanding when to act, keeping up with your screening and recognizing how much progress has been made in research and treatment can change the way we hold this conversation entirely. If this episode helped, you do share it with someone who may need it. Whether it's a friend, a sister, a mother, a daughter, or anyone who could benefit from hearing this with a little more perspective and a little less fear.

And please do subscribe to Wellness Curated. It's free and it helps us continue to bring thoughtful, event based conversations like this one to you. I'm Anshu Bahanda. Stay curious, stay informed, and keep engaging with the science that's shaping how we care for our health. Thank you.