This week, we spoke to Dr. Sanjay Kumar Suman, the Head of Department of Radiology at the Indira Gandhi Institute of Medical Sciences, a medical institution and hospital in Patna, Bihar that provides clinical services for local residents and other adjoining states in north east India. Dr. Sanjay Kumar Suman is our first participant from Bihar and we had an interesting and stimulating conversation on the role of screening, mammography, and other branches of radiology in breast cancer imaging and treatment for patients in Bihar. According to the 2012 census, Bihar had a population of 99.02 million and was the third most populous state in the country. The other interesting fact about Bihar is that 89% of its population resides in rural areas. Dr. Sanjay Kumar Suman shares his thoughts on how we can improve cancer diagnosis and care for women in rural areas.
We have been asking most of the radiologists we interview about whether the mammography screening recommendations in the West are applicable in India. The American Cancer Society recommends mammography every 2 years for women ages 55 and older. NHS breast screening program invites women aged between 55 and 70 years to have a screening done every 3 years. Considering we are seeing a higher incidence of breast cancer in younger women, do you feel that we should follow different/similar recommendations?
The National cancer registry program of India shows rising trends of breast cancer in younger age group and 48% of cases are found in less than 50 years of age. 4% cases are detected below 30 years of age and 16% cases in 30 to 40 age group. So we cannot follow American recommendations. We need a different program for screening.
Is India working towards a different screening program? If so, can you give us a few details and when do you think it is likely to be implemented?
The Indian government has recently (in 2016) launched a screening program for oral, breast and cervical cancer for women over age 30. But it is only for 100 districts of the country. (https://www.hindustantimes.com/health-and-fitness/world-cancer-day-india-begins-free-screening-for-oral-breast-and-cervical-cancers/story-1HhWe2qPCpRftX2kgjL5vK.html). At the local level, no such organized plan exists. Our institute holds a screening program for a month every year but that is insufficient. In my view, government should concentrate on prevention and early detection of disease. And this should be a continuous process and not in phases, so that a large population can be benefited.
What are the main reasons for the lower frequency of screening?
It is the lack of resources.
What measures can be taken to improve the current situation?
Bihar is very densely populated state and most of the population reside in the rural area. Their nearest health center is Additional Primary Health Center or Primary Health Center. These centers needs to be strengthened by recruiting qualified and trained health workers. The condition of primary health care facilities is improving in recent times but there is still a lack of trained health care personnel and necessary diagnostic equipment. For diagnosis, people are dependent upon district hospitals or tertiary centers.
Do the large hospitals in Patna provide transportation to rural women to visit their centers for screening?
No. There is no transportation facility for investigations. Provision of transportation will definitely improve the early detection of diseases.
What are your thoughts on offering mammograms as a free screening tool?
Mammography is an excellent tool for early detection of breast cancer. But it should be done for women over 35 years of age with mass level awareness program included. Awareness program should be started from school/college level. Print and electronic media has greater penetration now. Meticulous use of these resources may give better results. In addition, there are village level community health workers which work under the Health and Family Welfare Department. They can be used to spread awareness of breast diseases and the benefit of mammograms.
Are mammograms still considered the gold standard for breast cancer diagnosis in India?
Yes, Mammography is still the best tool for early detection of breast cancer and also it is cost effective. Development of Tomosynthesis has also increased the detection rate.
Can you please explain what is Tomosynthesis and how has it increased the detection rate?
Tomosynthesis is advanced X-Ray mammography where thin section of breast is imaged (like CT scan). Any overlapping of breast tissue in normal mammography can be viewed separately in Tomosynthesis. Smaller lesions can be visualized.
Is Digital mammography available in the majority of centers or do you use screen/ film?
Availability of digital mammography is very less. In the state of Bihar, only one digital mammography machine is available. We will be installing one more unit in my institute in a few months. Majority of mammography machines are of analog type (screen/film).
How many mammograms do you do as a part of routine checkup?
Average number of patient per day is 6.
How many of them test positive for breast cancer?
Incidence rate is about 41 patients per 100,000.
Apart from mammograms, what other methods can be used for effective screening without leading to over diagnosis?
MRI is the next modality for the diagnosis. Ultrasound may also be used for screening.
What are your thoughts on high risk screening MRI? When is it used? How does it differ from mammography?
First degree relatives of breast cancer patients are thought to be of high risk and have more chances to develop cancer. So screening of such women is very important. But increased glandular parenchyma in breast at early age reduces the detection rate by X-ray mammography. So breast MRI is the only solution.
Is MRI preferred over mammography for surveillance of neoadjuvant therapies?
Yes. MR Mammography with dynamic contrast scanning has excellent role for the surveillance during neoadjuvant therapy. It shows extent and distribution of the disease and any changes during therapy. It has potential to quantify the primary tumor response.
What are radioactive seeds? Are they commonly used for breast cancer?
Radioactive seeds are small pellets like substance impregnated with low dose radioactive material and it is placed in small lesion under guidance (either under ultrasound or stereotactic mammogram) so that during follow up or surgery, localization of lesions become easy. They are being used in larger centers. We are not using radioactive seeds. It is costly.
In terms of technology/equipment what do you think will benefit the people of Patna?
X-Ray mammography along with Ultrasonography will be adequate for general population. In selected patients breast MRI will also help.
Thank you very much Dr. Suman for taking the time to share your thoughts with us. Your insights are greatly appreciated!