BREAST CANCER SCENERIO IN NEPAL

Breast cancer is the second most common malignancy among Nepalese women. Breast cancer places a substantial burden on the Nepalese healthcare system, but information regarding the number of women living with breast cancer is not well recorded. In countries with lower levels of resources such as Nepal, breast cancers are commonly diagnosed at late stages and women may receive inadequate treatment, pain relief or palliative care. Socioeconomic disparities and insufficient financial resources hinder prevention of breast cancer in Nepal. The incidence of breast cancer is increasing in the developing world due to increased life expectancy, urbanization and adoption of western lifestyles.

However, till date, due to socioeconomic disparities, insufficient financial resources obstacles to cancer prevention, early detection, and treatment services the prevention of breast cancer has not been well conducted in Nepal.As a developing nation, Nepal is faced with several challenges with regards to the care of patients with breast cancer with inadequate funding; the uneven distribution of resources and services; inadequate numbers, training and distribution of health-care personnel and equipment; and a lack of adequate care.

Current Status of Breast Cancer in Nepal

Using the Globocan 2018 estimates of cancer incidence and mortality, in 2018 an estimated 2068 new breast cancer cases were diagnosed in Nepal.

There is multi-institution hospital-based cancer registry in Nepal, but population-based cancer registry is still in its infancy. Various population-based studies performed in different parts of Nepal have demonstrated that the common age of breast cancer patients was 40-50 years. Breast cancer occurs at a younger premenopausal age in Nepalese and Asian women compared to western women who get it more than a decade or later.

breast cancer stat in nepal

Breast cancer screening in Nepal

Most of the Asian countries, including Nepal have not initiated population-based breast cancer screening programs. Early cancer detection could reduce breast cancer death rates significantly in the long-term. Breast self-examination is still considered effective methods for early detection of breast cancer. The overall knowledge level of breast self-examination among Nepalese women was low to moderate. In remote areas of Nepal women’s disbelief that events are governed by fate and no one could change the course of the events. These kind fatalistic attitudes are responsible for late detection of breast cancer in Nepal. More efforts are required in creating awareness and to increase knowledge among women in order to detect early breast cancer and enhance prevention strategies that would decrease the burden of breast cancer in Nepal. Along with breast self-examination the clinical breast exams performed by well-trained clinicians, is paramount for early detection of breast cancer.

 In asymptomatic women screening mammography is most commonly used tool for the detection of early breast cancer and mammography screening could significantly reduce breast cancer mortality. Diagnostic mammogram is available at only few centers in Nepal and there is no nationwide systematic program for breast screening at the present time. 

Modalities of treating breast cancer

The main forms of breast cancer treatment are: surgery, radiation therapy, chemotherapy, hormone therapy, targeted therapy and bone-directed therapy. These treatments can also be classified into local therapy (surgery and radiotherapy) and systemic treatment (chemotherapy, endocrine, and targeted therapies). Late stage diagnosis of breast cancer is common in Nepal and most commonly used treatment modalities for breast cancer in Nepal are surgery, radiotherapy, chemotherapy and endocrine therapy. Depending on staging and biologic characteristics of the tumor and patient choice surgical treatment of invasive breast cancer may consist of breast conserving or total mastectomy with or without reconstruction. Surgical treatment of breast cancer in Nepal has changed over time with the evolution of Oncoplastic breast surgery and availability of expertise on particular field. Previously most of the breast cancer cases were managed with either radical or modified total mastectomy. However, now days most of Nepalese women prefer breast-conserving surgery over total mastectomy with robust evidence supporting breast conserving strategies.

The information obtained from pathologic examination of the lymph nodes obtained from axillary lymph node dissection plays an important role in the determine the pathologic staging of the disease and is an integral part of the treatment of breast cancer. Although axillary lymph node dissection has largely been practiced by many hospitals in Nepal, this technique is currently replaced by sentinel lymph node biopsy (SLNB) in some centers.

Radiotherapy is typically administered to the breast following conservation surgery, but the use of breast reconstruction and postmastectomy radiotherapy has increased over the past decade. Radiotherapy is one of the essential treatment modalities for breast cancer, for both curative and palliative intent in Nepal.

 Treatments such as chemotherapy, hormonal therapy, and targeted therapy are used as systemic treatment for breast cancer. The aims of systemic treatment are to palliate symptoms, prolong survival, and improve quality of life. Anthracyclines and taxanes are the two most active classes of cytotoxic agents for early and advanced stage breast cancer and are the mainstay in first-line treatment of breast cancer in the adjuvant, neoadjuvant and metastatic settings.

Hormonal therapy has significantly improved outcomes for patients with early-and advanced-stage hormone. receptor (HR)-positive breast cancer. Endocrine therapies such as tamoxifen have revolutionized the treatment of breast cancer, while aromatase inhibitors such as anastrozole and letrozole significantly improve disease free and distant disease-free survival.

The HER2 protein is most commonly overexpressed receptor in breast cancer and therapies targeting HER2 have revolutionized the treatment of breast cancer. Trastuzumab is the first-generation targeted therapy drug and has been used widely to treat women with HER2- positive breast cancer. Trastuzumab, pertuzumab, trastuzumab-emtansine, and lapatinib are currently approved HER2-targeted agent for breast cancer.These targeted agents are not the concerns in Nepal, where people are not able to afford even trastuzumab.

Challenges in breast cancer prevention and future directions

In low income countries like Nepal economic burden of breast is negatively impacting healthcare budgets. The financial impact of breast cancer may be much worse in future and affected patients are at increased risk of financial hardship. The role multidisciplinary treatment team is becoming vital in the management of breast cancer patients. However, in Nepal a significant percentage of patients still do not have the opportunity to meet with Breast Cancer specialist in most of the hospitals. Authorities should prioritize the establishment of multidisciplinary treatment teams which will help patients to understand all the components of their breast cancer treatment prior to starting treatment and this increased knowledge may have an impact on treatment decisions regarding surgery for breast cancer.

Majority of the Nepali women are living in poor conditions and cannot afford expensive screening tests and Illiteracy is also a major cause of breast cancer among women because women have no awareness about personal hygienic conditions. Adopting healthy lifestyle, including limiting alcohol consumption, maintenance of ideal body weight, regular physical activity, and avoidance of postmenopausal hormone replacement therapy, may reduce breast cancer incidence. Rural women are at risk of late stage breast cancer due to poor education and lack of awareness, fear, familial and social stigma, myths and misconceptions, neglect, and fear the potential loss of the breast.

 Using media and including men while creating awareness about women’s issues to promote an attitude change regarding breast cancer in women are quite important for effective breast cancer control. Some limited studies in Nepal have shown that the awareness level about risk factors and early detection measures of breast cancer among Nepalese women such as clinical breast examination (CBE) and breast self-examination (BSE) was low. Furthermore a cross-sectional study conducted in western Nepal among higher secondary students found that the students have a poor knowledge on many breast cancer risk factors, symptoms and curability and most of them had misleading information about age, early menarche and delayed menopause as the risk factor. In Nepal cancer prevention, education, and access to cancer screening tests as well as cancer treatment are inadequate. In collaboration with national and international organizations government should develop a policy and guidelines for effective control of breast cancer in all seven provinces of Nepal.

Conclusion

Breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death among women. The detection of breast cancer in Nepal is significantly delayed leading to diagnosis at advanced stages associated with poor prognosis. It is urgent to have a national breast cancer program in Nepal, while at local level is necessary to raise awareness of the symptoms and their attitudes towards treatment. Due to the unavailability of a population-based cancer registry it is difficult to precisely predict of future incidence rates. Hence government should initiate a population-based cancer registry in at least every province of Nepal.