If you’re fortunate enough to have been made aware, then you will know that women between the ages of 25 and 40 are encouraged to have annual clinical breast examinations to rule out developing breast cancer. Additionally, all women should consider performing a monthly self-breast exam beginning at age 20 and become familiar with their breasts so that they are better able to notice changes and flag them in order to detect cancers in their early stages to be treated accordingly.
Breast cancer takes the lives of a large number of women each year. Data from 2021 showed that breast cancer accounted for 27% of all female cancers. An average of 4,000-4,500 new cases of breast cancer are diagnosed every year and there has been an increasing trend of breast cancer incidence over the past 25 years in Sri Lanka.
If detected and treated early, breast cancer can be cured with minimal complications with a high five-year survival rate. Studies have even shown that annual mammography screening of women with no symptoms of breast cancer has lowered the number of women who die from the disease by about 30%. Early treatment also results in greater possibilities of conservative surgery preserving body image as well as less aggressive treatment options, leading to a better quality of life for survivors.
Beyond immunohistochemistry
TLC (Touch, Look, Check) is the stock advice that women are given and it is well recommended to follow with. However, what happens when you find yourself to be suffering from symptoms and are eventually diagnosed with breast cancer?
According to Consultant Clinical Oncologist Dr. Nuradh Joseph, things really do not end at your first diagnosis. He shared that when it came to the management of many cancers, including breast cancer, further diagnostics were imperative for treatment. He further stated that molecular diagnostics played a role in the management of many cancers.
From left: Prof. Ryhana Raheem, Surangani Ratwatte, Dr. Nuradh Joseph, Mala Thalyasinhgam, and Sharona Naizer
“The first step is to confirm if it is cancer or not – that is a very basic test. Then the second level of testing is what we call immunohistochemistry, which is also a pretty routine test now. This is where we employ routine hormone receptor testing, look for a molecule called HER2, and identify whether the breast cancer is sensitive to hormones and whether the cancer will be sensitive to the newer drugs. This testing is available in the Government sector,” Dr. Joseph said, adding that despite this test being a basic one, owing to the current situation they were facing some challenges in carrying out this test.
The doctor then shared that, even following this immunohistochemistry, there could still be some uncertainty. “Sometimes it is not clear. You then need to do another test to confirm it further,” he said, simplifying what is a complex mechanism to share that we must then do another test called In Situ Hybridisation (ISH).
He said that Sri Lanka, up until very recently, would carry out this second level of testing in India as we did not have the resources to carry out the testing here. The samples would be flown to India and the cost would be borne by the patient.
“Not every patient can afford this often and because of the dollar rate fluctuating, it is even more expensive. We actually have the drug – the medication to treat the cancer. It’s the testing that requires this expense,” he said. He added that for some patients, their immunohistochemistry test was very clear and they could go ahead with treatment, however those whose test was equivocal had to definitely do the next test.
Meanwhile, a new pilot project has been implemented thanks to a few stakeholders where the existing machinery that is already in use can be utilised to carry out this second level of testing with the use of what Dr. Joseph referred to as certain “reagents,” which also come at a cost. These essential reagents have been donated by a charitable organisation, මිතුරුවැල පිලිකා සහායක ජාලය (Mithuruwela Cancer Support Network).
Why it’s important
The Mithuruwela Cancer Support Network is a charitable organisation comprising cancer survivors. Its Chairperson Mala Thalaysingham said the organisation had been founded by cancer survivors and that it provided assistance to those suffering from cancer and Sri Lankan cancer service providers and mechanisms.
From left: Prof. Ryhana Raheem, Surangani Ratwatte, Dr. Nuradh Joseph, Mala Thalyasinhgam, and Sharona Naizer
Thalaysingham said that they used to carry out awareness programmes for estate workers and other rural areas to educate women. “We would take a few nurses with us and carry out examinations during these awareness programmes and we would carry out other activities in the field with rural hospitals, including some in Jaffna, Badulla, Trincomalee, Anuradhapura, etc.,” she noted, adding however that all of these activities had been forced to come to a halt due to the pandemic.
While Mithuruwela raised the funds to purchase the reagents, following the dollar rate fluctuation it had to raise more funds as the amount required had risen further, coming up to about Rs. 2 million. Thalaysingham stated that she was incredibly thankful to the donors who had made this pilot project possible. Sharing her personal experience with breast cancer, she said that emphasis must be placed on this testing. She said that during her diagnosis and the eventual management of her treatment, it had been later revealed that if she had access to this level of testing, then perhaps she may not have had to lose her breasts.
“My diagnosis was not that correct. I lost both my breasts when it really wasn’t necessary. If we had access to more advanced testing, consequences such as this could be avoided,” she shared, noting that she was appreciative of the treatment she had received and similar to herself, all other cancer survivors who are a part of Mithuruwela were striving toward disseminating as much information and assistance as possible to ensure that cancer treatment in Sri Lanka kept getting better and more accessible to the general public.
The pilot project
With regard to the current pilot that is underway on introducing this new type of testing, Dr. Joseph reiterated the significance of this entire project. “We are just implementing this new method. To get a new allocation from the Government is usually difficult, therefore once we are able to show the success of the project and the potential of carrying it out here, we are confident that Government funding will be allocated,” he said. “This was all in the works well before this financial crisis; Mithuruwela donated it so we could do the pilot, to make it easier to convince the Government to fund this.”
“Right now the Government does not have the funds to provide for this, but Mithuruwela has sponsored up to 100 tests and we might actually be able to do more. It would also show that it is much cheaper than sending it abroad,” he added.
The pilot will be carried out at the Anuradhapura Teaching Hospital and once they have completed the 100 tests, they are confident they will be able to implement a sustainable plan for this type of testing.
Anuradhapura Teaching Hospital Department of Histopathology Pathologist Dr. Jayanjana Asanthi, who will be overlooking the project, said that they were yet to initiate the project as they had faced some delays in receiving the reagents.
She said that owing to the current country situation, the lack of fuel had delayed the transportation of the reagents to the hospital. However, she noted that they were expecting the reagents to reach the hospital within this week, which would allow them to get started in initiating the pilot immediately.
Considering the future of molecular testing, Dr. Joseph shared that the Apeksha Hospital – National Cancer Institute, Maharagama was currently in the process of developing a dedicated molecular testing facility. He noted that the setting up of this facility was taking time owing to the various challenges facing the country. However, for the time being, they are able to carry out this test with these reagents that have been donated and may even be able to economise on the chemicals in such a way that they can double the number of tests that can be carried out.
Dr. Joseph also spoke about the impact of the current situation on cancer treatment in general, noting that to mitigate the severity of issues relating to the shortage of certain medication, the College of Oncologists had issued a list of essential drugs. “These drugs are absolutely necessary and we are working with the Ministry so that they are made available, which will allow the management of most cancer curative treatments. It is a cost-effective list, leaving out many of the more expensive drugs. At the moment we are relying on the Indian credit line to get these drugs,” he said.
