Over the years, with efforts from various department members, and help from various collaborating individuals, departments and organizations, following activities relating breast health have been carried out:
Breast Health Care Delivery at SGPGI
The Breast clinic at SGPGIMS has been offering counseling, screening and diagnostic services to a large number of women, mostly those at particular risk of developing breast cancer. The department has developed comprehensive economically viable, evidence based scientific and culturally appropriate screening, diagnostic, treatment and follow-up protocols and guidelines (Annexure 1) for breast cancer patients for use at the institute, as well as by surgeons and primary care health workers in rest of the state. The clinic has been treating about 1000 patients of benign breast disease and about 120 patients with breast cancer every year. There are some 1200 breast cancer patients on follow-up in the clinic treated over last one decade. In close collaboration with the departments of Radiation oncology, Radio-diagnosis, Pathology and Nuclear Medicine, the department of Endocrine and Breast Surgery provides a comprehensive and state of art Protocol based management plan for breast cancer patients.
With addition of new facilities, techniques and procedures- the breast clinic of the department of Endocrine Surgery that used to be run just once a week until 1999, now runs five days a week from Monday to Friday- offers clinical and operative care for entire spectrum of benign and malignant breast conditions and diseases. Please refer to Annexure 2 for some details and data of activities. The volume and quality of the services being offered have shown a consistent up-trend, and these include:
- Clinical and investigative diagnostic services, counseling and advise to patients with benign and malignant breast conditions.
- Breast surgery- breast conservation/ mastectomy procedures for breast cancers; sentinel lymph nodes studies using a combination of blue dye and radio-pharmaceutical; breast reconstructive surgery
- Adjuvant treatment: chemotherapy, hormone treatment , interstitial and external beam radiation therapy (Dept of Radiation Oncology), and targeted biological therapy.
- Supportive and rehabilitative treatment: In collaboration with departments of Radiation Oncology, Anesthesia and pain management, Hematology and Transfusion medicine, basic supportive and palliative management of advanced breast cancer is being provided. Efforts to involve NGO’s and other social organizations in this endeavor have borne limited success. However, the department is well aware of the short comings in this direction, and a full-fledged palliative care and hospice facility is felt imperative for appropriate and adequate services.
About a third of all breast cancer patients are now treated with a breast conservational approach and this proportion has steadily risen over past five years. Majority of our patients however continue to present in locally advanced stages, and about a fifth of all have metastatic disease at presentation. Being a tertiary care referral center, this hospital may be seeing a wrong end of the spectrum of breast cancer in our society as a result of referral bias towards advanced and metastatic disease. All these patients are managed with multi-modality comprehensive protocols with reasonable outcomes, and there have been strong indicators towards improving outcomes in regard to survival and quality of life over recent few years. An informal system of a support group of breast cancer patients and survivors has been functioning in the hospital for past 3 years, where breast cancer survivors and volunteers- mostly members of the medical and nursing staff of the institute, and volunteer ladies from a non-governmental organization help patients and family members understand the nature and outcome of breast cancer treatment.
Breast Cancer screening and Early detection
The breast clinic at SGPGI has been offering counseling, clinical and imaging screening for breast cancer and other breast conditions to an ever increasing number of women, concentrating mostly on individuals with higher perceived risk, though not denying the services to any woman who seeks such advise and care.
Teaching and training for trainees at SGPGI, Conducting CME’s - “SGPGI Breast Courses”
Breast surgery and oncology related contents make an integral part of the regular departmental teaching and training curriculum and schedule for the residents. In the past 5 years, these have constituted substantial proportion of the seminars, journal club presentations, interdepartmental case conferences and case presentations (please refer to Annexure 2).
Over last decade, 7 in-service surgeons have received short-term training in Endocrine & Breast surgery in the department. Numerous requests are received every year for short to intermediate term training from surgeons from Asian and African countries, as well as from various parts of India. In most cases, the lack of a diploma/ certificated course in breast surgery and the fact that the Institute does not grant a certificate of short term training have been deterrent for these surgeons. At present, applications from 3 surgeons- one each from Philippines and Saudi Arabia, and one from Ahmedabad are pending with the institute authorities.
The SGPGI Breast course have been reasonably successful in attracting a large number of surgical and oncology trainees and practicing surgeons and physicians. The quality of deliberations at both the editions of the breast course have been praised by one and all. The department is committed to continue with the breast course in future, with contentious and interesting issues for discussion.
Research activities
The department faculty members have undertaken numerous research projects (2extra-mural, 5 intra-mural), and have been able to get research grants to the tune of Rs 35 lacs approximately from various agencies. Besides, they have been involved with many more collaborative research projects, drug trials, and other studies collaborating with researchers from other institutions like CDRI, ITRC, KGMU, Lucknow and other departments of SGPGIMS. (Refer to Annexure 2). The department is committed to training of health care providers in the region to develop expertise in breast cancer screening/early detection, diagnosis and treatment, with special emphasis on addressing peculiar local situations arising out of the socio-cultural, economic and nutritional circumstances of the society the institute caters to.
The clinical research conducted by the department has led to a better understanding of the disease behaviour in young Indian ladies with breast cancer, specifically their discrepant hormone receptor status and hormone responsiveness. Our work has resulted in publication of a few short clinical reports on interesting aspects of breast cancer in Indian patients (list of breast related publications enclosed). The department is actively pursuing interests in sentinel lymph nodes studies in node negative early breast cancer and post-chemotherapy LABC patients, and is engaged in a multi-center North Indian validation trial of these studies, of which Dr Gaurav Agarwal is one of principal co-ordinators. The department is a participant in the Adjuvant Tamoxifen- Long Against Short (ATLAS) international multi-centric trial. In collaboration with members of the “Indian Breast Group” which is comprised of prominent breast researchers in the country, efforts are on to undertake a few multi-center trials targeting issues such as appropriate hormone intervention in locally advanced and metastatic pre-menopausal hormone receptor negative patients, and role of surgical oopherectomy versus hormone therapy. The department has been a participant in IBG research studies, as well as in a few drug trials concerning locally advanced and metastatic breast cancer patients.
Research being conducted in the department is aimed at addressing the research questions relating breast carcinogenesis such as the relationship of iodine deficiency and breast carcinogenesis; and the use of biochemical bone turn-over markers in prediction of skeletal metastases and monitoring response to therapy in such patients. We have reported findings linking expression of human Sodium iodide symporter gene and iodine uptake and organification in breast cancer tissue- in-vitro and in-vivo have given rise to a hope of utilizing radio-active iodine as a targeted radiation therapeutic strategy in breast cancer patients. A few other basic research studies are underway in which the department is collaborating with basic scientists in other departments of the institute and other research institutions in the vicinity, such as “study of Gene polymorphism of GSTT1 and GSTM1 null type in breast cancer”, under way in collaboration with scientists at the Indian Toxicology Research Institute, Lucknow.
Selected publications
- Agarwal G, Pradeep PV, Aggarwal V, Yip CH, Cheung PSY. Spectrum of Breast cancer in Asian women. “World J Surg” 2007 ePub March 26 2007. PMID: 17387549
- Upadhyay G, Singh R, Agarwal G, Pal L, Pradhan PK, Das BK, Mishra SK, Godbole MM. Functional Expression of Sodium Iodide Symporter (NIS) in human breast cancer tissue. "Breast Cancer Res Treatment", 2003;77:157-165. PMID: 12602914
- Agarwal G, George RK, Gupta SK, Dutta NR, Mishra SK. Use of Biochemical bone turnover markers for predicting bone metastases and monitoring of therapy in breast cancer patients: preliminary report. (abstract) “J Japan Surg Soc” 105: 2004.
- Agarwal G, Upadhyay G, Singh R, Godbole MM, Mishra SK. Evidence of a Breast specific iodine transport mechanism in breast cancer tissue. (abstract)“J Japan Surg Soc” 104: 2003.
- Das BK, Pradhan PK, Agarwal G, Mishra SK, Godbole MM, Nagbhushan S. Study of the pattern of inhibition of sodium iodide symporter (NIS expression) in thyroid, normal human breast and breast cancer. World J Nucl Med 2002 Sept; 1(Suppl. 2): S34
- Pradhan PK, Das BK, Agarwal G, Mishra SK, Godbole MM. Study of effect of potassium perchlorate on the expression of sodium iodide symporter (NIS) in human breast cancer. Eur J Nucl Med 2002 Aug; 29 (Suppl. 1): S235.
- Khanna HD, Singh S, Agarwal G, Khanna R, Singh LP, Khanna R, Khanna S. Intra nuclear estrogen receptor and its clinico-pathological correlation in breast cancer patients. “Cancer Biophys Biochem”, USA, 1996; 15(3): 141-149. PMID: 8937738
- George RK, Agarwal G, Mishra SK. Consequences of axillary recurrence of early breast cancer. British J Surg, 2002 Nov; published online 25/11/02.
- Mishra AK, Agarwal G, Agarwal A, Mishra SK. Occult Breast Cancer: A Report of four cases and Review of Literature. “Indian J Cancer” 2001 Mar; 38: 49-54. PMID: 14758886
- Baxi M, Agarwal A, Mishra A, Agarwal G, Mishra SK. Multiple bilateral giant juvenile fibroadenomata of breast. “Eur J Surg”, 2000; 166(10):826-30. PMID: 11071174
- Agarwal G, Mishra SK, Dutta NR, Jain M. Occult squamous carcinoma of the axillary tail of breast presenting as isolated axillary lymph nodes mass. "Eur J Surg", 2000;166(2):177-179. PMID: 10724499
- Misra AK, Mishra A, Agarwal A, Agarwal G, Mishra SK. Occult breast cancer- a management dilemma. "Annals Endocrine Surg", 1999;4(4).
- Agarwal R, Mishra AK, Agarwal G, Agarwal A, Mishra SK. Diabetic Breast Ulcer: Unique observations.
J Assoc Physicians India (Accepted) - Mishra A, Agarwal G, Agarwal A, Mishra SK. Giant fibroadenomata of breast: management options. J Ind Med Assoc (Accepted)
- Agarwal R, Agarwal G, Mishra AK, Agarwal A, Mishra SK. Carcinoma of the male breast: clinico-pathological profile. Indian J Cancer (Accepted)
Community Activities
The department has been conducting numerous breast cancer awareness and detection camps in and around Lucknow, as well as at distant places such as Uttaranchal. Some 33 such camps/ meetings have been conducted in last 6 years, with help from NGO’s such as the Cancer-aid society, and social organizations like the Lions International. Please refer to Annexure 2.
Efforts are mostly focused on educational institutions and other organizations where addressed ladies are in a position to come in contact with large number of other women, and thus disseminate messages received at the breast health awareness campaigns to a wider audience. In this endeavor, the department is helped by a non-governmental organization which looks after the organization of such breast health awareness community campaigns and also provides financial assistance to needy cancer patients. In the campaigns conducted during the last 3 years, over 6000 women were addressed, and about 1200 given a screening physical examination by a team of surgeons and nurses. 83 ladies with breast lumps and other lesions were advised needle aspiration cytology and / or mammography/ breast ultrasonography. Seventeen of these ladies have been operated upon with 3 confirmed infiltrating cancers, and rest with benign lesions. These efforts have brought about a perceptible difference in the attitude of women towards the breast diseases, and many have started shedding their social and cultural barriers to seek medical advice for a wide spectrum of breast conditions. However, these efforts can only be considered just a beginning, and a huge proportion of our population still remains out of reach of such activities.