Dr.(Mrs.) S. Muthulakshmi Reddy

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BREAST CANCER IN INDIA CANCER INSTITUTE EXPERIENCE
Dr.(Mrs.) S. Muthulakshmi Reddy 1886-1968 Founder
Cancer Institute (WIA), Chennai, India
2
Carcinoma of the Breast Estimated Annual Burden
in 2005 Global 1,218,000 45 Occur in
Developing Countries India 79,000 Source
GLOBOCAN 2002, IARC
3
Breast cancer CIR Risk World Pattern
India
Registry Period CIR One in
Chennai 2001-02 26.1 32
Bangalore 2001-02 20.0 33
Mumbai 2001-02 22.8 33
Source NCRP Consolidated Reports
Affluent countries
Registry Period CIR One in
U.S. White 1993-97 134.1 10
U.K. Oxford 1993-97 124.6 11
Finland 1993-97 114.1 13
Japan, Miyagi 1993-97 48.1 29
Other Developing countries
Registry Period CIR One in
Colombia, Cali 1992-96 29.6 24
Brazil, Goiania 1988-92 38.1 18
Philip,Manila 1983-87 34.2 17
Peru, Trujillo 1988-92 22.3 32
Source Parkin et al., 2002 CI5, Vol VIII, IARC
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Trend of ASR of Breast Cancer in Indian
Registries (1982-2002)
Trend of ASR of Cervical and Breast Cancers
Urban India 1982-02
Period Cervix (Cx) Breast (Brt) Cx Brt
1982-86 29.0 20.7 1 0.71
1987-91 26.8 22.8 1 0.85
1992-95 23.9 24.0 1 1.01
1996-02 19.8 24.8 1 1.25
Age Standardised Rate
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ASR of Breast Cancer in India
Registry Period Urban Rural
Tamil Nadu
Chennai 2001-02 28.6
Dindigul 2003 12.0
Karnataka
Bangalore 2001-02 26.6
Kerala
Trivandrum 2000 26.5
Karunagapally 1993-01 16.1
Maharashtra
Mumbai 2001-02 27.4
Barshi 2001-02 10.3
Age Standardised Rate Source Individual
Registry Reports, 1993-02
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CARCINOMA BREAST, 1993-97 AGE GROUP DISTRIBUTION
()
INDIA INDIA Developing Countries Developing Countries Affluent Countries Affluent Countries
LESS THAN 40 YEARS LESS THAN 40 YEARS LESS THAN 40 YEARS LESS THAN 40 YEARS LESS THAN 40 YEARS LESS THAN 40 YEARS
Chennai 20.8 Philippines 18.0 U.K. 6.5
Mumbai 22.0 China 13.6 USA 6.1
Bangalore 19.8 Thailand 23.5 Finland 4.6
Japan 8.4
India over 20 Affluent countries about 6
INDIA INDIA Developing Countries Developing Countries Affluent Countries Affluent Countries
MORE THAN 65 YEARS MORE THAN 65 YEARS MORE THAN 65 YEARS MORE THAN 65 YEARS MORE THAN 65 YEARS MORE THAN 65 YEARS
Chennai 19.3 Philippines 16.7 U.K. 41.0
Mumbai 21.1 China 27.0 USA 45.7
Bangalore 15.6 Thailand 13.3 Finland 39.3
Japan 26.5
Source Parkin et al., 2002 CI5, Vol VIII
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CARCINOMA BREASTDISTRIBUTION () BY MENSTRUAL
STATUS
Country, Registry Pre-menop Post-menop
India, Chennai (2002) 45.0 55.0
Philippines, Manila 48.7 51.3
Thailand, CMai 57.9 42.1
USA, SEER, Black 34.1 65.9
USA, SEER, White 22.2 77.8
UK, Oxford 24.7 75.3
Japan, Miyagi 39.9 60.1
lt50 years of age ?50 years of age Source
Parkin et al., 2002 CI5, Vol. VIII, 1993-97
Menstrual status Receptors in Breast
cancer Cancer Institute (WIA)
Menopausal status No. Receptor Receptor
Menopausal status No. ER ve ER -ve
Pre menopausal 753 38.5 61.5
Post menopausal 1203 41.5 58.5
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Stage Distribution Carcinoma Breast 1960-1999
HBCR
Stage 1960-79 1960-79 1980-89 1980-89 1990-99 1990-99
Stage No. No. No.
I 17 1.6 30 1.4 58 1.7
II 185 17.0 447 21.3 884 26.6
III 523 48.2 908 43.2 1371 41.2
IV 178 16.4 454 21.6 412 12.4
SNP 182 16.8 262 12.5 600 18.0
Total 1085 100.0 2101 100.0 3325 100.0
No change in stage of disease
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Carcinoma Breast 1960-99 - Cancer
Institute(WIA), Chennai
All cases accepted for treatment (All Stages
All modalities of trt)
Period No. of Cases Overall Survival () Overall Survival () Disease Free Survival () Disease Free Survival ()
Period No. of Cases 5 Yrs. 10 Yrs. 5 Yrs. 10 Yrs.
1960-75 776 35.0 24.3 29.3 21.5
1976-89 2503 49.3 35.7 44.5 31.8
1990-95 1767 60.6 46.8 47.8 36.8
1996-99 1558 66.3 57.3 55.7 46.3
Trend 6604 ? ? ? ?
? survival by ? calendar period statistically
significant
9 year survival
All cases accepted for treatment (Stages
llB-IIIB), LABC
Period No. of Cases Overall Survival () Overall Survival () Disease Free Survival () Disease Free Survival ()
Period No. of Cases 5 Yrs. 10 Yrs. 5 Yrs. 10 Yrs.
1960-75 456 35.7 22.9 29.5 19.8
1976-89 1429 49.2 34.2 44.7 30.5
1990-95 1024 64.3 49.0 50.9 38.5
1996-99 949 67.7 60.0 56.8 47.5
Trend 3853 ? ? ? ?
? survival by ? calendar period statistically
significant LABC 58.3 of all cases
9 year survival
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Carcinoma Breast 1990-99 - Cancer
Institute(WIA), Chennai
5 Year Survival among neo-adjuvant concurrent
CTRT followed by surgery (LABC) n1259
CMFANTHRA (1259 cases) (5 year survival) CMFANTHRA (1259 cases) (5 year survival)
OS DFS
75.9 64.6

CMFANTHRA (1259 cases) (10 year survival) CMFANTHRA (1259 cases) (10 year survival)
OS DFS
63.6 52.5
Stage CMF CMF CMF Anthracycline Anthracycline Anthracycline
Stage No. OS DFS No. OS DFS
II B 353 84.8 74.7 22 81.2 72.2
III A 338 73.2 63.3 53 83.2 74.2
III B 270 69.4 55.4 90 61.4 47.4
IV 22 63.0 39.7 7 35.1 28.6
Unstaged 101 84.3 73.5 3 100.0 66.7
Total 1084 76.8 65.5 175 70.2 58.4
Includes CMF, ANTHRA cases Excision
done outside cases OS Overall Survival DFS
Disease Free Survival Stage IIB, III A III B
constitutes 59.3 of all cases
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Carcinoma Breast 1990-99 - Cancer
Institute(WIA), Chennai
Study of Tumour response by type of chemotherapy
among neo-adjuvant (LABC) n1259 Tumor Sterility
Type of chemo No. of cases Tumour residue (TR) Tumour residue (TR) Tumor Sterility ()
Type of chemo No. of cases Present () Absent () Tumor Sterility ()
CMF 971 529 (54.5) 442 (45.5) 45.5
Anthra 171 102 (59.6) 69 (40.4) 40.4
Includes CMF ANTHRA Excludes ETNM Cases (117)
Study of path. Node response by type of
chemotherapy among neo-adjuvant (LABC)
n1259 Nodal Downstaging
T-status Clin. nodes Pathological node (PN) response Pathological node (PN) response Pathological node (PN) response Pathological node (PN) response Pathological node (PN) response Pathological node (PN) response
T-status Clin. nodes CMF CMF CMF ANTHRA ANTHRA ANTHRA
No. PN- () PN () No. PN- () PN ()
Any T CN- 87 72 (82.8) 15 (17.2) 11 7 (63.6) 4 (36.4)
CN 995 593 (59.6) 402 (40.4) 163 77 (47.2) 86 (52.8)
Includes CMF ANTHRA Excludes axillary
clearance not done cases(3)
Node sterility CMF gt Anthra Statistically
significant Occult met. CMF lt Anthra No
statistical difference
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Eliciting independent prognostic factors for
survival among neo-adjuvant cases (LABC),
n1259 Carcinoma Breast 1990-99 - Cancer
Institute(WIA), Chennai
Variables No Hazard Ratio 95 (Confidence Intreval)
Clinical Node
-ve 98 1.00
ve 1161 1.29 (0.79 2.09)
Path. Node
-ve 749 1.00
ve 507 2.67 (2.14 3.34)
Tumour Residue
Absent 579 1.00
Present 656 1.13 (0.90 1.43)
Type of Chemotherapy
CMF 1084 1.00
Anthracycline 175 1.15 (0.85 1.54)
plt0.05 Includes CMF, ANTHRA cases

• Path node status emerges as the only independent
  prognostic factor for survival from breast cancer
• 2.7 folds ? risk of dying among ve cases
  compared to ve cases
• statistically significant

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Carcinoma Breast (1990-99) LABC Overall
Survival by Calendar Period Neo adjuvant and
Adjuvant
Period Neo-Adjuvant Neo-Adjuvant Neo-Adjuvant Neo-Adjuvant Neo-Adjuvant Adjuvant Adjuvant Adjuvant Adjuvant Adjuvant p-value
Period No. OS () OS () DFS () DFS () No. OS () OS () DFS () DFS () p-value
Period No. 5 Yr. 10 Yr. 5 Yr. 10 Yr. No. 5 Yr. 10 Yr. 5 Yr. 10 Yr. p-value
90-95 751 77.8 63.8 65.0 52.0 342 59.8 46.3 46.8 37.1 lt 0.001
96-99 777 78.0 68.3_at_ 69.3 55.1_at_ 265 68.4 60.4_at_ 61.3 43.4_at_ 0.05
90-99 1528 78.0 64.9 67.2 54.3 607 63.4 50.7 53.0 42.3 lt 0.001
_at_ 9 year survival Includes CMF, ANTHRA, OTHERS
PRE OP-RT ONLY cases
Survival by neo-adjuvant significantly ? than
adjuvant in all calendar periods
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Carcinoma Breast 1990-99 - Cancer
Institute(WIA), Chennai
Survival by family income (All treated cases,
n3325)
INCOME GROUP No. of Cases Overall Survival () Overall Survival () Disease Free Survival () Disease Free Survival ()
INCOME GROUP No. of Cases 5 Yrs. 10 Yrs. 5 Yrs. 10 Yrs.
500 1760 62.6 48.6 49.0 38.5
501-5000 1295 61.5 49.4 51.3 39.7
gt5000 270 75.1 61.9 66.8 48.9
SURVIVAL BY INCOME GROUP STATISTICALLY
SIGNIFICANT
Survival by Education (All treated cases, n3325)
Education No. of Cases Overall Survival () Overall Survival () Disease Free Survival () Disease Free Survival ()
Education No. of Cases 5 Yrs. 10 Yrs. 5 Yrs. 10 Yrs.
IllitPri 1744 62.5 48.7 48.7 37.4
MidSec 1253 61.9 48.8 52.6 41.1
College 328 72.0 61.4 60.5 47.8
SURVIVAL BY EDUCATION STATISTICALLY SIGNIFICANT
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ONGOING PROGRAMMES

• Hereditary cancer detection and prevention
  programme
• Genetic polymorphisms in breast cancer

HEREDITARY CANCER DETECTION AND PREVENTION
PROGRAMME

• The first in the country.
• Components
• Population based Hereditary cancer registry
• Comprehensive hereditary cancer registry
• Mutation analysis for relevant genes (entire
  coding region of BRCA1, BRCA2, MSH2, MLH1)

FUTURE PROGRAMS PLANNED

• Gene expression studies in breast cancer using
  microarray based technology development of low
  density arrays, relevant to our population for
  routine use, for predictive and prognostic
  applications,.