The cancer load off your chest

Let us, for a moment, ignore the debate on femininity, which has been going on since Angelina Jolie disclosed that she had gone in for a double mastectomy. Let us also ignore the cheers from across the world for her brave decision to risk her career and go public about the surgery. Instead, let us look at the issue purely from a clinical point of view.

Breast cancer is the most common cancer in urban India and accounts for 25-33 per cent of all cancers in women. Which is why it is critical to understand whether a genetic test, such as the one Jolie underwent, and mastectomy - or the surgical removal of a breast- can reduce and maybe even eliminate the risk.

Cancer in the genes: Five to 10 per cent of all cancers have familial, or genetic, risk association. "Mutation in the two genes, BRCA1 and BRCA2, has been identified as a major cause of familial breast and ovarian cancer, increasing the risk to 85 per cent," says I C Verma, head of department, medical genetics, Sir Ganga Ram Hospital, Delhi. Around one in every 500 women is said to have a mutation in BRCA1 or BRCA2. Verma suggests that if breast or ovarian cancer develops in a young parent, when she is under 50, then her daughter should go in for a genetic test. Ideally, the test for gene mutation should first be conducted on the mother. If she tests positive, younger female relatives should also be tested.

The mutation could be in either of the genes. "If not, then certain other genes such as p53, which is also called the housekeeping gene (or 'the guardian of the genome'), and CHEK2 should also be tested for mutation," says Verma. The gene p53 functions as a tumour - especially malignant tumour - suppressant. Abnormality in CHEK2 also increases the risk of developing breast cancer by three times.

Most major hospitals in India offer genetic screening facility. The screening is mostly done through blood sample, "though saliva sample is equally good," says Saleem Mohammed, co-founder of the Chennai-based Xcode Life Sciences, which has a DNA-based programme to assess genetic makeup. "The larger the gene, the more expensive the test," says Saleem.

The tests for screening BRCA1 and BRCA2 genes cost around Rs 60,000 (Rs 25,000-35,000 for each gene). The test results take about a month. The test, says Saleem, can be conducted at any age because the person is born with the mutation, though some doctors advise against genetic screening in very young girls.

The surgery question: If there is a family history of cancer and the genetic test shows a faulty gene, should a woman go for preventive mastectomy? "Yes, it is advised," says Verma. "This will bring down the risk by 80-85 per cent, though it won't eliminate it altogether." There is still a minor risk of the cancer developing in the armpit or the skin left behind. Also, mastectomy alone isn't enough. Mutation in these genes also increases the risk of ovarian cancer. "So, if the woman does not intend to have more children, she should ideally also get the ovaries surgically removed," says Verma. This is precisely what Jolie is doing.

A mastectomy costs Rs 1-3 lakh and takes between one and two hours. If the lymph nodes are also being removed, then the surgery can take longer. Immediate breast reconstruction is possible (and popular) or it can be opted for at a later date. This costs over Rs 2 lakh.

Verma says women with family history of breast cancer should start screening early - about five years before the youngest member of the family developed cancer. "So, if the mother or aunt had cancer at the age of, say 35, the daughter or niece should start screening for it at age 30." Screening includes yearly mammography which costs Rs 5,000-7,000.

The doctor explains why Indian women are susceptible to breast cancer. "Jews were found to have very high incidence of breast cancer. Studies later showed that three genetic changes were behind this. One particular mutation seen in the Jewish population is also common in Indian women," says Verma.

After mastectomy, which is generally safe and seldom has any serious side-effects, avoid strenuous activity and driving till the doctor gives a go-ahead. The person might experience pain or tightness in the breast area for some time after the surgery. There could also be temporary numbness and tingling in the upper arm.

Most people return to work in a month or a month-and-a-half.