As I reflect on International Women's Day, I am compelled to address a topic that is close to my heart: the glaring gender disparities within India's healthcare sector. As a surgical oncologist with over two decades of experience, I have had the privilege of witnessing countless women defy the odds and conquer cancer with unwavering strength and resilience. These women, just like their male counterparts, navigate the complexities of treatment with grace and fortitude, proving time and again that gender is no barrier to triumph over adversity.

Yet, despite the remarkable achievements of women, we cannot ignore the sobering reality that they continue to be underrepresented in leadership positions. This observation is not merely anecdotal; recent reports indicate that women occupy a mere 18% of leadership roles in India's healthcare sector, earning significantly less than their male counterparts.

I firmly believe that achieving gender parity goes beyond mere representation; it is about ensuring that women have equal opportunities to contribute meaningfully and be included in decision-making processes on a daily basis. Too often, women may hold leadership titles but find themselves sidelined when it comes to pivotal decisions that shape the direction of their organizations.

In my career, I have been fortunate to work in environments that prioritize inclusivity and empower women to thrive. At Fortis Hospital Bannerghatta Road, we have cultivated a culture that values diverse perspectives and fosters collaboration at every level.

However, I have also witnessed firsthand the biases that persist within our healthcare system, where the head of the family, often male, predominantly dictates the choice of doctor for their family members. This tendency frequently leans towards selecting male doctors, reinforcing traditional gender roles in decision-making processes.

This International Women's Day, let's not merely pay lip service to the idea of gender equality. Let us commit to dismantling the systemic barriers that hinder women's advancement in healthcare. It is time to challenge the status quo and advocate for tangible changes that ensure every woman has a seat at the table, where our voice is heard and our contributions are valued.

The road ahead may be daunting, but I am optimistic that together, we can create a healthcare sector that celebrates the diverse talents and experiences of women. Let's harness the collective power of our voices to drive meaningful change and pave the way for a more inclusive future.

References:

Breast cancer, a formidable adversary, has transformed countless lives, challenging individuals to confront their mortality and redefine their sense of self. As a surgical oncologist in India, having performed over a thousand surgeries with a remarkable success rate, I have witnessed first-hand the transformative journey that follows a breast cancer diagnosis. In this article, I aim to shed light on life after breast cancer, emphasizing the importance of early detection, empowerment, and embracing the newfound perspective that accompanies survivorship.

Breast Cancer:

It is crucial to understand that breast cancer is a diagnosis, not a definition. It is as normal as any other aspect of life, and while it may leave an indelible mark, it does not define one's identity.

Two things to remember here:

Navigating Towards the Right Medical Practitioners:

- In the journey towards early detection, individuals often face obstacles due to a lack of awareness and proactive healthcare-seeking behavior. In the existing scenario both healthcare providers and the public have to be educated about the importance of vigilant screening as it is crucial to ensure abnormalities are identified through screening and are pursued with the urgency they demand.

Early Detection: The Cornerstone of Battle Against Breast Cancer:

- Early detection is paramount in the fight against breast cancer. Conducting regular screenings every year significantly enhances the chances of identifying cancer in its early stages, facilitating timely intervention and ultimately improving patient outcomes.

For those who embark on the journey of survivorship, life takes on a renewed sense of purpose and appreciation. Having navigated the challenges of breast cancer, survivors emerge with a newfound resilience and perspective that transcends the confines of illness.

Life After Breast Cancer: A Journey of Resilience

- Survivors emerge with a newfound resilience and appreciation for life's blessings.

- They value their health and life more profoundly, recognizing the fragility of existence and seizing each day as a precious gift.

Transformation and Empowerment

- Overcoming breast cancer fosters a profound transformation within individuals.

- Survivors embrace their vulnerabilities and strengths, discovering a newfound sense of purpose and identity.

The New You: Confidence and Self-Awareness

- The journey of survivorship instills confidence and self-awareness in individuals.

- Liberated from fear and uncertainty, survivors celebrate their journey and embrace life's challenges with grace and determination.

In conclusion, breast cancer is not merely a medical diagnosis; it's a transformative journey that reshapes lives and perspectives. Through early detection, empowerment, and resilience, individuals can navigate the challenges of breast cancer and emerge stronger and more resilient than ever before.

As a testament to the indomitable human spirit, breast cancer survivors embody courage and hope, inspiring us all to embrace life's challenges with grace and determination. Together, let us continue to raise awareness, support survivors, and strive for a future where breast cancer is no longer a threat to life and well-being.

#ForAWomanByAWoman

Ovarian cancer is a serious condition and unfortunately, many women aren't diagnosed until later stages. As surgical oncologists, we see far too many cases where ovarian cancer reaches Stage 3 before detection. Early diagnosis is crucial for successful treatment, and a major hurdle in achieving this is the inherent difficulty in diagnosing ovarian cancer due to the nature of its symptoms. In this article, we'll explore the challenges of early detection and some of the common symptoms that can often be misleading.

Ovarian Cancer: The Deceptive Symptoms*

Ovarian cancer is often referred to as the "silent killer" because its symptoms are frequently vague and easily confused with other, less serious conditions. These common symptoms include:

1.     Bloating

2.      Feeling full after eating even small amounts:

3.     Urinary urgency or frequency

4.     Changes in bowel habits, such as constipation or diarrhea

5.     Pelvic or abdominal pain

6.     Pain during sexual intercourse

These symptoms can be readily attributed to gastrointestinal issues, urinary tract infections, or even menstrual irregularities. This misinterpretation can lead to delays in seeking proper evaluation, and ultimately, a later diagnosis. Unfortunately, there is currently no reliable screening test for ovarian cancer, making awareness and early detection even more critical.

Also, for women with an increased risk of ovarian cancer, such as those with a family history of breast or ovarian cancer, genetic syndromes linked to these cancers, or BRCA1/BRCA2 gene mutations, regular screening may be recommended by their oncologist. This screening typically involves a combination of transvaginal ultrasound and CA-125 blood tests performed at specific intervals, often every six months.

The Call to Action: Be Your Own Advocate

As a healthcare professional, I urge all women to be proactive about their health. If you experience any of the symptoms listed above, and they persist or worsen over a period of 8-12 weeks, insist on a thorough checkup with your doctor. Early detection can significantly improve the chances of successful treatment.

Spreading Awareness for a Brighter Future

There is a significant gap in public awareness regarding ovarian cancer. By openly discussing the challenges of diagnosis and the importance of early detection, we can empower women to advocate for their health and fight back against this silent threat.

Let us work together to spread awareness about ovarian cancer and encourage regular checkups. Early detection saves lives.

#ForAWomanByAWoman

* It's important to note that these are just some possibilities, and the experience can vary from woman to woman.

As a surgical oncologist in India, I am deeply encouraged by the recent push from our government to prioritize cervical cancer prevention. The proposed national vaccination program for girls aged 9-14, announced by Finance Minister Nirmala Sitharaman in the 2024-25 Interim Budget and the discussions between Prime Minister Narendra Modi and Bill Gates regarding wider access to the vaccine, signal a turning point in the fight against this preventable disease.

Cervical cancer (mostly caused by HPV) continues to be a significant public health concern for Indian women. Witnessing its devastating impact first-hand motivates me to advocate for proactive measures like HPV vaccination. This safe and effective vaccine has the potential to significantly reduce cervical cancer cases, saving countless lives and alleviating immense suffering.

While cervical cancer remains a leading concern for women, the human papillomavirus (HPV) poses a broader threat, encompassing a range of malignancies in both men and women. Here, I delve into the importance of HPV vaccination, addressing common misconceptions and highlighting its potential to safeguard the health of our future generations.

Beyond Cervical Cancer: The Spectrum of HPV-induced Cancers:

The HPV vaccine offers a powerful shield (from ages 9 yrs to 45 yrs) against not just cervical cancer, but a multitude of HPV-induced malignancies. These include:

Vulvar and vaginal cancers: These cancers affect the external and internal structures of the vagina, respectively. Research suggests a strong association between HPV and these cancers, emphasizing the preventative role of the vaccine.

Anal cancer: This cancer develops in the rectum and anus. Studies conducted by the Indian Council of Medical Research (ICMR) have shown a rising prevalence of anal cancer, particularly among young adults. HPV vaccination offers a crucial preventive measure.

Oropharyngeal cancers: These cancers develop in the back of the throat, including the base of the tongue and tonsils. A 2020 study published in the Journal of Clinical Oncology India reported a significant increase in HPV-positive oropharyngeal cancers in India, highlighting the need for broader HPV vaccination coverage.

Penile cancer: This cancer affects the penis, and HPV is a recognized risk factor.

Genital warts: Although not cancerous, they can be a source of discomfort and can sometimes progress to cancerous lesions.

The recent study published in The Lancet Oncology projected that a national single-dose HPV vaccination program for girls in India could significantly decrease cervical cancer incidence by over 80% within a few decades. This research underscores the effectiveness of the vaccine in preventing a major women's health concern. However, expanding HPV vaccination coverage to include boys offers an opportunity for a more comprehensive approach to HPV prevention.

Empowering Both Genders: Dispelling Myths and Prioritizing Equity

Traditionally, HPV vaccination programs have primarily focused on girls. However, recent research and public health considerations emphasize the importance of vaccinating boys as well. Here's why:

HPV Doesn't Discriminate: Anyone sexually active without vaccination is susceptible to HPV-related cancers, regardless of gender.

Men's Health Matters Too: HPV is a significant contributor to head and neck cancers in men. Unlike a Pap test for women, there's currently no reliable screening test for these cancers in men. Early vaccination becomes even more crucial for preventing these cancers. A study published in the Indian Journal of Cancer reported a high prevalence of HPV in head and neck cancers among Indian men, emphasizing the need for HPV vaccination.

Herd Immunity for a Stronger Community: Widespread vaccination of both genders fosters herd immunity, providing indirect protection to those who haven't been vaccinated or who have compromised immune systems. This creates a safer environment for the entire community.

In recent years, India has witnessed a beautiful shift towards inclusivity, with many individuals from the LGBTQ+ community feeling empowered to embrace their identities openly. However, it's crucial to acknowledge that certain health considerations might require a more nuanced approach.

Here's where HPV vaccination becomes particularly important. This vaccine protects against a range of HPV-related cancers that can affect not only women, but also men, and especially those with a broader range of sexual partners. By ensuring wider HPV vaccination coverage, we can create a more comprehensive safeguard against these cancers for all individuals, regardless of sexual orientation or gender identity.

This isn't about singling out any specific community – it's about promoting a preventive healthcare measure that benefits everyone. HPV vaccination empowers individuals to take control of their health and reduces the overall risk of HPV-related cancers across the population. Let's embrace inclusivity in healthcare as well, ensuring everyone has access to this potentially life-saving tool.

Addressing Concerns and Ensuring Safety

The recommended age for HPV vaccination in India is 9 years. Studies conducted in Andhra Pradesh and Gujarat demonstrated the vaccine's safety and immunogenicity in the Indian population. However, it's important to address concerns regarding side effects and program implementation:

Open Communication: Open communication with healthcare providers can address anxieties and ensure informed decisions about vaccination. Healthcare professionals play a vital role in educating parents and young adults about the benefits and safety of HPV vaccination.

Cost and Accessibility: Making the vaccine more affordable and readily available across all socioeconomic brackets is crucial to improve vaccination rates. Government initiatives and healthcare partnerships can play a key role in ensuring equitable access to the vaccine.

Single-dose vs. Multi-dose Regimen: Recent research suggests that a single-dose HPV vaccination regimen may be as effective as the traditional two-dose regimen. Studies like the one published in The Lancet Oncology provide valuable data on the potential benefits of a single-dose approach, which could enhance program feasibility and cost-effectiveness.

Conclusion: A Collective Effort for a Healthier Future

By prioritizing HPV vaccination for both boys and girls, we can significantly decrease the burden of HPV-related cancers in India. Research findings and ongoing studies provide valuable evidence for the vaccine's effectiveness.

Let us work together to leverage this momentum and build a healthier future for the women of India.

Reference: https://www.thelancet.com/

Ovarian cancer is a formidable adversary in the realm of women's health, often proving to be one of the most lethal gynecologic cancers. Despite advances in medical science, the prognosis for ovarian cancer patients remains stark, with less than half surviving beyond five years post-diagnosis. In this article, we delve into the complexities surrounding ovarian cancer, exploring the reasons behind its lethality and the critical need for early detection and screening methods.

Understanding Ovarian Cancer:

1. Pathogenesis: Ovarian cancer begins when healthy cells in the ovaries undergo abnormal changes, leading to uncontrolled growth and tumor formation. Unlike some other cancers, early-stage ovarian cancer typically presents with minimal or no symptoms, making early detection challenging.

2. Late-stage Diagnosis: Due to the lack of distinct symptoms in the early stages, ovarian cancer often goes undetected until it has progressed to an advanced stage. At this juncture, treatment becomes significantly more challenging, and the prognosis becomes considerably grimmer.

3. Survival Rates: The overall 5-year survival rate for epithelial ovarian cancer remains dishearteningly low, hovering around 30% for decades. Despite efforts to improve treatment modalities, the lack of an effective screening test for early-stage disease continues to impede progress in improving survival rates.

Challenges in Early Detection:

1. Symptom Recognition: Ovarian cancer symptoms are often nonspecific and can easily be mistaken for other benign conditions. This further complicates the early detection process, as patients may not seek medical attention until the disease has progressed significantly.

2. Screening Limitations: Unlike some other cancers, such as breast or cervical cancer, there is no routine screening test for ovarian cancer that has demonstrated sufficient efficacy in detecting early-stage disease. Current screening methods, such as transvaginal ultrasonography and measurement of biomarkers like cancer antigen 125, have limitations and may not reliably detect early-stage ovarian cancer.

Opportunities for Improvement:

1. Enhanced Screening Protocols: There is an urgent need for the development of more effective screening methods for early-stage ovarian cancer. Research efforts focused on identifying novel biomarkers and imaging techniques hold promise in improving early detection rates and ultimately enhancing patient outcomes.

2. Patient Education and Awareness: Empowering women with knowledge about the signs and symptoms of ovarian cancer is crucial for early detection. Healthcare providers should prioritize educating patients about the importance of seeking medical attention promptly if they experience symptoms suggestive of ovarian cancer.

3. Collaborative Approach: A multidisciplinary approach involving healthcare providers, researchers, and advocacy groups is essential for advancing the field of ovarian cancer detection and treatment. By collaborating on research initiatives and sharing knowledge and resources, we can accelerate progress towards improved outcomes for ovarian cancer patients.

In conclusion, ovarian cancer remains a formidable challenge in women's health, characterized by its lethality and the challenges associated with early detection. Addressing these challenges requires a concerted effort from healthcare providers, researchers, policymakers, and patients themselves. By investing in research, enhancing screening protocols, and promoting patient education and awareness, we can strive towards better outcomes for individuals affected by ovarian cancer.

Breast cancer is the leading cause of cancer death in women worldwide. Because being a woman and advancing age are the most significant risk factors for breast cancer, screening is considered an essential part of women's health care.

The goal of screening for cancer is to detect preclinical disease in healthy, asymptomatic patients to prevent adverse outcomes, improve survival, and avoid the need for more intensive treatments. Screening tests have both benefits (e.g., improved health outcomes) and adverse consequences (e.g., cost, anxiety, inconvenience, false-positive results, and other test-specific harms such as overdiagnosis and overtreatment).

Mammography screening is the only method presently considered appropriate for mass screening of asymptomatic women. Screening modalities include imaging, a physical examination completed by a health care provider, and self-examination. Imaging modalities may include mammography, sonography, magnetic resonance imaging (MRI), and most recently, tomosynthesis and contrast-enhanced mammography

 The ACS (American Cancer Society) recommends annual screening for women ages 45 to 54, biennial or annual screening for women ages 55 and older, and the opportunity to begin annual screening at age 40. Current NCCN guidelines also recommend that women at average risk for developing breast cancer begin screening mammography at age 40

Limitations of Mammograms

Overall, the sensitivity for breast cancer detection by mammography is 85%. However, in women with dense breast tissue it is reduced to 47-64%. Mammograms are the best breast cancer screening tests we have but have their limits. For example, they aren’t 100% accurate in showing if a woman has breast cancer: 

• A false-negative mammogram looks normal even though breast cancer is present.
• A false-positive mammogram looks abnormal even though there’s no cancer in the breast.

A false-negative mammogram looks normal even though breast cancer is present. Women with dense breasts have more false-negative results which is the case in younger women. It gives a sense of security even though cancer is there.
A false-positive mammogram looks abnormal even though no cancer is actually present and which is more commonly observed in younger women with dense breast. Abnormal mammograms require extra testing (diagnostic mammograms, ultrasound, and sometimes MRI or even a breast biopsy) to find out if the change is cancer and it can cause anxiety too.

Mammograms can pick up cancers which needs to be treated but it’s possible that some of the cancers would never grow or spread. Finding and treating cancers that would never cause problems is called overdiagnosis. These cancers are not life-threatening, and never would have been found or treated if the woman had not gotten a mammogram. Overdiagnosis leads to some women getting treatment that’s not really needed which is called overtreatment. Doctors don’t know which women fall into this group when the cancer is found because they can’t tell which cancers will be life-threatening and which won’t ever cause problems. Because of this, all cases are treated. Because mammograms are x-ray tests, they expose the breasts to radiation. The amount of radiation from each mammogram is low, (0.4msv) but it can still add up over time.

Nevertheless, mammography is an impactful tool and is effective in all women but women with high breast density(younger women) are often screened with ultrasound, because mammograms of women with dense breast tissue (younger women) tend to be harder to interpret. For this reason, ultrasound is frequently a diagnostic imaging method for women under 35.

The usual indications for breast ultrasound would be a suspicious finding on mammography or for further diagnostic evaluation of a palpable lesion felt on a clinical breast exam.

Breast MRI is not recommended as a routine screening tool for all women at average risk of developing breast cancer. However, it is recommended for screening women who are at high risk for breast cancer, usually due to a strong family history and/or a mutation in genes such as BRCA1 or BRCA2. If you are considered high-risk, you would have breast MRI in addition to your annual mammograms.

Breast MRI is more sensitive than mammograms but a major disadvantage is that breast MRI screening results in more false positives — in other words, the test finds something that initially looks suspicious but turns out not to be cancer. If breast MRI were adopted as a screening tool for everyone, many women would end up having unnecessary biopsies and other tests. That is why current recommendations reserve breast MRI screening for high-risk women only. MRI is also more expensive than mammography, and dedicated breast MRI screening equipment is not widely available.

Despite the potential drawbacks of mammography, it remains the gold standard and continues to be the only method of breast cancer screening proven to reduce mortality.

Cervical cancer is one of the most common women cancers in developing countries like India. As we know that women with early-stage cervical cancer who undergo radical hysterectomy show an excellent 5- year disease free survival rates. Over the last few years, there is wider acceptance of minimally invasive hysterectomy over open abdominal approach. This provides a perfect platform for systematic review and meta-analyses comparing the risk of recurrence and death between patients who underwent minimally invasive vs open radical hysterectomy for early stage cervical cancer.

Brief overview of this meta-analysis

Roni Nitecki at al. reviewed and analysed various observational studies from multiple data sources that used survival analyses to compare outcomes after minimally invasive and open radical hysterectomy in patients with early-stage cervical cancer. All relevant studies related to this topic were searched in various search engines like ovid medline, ovid embase, pubmed, scopus and web of science (from inception to march 2020)

Studies fulfilling following criteria were included in analysis

1. Enrolled adult (18 years) with stage IA1 to II A as per FIGO 2009 (irrespective of histologic type)
2. Studies which compared overall survival or disease-free survival or disease-free progression.
3. Studies which used a survival analyses method
4. Reported median follow up of at least 24 months
5. Had New castle Ottawa scale score of 7 points or higher and was interpreted as being of good quality.

 Studies fulfilling these above criteria were thoroughly analyzed which was approximately 1428 in number, to which inclusion and exclusion criteria were applied and 863 studies were excluded and 49 articles were retrieved. Finally, 15 articles were selected after excluding confounding factors, poor quality studies and duplicated populations.

Pros and cons of the meta-analysis

Pros

1. Present meta-analysis is a large analysis conducted so far and included studies that were not included in prior meta analyses
2. Study addressed to minimize confounding factors by demographic factors and tumor characters like stage and size.

Cons

1. Low to moderate heterogeneity was found in estimates of hazard of recurrence and mortality associated with minimally invasive surgery.
2. Many studies included laparoscopic and robotic as minimally invasive surgeries which greatly depends on various factors like surgeons learning curve, selection of cases, operative techniques which were not analyzed in studies.

Conclusion

Data from 9499 patients who underwent radical hysterectomy were included in the meta-analyses. Of these 49% of patients received minimally invasive surgery. Of these patients who received minimally invasive surgery, 57% received robot-assisted laparoscopy. The total recorded recurrences in all the studies included is 530 and death in 450. It was observed that pooled hazard of recurrence or death was 71% higher among patients who underwent minimally invasive radical hysterectomy compared with those who underwent open surgery. No association was found between the prevalence of robot-assisted surgery and the magnitude of association between minimally invasive radical hysterectomy and hazard of recurrence or death or all-cause mortality.

Finally, the systematic review and meta-analyses concluded that among patients undergoing radical hysterectomy for early-stage cervical cancer, minimally invasive radical hysterectomy was associated with an elevated risk of recurrence of and death compared with open surgery.

COVID -19 is a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and spreads through human-to-human transmission first emerged in Wuhan, China, in December 2019. On March 11, 2020, the World Health Organization (WHO) declared that COVID-19 has become a global pandemic which means that disease spread widened and cases were present in multiple countries.

The pandemic has created a number of challenges for healthcare professionals across the globe. From doctors to nurses, the last seven months have been extremely difficult for those involved in delivering treatment and care. Social distancing norms, lockdowns, fear of contracting the virus have added to the stress and anxiety of patients. This is more severe in the case of cancer patients. Over the last few months many cancer patients have delayed their treatment due to the fear of contracting the virus. On the other hand, oncologists have faced challenges in delivering treatment due to changed protocols, social distancing norms, travel restrictions and many other changes. This pandemic has posed many challenges to the routine delivery of safe oncological treatment to all cancer patients including screening, diagnosis, treatment, follow ups and supportive care.

Breast cancer is one of the most common cancers and most of the patients are facing challenges at various steps of their treatment. One of the key challenges that patients and oncologists face is when a patient gets diagnosed with COVID. For instance, a young 29-year-old girl was diagnosed with rapidly growing breast sarcoma (type of malignant tumor). We were planning for a simple procedure without any flap (plastic surgery) cover so as to start her adjuvant treatment as early as possible. Unfortunately, her preoperative COVID-19 test turned out to be positive and we had to postpone her surgery till she became negative. After two weeks when she was taken up for surgery her tumor had almost doubled in size and we had to take plastic surgical help to provide necessary cover post resection. This not only delayed her entire cancer treatment but also had become difficult to manage as the cancer had progressed. This also creates severe psychological trauma for the patient. Same was the cause with another 64 year patient who had to delay her chemotherapy treatment when she tested positive for the disease.

Some of the main problems faced are as below

Delay or avoidance of hospital visit: A number of times even if patients notice a lump on the breast, they tend to ignore it and delay seeking consultation. This is mainly due to the fear of contracting COVID infection by visiting a hospital. Due to the delay in seeking consultation, there is an increasing number of locally advanced and metastatic breast cancer as compared to early breast cancer being diagnosed these days. Unless the lump is quite large with significant symptoms, patients tend to avoid visiting hospitals. According to a recent survey, almost half of breast cancer patients experienced delays in cancer care and treatment as a result of the present pandemic due to various reasons.

Changes in hospital experience: Patients who visit the hospital for consultation and treatment often have to follow strict social distancing norms. Not many family members are allowed into the hospitals. This makes the whole experience quite lonely for them. They tend to miss the physical and emotional support of their family and friends during treatment and consultation. Dealing with the treatment, stressing about contracting the infection, the lack of human touch and physical support during hospital visits and a number of other aspects can mentally impact the patients. Now is the time they need more support. Patients must seek help from mental health professionals who can help them talk about what they are going through. Family members must step up and ensure that the patient is eating healthy and talking to their loved ones to overcome anxiety.

Fear of treatment: Due to compromised immunity due to chemotherapy or because of the disease, cancer patients are at high risk of catching the infection. They are inherently immunosuppressed from their malignancy and therapies which they are undergoing. A number of patients delay their treatment and consultation due to fear of visiting the hospital and contracting infection. Patients and their families must understand that treatment cannot be delayed for cancer. It’s important to balance the risk of exposing themselves to COVID-19 with the risk of advancement or progression of disease.

Continuity of consultation and treatment: Oncologists across the country have had to make significant changes in their treatment protocols and consultation procedures in order to meet the changes in the current environment. To ensure continuity of treatment, oncologists are now offering tele consultation services to help patients manage the disease better. Though oncologists have successfully adapted to tele consultation and other modes to interact with their patients, it becomes fairly challenging to ensure continuity of conversation with their patients. The effectiveness of in person consultation can never be replaced with tele consultation. This is a challenge that oncologists have been continuously working to address.

Financial challenges: The pandemic has led to job losses and decreased incomes for many families. Covering the cost of the treatment and consultation, managing insurance in case of job losses, travel expenses for those from other towns all these factors creating financial difficulties for patients and their families.

After having faced pandemic for more than six months most of the cancer centers have initiated recommended cancer treatment as per the guidelines with fewer deviations following all the precautionary measures. Major challenge is if a patient is diagnosed with COVID before or during the treatment which imposes threat of delay in treatment and progression of the disease is unavoidable. Hopefully, with better drugs available and possibly even vaccines, we can give cancer patients a more level playing field to complete their cancer treatment.

Worldwide, obesity has become a major public health crisis. Although smoking is the most common cause of death that can be prevented, obesity is the second most common.

Endometrial cancer is the most common invasive neoplasms of the female reproductive system in most developed countries with increasing incidence in urban India.

Overweight and obesity not only increase the risk of cardiovascular disease and type-2 diabetes, but also are now known risk factors for a variety of cancer types. Among all cancers, increasing body mass index is most strongly associated with endometrial cancer incidence and mortality but lacks the awareness.

The most frequently mentioned risk factors, which are associated with the occurrence of endometrial cancer are obesity, infertility, high blood pressure, diabetes, liver disease, hormone active tumors of the ovary, and the use of external estrogen.

Obesity is not only associated with increased incidence of endometrial cancer but has also been related to ovarian, breast and colon cancers. It may also be linked with other cancers, including esophageal, pancreatic and kidney (renal).

RELATIONSHIP BETWEEN OBESITY AND CANCER; MECHANISM HOW OBESITY FUELS CANCER

Obesity is defined by the World Health Organization as body mass index> 30 kg / m2 (BMI> 30 kg / m 2 ). In obese patients with overweight from 9.5 to 23 kg develops three times more often endometrial cancer compared to women with normal weight, those over 23 kg overweight frequency of occurrence increases tenfold.

Obese women definitely have an increase in estrogen, which is a hormone that makes some cancers grow.

The association between obesity and endometrial cancer begins with visceral fat, a complex endocrine organ whose components secrete an array of adipokines that induce intermediate effects leading to increased endometrial proliferation and promotion of tumorigenesis. Additionally, adipose tissue contains mesenchymal cells that can be recruited to support tumor growth and progression.

In premenopausal women, cyclic ovarian expression of estrogen further stimulates endometrial proliferation. After menopause, peripheral tissues, especially adipose tissue (fat), becomes the principal site of estrogen synthesis.

 Estrogen and it’s metabolites act to interact with DNA to produce an accumulation of double-stranded DNA breaks to contribute to genetic instability which finally leads to tumor formation.

Type 2 diabetes, also strongly associated with obesity, results in elevated levels of insulin and insulin-like growth factor (IGF)-1, as well as hyperglycemia, all of which contribute to endometrial cancer pathogenesis. In the endometrium, insulin and IGF-1 are characterized by hyperactivity and increased signaling in pathways associated with the development of endometrial cancer.

Obesity also stimulates production of a variety of pro-inflammatory adipokines and cytokines that increase endometrial cancer risk.

So, molecular mechanism of obesity contributing to increased incidence of cancer is fairly well understood.

WHAT SHALL WE DO?

It is important to realize that a large weight loss will reduce cancer risk.

Life style modifications, dietary changes, regular exercises should be inculcated to maintain healthy body weight. Multiple interventions have demonstrated efficacy to ameliorating obesity and, by extension, associated endometrial cancer risk.

Bariatric surgery has demonstrated the ability to achieve dramatic and sustainable weight loss in obese individuals. More specifically, a recent meta-analysis of six observational studies showed a 60% reduction in endometrial cancer risk among obese women who underwent bariatric surgery.

Progestin medications counteract estrogen's proliferative effects on the endometrium, and progestin-containing oral contraceptives have a well established protective effect against endometrial cancer. Intrauterine devices, including those without embedded progestins, also have shown an ability to reduce the risk of endometrial cancer.

Surgery is a principal component of treatment for endometrial cancer. However, obesity can complicate surgery and other clinical management strategies. Obesity not only directly complicates surgery, but obesity-associated medical comorbidities also increase the risk of perioperative complications.

In the end, the message that should be getting out to women is to avoid sedentary lifestyles and maintain a more appropriate/ideal weight, and to plan weight loss for women who are overweight or obese as a means of overall health maintenance.

Screening mammography is considered to be the most recommended way to detect breast cancer; however when it comes to screening cancer for younger women, this method is not considered to be the best option.

Breast cancer can affect at any age, hence cancer screening even at early age is essential. Usually, younger women, do not consider themselves to be at risk of suffering from breast cancer, so they tend to ignore the symptoms. There are several factors that can put young women at high risk from this disease such as:

1.  Family history of breast cancer,  particularly in a mother, daughter, or sister
2. Women who carry genetic defects are also at great risk
3. History of radiation therapy

Breast cancer is one of the few cancers when detected early and treated appropriately, can be completely cured. Normal life after breast cancer treatment is possible but the pre-requisite is early detection. When detected early, the treatment becomes simpler, shorter and cheaper. And more importantly complete cure is possible.

For the early detection of breast cancer, regular mammograms are not recommended by the doctors for women under 40 because breast tissue tends to be denser in young women, making mammograms less effective as a screening tool. Hence, screening mammograms may be recommended only for younger women with a family history of breast cancer and other risk factors.

To detect this disease early, there are certain guidelines recommend by the medical experts, which can help in detecting cancer early for the timely and effective treatment. Doctors recommend monthly self-breast examination (SBE) and annual clinical examination for >20 years aged women. It has to be done on seventh day of the periods. However, women who have achieved menopause or have undergone hysterectomy or have irregular periods need to do it on a particular date of the month.

 Younger women generally have dense breast tissue making mammogram interpretation challenging; hence other modalities are still being explored.  Contrast enhanced MRI is highly sensitive (99% when combined with mammography) can lead to malignant changes.

 While performing the self-examination, if the person finds a breast lump or an unusual discharge from nipples, must not be ignored. It is essential to seek help immediately but all lumps, skin changes or nipple changes do not necessarily mean it is cancerous.  It is essential to approach the right specialist (Breast oncologist) to detect the right symptoms.

Nowadays new methods are experimented to detect breast cancer among younger women, one of the methods are iBreast Exam (iBE). This instrument is a hand held pre-screening device that can be used in resource constraint area and women with suspicious features can further undergo mammogram. iBE is based on piezoelectric detector, which can be effectively used by non clinician with a sensitivity of 60%.

Breast cancer in men is rare but this is the potential cause of neglecting the symptoms as more priority is given to women than men due to the high risk found among women. Mostly, male breast cancer is detected between the ages of 60 and 70 and they are at higher risk when they are exposed to radiation, has a family history of breast cancer, a genetic mutation, and having high estrogen levels. Early detection can be achieved with MRI or ultrasound.