Welcome to Yale Cancer Center Answers with doctors Francine Foss and Anees Chagpar.  Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven.  If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC.  This week, Dr. Chagpar is joined by Prathima Kanumuri.  Prathima is a breast fellow at Smilow Cancer Hospital at Yale-New Haven.  Here is Anees Chagpar.
Chagpar        Many in the audience may know that my day job is Director of the Breast Center at Smilow Cancer Hospital and a breast surgical oncologist. I am also Program Director of our Interdisciplinary Breast Fellowship, which received approval by the Society for Surgical Oncology just a few days ago.  So this is news that you are getting here on Yale Cancer Center Answers first.  Prathima is actually our first official SSO accredited fellow, and so what makes Prathima special is the fact that she has as her goal to go back to India.  Tell us a little about your story Prathima?  Where you grew up?  Where you have trained and what your future ambitions are?
Kanumuri     I was actually born in the United States.  I was born in Brooklyn, Massachusetts but I moved back to India when I was one year old.  So my childhood and medical training were in India, but I moved back to America in 2000 to pursue further medical training.  I completed my general surgery residency at Baystate Medical Center in Springfield, Massachusetts, which is not too far from here, and then I actually moved to India for a couple of years to work at a cancer center in my hometown of Hyderabad, which is one of the major cities in South India.  It was a regional cancer center where I helped take care primarily of patients with upper GI cancers, breast cancer, cervical, other gynecological cancers and head and neck cancer, but it was breast cancer that really caught my interest because during my training in the United States the two cancers I was most exposed to were breast cancer and colon cancer, and what was really eye opening for me was to see how things were done so differently in India, and I just felt that there was huge room, tremendous room, for change and hopefully improvement, and that is why I decided to come back and further pursue training. I have been taking care of breast disease, both benign and malignant, with the intention to go back to help take care of breast patients in India.
Chagpar        That is phenomenal and I want to congratulate you on that ambition.  Tell us more about some of the differences that you see between how breast cancer is taken care of in India versus how it is taken care of here?  Many of us who listen to Yale Cancer Center Answers may never have visited India and while we hear about and we think about how things may be different, none of us really know what it’s like for sure, so give us an inside scoop.
Kanumuri     A little bit about the background of about breast cancer in India, over the last couple of decades the incidence of breast cancer has steadily been growing and it is not just because it is now being documented, it is just because it is on the rise and we are actually noticing more and more patients with breast cancer in their 30s, 40s, and 50s, which was not the case before.  Our census basically
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shows that 60% of the cases were above 50 years of age in the past, but now they are more in the 30 to 50 range which is interesting, and is different from cancer in America.  Apart from that, the other differences that we see are because we do not have very strong screening programs, actually it is not a part of our national initiative at this point and this is unfortunate because most of our patients present with stage III and IV cancers.  50% of our patients present at a later stage, actually it may be even more, and that has a huge effect on how these patients do. Cancer care has improved, but I think most of the improvement has been because cancers are screened and caught earlier so the prognosis has been much better, but that has not been the case in India, and those are some of the differences, and during my training in America I never saw an ulcerative, maybe a patient or two who had ulcerative changes in her breast because of her cancer growing through the skin, but that was pretty common for me to see when I was in India and most patients presented with very significant size masses, more than 5 cm to 10 cm masses with very significant disease in the axilla as well.  So this was very eye opening and most patients got the most aggressive therapy we do for breast cancer now-a-days, which is basically a complete mastectomy along with all of the lymph nodes removed, and that was the most common surgery that we did, which was not the case when I was in America, so those are some of the major differences I saw.
Chagpar        I have, as you know, an interest in international health and the story of people presenting with fungating, ulcerating, large smelly masses growing through their breasts is a story that is not uncommon when I talk to surgeons from other parts of the world, from India, from Nigeria, from Ghana and part of this is that for many of them screening mammography is not as ubiquitous as it is here in the States, but I wonder whether there are other things at play. How is cancer perceived in India?  Is it something that people talk about like they talk about it here? Where October is Breast Cancer Awareness Month and everyone goes out and gets mammograms and people talk about the importance of self-breast exams, or is it something that is a little bit more taboo?
Kanumuri     Things have really changed over the last five years and every time I go back to India, I see a huge difference.  Just looking at the national census now, and unfortunately our registry data is not very complete because it has not been happening like in other countries, we just do not have the resources where people are capturing all the data as far as the incidence and the survival in these patients, but in the data that we have, breast cancer is the leading cancer among women in the urban areas and in the rural areas it is the second most common cancer that we see, cervical being first in the rural areas.  A part of that is that I think awareness has grown exponentially grown with this type of understanding.  People are very aware with the internet and India has definitely been technologically savvy so the awareness has really grown, but as far as screening, we have a long way to go and I think in the past it was a little more taboo and people were not very open.  We still see that in certain patient populations, such as in the rural areas, but definitely in the urban setting there is a lot more openness and there is a lot more awareness, and they do have steady screening programs that are run by different private hospitals, so things are changing and I am very hopeful that we are only heading in the right direction.
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Chagpar        You just mentioned private hospitals. In India is there a system whereby there are the public kinds of safety net hospitals versus the more elite private hospitals, such that the care is different or the screening is different in these two different areas? Do the people with money have more resources and more education than people without?
Kanumuri     Absolutely, we definitely see that difference.  At this time there are no national programs being run for screening of breast cancer available to everybody.  They are trying to work on a few things like teaching social workers about palpating and doing breast exams, and there is an initiative for that, but as far as in the private hospitals and government hospitals that you are asking about, the government hospitals definitely do not have the resources that the private hospitals do and most care happens in India with money that is out of the pocket.  Over the last five years there has been increasing availability of private insurance through employment and also the government is actually providing something similar to a Medicare, or Medicaid in certain states, for certain types of procedures. For example, they have a set amount that they will provide for breast cancer, for chemotherapy, so there will be a set amount and we will have to work within that amount, so those kinds of facilities are becoming more and more available.  We are heading in that direction, but definitely we have our own glitches and problems with it.
Chagpar        Another thing that you have mentioned that I found intriguing was there is the shift in India towards younger women with breast cancer. In the States, as you know, the median age, the average age, at which women will get breast cancer is about 67 and when we see breast cancers occurring in younger women, less than 40, less than 50, we start thinking about genetic risk.  Are genetics something that are screened for or available in India?
Kanumuri     The biggest problem that India faces is we are not really collecting our data.  Yes they have noticed from our census that over the last 20 years there has definitely been a shift in breast cancer in younger patients, but I do not think we have really captured this data and looked at the genetic information behind it. It does happen that people are looking at these things, but it is not really happening with the interest that it should be because we are still caught up on making patients more aware, and we have more significant problems like trying to improve our survival by screening, and we have so many other problems that become important where we need to really focus our energies on that and simultaneously work on trying to understand breast cancer at the molecular level in Indian patients, but that is where I hoping we will head with time.
Chagpar        It is so fascinating to hear about how cancer treatment is different in different parts of the world and it is just a complete delight to have you with us to share this.  When we come back we are going to talk more about breast cancer treatment in India and talk a little bit about what a
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fellowship is and what you hope to gain out of your experience here at Yale, but first we are going to take short break for a medical minute.  Please stay tuned to learn more information about breast cancer care in India with my guest Prathima Kanumuri. 
Minute          The American Cancer Society estimates that the lifetime risk of developing colorectal cancer is about one in twenty and that risk is slightly lower in women than in men.  When detected early, colorectal cancer is easily treated and highly curable.  Men and women over the age of 50 should have regular colonoscopies to screen for the disease.  Each day more patients are surviving colorectal cancer due to increased access to advanced therapies and specialized care, which is giving colorectal cancer survivors more hope than they have ever had before.  Clinical trials are currently underway at federally designated comprehensive cancer centers like the one at Yale to test innovative new treatment for colorectal cancer.  New options include Chinese herbal medicine being used in combination with chemotherapy to reduce side effects of treatment and help cancer drugs work more effectively.  This has been a medical minute and more information is available at yalecancercenter.org.  You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.
Chagpar        Welcome back to Yale Cancer Center Answers.  This is Dr. Anees Chagpar and I am joined tonight by my guest Prathima Kanumuri.  We are discussing breast cancer care, particularly in India, which is Prathima’s home nation.  She is with us here at Yale doing an interdisciplinary breast fellowship before she goes back to India to try to change the world.  Prathima, we were talking a little bit about cancer care in India and I want to delve a little bit deeper into that.  Let’s talk about each of the different disciplines that affect breast cancer patients here in the United States and how things are similar or different in India.  For example, here in America, if a patient comes in with breast cancer, usually this is screen detected and is found on a mammogram and oftentimes they can have breast conserving surgery, where the radiologist can put in a little wire to show us where that cancer is and we can take that little spot out.  You had mentioned in India that people present with much later cancers, but even from an imaging standpoint, from just getting the mammogram from getting the ultrasound from having the capacity to put in that wire, is that available in India?
Kanumuri     One of the problems with India is that we have all the technology available, so there are hospitals with the state-of-the-art machinery, we do everything from MRIs of the breast, we do digital mammography, we do breast tomosynthesis, everything is available, and we do ultrasound. They are able to do biopsies and the major issue really becomes a lack of standardization that happens because there is no uniform standard that all the centers that provide imaging follow, which becomes a problem because the patient is not aware of what the breast mammogram is supposed to do, they do not know if the film is adequate enough to read, the quality of the film, the quality of the monitors.  And this is the kind of thing that is really not monitored and I do not think they are able to pick up appropriately, and there is a huge shortage of radiologists and there is so much of
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an emphasis on just doing general radiology that people are not specifically trained to read and screening is not routinely done, it is becoming more prevalent, but in the past it was not done.  I do not think people have become very good at reading.  So I think the problem with India becomes a discrepancy and the lack of standardization, and it is unfortunate that sometimes that kind of decreases the quality of care that the patient will ultimately get.
Chagpar        Let’s talk a little bit about surgery, patients here get a wide variety of options.  You can have breast conservation or you can have a mastectomy.  If you have a mastectomy, you can have immediate reconstruction, when we look at lymph nodes, we can do a sentinel lymph node biopsy where we can inject a radiotracer and a blue dye into the breast and track right in the operating room those lymph nodes that are the most likely to carry cancer cells are and take those out, and have them tested right at the same time.  We do a lot of different kinds of techniques, many of which relay on other disciplines, how does it work in India for a breast cancer patient?
Kanumuri     Sentinel node biopsy is available, some centers do them, but it is not uniformly available.  Some people are not familiar with the technology and like I said more than 50% of the time it is such advanced disease they end up having to do more aggressive surgery.  The concept of breast conservation has been a little challenging because of advanced disease, but also I think because of the older doctors and the training that they have had, and they really promote that.  It is kind of like how things were done in the United States 25 years ago, and we have had to make this transition from just being very aggressive to now come into doing lesser and so I think that the same transition is happening over there.  I think it is available in very small portions of the institutions and most of them just get more aggressive surgery than necessary, and reconstruction is something that is available, but it is not commonly done.  It is also that the patient does not demand it that much because of lack of education.
Chagpar        The other piece with breast conservation here, is that we really need radiation oncology to be able to provide radiation therapy after breast conservation, is radiation readily available in India?
Kanumuri     It is available in the cities, but definitely in the periphery there is a problem, but radiation is definitely available.
Chagpar        And so for people who live in rural parts of India, where transportation may be an issue, might that sway them than to have more radical therapy?
Kanumuri     Yes, definitely, and I think everybody knows we have a huge population and definitely most of the people live in the peripheries and have difficulties accessing care because of that, which I think is slowly improving, but I still think that at the government level, there is nothing happening as far as helping to provide transportation for these patients to come into the cities.  There are concessions
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available, but I think they still expect the patients to be more proactive and I think sometimes people just get missed in this process and probably are not able to access the care that is needed.
Chagpar        That is pretty sad, and I guess the last of the big disciples in terms of breast cancer care, and there are many of them, but one that is important is with regards to medical oncology, and we frequently hear on Yale Cancer Center Answers people talk about personalized medicine and targeted therapies, and certainly breast cancer has come a long way in terms of Herceptin that can target HER2 and drugs that can target estrogen receptors and advanced lines of chemotherapy and clinical trials that are really pushing the envelope.  Talk to us a little bit about the availability of these medications in India, the availability of clinical trials, and who pays for all of this?
Kanumuri     We do have the receptor, so in all cancers we do test for estrogen receptors and progesterone receptors as well as HER2 receptors, and all the drugs that we have over here are available in India.  We were not very active in trials as of yet, as far as I know.  There are a few that are running through the Tata Memorial Institute and there are certain cancer institutes in the country that things are running through, but in general we are not very active with trials.  The exciting thing about India is the technology is available, we have the medication, we have the resources, unfortunately they are not uniformly available.  I think a lot of it is just the change in the mentality and the change in the awareness and the change in giving the importance to the problem and trying to make a difference and that is what we are struggling with at this point and that was a huge reason why I made the decision to go back to India, because I think it is an important time for us. We have recognized that this is a huge health problem, breast cancer especially as far as cancers, and this is one of the primary problems right now and coming from training in America, and just the exposure I have had, I do realize in breast cancer there are so many aspects to it and it is not a single approach, it is a multidisciplinary approach and that is the main reason why I did general surgery, but I needed specific breast training, especially if I am going back and want play an active role in bringing about these changes. I have to learn to be an expert in that area and have a good understanding of all the different aspects, and that is why I chose to do a fellowship and I think we are going to see a very positive change in India and I think it is going to be a very rapid change and I am really excited about what is going to happen because we have the resources.  We just have to put them to good use.
Chagpar        Talk to us a little bit about education and the educational process because I think that again you are to be congratulated that you were proactive in terms of getting sub-specialized fellowship training to really become an expert in all of the different aspects of breast cancer care.  Is that available in India?  How are people trained in India?  Is breast cancer still being treated by the generalists and do they in fact have enough specialists treating this disease?
Kanumuri     Most of the care is given by a general surgical oncologist in India.  The general surgeons and sometimes even gynecologists participate in taking care of at least benign breast problems.  More
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advanced care will go to a surgical oncologist or a general surgeon and so we do not have specific training programs.  I know there is one training program at Tata Memorial which is in Mumbai, but otherwise there is no specific breast fellowship where you can get good learning just focused on benign and malignant training, taking care of benign and malignant breast diseases, so that was one of the main reasons why I decided to come back to do this here.
Chagpar        If you are going to spend a year here, you are going to learn about breast surgery and medical oncology and radiation oncology and pathology and plastic surgery and imaging and genetics and high risk and palliative care and you are going to go back to India.  What is your plan? How are you going to make a difference, because I can see that you are committed to making a difference in India and I want to know what your first three steps are going to be in order to do that?
Kanumuri     There is a lot of work already happening in India, at the local level and at the national level, so recently there are a lot of awareness programs that go on all the time and also nationally we have the Association of Breast Surgeons of India that was started over the last few years.  So the stage has already been set and when I go back I want to be very active both locally and nationally, and hopefully, international interaction as well and collaboration.  I really want to play an active role in trying to make some of these changes and starting with awareness and screening which are going to be the two big things that I feel like our focus should be on and simultaneously work on other things because the way we are really going to improve breast cancer survival is to try to catch it early and I think standardizing screening programs and our imaging and then how we are going to go about it is I think of primary importance and simultaneously, I would like to obviously offer the best surgical care and work in a multidisciplinary fashion with other colleagues. My dream is to actually have my own breast center where I am able to provide comprehensive care to my patients working with other colleagues that also have a similar outlook on things.
Prathima Kanumuri is a breast fellow at Smilow Cancer Hospital at Yale-New Haven.  If you have questions or would like to add your comments, visit yalecancercenter.org where you can also get the podcast and find written transcripts of past programs.  You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.