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The incidence of breast cancer is increasing rapidly in urban India due to the changing lifestyle and exposure to risk factors. Diagnosis at an advanced stage and in younger women are the most concerning issues of breast cancer in India. Lack of awareness and social taboos related to cancer diagnosis make women feel hesitant to seek timely medical advice. As almost half of women develop breast cancer at an age younger than 50 years, breast cancer diagnosis poses a huge financial burden on the household and impacts the entire family. Moreover, inaccessibility, unaffordability, and high out-of-pocket expenditure make this situation grimmer. Women find it difficult to get quality cancer care closer to their homes and end up traveling long distances for seeking treatment. Significant differences in the cancer epidemiology compared to the west make the adoption of western breast cancer management guidelines challenging for Indian women. In this article, we intend to provide a comprehensive review of the management of breast cancer from diagnosis to treatment for both early and advanced stages from the perspective of low-middle-income countries. Starting with a brief introduction to epidemiology and guidelines for diagnostic modalities (imaging and pathology), treatment has been discussed for early breast cancer (EBC), locally advanced, and MBC. In-depth information on loco-regional and systemic therapy has been provided focusing on standard treatment protocols as well as scenarios where treatment can be de-escalated or escalated. [ABSTRACT FROM AUTHOR]

Young (≤40 years) breast cancers (YBC) are uncommon, inadequately represented in trials and have unique concerns and merit studying. The YBC treated with a curative intent between 2015 and 2016 at our institute were analysed. There were 1228 patients with a median age of 36 (12–40) years; 38 (3.1%) had Stage I, 455 (37.1%) - II, 692 (56.3%) –III, and remaining 43 (3.5%) Stage IV (oligo-metastatic) disease; 927 (75.5%) were node positive; 422 (34.4%) were Triple negatives (TNBC), 331 (27%) were HER-2 positive. There were 549 (48.2%) breast conservations and 591 (51.8%) mastectomies of which 62 (10.4%) underwent breast reconstruction. 1143 women received chemotherapy, 617 (53.9%) received as neoadjuvant and 142 (23.1%) had pathological complete response; 934 (81.9%) received adjuvant radiotherapy. At the median follow-up of 48 (0–131) months, 5-year overall and disease-free survival was 79.6% (76.8–82.5) and 59.1% (55.8–62.6). For stage I, II, III and IV, the 5-year overall-survival was 100%, 86.7% (82.8–90.6), 77.3% (73.4–81.2), 69.7% (52.5–86.9) and disease-free survival was 94% (85.9–100), 65.9% (60.3–71.5), 55% (50.5–59.5), and 29.6% (14–45.2) respectively. On multivariate analysis, TNBC and HER-2+ subgroups had poorer survival (p = 0.0035). 25 patients had BRCA mutations with a 5-year DFS of 65.1% (95% CI:43.6–86.6). Fertility preservation was administered in 104 (8.5%) patients; seven women conceived and 5 had live births. Significant postmenopausal symptoms were present in 153 (13%) patients. More than half of the YBC in India were diagnosed at an advanced stage with aggressive features leading to suboptimal outcomes. Awareness via national registry and early diagnosis is highly warranted. Menopausal symptoms and fertility issues are prevalent and demand special focus. • Largest data of young breast cancer from India analysing demographics, outcomes and fertility. • Higher proportion of YBC with advanced stage and aggressive features compared to western data. • Inferior survival in HER-2+ not receiving Trastuzumab, need access of life saving drugs to all. • Scope of improvement and collaboration in challenges like fertility, pregnancy and quality of life. [ABSTRACT FROM AUTHOR]

Pregnancy associated breast cancer (PABC) is a rare entity and defined as breast cancer diagnosed during pregnancy or one-year post-partum. There is sparse data especially from low and middle-income countries (LMIC) and merits exploration. The study (2013–2020) evaluated demographics, treatment patterns and outcomes of PABC. There were 104 patients, median age of 31 years; 43 (41%) had triple-negative disease, 31(29.8%) had hormone-receptor (HR) positive and HER2 negative, 14 (13.5%) had HER2-positive and HR negative and 16(15.4%) had triple positive disease. 101(97%) had IDC grade III tumors and 74% had delayed diagnosis. 72% presented with early stage (24, EBC) or locally advanced breast cancer (53, LABC) and received either neoadjuvant (n = 49) or adjuvant (n = 26) chemotherapy and surgery. Trastuzumab, tamoxifen, and radiotherapy were administered post-delivery. At a median follow up of 27 (IQR:19–35) months, the estimated 3-year event-free survival (EFS) for EBC and LABC was 82% (95% CI: 65.2–100) and 56% (95% CI: 42–75.6%) and for metastatic 24% (95% CI: 10.1%–58.5%) respectively. Of the 104 patients, 34 were diagnosed antepartum (AP) and 15 had termination, 2 had preterm and 16 had full-term deliveries(FTDs). Among postpartum cohort (n = 70), 2 had termination, 1 had preterm, 67 had FTDs. 83(including 17 from AP) children from both cohorts were experiencing normal milestones. Data from the first Indian PABC registry showed that the majority had delayed diagnosis and aggressive features(TNBC, higher grade). Treatment was feasible in majority and stage matched outcomes were comparable to non-PABCs. • Pregnancy associated breast cancer (PABC) is a rare and Challenging entity with lack of data from low-middle income countries. • First Indian data showed that stage matched oncologic outcomes were comparable to non-PABC. • Obstetric outcomes were similar to non-cancer associated pregnancies with normal cognitive development. • Creating awareness and early diagnosis is of utmost importance to improve prognosis in this unique entity [ABSTRACT FROM AUTHOR]

Cancer is a major health problem in India, with an estimated incidence of 1 million cases in 2012 that is likely to double in 2035 to approximately 1.7 million. The majority of cases are diagnosed in advanced stages, and approximately two thirds of patients die as a result of their disease. The mortality-to-incidence ratio is 0.68 in India, which is far higher than that in developed countries (approximately 0.38). One of the important reasons for this discrepancy is inequitable distribution and inaccessibility of health care resources in India. One component of scarce health care resources is the low ratio of oncologists to patients with cancer (1:2,000), which leads to delivery of systemic anticancer therapy in many hospitals by health care professionals who do not have required training. Given these facts, there is a need to focus on organization of medical oncology services in terms of manpower and infrastructure to standardize the delivery of systemic anticancer therapy. Redistribution of resources can streamline the delivery of cancer care, preferably close to the patient's home. This article describes the blueprint for organization of medical oncology services and delivery of chemotherapy and other systemic therapies to Indian patients. The model uses existing health care services in the country and is a fourtiered system of increasing sophistication: District Hospitals, Medical College Hospitals, Regional Cancer Centres, and Apex Cancer Centres. Delivery of quality care to patients with cancer through standardized protocols is crucial in improving cancer outcomes in India. [ABSTRACT FROM AUTHOR]