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Breast Cancer

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focus on early detection

Breast is an organ paramount for the nourishment of offspring as well as it denotes female identity and beauty.

The month of October is named as Breast Cancer awareness month by the World Health organization (WHO) to make people aware of the burden of the Breast Cancer and motivate them for early detection which is the corner stone for cure of this, otherwise dreaded disease.

Annually around 4,000 women in Sri Lanka diagnosed to have Breast Cancer and unfortunately a third of them succumb in a year, mainly because of the advance of the disease at the time of seeking medical advice.

The main reasons behind the reluctance of seeking medical advice are fear of losing the breast, side effects of Radiotherapy & Chemotherapy, stigma associated with breast cancer and cultural backwardness to reveal private parts of the body for edical examination.

This article focuses on the following main areas,

1. The importance of early detection

2. Diagnosis of Breast Cancer

3. Novel modalities of treatment available in Sri Lanka

Importance of early detection of Breast Cancer

A Cancer cell must divide on average 30 times before it forms a mass that can be felt in the breast. Since tumor cells multiply and divide exponentially – one cell become two, two cells become four and so on- a tumor will increase more rapidly in size the larger it is.

Longer one waits larger it gets and further away spreads from the place of origin (metastasis) leading to incurable systemic disease.

How do we detect a Breast Cancer early?

1. Self-Breast Examination

2. Screening Mammogram

3. Medical Breast Examination

Self-Breast Examination (SBE)

SBE is a simple technique to master by all females over the age of 20 to check their own breasts monthly.

Salient features of SBE are;

Regular Examination,

Fix a date convenient to remember; usually a menstruating female can perform these 7-10 days after each menstruation. Others can fix an easy date to remember, e.g. 1st of the month etc.

Repeated practice makes you master the technique, initially you may not feel much but when it is repeated monthly one become aware of the normal consistency, shape & contour of the breast so when there’s slightest change, can be discovered easily.

Privacy & Place

SBE takes 5-10 minutes, and must be done in a properly covered & secure place with a mirror.

Inspection

Undress the upper body and stand in front of a mirror and observe any changes of color, shape, size of breasts; inspecting by keeping arms by the side of the body, pressed at hip and raised above the head.

Palpation

This can be done standing or lying down, the left breast is examined by the right hand and vice versa. Start at the periphery of the breast and proceed in a circular manner, like a mosquito coil; at the end squeeze the nipple to see whether any discharges occur.

Once you finish with the breast feel under the armpit for any lumps.

I hope you will surf the internet to find out many educative videos on SBE to master the technique today itself.

Screening Mammogram

Mammogram is similar to a X-ray film but with very low radiation. It can detect cancers very early which are not felt by the hand.

‘Screening’ means it performs in healthy individuals who have a higher risk of the disease; some western countries screen their entire female population at the age of 45-years and every 3-5 yrs thereafter. In Sri Lanka there are no such guidelines but if you fall in the high risk category (Table 1) it is advisable to undergo screening mammogram periodically .Your first mammogram is considered a baseline mammogram against which all future tests will be compared to look for changes in your breast tissue.

Mammograms are not performed below the age of 35 yrs due to difficulties in interpreting when the breast tissues are dense.

Table No 1

Risk factors for Breast Cancer

Non-Modifiable risk factors

1. Advanced age

2. Family history of Breast Cancer

3. Radiation exposure

4. Family History of early Ovarian Cancer, Uterine Cancer, Colon Cancer

5. Certain inherited genes (BRCA 1, BRCA2, TP53, Atm, CDH1)

6. First pregnancy after 35yrs of Age

7. Early Menopause

8. Late Menopause

9. Nulliparity

10. Never breast fed a child

Modified Risk Factors

1. Hormone replacement therapy

2. Obesity

3. Alcohol consumption

4. Type 2 Diabetes Mellitus

5. Tobacco Use

6. Sedentary lifestyle

Even though many are not aware, risk of Breast Cancer development can be reduced on your own, see modifiable risk factors

Medical Breast Examination

This will be done by a consultant or a medical doctor to detect any abnormality or problems as well as to address any concerns arisen from the SBE.

This is more advanced than SBE as it will be performed by a trained and experienced professional who can determine features suggestive of Cancer in order to proceed with further investigations.

Diagnosis of Breast Cancer

Early detection and confirmation pave the way for early treatment. Diagnosis of Breast Cancer is achieved through three stages referred as Triple assessment.

1. Clinical Assessment

2. Radiological Assessment

3. Pathological Assessment

Clinical Assessment

This is done by a Consultant doctor. Breast examination & thorough systemic examination will be performed and findings will be graded in a scale from 1-5 (5 bears most probability of Breast Cancer)

Radiological Assessment

Mainstay of radiological assessment is by ultrasound scan (USS) and diagnostic mammogram.

Diagnostic mammogram differs by screening mammogram as it is performed in patients where breast cancer is suspected. and may take more pictures in different angles than screening mammogram.

Ultrasound scan is an outpatient procedure. Below the age of 35 yrs. when the breasts are denser, it is a safer and reliable mode. It can detect lumps, cysts (water bubbles), infections etc.

USS can reveal valuable information as an adjunct to mammogram where sensitivity of picking a lesion can be as high as 98% when both are combined.

There are other advanced tools such as CT scan and MRI which are reserved for more complex and advanced cases.

After the radiological diagnosis radiologist will scale the findings in a scale of 1-5 (5 being the most probable of cancer)

Pathological Assessment

This is the most important step of confirmation of a breast cancer, where a small piece or few cells from the lump is taken out to be examined under the microscope.

Commonly known as fine needle aspiration cytology (FNAC) is performed on an outpatient basis by inserting a small needle to the mass and taking out few cells. If the lump is not readily probable this could be done under the USS guidance.

In case a larger sample of tissues are needed for confirmation a core of tissue or part of the lump is taken out and examined under the microscope.

Again, the results of pathological assessment will be graded in a scale of 1-5 (5 being the most probable of Cancer) by the Pathologist.

Once the results of above are available another set of tests will be performed to assess the spread of the disease outside the breast. These are chest X-ray, USS Abdomen, Bone scan, CT scan, MRI Scan, PET Scan and the most appropriate of these will be selected by the clinician according to the disease & the patient.

When the results of above tests are available he/she will summon a multidisciplinary team meeting (MDTM) to decide the best treatment option for a particular patient. This will enable to tailor made the treatment for each and every individual rather to impose a set guideline for everyone. Information which needs at the MDTM are,

1. Confirmation of Cancer, its type & behavior

2. Spread to the arm pit

3. Spread to the other areas of the body

4. Proportion of cancer size compared to the breast size

5. Patient wishes and compliance

Novel modalities of treatment available in Sri Lanka

In 1894 Dr. William Stewart Halsted performed the first series of mastectomies to remove the whole diseased breast and this technique was the gold standard for the treatment of breast cancer with slight modifications until recently.

But in recent past there has been a paradigm shift of treatment modalities for the disease mainly due to the way we analyze it now.

Treatment options for Breast Cancer are subdivided as follows,

1. Treatment of Breast

2. Treatment of Armpit

3. Systemic Treatment

Treatment of the Breast

There has been a drastic change of the way we treat breast nowadays with mastectomy seldom required. Following are some approaches,

1. Wide local excision (WLE)

If the cancer is small compared to the size of the breast, it can be taken out with a clear margin of normal tissues carefully through a small incision. This will be assessed under the microscope to determine complete removal.

2. Quadrantectomy

Breast is divided arbitrarily in to four quadrants; Upper medial, Upper lateral, Lower medial & Lower lateral.

In case of a relatively large cancer which is in a quadrant can be taken out along with this entire quadrant. And the resulted defect can be filled with fat from under the armpit. (Li cap)

In some cases, it is necessary to remove more than one quadrant, in these cases resultant defect can be filled with fat & muscles taken out from the arm pit and back.

3. Skin and nipple sparing mastectomy

When the tumor is much bigger or it is in several different places, whole breast tissue is taken out leaving the skin & nipple. Obviously large defects created by this surgery can be filled with silicon prosthesis which are commercially available to restore the size & context of the breast.

4. Mastectomy and reconstruction

Still mastectomy has its ground for advanced cancer when the patients presents herself late for examination. It can now be combined with immediate, early or late breast reconstruction to restore the beauty.

Treatment of the Armpit

It was customy to remove all lymph nodes under the armpit along with Mastectomy as described by the Halsted, but now mainly due to the knowledge of lymph draining pathways, we perform sentinel lymph node biopsy.

When cancer cells travel from breast to armpit it goes along the lymph channel to one lymph node first, which we call as sentry or sentinel lymph node.

When we inject a dye or radioactive particle around the cancer and nipple it drains first to the sentinel lymph node which will be identified using a gamma camera and removed through a small incision to be examined under the microscope for cancer cells. If there are no Cancer cells detected rest of the lymph nodes will not be removed. Only when there is cancer present at the sentinel node rest of the lymph nodes are cleared away.

This will greatly reduce the complications and side effects associated with arm pit clearance.

Systemic Treatment

Usually, systemic treatment is advocated for patients with advanced breast cancer. There are several modalities,

1. Radiotherapy

2. Chemotherapy

3. Hormone Therapy

4. Immune Therapy

These can be given prior to the surgery, after the surgery or both to achieve maximum effect.

Take home message

Breast Cancer is completely curable without removing the breast if treated early. SBE and Screening Mammogram are crucial in picking up early cancer.



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A nation comes together: Business, compassion and public service unite to protect Sri Lankan women from cervical cancer

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Distinguished guests covering a wide spectrum of society

In an emotionally charged and inspiring gathering that brought together business leaders, healthcare professionals, philanthropists and community organisations, Sri Lanka, this week, reaffirmed its determination to defeat one of the country’s most preventable yet devastating diseases—cervical cancer.

The event was more than a formal announcement of financial assistance. It was a story of legacy, compassion, partnership and hope. It was also a reminder that when private enterprise, government institutions and civic organisations stand together with a shared purpose, lives can be saved and futures protected.

At the centre of the initiative was a renewed commitment by Dilmah and the Fernando family to continue funding cervical cancer screening programmes, in partnership with the Ministry of Health and Rotary.

The programme, which has already helped thousands of women through early detection, will receive a further Rs. 50 million this year, enabling 20,160 additional screenings.

This follows an earlier Rs. 75 million commitment made in January 2024 under a Memorandum of Understanding signed between Dilmah, Rotary and the Ministry of Health.

A Son Honours a Father’s Vision

Delivering one of the most moving speeches of the event, Dilmah Chairman/CEO Dilhan C. Fernando reflected on the values of his late father, Merrill J. Fernando, founder of Dilmah, whose philosophy continues to guide the company.

Fernando said his father began his journey in 1950 not merely to create a successful tea business, but to build a company that would improve lives and protect nature.

“My father started on a mission to make the world a better tea,” Fernando said. “Now, better tea is always welcome because it implies good taste, but his vision was quite different. It was about tea that would have an impact on the lives of people and on natural ecosystems.”

He said he and his brother Malik were blessed to steward a business that values kindness to people and the environment as much as profit.

“Businesses do not exist to make profit. Businesses exist to create value,” he said. “Value begins with people and livelihoods. It continues through nature, which is an inextricable part of welfare. And if you get those two right, then you have the right to secure economic value.”

Fernando said learning that hundreds of Sri Lankan women were dying annually from cervical cancer—an entirely preventable disease—was deeply disturbing.

“It was something that was really quite abhorrent to us,” he said. “An entirely preventable form of cancer should not be taking so many lives.”

He said the contribution was not about publicity or recognition.

“We announce this not to boast, but in appreciation of all those who made it possible, particularly my father, because that is how it is possible for us to make this assistance.”

Thousands of Lives Already Touched

Fernando said the true value of the investment could not be measured in rupees alone.

“That value may seem like a big number, but it is insignificant when you consider that it has saved thousands of women from the scourge of cancer and in many cases helped them avoid late-stage disease.”

He praised Sri Lanka’s healthcare system for maintaining an admirable record, despite national hardships.

Dilhan C Fernando

“Whatever anyone may say about systems or governance, the fact is Sri Lanka’s healthcare system has an enviable track record,” he said.

Rotary’s Promise of Early Detection

Representing the Rotary Club of Colombo, former Rotary International President K.R. Ravindran delivered a powerful message on the life-saving power of partnerships.

“This is not a discussion. This is a promise of early detection,” Ravindran said. “Cancer, especially cervical cancer, does not arrive with a bell ringing or a warning. It whispers, and so often by the time it is heard, it is too late.”

He spoke emotionally of the grief caused by delayed diagnosis.

“For millions of women, that whisper is a devastating reality. Families left grieving—that is the reality.”

Ravindran recalled how Rotary had earlier established a stand-alone early detection centre offering free screening for breast, cervical and oral cancers. Through those efforts, more than 120,000 women had access to screening.

“During that journey, we learned something profound,” he said. “Early detection is not just saving lives. It transforms fear into hope, into possibility.”

That experience led Rotary to intensify efforts against cervical cancer, supported by overseas partners who introduced expertise and advanced screening technology.

A Crisis That Nearly Stopped Progress

Ravindran revealed that Sri Lanka’s financial crisis nearly derailed the programme when funds for HPV testing kits became unavailable.

“Without the money, the whole thing would have gone awry,” he said.

It was then, he said, that Dilmah stepped in.

“They did something far greater than simply giving money. They made scale possible. They made continuation possible. They made impact possible.”

He paid tribute to Merrill J. Fernando’s values.

“He believed business was a matter of human service. It was not just about making money. He did not just speak it. He lived it.”

He added that Dilhan Fernando had strengthened that legacy through direct leadership and compassion.

Sri Lanka Can Lead the World

Ravindran said Sri Lanka has every reason to believe it can become one of the first countries in the world to eliminate cervical cancer by 2030.

He cited the country’s literacy, school vaccination programmes, far-reaching public health system and highly respected midwife service.

“One thing we have to be proud of is our public health service,” he said. “And we have an excellent midwife system. If you involve the midwives, you are effectively empowering the community.”

He concluded with a message of hope.

“I think this country can become one of the first countries to be rid of this disease. Perhaps one day no woman in Sri Lanka will ever again hear the whisper of cervical cancer.”

Science, Prevention and Public Health

Consultant Community Physician Dr. Nadija Herath, of the Family Health Bureau, explained that cervical cancer is caused mainly by persistent infection with the Human Papillomavirus (HPV), which can take years to develop into cancer, if left untreated.

She said this makes screening especially important because pre-cancerous changes can be detected and reversed.

“The most important thing about this cancer is that it is preventable,” she said. “If identified early, women can be fully cured and live normal lives.”

Sri Lanka’s Well Woman Clinic programme, introduced in 1996, currently focuses on women aged 35 and 45.

Dr. Herath said the country is now expanding the use of HPV DNA testing, which offers much higher sensitivity than traditional methods.

She added that outreach clinics in factories and underserved communities would be strengthened, ensuring women can access services close to where they live and work.

Cancer Society Calls for Social Change

President of the Sri Lanka Cancer Society, Anoja Karunaratne, said awareness and stigma remain serious barriers.

“We need to take this message beyond hospitals and clinics—into schools, workplaces, religious institutions and community groups,” she said.

She stressed that women should view screening as a normal and responsible part of healthcare.

“Women must not fear screening. They must see it as routine care that can save their lives.”

A Partnership with Purpose

Throughout the event, one theme stood above all others—the power of unity.

Government institutions brought infrastructure and expertise. Rotary brought leadership and international support. The private sector brought resources and purpose. Civil society brought compassion and outreach.

Ravindran summed it up simply:

“This is not just institutions coming together. It is values coming together.”

“When governments, civil society, global networks and responsible businesses all come together, we do more than fight disease—we change destiny.”

Hope for Every Woman

As Sri Lanka moves toward the World Health Organisation goal of eliminating cervical cancer as a public health threat by 2030, the gathering offered more than policy announcements. It offered confidence that progress is possible.

It reminded the nation that some of the greatest victories are won not in boardrooms or conference halls, but in clinics where disease is detected early, in families spared grief, and in women given the chance to live healthy, full lives.

And in that shared effort, Sri Lanka may yet become a global example of what compassion, courage and collaboration can achieve.

By Ifham Nizam

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Rheumatoid Arthritis doesn’t stop at your joints; And neither should your treatment

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Dr. Aruna Caldera

By Dr. Aruna Caldera, Consultant Rheumatologist MBBS, MD, MRCP (UK), MRCP (Rheumatology)

The word arthritis comes from ancient Greek. “Arthron” means joints; “itis” means inflammation; so, arthritis means inflammation of joints. Arthritis is one of the commonest disease categories which effect man. Some forms of arthritis may not even require any form of specific treatment, whereas some may even kill you.

Among long-term arthritis conditions, the most serious is rheumatoid arthritis. This disease occurs due to genetic variations that cause the immune system to malfunction and produce antibodies against the joints, leading to joint damage. We call this process, auto immunity; in simple words, your immune system which is supposed to protect you, starts to work against you.

If proper treatment is not started on time, the progression of the disease will be extremely difficult. Without proper treatment, it can make life miserable and may even lead to premature death.

Rheumatoid arthritis is a chronic, systemic inflammatory disease. Joint involvement is only one part of it. In simple terms arthritis is not limited to the joints. This is why relying only on ointments or topical treatments can lead to extra-articular (other organ) damage some of which could be catastrophic and lead to premature death.

If untreated, inflammation damages the joints—causing deformities, cartilage loss, and involvement of more joints over time. Complications usually appear after 10–15 years. Those who don’t understand, or refuse to believe this, often rely on short-term fixes and, unfortunately, will suffer later.

Eventually, joint deformities can become so severe that a person may not be able to walk without aid, button clothes, dress themselves, go to the toilet independently, open a bottle, or even open a door.

There are several types of rheumatoid arthritis:

Classical rheumatoid arthritis:

Affects small joints (fingers, wrists) and large joints (elbows, ankles, knees). Symptoms include morning stiffness, joint pain, swelling, weak grip, and fatigue.

Palindromic rheumatism

: Sudden joint pain (and swelling) that disappears within hours or days. Many of these patients may later develop classical rheumatoid arthritis. However, treatment can reduce this risk of progression to classical type. Medication may be needed even when symptoms are absent.

Monoarticular rheumatoid arthritis:

Affects a single joint. It is often mistaken for other conditions like gouty arthritis or osteoarthritis. Without proper treatment, it can destroy the joint and later progress to classical rheumatoid arthritis. Commonly affects larger joints, like knees, ankles, hips, and shoulders.

Polymyalgic onset (proximal) rheumatoid arthritis:

Seen in older individuals and even could be missed by clinicians. Patients usually complain of stiffness in both shoulders rather than joint pain or swelling.

Most patients experience morning stiffness (difficulty moving joints after waking) and joint “gelling” (stiffness after rest). Stiffness can last from minutes to hours and is caused by inflammatory substances accumulating in joints during sleep and rest.

Other symptoms may include whole-body pain, fatigue, weight loss, mild fever, depression, fibromyalgia (generalised wide spread pains)

Rheumatoid arthritis affects the whole body. The effects on other organ systems are identified as” extraarticular manifestations”. Most organs can get involved in poorly controlled disease. Some of the common manifestations include,

Skin vasculitis rashes and skin nodules

Lung disease (interstitial lung disease)

Heart disease (ischemic heart disease)

Osteoporosis

Eye problems which can even cause blindness (uveitis, scleritis)

Nerve disorders (polyneuropathy, mononeuritis)

Dry mouth (Sjogren’s syndrome)

About 40% of patients may develop such complications. The only way to reduce them is timely treatment.

In addition to joint swelling, the whole hand may swell like wearing a boxing glove. Swelling in the wrist can compress the median nerve, causing carpal tunnel syndrome (numbness in fingers). Surgery should not be rushed—arthritis must be treated first.

The disease can even affect the upper spine (neck joints). Neck pain along with other joint pain should not be ignored. In simple terms, rheumatoid arthritis can affect almost any joint except most parts of the spine.

No blood test is required to suspect or even diagnose rheumatoid arthritis. In some patients the rheumatoid factor antibody test will never be positive (seronegative rheumatoid arthritis). Waiting for lab confirmation before starting treatment is an unwarranted delay.

Some tests may show abnormalities:

Rheumatoid factor antibodies, Anti-CCP antibodies, ANA may be positive

ESR and CRP may be elevated

Haemoglobin may be low (anaemia of chronic disease)

Platelets may be high

Blood tests are more useful for monitoring treatment and medication safety rather than initial diagnosis. One important fact we must realise is the titre of the antibody test positivity has no correlation to disease activity and we cannot use the antibody titres to evaluate the response to treatment.

There are treatments that can even bring the disease into remission in no time at all. However, patients who delay treatment, take insufficient doses of medicines, stop medication early, follow inconsistent treatment, or rely on unscientific treatment methods are unlikely to achieve this.

Proper treatment involves starting with stronger medications and gradually reducing it as the disease improves. Simply controlling symptoms, without addressing the disease progression, is not enough; that is why using pain killers and prednisolone only cannot prevent extraarticular manifestations.

The first goal is on-drug remission. After that, patients should continue medication for more than 12 months without symptoms before gradually tapering. Stopping/tapering medications too early often causes relapse, which is a major reason why many patients fail to recover. Some patients may relapse even after stopping medication, but modern treatments allow long-term control without harm and sustained, drug-free remission in other patients. Most novel therapies are available in Sri Lanka as well.

The medications used are called DMARDs (Disease-Modifying Anti-Rheumatic Drugs). These do not just control symptoms—they change the course of the disease. Most patients respond to conventional DMARDs, but if not, biologic or targeted synthetic DMARDs should be started early—not after joint damage occurs. These treatments are available in Sri Lanka. Without consulting rheumatologist, patients may not receive these advanced forms of novel treatments.

Having rheumatoid arthritis is like being trapped in a room with a venomous snake. As long as you stay alert, you can avoid harm—but if you ignore it, it will strike. The disease must be treated at any cost. The choice is yours. With proper treatment initiated early, you can live a normal life. Ignoring the disease will not make it go away. Misinformation by people who aren’t aware of the severity of the disease and medications used often causes patients to avoid ideal treatment, leading to worse outcomes.

There is no point worrying after diagnosis; see a specialist early and seek treatment. You can live a normal life. Even pregnant or breastfeeding mothers can be treated safely without harming the baby. The precious time you waste starting a DMARD will definitely impact the final outcome.

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Avurudu spirit comes alive

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Niroshan, Priyan and host

The Sinhala and Tamil New Year stands as one of Sri Lanka’s most significant cultural observances, marking not only the transition of time but also a collective moment of renewal, reflection and togetherness. The Sinhala and Tamil New Year is deeply rooted in age old customs that continue to shape both domestic life and wider social culture across the island. Priyanthi Fernando brought the spirit of Sinhala and Tamil New Year to life, hosting a thoughtfully curated Avurudu celebrations that brought together elegance, culture and the timeless spirit of togetherness. The Sinhala and Tamil New Year festivities were held at Colombo City Centre, followed by a strong service of cultural authenticity. The event unfolded with traditional observances carried out in glamour and style. The atmosphere was warm, yet distinctly elegant, with carefully curated details. Priyanthi embraced tradition in a striking reddai hatta, even the invited guests embraced the occasion in equally colourful ensembles that added a rich, cultural vibrancy.

The food presentation added to the charm of the evening, with a beautifully arranged spread of Avurudu delicacies.

The gathering blended festive decor with familiar Avurudu touches, games sweet meat spreads. and a musical backdrop inspired by local rhythms. Both men and women opted for the national attire, while traditional sweets, such as kavum, kokis, aluwa and mung kevum, were among the food highlights, alongside other savories and contemporary bites.

Adding to the celebrating tone were the traditional Avurudu games which brought moments of laughter and friendly competition. As the Avudu Kumari was announced, the evening reached its natural clima, filled with smiles photographs and applause. The gathering captured the true essence of Avurudu with warmth and celebrations.

Avurudu vibes with singer Kirthi Pasquel

Predipika, Preethi and Ramani Pelpola

Shereen Kumaratunga

Pix by Thushara Attapathu

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