Cancer being a leading cause of death, is a threat to a country’s life expectancy. There has been a fast paced increase in cancer incidence, and mortality is a matter of great concern particularly in low- and middle-income countries (LMICs). According to GLOBOCAN1 the incidence of cancer cases worldwide in 2020 was around 19.3 million cases, with 10 million annual cancer deaths. One-half of all the cases (58.1%) and an equal proportion of cancer deaths were estimated in Asian countries in 2020. Surprisingly, when compared to other parts of the world, cancer incidence among females in LMICs like Asia (48.6%) and Africa (6.9%) was high when compared to America (20.9%) and Europe (22.3%). Of all cancers among women, breast cancer is considered the most extensive specific site cancer, attributing to nearly 24.5 per cent out of 9.2 million new cases and 15.5 per cent of 4.4 million deaths1. These reports clearly state that breast cancer is rapidly increasing in LMICs. The breast cancer burden is concerning because its incidence has exceeded lung cancer and is currently the sole leading cause of cancer incidence across the globe in 2020, with around 2.3 million new cases, which represented 11.7 per cent of all cancer cases1. In most countries, breast cancer incidence has reached one in four women, with a death rate of one in six. In LMICs, there has been a rapid increase in breast cancer, with a reported 17 per cent higher mortality in developed countries1.

The breast cancer incidence in India has been steadily increasing in over the last 30 yr, and currently, it ranks as the top cancer among Indian women2 and is now the most common cancer among females in India. The five year net survival period for breast cancer ranged from 80 per cent to 13·6 per cent3. The breast survival rate in India is around 60 per cent, which highlights the significance of the topic being discussed. In India, the age-adjusted incidence rate of breast cancer was noted to be high as 41/ per 100,000 women in Delhi, followed by Chennai at 37.9 per 100,0002. As per the National Cancer Registry Program (NCRP), the projected incidence of breast cancer burden in India was 2,05,424 in 2020 to 2,32,832 in 20224 . In the global as well as Indian research, there has been a steady increase in cancer incidence, morbidity as well as mortality5. The World Health Organization (WHO) has projected an exponential increase in the cancer incidence by 2030, ranging from 14.1 million in 2012 to 21.6 million annually in 2030. Furthermore the deaths due to cancer are also projected to increase from 8.8 million worldwide in 2015 to over 12 million in 2030.

The cancer diagnosis has a long-term psychological impact that may negatively affect the treatment and recovery process. A high prevalence of anxiety and depression among them is observed, causing poorer recovery and quality of life (QoL) in the survival phase6,7. Anxiety due to the diagnosis of cancer can lead to insomnia which may further be a risk factor for depression8. Long-term side effects of treatment are mostly reported among patients with symptoms of anxiety, depression and PTSD. Many breast cancer survivors undergo long-term iatrogenic effects of cancer treatment like fatigue, lymphedema, pain, infertility, vasomotor symptoms, etc., which hamper their quality of life as well as mental health9.

Studies on survival in India have also found that most patients reported advanced-stage at diagnosis leading to poor survival10,11. Research has also observed a difference in the age-wise breast cancer trends among Indian women, where breast cancer occurs for the younger pre-menopausal group in Indian women and is reported a decade younger than western women

Among Indian women, cancer peaks at 40-50 yr10 contributing to the early onset of cancer which is the most aggressive form at presentation and stage or triple-negative breast cancer (TNBC) subtype12. In meta-analysis studies, an increased prevalence of TNBC in India was reported in comparison with the western population13. Indian women living in urban areas reported higher risk for breast cancer when compared with women living in rural areas primarily due to the lifestyle followed by them14. Genetic factors is yet another risk for breast carcinoma with mutations in the BRCA1 and BRCA2 gene inherited15. Among the Indian population many studies on frequency of BRCA 1/2 gene mutations ranged between 2.9 per cent to 24.0 per cent3.

Breast cancer diagnosis is one of the most distressing diagnosis for individuals, and they may experience a range of psychological issues individually or in combination. A high prevalence of anxiety and depression has been observed among breast cancer survivors16. One in every five breast cancer patients, reportedly exhibit depressive symptoms persisting at least two years after diagnosis17.

The prevalence of depression among breast cancer survivors self-reported, was the highest globally around 30 per cent. The average prevalence of depression is reportedly around 13 per cent in studies using diagnostic criteria16. The range varies between 4-49 per cent based on the assessment techniques. Some studies report that depressive symptoms linger for a more extended period (over 5 yr) among breast cancer patients than anxiety. Breast cancer survivors reported increased post-traumatic stress disorder symptoms, which was similar to the meta-analysis finding of around 10 per cent18.

Both during and post cancer treatment, insomnia has been reported as an adverse mental health outcome among affected individuals19. Long-term survivorship challenges include problems in readapting to professional, social and family relationships and managing future uncertainties8. While exploring the unmet needs of cancer patients, it was observed that fear of cancer recurrence was one of the most significant and prevalentconcerns20.

Knowing that one has a life-threatening illness can be a dreadful experience and can undermine invulnerability, predictability, and control assumptions21. Studies show that compared with different types of cancers like colorectal, head & neck, and prostrate, the prevalence of PTSD diagnosis is higher in breast cancer18,22.

Fear of cancer recurrence (FCR) is yet another universal condition that is widely reported among survivors23. Literature indicates that 97 per cent of survivors report some degree of FCR and predictors of having FCR as age, type of surgery, depression, fatigue and pain24.

Survivorship is identified to play a significant role in the continuum of cancer care. The unmet psychosocial needs of cancer survivors are related to coping mechanisms and QOL outcomes. Quality of life is a dynamic concept that changes over time. The QOL model of breast cancer survivors adapted from Betty Ferrell & Marcia Grant states that QOL combines physical, psychological, social and spiritual well-being25. Long-term effects of treatment on breast cancer, like surgery, radiotherapy, and chemotherapy notably affect the breast cancer survivors’ physical, psychosocial and emotional well-being26.

A systematic review on the psychological concerns among Indian women with breast cancer pertaining to different national context concluded that whether in India or abroad, distressing symptoms could be tackled with culturally congruent care, ability to communicate and by receiving relevant information27.

Breast cancer ranks first in incidence at 1,78,361 (13.5%) and mortality at 90,408 (10.6%) in India, with a corresponding 5 yr prevalence of all ages of 69.28 per 100,00028. The increasing incidence of breast cancer among Indian women is now well confirmed. However, the mental health of people living beyond cancer is important and is a growing research area with clinical priority. In India, breast cancer survivors are predominantly an understudied population, and data on psychological issues, QoL, and survivorship are minimal. Further research and multi-centric studies are recommended as women living with breast cancer and beyond go through psychological issues and lest we forget about the trauma they undergo and to empower them to get back to normal life.