She’s financially independent, successful and lives on her own in New York. Her yearly trips to Chennai include visits to her parents and relatives—and to her oncologist. Diagnosed with breast cancer in her 20s, Sreevidya Balasubramaniam is still single and it’s not because she doesn’t want to get married—it’s because her fiancé called off the wedding when he found out that she is a breast-cancer survivor.

This is not a unique case. According to counsellors and oncologists, the number of couples who have had marital issues after a woman is diagnosed and treated for breast cancer—even ending in divorce—has increased in the last decade. According to Sumana Premkumar, senior radiation oncologist, Global Hospitals, Chennai, the incidence of break-ups is likely to be higher in couples who aren’t married.

Sumeet Shah, consultant surgical oncologist, Holy Spirit Hospital, Mumbai, says: “The one single thing that a woman suffering from breast cancer wishes and needs (especially the one who has undergone a mastectomy), is to be made to feel that she is still as beautiful as she always was. Her position in her husband’s heart and her position in the house are two things that need to be absolutely maintained. It is this thing that many men find difficult to understand."

Counsellors and oncologists who help women diagnosed with breast cancer say most women don’t openly acknowledge the problems they may be facing in their marriage. Dr Shah says, “Most couples, even when confronted with questions on personal issues, do not open up easily." He narrates an instance where the husband walked out on the patient and she was forced to fend for herself—financially and otherwise. “I had to refer her to a social cell helping women in such situations," he says.

Finding, in fact, that many women across India lack support, Dr Shah set up an online breast cancer support board through his non-governmental organization, The Pink Initiative, where those undergoing a similar experience could connect and seek information.

Ujwala Raje, 42, is the head of trading law and technical, Trent Hypermarket Ltd, Mumbai, and a core member of this initiative. Her mother was diagnosed with breast cancer in 2000 and she, in 2013. Today, she spends her spare time raising awareness about breast cancer and counselling patients online and offline.

Says Raje: “Some of the biggest concerns that women have is the side effects of the treatment (radiation and chemotherapy), the financial cost of treatment, the burden on their family, and the question—why me? If a couple already has a rocky relationship, then yes, a diagnosis of breast cancer can cause more strain. But from a medical point of view, people need to understand that there’s nothing wrong with a woman who has breast cancer—it can happen to anyone." Raje says she spends time boosting the morale of patients and counselling their family members on how to support the patient emotionally.

How a man perceives a woman changes drastically when she is diagnosed with breast cancer and undergoes treatment. Her hair, breasts and figure change. The couple needs to deal with her hair loss (due to chemotherapy), removal of a breast (mastectomy), weight gain and fear of recurrence. Love and intimacy often take a back seat, and this leads to upheavals and stress in the relationship. “The majority of Indian men are supportive; at least they appear to be! Others are duty-bound and do the needful. Indian men rarely express their emotional concerns. During our interactions, the men mainly talk about the financial aspects and coping with children and home responsibilities rather than their feelings. They do not understand how the woman feels about herself or her need to express her feelings to anyone. For the first few years after the treatment, the constant fear of the cancer coming back looms large on a woman’s mind and sometimes husbands don’t understand this feeling," says Rohan Khandelwal, oncoplastic breast surgeon at the Mazumdar-Shaw Cancer Center, Bangalore.

In India, many people are unaware of the various emotional, psychological, physical and financial aspects involved with breast cancer. “Hair loss, for instance, is a traumatic event and it affects a woman’s self-image, personal and social life," he says.

Older couples, such as those in their late 40s or 50s, are better able to cope with a mastectomy than young couples, say many oncologists and counsellors. “Yes, definitely, but couples are generally not able to accept a mastectomy," adds Dr Premkumar. In her experience, it’s only when you tell the woman it is life-threatening that she agrees to undergo the surgery. “Breasts are a symbol of femininity just like the uterus. In this day and age, women are looking at breast augmentation and here we are telling them it needs to be removed. So when you tell a woman the breast needs to be removed, she feels she’s losing her femininity," she explains.

Says Raje, on the basis of her experience: “If a couple has been married for many years and already has children, then a mastectomy doesn’t affect them as much as it does those who are in the early stages of marriage and don’t have kids. Some of the concerns for the young patient are whether she can have a child, breastfeed the child, and if she can share normal sexual relations with her husband. It is here that breast reconstruction becomes important."

After a mastectomy, young couples have a harder time resuming normal sexual relations. Dr Premkumar says: “Once a breast is removed, the woman feels less feminine and therefore loses self-confidence. She feels less desirable to the husband. In some cases, I have seen that the husband thinks the cancer will recur if they resume sexual relations and prefers to avoid it. One must also note that in India, beyond a certain age (post-40 usually), sex is not seen as important in a marriage; it’s more about companionship. So it’s only when the couple is young that sexual relations are affected because of a mastectomy." Dr Khandelwal agrees, “Marital relations after a mastectomy are dependent on the couple but young couples have a harder time coping."

Neerja Malik took the initiative of setting up a counselling centre in 2004 at the Apollo Speciality Cancer Hospital, Chennai, after she fought breast cancer—twice—and realized there was no support system to help patients and their families during this period of trauma and treatment. The fact that a cancer survivor plays a better role in counselling led Malik to handhold patients and their families right from the time of diagnosis, till their recovery and beyond. Having helped hundreds of patients from all walks of life, she says, “If a couple are already experiencing trouble in their marriage, then this diagnosis precipitates it and leads to the couple’s break-up."

Oncologists admit that breast reconstruction helps couples cope better and improve their marital relations. Dr Premkumar explains: “A woman is able to look at herself in the mirror and say yes, I have breasts, and it boosts her confidence. Today, more oncologists are opting for breast conservation but this again depends on the size of the breast, the size of the tumour, ancillary nodal spread and any metastasis."

Dr Shah says that though breast reconstruction is advocated today, most women do not opt for it. “But more than breast reconstruction, the first step towards a good cosmetic outcome for a woman is breast conservation surgery—try to conserve the breast in a cosmetic manner, and there is no need for reconstruction at all. I would advocate reconstruction (and very much breast conservation as well), as it does help in giving a positive attitude in a woman who has lost her breast; it does reduce her insecurity, especially in her own mind, and will boost her image," he says.

In India, however, breast reconstruction is not common, and is not given as much value, as in the West. Dr Khandelwal says: “Breast reconstruction is offered in very few units around the country. Lack of counselling and the cost of reconstruction are other factors which lead to lack of breast reconstruction after a mastectomy." Breast reconstruction can be done either by using the patient’s tissue or by using implants and can cost from 1-1.5 lakh per breast (the cost varies depending on whether an implant or the patient’s own tissue is used).

So there are three barriers to breast reconstruction: cost, lack of awareness, and a fear of recurrence. Dr Premkumar says: “An important factor is that there’s always a possibility of local recurrence of cancer. So the stage of the disease in the breast needs to be considered. If the disease is in the early stages, then oncologists would advise breast reconstruction. However, if the disease is in the later stages, they will ask the patient to wait for a few years to see if there’s any recurrence. They prefer to be safe."

So even though more and more oncologists are advising women to opt for breast reconstruction now, Dr Premkumar says 90% of her patients still use a prosthesis.

What is important to understand is that breast cancer is one of the few cancers with a high survival rate. “It is essential for the husbands to understand that after completion of treatment (or even during treatment), their spouse is going to be as normal as she was earlier and they will very much lead the same normal life," says Dr Shah.

As for Balasubramaniam, though she has been out on numerous dates, she’s yet to find her Mr Right. She says: “When the men showed interest in taking the relationship further, I did bring up my medical history. They just stopped calling me abruptly, no reasons given. Men just seem to panic—they don’t even ask questions to understand what really happened. They should understand that science has advanced and breast cancer can be curable."

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