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United Kingdom to India—a “Living Bridge”: Celebrating 25 Positively Eventful Years (1996–2021)

After completing my Basic Surgical Training in India, I went to the UK in 1996 and obtained structured Higher Surgical Training and subspecialty training in oncoplastic breast surgery at some of the world renowned centres of excellence. My first training Post in the UK was with Prof. Robert Mansel, a world renowned breast surgeon, who was the then Chief of Surgery & Head of Cardiff Breast Unit at the University Hospital of Wales in addition to being the Programme Director for the All Wales Higher Surgical Training Programme.Working with him, in fact, inspired me to take up breast surgery as a career.

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With Professor Robert Mansel at Annual Conference of The Association of Breast Surgeons of India (ABSICON 2017), Bengaluru

In 2002 came a defining moment: my mother, Dr. Ushalakshmi, a renowned Obstetrician & Gynaecologist from Hyderabad, was diagnosed with breast cancer. The unexpected diagnosis to someone close to me, coupled with huge disparity in breast cancer care across India, became the turning point in my life. Despite having rewarding career opportunities in the UK, my spouse, Dr. Vyjayanthi, and I relocated to India in 2007 to take care of my parents and equally work with missionary zeal alongside passionate colleagues and a proactive Government to improve the delivery of breast healthcare in my motherland.

For well over a decade, I have strived to replicate the best of British practices in my motherland and feel immensely proud to be a “living bridge” between the UK and India. Although there is so much more to reflect upon, I shall strictly confine myself to Breast Healthcare as this article is being published in the special “Breast” issue of Indian Journal of Surgery.

Take up one idea. Make that one idea your life – think of it, dream of it, live on that idea. Let the brain, muscles, nerves and every part of your body, be full of that idea, and just leave every other idea alone.

This is the way to success

I arrived home in 2007 with three main short-term goals:

  1. 1.

    To establish a dedicated Breast Health Centre incorporating the Breast Unit concept in the UK.

  2. 2.

    To transform breast cancer from a “taboo’ issue” to a much commonly discussed one and implement a population-based screening programme under the auspices of a “not for profit” Breast Cancer Foundation.

  3. 3.

    To garner support from likeminded colleagues and form a Breast Surgical Society similar to the Association of Breast Surgeons in the UK & American Society of Breast Surgeons.

Dedicated Centre for Breast Health

Breast cancer is the most common cancer and the leading cause of death from cancer affecting women in India [1]. There is now robust evidence that improved outcomes for breast cancer can be achieved if specialists with a declared interest and training manage patients in dedicated comprehensive breast centres [24]. The world’s first specialist breast unit was established in Van Nuys (California) by Professor Mel Silverstein. Breast units and breast specialization became a distinct entity in the UK in 1995.

Mirrored upon my experience of having trained in the UK, I conceived and designed South Asia’s first free-standing, purpose-built, and comprehensive breast health centre in Hyderabad, the capital city of the southern Indian State of Telangana (2007). KIMS-USHALAKSHMI Centre for Breast Diseases (www.breastcancerindia.org) was established under the auspices of KIMS Hospitals, which is one of the largest private hospital groups in South India. To honour my mother’s struggle and applaud her strength in the fight against breast cancer, the Breast Centre & the Foundation established in Hyderabad bear her name.

The breast centre has incorporated the best aspects of the Cardiff, Nottingham & Royal Marsden Breast Centres. This is not just “another cancer centre”. In fact, this is not a “cancer centre”. Clinical assessment, breast imaging, breast biopsy, and counselling are all done in this free-standing, purpose-built unit that is dedicated to the management of all types of breast disease, both benign and malignant, by a committed multidisciplinary team trained in the management of breast disease.Importantly, the mammography system is housed at the breast centre. This avoids the need for patients, who are often anxious, to move around visiting the specialist in one place and then going to radiology department for breast imaging [5, 6].

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Multidisciplinary team (MDT) approach, which is the “gold standard”, was first described in management of breast cancer in 1996. Collaboration between various members of the team without prejudice and personal egos is absolutely essential to ensure standardized individualized treatment based upon established evidence-based protocols, which translates to better outcome and survival [79].

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You are not a Team because you work together...

You are a team because you trust, respect & care for each other

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Just as a stethoscope is absolutely essential for a physician in clinical practice, the radiologist and pathologist are the “eyes and ears” for a surgeon exclusively practicing the art and science of breast surgery. My work experience in the UK has made me aware of the fundamental fact that a radiologist trained breast imaging and image-guided procedures is the “nerve centre” for the breast centre. Therefore, well before returning to India, I facilitated training for my radiology colleague from KIMS Hospitals at the breast radiology division in the St. George’s University Hospitals NHS Trust, London. As 9 out of 10 breast health issues are not cancers, the essential function of a breast centre is to reassure the vast majority of women who are “worried well”, in addition to diagnosing accurately and treating those who have breast cancer with evidence-based protocols. This can only happen if there is seamless “team working” between the surgeon, radiologist, and pathologist to provide best possible care to women presenting to the breast centre.

Quality is never an accident. It is always the result of intelligent effort

The first port of call for a patient at the breast centre can sometimes be a radiographer who does the mammography. Reassuring the lady who presents for the test and getting to understand the various nuances in positioning the patient and other related knowledge is very important. Recognizing this often neglected aspect, I arranged for two radiographers (who came in turns) from the Jarvis Breast Screening Centre in Guildford (one of the foremost screening centres in the UK) to train the breast radiographers at KIMS-USHALAKSHMI Centre for Breast Diseases.

In the UK, Radiographers interpret & report Mammograms. In order to ensure quality assurance in mammography reporting, I had also arranged for the Radiographers from the Jarvis Screening Centre and a senior Consultant Breast Radiologist from the same centre in the UK to“double read” the first 950 screening mammograms that were reported by my Radiology colleague at the KIMS-USHALAKSHMI Centre for Breast Diseases. A specially designed bus equipped with mammography and ultrasound machine was hired from my own resources and help from Dr. Reddys Laboratories. Close to 1000 screening mammograms were performed in women over the age of 40 years in this mobile bus over a 3-month period between October and December 2007. Mobile screening was not new to India in 2007. However, large-scale mobile screening in collaboration with one of the most respected breast screening centres in the UK was the first initiative of its kind in India.

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Mobile Breast Screening Unit. Radiographer from Jarvis Screening Unit, UK

950 free screening mammograms over a 3-month period (October–December 2007)

Any sufficiently advanced technology is indistinguishable from magic

“Early detection of breast cancer” has been my “mantra” from day 1. I successfully convinced KIMS Hospitals Management to invest in “early detection”. In 2007, we acquired South India’s first and India’s second full-field digital mammography system (within 1 month of Tata Memorial Hospital getting it!). At that time, Digital Mammography Unit, priced at Rs. 2 crores (ten times more expensive than conventional mammography system), was considered to be a revolutionary advance. The principal advantages are its ability to detect very early subtle changes in the breast particularly in younger women with dense breasts with much greater accuracy in addition to significantly less discomfort and minimal radiation when compared to conventional mammography system [10].

As majority of breast cancers in India are diagnosed between 40 and 60 years, the Digital Mammography Unit at the KIMS-USHALAKSHMI Centre for Breast Diseases was not only the “talk of the town” but soon became the “talk of the country”. Several hospitals and diagnostic centres across India, that were initially sceptical about this technology, soon embraced it wholeheartedly.

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Investing in technology is fruitful only when the “man behind the machine” is well trained. The eyes need to be trained to focus upon picking up early subtle changes on a mammogram. In an endeavour to empower radiologists, surgeons, and pathologists to develop greater accuracy in detecting early breast cancers, I invited Professor Laszlo Tabar, the world-renowned breast radiologist from Sweden to conduct his highly sought-after 3-day courses in Hyderabad. Professor Tabar is widely considered to be the “godfather” of breast radiology and is credited with having demonstratedthe benefit of breast screening in saving lives through his landmark publications. His courses, which are normally held in Sweden and the USA, are extremely expensive [11].

I cajoled, pleaded, and eventually persuaded Professor Tabar to reduce his fee significantly, to which he very kindly agreed. Funds were raised to heavily subsidize the breast radiology training courses that were held for the first time in India (Hyderabad) in partnership with the KIMS-USHALAKSHMI Centre for Breast Diseases and Ushalakshmi Breast Cancer Foundation, for 3 consecutive years in 2010, 2011, and 2012. After these courses were held, the concept of breast radiology evolved in India, which led to the formation of a national organization—The Breast Imaging Society of India (BISI) in 2012—inspiring many radiologists across India to take up breast radiology as a career. This initiative has also paved the way towards improving standards of breast radiology services throughout the country.

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Prof. Laszlo Tabar’s courses in Hyderabad (2010, 2011, and 2012)

Cure sometimes, relief often, but comfort always.

Counselling is a very important component of the breast centre’s activities.This is because cancer does not affect just the body; it affects the mind too. To precisely address this critically important aspect of breast cancer care, “ASHA” (meaning “hope”), a dedicated Breast Cancer Support Group was established by Ushalakshmi Breast Cancer Foundation in 2009. This is the very FIRST dedicated Breast cancer support group in Telangana & Andhra Pradesh, which is led by Ananda Shankar Jayant, a world renowned Indian Classical dancer & my patient who ‘conquered’ breast cancer. Counselling essentially involves empowering the patient and relatives about the diagnosis/treatment options in simple easy to understand format, and equally, giving the much needed confidence to deal with the disease. We take great pride in providing this vitally important service for our patients at the KIMS-USHALAKSHMI Centre for Breast Diseases. Link to a brief, crisp & impactful message from Ananda Shankar Jayant expressing her triumph after battling breast cancer & creating awareness through the medium of Indian Classical dance – https://www.youtube.com/watch?v=kSr8A4H7VLc.

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Sir Dominic Asquith, British High Commissioner to India, interacting with patients at the KIMS-USHALAKSHMI Centre for Breast Diseases (2019)

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Sir Dominic pays rich tributes to Dr. B. Bhaskar Rao, Managing Director, KIMS Hospitals

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Sir Dominic and Mr Andrew Fleming, British Deputy High Commissioner to Telangana and Andhra Pradesh, commend Dr Jwala Srikala, Consultant Radiologist and Head of Breast Imaging, KIMS-USHALAKSHMI Centre for Breast Diseases

Up until 2007, practicing the art and science of oncoplastic breast conserving surgery was at a nascent stage in India. During the late 1990s, this concept emerged as one of the most interesting and challenging advances in breast surgery, which involves removal of cancer and, equally, aims to ensure best possible cosmetic outcome in women undergoing breast conserving surgery. It has been my earnest endeavour to popularize oncoplastic breast conserving surgery ever since the breast centre was established. Women who underwent these procedures at the KIMS Hospitals were very forthcoming in sharing their experience in public platforms and proactive support from the print and electronic media has enabled me to engage and empower the community at large about the fact that more women can indeed be offered breast conserving surgery with excellent aesthetic outcomes.

The Chapter on “Oncoplastic Breast Surgery” published in the 32nd edition of Recent Advances in Surgery (the hugely successful and well-established series edited by Irving Taylor & CD Johnson) [12], which was reprinted in the Indian Journal of Surgery [13] set the tone for this new and upcoming subspecialty and techniques gaining widespread acceptance in India [14]. Over the years, with active contribution from likeminded colleagues, oncoplastic breast surgery has become part and parcel of scientific programmes in major conferences all across the country.

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It is indeed very gratifying that the KIMS-USHALAKSHMI Centre for Breast Diseases has made significant and meaningful difference to many lives, in addition to bringing about a revolutionary change in the way “breast health centre: is understood in the Indian subcontinent.

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Mrs Jeannie Mulford, Breast cancer “çonqueror”, and Mr David Mulford, United States Ambassador to India, interacting with Dr Ushalakshmi at the KIMS-USHALAKSHMI Centre for Breast Diseases (2008)

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Sir Richard Stagg, British High Commissioner to India, and Mr Mike Nithavrianakis, British Deputy High Commissioner to South India, at the KIMS-USHALAKSHMI Centre for Breast Diseases (2011)

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Breast Cancer Foundation—Advocacy and Screening

Passion is undefeatable

Advocacy

Due to lack of awareness, absence of a robust nationwide population-based breast cancer screening programme, and inequitable cancer care, the vast majority present in advanced stages with poor survival [1]. In many parts of the country, it is still a “closet” issue that is not talked about. With a vision to make breast cancer an openly discussed one and empower women about the importance of early detection of breast cancer in addition to spreading the message of hope, survival and courage in the fight against breast cancer, the Ushalakshmi Breast Cancer Foundation, was founded as a “not for profit” charity in 2007 (www.ubf.org.in).

Since its inception, the foundation liaised closely with Breast Cancer Care UK, Britain’s largest UK-wide charity in providing information, care, and support to people affected with breast cancer or other breast health concerns in Telangana and Andhra Pradesh. I was able to incorporate all the successes of this widely respected UK charity into the foundation’s activities.

The “Pink Ribbon Campaign” is a one of its kind large-scale breast cancer awareness drive across the southern Indian states of Telangana and Andhra Pradesh. For well over a decade (2007–2021), this impactful campaign spearheaded through a number of unique and innovative initiatives championed by the foundation made a huge impact, creating the much needed awareness about importance of early detection [6].

No stone was left unturned in accomplishing this goal. Several celebrity breast cancer “conquerors” and prominent people lent their support to this worthy cause. Over the past 14 years, the campaign has addressed more than 2000 organizations across India and has been regularly featured prominently in print and electronic media.

Pink Ribbon Walk [6]

In order to take this campaign into the community, since 2008, the foundation has been organizing the 2-km Pink Ribbon Walk, which is held on the first Sunday of October to mark the beginning of International Breast Cancer Awareness Month. People from all walks of life, including breast cancer “conquerors” and their families, have been participating in these walks—the number of enthusiastic participants has been significantly increasing year on year, starting from a few hundreds in 2008 to several thousands in 2019. Due to the ongoing pandemic, the walk was not held in 2020. A special effort is always made to involve women from a conservative background living in the old city. Over the years, this initiative has become a “benchmark annual calendar event” during the International Breast Cancer Awareness Month in Hyderabad and other cities and towns in Telangana and Andhra Pradesh.

After the foundation introduced the innovative Pink Ribbon Walk in 2008, it is very gratifying that many NGOs and hospitals in the region have embarked upon conducting similar programmes not only for breast cancer awareness but for other illnesses as well, which also desperately need urgent attention. This speaks volumes of the “Pink Ribbon Campaign” that has enthused individuals, organizations, and institutions to take up and spearhead impactful awareness activities. Much as Hyderabad has contributed in a big way to the “awareness” journey, much more needs to be done as there are still significant number of women who still shy away from visiting a doctor when they notice a lump in the breast.

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Glimpses from Pink Ribbon Walks held in Hyderabad, Warangal, Vijayawada, and Visakhapatnam in October (International Breast Cancer Awareness Month)—major cities and towns in Telangana and Andhra Pradesh (2008–2019)

Paint the City Pink [6]

“Paint the City Pink” campaign was launched in 2010, in which the historic monuments and prominent buildings in Hyderabad are illuminated in pink to reinforce the message of early detection during the International Breast Cancer Awareness Month. Over the past 10 years, the iconic 400-year-old Charminar, the majestic Buddha statue in the lake by the city centre, the IMAx theatre, US consulate building, Ravindra Bharathi (the state auditorium for public events), the 115-year-old Legislative Assembly (the seat of state legislature in Telangana), and the Rajiv Gandhi International Hyderabad Airport (one of the largest airports in the country) turned pink in October.

Inspired by this impactful decade long campaign, the Hon’ble Governor of Telangana gave permission to the foundation to illuminate Raj Bhavan in pink on the last day of October 2020. Hyderabad is the only city in Asia pacific region where several monuments and historic buildings have been lit up in pink annually, consistently for 10 consecutive years.

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“Paint the City Pink Campaign” (October)—Charminar, Buddha statue, Legislative Assembly, United States of America Consulate, Raj Bhavan, and many other prominent buildings in Hyderabad illuminated in PINK during the International Breast Cancer Awareness Month (2010–2020)

Pink Ribbon Evening (2008–2020)

Several celebrities and breast cancer “conquerors” featured in annual editions of innovative “Pink Ribbon Evenings” organized by the foundation during the month of October (International Breast Cancer Awareness Month), which has played a big role in sensitizing the community to the cause of “early detection”.

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World’s First Mobile App on Breast Health in 12 Languages [6, 15]

You can have brilliant ideas, but if you can’t get them across...

Your ideas won’t get you anywhere

Inspired by the Prime Minister of India’s dream of Digital India, the foundation developed the World’s first mobile app on breast health in English and 11 commonly spoken Indian languages (Hindi, Telugu, Tamil, Kannada, Malayalam, Gujarati, Punjabi, Bengali, Marathi, Oriya, and Assamese). The mobile application, “ABCs OF BREAST HEALTH”, which is freely downloadable in both Apple and Google play store, provides information about every aspect of breast cancer and benign non-cancer breast health issues explained in simple easy to understand format. The aim of this landmark initiative, which was launched in 2017, is to counsel, guide, and educate people across the nation about various aspects of breast health so that they are well informed and better prepared, thus filling a huge void in breast healthcare in South Asia [6, 15]

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World’s first mobile app on breast health launched by Mr. Amitabh Bachchan (2017)

Links for Free Download

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https://apps.apple.com/us/app/abcs-of-breast-health/id1482487468

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https://play.google.com/store/apps/details?id=devatech.kims.avantari

World’s First Life Size Augmented Reality for Breast Cancer Awareness [16]

As an adjunct to the landmark mobile app launched in 2017, in an initiative for the first time in the world, life size augmented reality technology has been integrated in the mobile app to spread the message of early detection of breast cancer to a large section of people.

This futuristic technology has a potential for the “celebrity and doctor” to enter into people’s homes and create awareness, without actually physically being present. Launched by P.V. Sindhu, a world renowned Badminton Star in 2019, the foundation has been conducting breast cancer awareness sessions in rural India (where more than 70% of the population reside) through this creative effort.

Pink Connexion [17]

In yet another innovative initiative to spread the message of hope, courage, and survival against breast cancer and equally to empower people about various breast health issues, the foundation launched “PINK CONNEXION”—South Asia’s first quarterly breast health newsletter. Since August 2014, the foundation has been reaching out to the nation through this publication, both in print and online.

Every issue focuses mainly upon:

  • A breast cancer “conqueror’s” story

  • An article on breast health

  • An inspiring feature

  • Something else that might interest readership from all walks of life

  • A round up of the foundation’s quarterly activities

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A few “Pink Connexion” cover images featuring breast cancer “conquerors” who have given an inspiring account of their fight against cancer (2014–2021)

Screening

There is robust evidence to suggest that screening mammography ensures early detection of early breast cancer with statistically significant reduction in mortality [1823]. Over the past decade, the impactful Pink Ribbon Campaign has raised awareness about the importance of early detection in Telangana and Andhra Pradesh, and consequently, the number of women presenting for screening mammography has significantly increased in the region.

Whilst opportunistic screening (where women over the age of 40 present themselves for screening mammogram) must be actively encouraged, population-based screening mammography is not a viable option for India. Reasons are enormous costs [24] [25], early age at diagnosis (<50 years) [26] [27], huge variation in mammographic reporting, and quality assurance issues.

Breast self-examination (BSE) is not a useful screening tool as it cannot be standardized [28] [29]. There is considerable evidence to suggest that Clinical Breast Examination (CBE) performed by trained healthcare workers is a valuable alternative screening method [30]. CBE downsizes tumour size and equally provides an excellent opportunity to create awareness about importance of early detection. However, no randomized controlled trial has demonstrated statistically significant reduction in mortality with CBE-based screening. A clinical trial randomizing women to screening mammography versus CBE will answer this vitally important question.

Ushalakshmi Breast Cancer Foundation in partnership with the Governments of Telangana and Andhra Pradesh has implemented a large-scale Clinical Breast Examination (CBE)-based Breast Cancer Screening Programme in rural Telangana and Andhra Pradesh, which has very limited access to mammography services [6].

Underprivileged women in rural India are innately shy of doctors and reluctant to discuss anything as intimate as breast care. Therefore, the governments of the two states were approached with a request to utilize the expertise of existing healthcare workers. Both the state governments readily agreed to the proposal. Core trainers in both the states were identified and trained to perform CBE under the auspices of the foundation. These core trainers further trained all other healthcare workers across the region. Specifically prepared audio visual aids in English and Regional language (Telugu) were used to empower healthcare workers before imparting “hands on” training.

Link to Training Film (English Version)

https://www.youtube.com/watch?v=NjwcvePhROo

Between 2012 and 2016, 200,000 underprivileged women between the ages of 35 and 65 spread across 4000 villages in the region have been screened for early signs of breast cancer by way of CBE performed by 3750 trained healthcare workers, employed with the Governments of Telangana and Andhra Pradesh. A total of 392 breast cancers detected through this initiative have been treated free of charge through the State Government-Funded Aarogyasri Scheme.

Typically, an awareness film is played out by healthcare workers to women assembled at the Village Community Centre in Regional language (Telugu) prior to undertaking CBE-based screening. The film, in simple language, explains the risk factors, symptoms, preventive aspects, basics of treatment, and inspiring messages from breast cancer “conquerors” and healthcare workers.

Link to “Awareness Film” (English Version)

https://www.youtube.com/watch?v=tHlamm6SHz8&feature=youtu.be

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Launch of the screening programme in Telangana by the Health Secretary, Government of Telangana

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Launch of the screening programme in Andhra Pradesh by the Chief Minister, Government of Andhra Pradesh

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Healthcare workers training and women being educated in the Village Community Centre

This milestone project made national impact in 2016, and a high-powered Steering Committee and Technical Advisory Group (TAG) set up by the Government of India’s Union Ministry of Health, of which I was a member, approved the proposal to implement CBE-Based Breast Cancer Screening Programme all over India. This initiative is currently being rolled out nationwide.

Breast Surgical Society—the “Voice” for Breast Surgery in India

Leadership is the capacity to translate vision into reality

Up until 2011, there was no dedicated surgical society that focused exclusively upon issues surrounding breast disease. Recognizing the need to standardize the delivery of breast healthcare in India, I garnered support from colleagues majorly practicing breast surgery and was the principal driving force in establishing the Association of Breast Surgeons of India (ABSI) in 2011, which is the first and only organization in South Asia that represents general surgeons, surgical oncologists, and plastic surgeons treating patients with breast disease. ABSI was established along similar lines to the Association of Breast Surgeons in the UK and the American Society of Breast Surgeons. The formation of ABSI (www.absi.in) in many ways is the first step towards developing breast surgery as a distinct subspecialty in India [5, 6].

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ABSI Training Module, ABSI-UK Fellowship Programme, and ABSI Guidelines

During my term as the ABSI President (2015–2017), “ABSI Training Module” was launched in twelve cities and towns all over India. This pan India training module initiated in 2016 achieved the objective of imparting standardized teaching to trainees and surgeons regarding management of patients presenting with various breast disorders.

During the same period, I had also spearheaded the “ABSI-UK Fellowship Programme”, which allows surgical trainees from India selected on merit to obtain “hands-on” 1-year subspecialty training in breast centres of excellence in the UK. Commenced in 2016, several trainees from India have completed their training in the UK and have since returned back to India [31, 32].

In developing countries like India, there is a need to develop the guidelines to streamline the management of breast cancer. To address this issue, during my presidential term, an expert panel was assembled to discuss and arrive at a consensus statement to provide community oncologists practical guidelines on the management of breast cancer in India. The mandate was to develop practical consensus recommendations applicable globally with emphasis on countries with limited resources. This initiative was spearheaded by Dr. S.P. Somashekhar, Organizing Chairman of ABSICON 2016 and Current President of ABSI. A questionnaire was developed by a panel of experts from academia and ABSI, and these were in sync with the St. Gallen Consensus panel questions which suited to Indian needs and included limitations to evaluation, surgical treatment, surgical pathology, and adjuvant/neo-adjuvant treatment. Each question was projected to panel of experts and audience. Voting through “voting pads” was done by both expert panel and audience simultaneously during ABSICON 2016 (annual conference of ABSI).

The survey answers were used as the basis for formulating the consensus statement. This first of its kind initiative has been published in the Indian Journal of Surgery, which provides ready-to-use practical consensus recommendations for breast cancer management [33].

Conclusion

Traveler there are no paths…Paths have to be made

The organization and delivery of dedicated breast health service has not happened by serendipity but by diligent, meticulous, and strategic planning. The KIMS-USHALAKSHMI Centre for Breast Diseases has been at the forefront in bringing about this revolutionary comprehensive “Breast Health Centre” concept in the Indian subcontinent.

If valuable lives are to be saved from breast cancer “tsunami” in India, there is an urgent need to ensure “early detection”. Breast cancer advocacy and population-based screening programme championed by the Ushalakshmi Breast Cancer Foundation are tactical steps in this direction, which has a potential to be replicated all over India.

The Association of Breast Surgeons of India has rapidly emerged to become the “Voice for Breast Surgery”, with a commitment to improving and standardizing the art and science of breast surgery in the country. During my professional lifetime, I am very hopeful that breast surgery would evolve as a distinct subspecialty in India.

There are turning points in everyone’s life. From taking the bold step to relocate from the UK to India in 2007, my journey over the past 14 years in a country that I was born and raised has given me the greatest satisfaction. With folded hands, my heartfelt gratitude to everyone who made this journey possible.

Gratitude is not an attitude…

Gratitude is something that flows out of you when you are overwhelmed by what is given to you

In closing, delighted to share my poetic musings 14 years ago (2007) whilst preparing to relocate from the UK to India…

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Correspondence to Raghu Ram Pillarisetti OBE.

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Pillarisetti, R.R. United Kingdom to India—a “Living Bridge”: Celebrating 25 Positively Eventful Years (1996–2021). Indian J Surg (2021). https://doi.org/10.1007/s12262-021-02806-1

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