Demographic and clinical profiles of female patients diagnosed with breast cancer in Iraq
AbstractObjective To highlight the main demographic characteristics and clinical profiles of female patients registered with breast cancer in Iraq; focusing on the impact of age.Methods This retrospective study enrolled 1172 female patients who were diagnosed with breast cancer at the Main Center for Early Detection of Breast Cancer/Medical City Teaching Hospital in Baghdad. Data were extracted from an established information system, developed by the principal author under supervision of WHO, that was based on valid clinical records of Iraqi patients affected by breast cancer. The recorded information regarding clinical examination comprised positive palpable lumps, bloody nipple discharge, skin changes, bilateral breast involvement, tumor size, lymph node status, and the stage of the disease.Results The mean age at the presentation was 51 years; patients under the age of 50 constituted 46.8%. Overall 9.8% were not married, 22.4% were illiterate whereas 19.2% graduated from universities. About 72% of the patients had more than two children, merely 7.5% delivered their first child after the age of 35 years and only 11% were nulliparous. History of lactation and hormonal therapy was recorded in 57.6% and 19.4% respectively. Family history of cancer was positive in 28.8% and breast cancer specifically in 18.7%. Clinically, the most common presenting symptom was breast lumps (95%) followed by skin changes/ulcerations (6.7%) and bloody nipple discharge (4.3%).Bilateral breast involvement was encountered in 4.7%. More than two-thirds of the patients (68.2%) had palpable axillary lymph nodes; classifying 40.5% into advanced stages III and IV. In general stages I–IV comprised 12%, 47.5%, 31.9%, and 8.6% respectively. Upon stratifying the studied sample with respect to age at diagnosis, it was observed that the frequency of unmarried patients was significantly higher among younger women under the age of 50 years, whereas illiteracy and nulliparity features were statistically lower (p < 0.05).Conclusion A considerable proportion of breast cancer patients in Iraq still present with locally advanced disease at the time of diagnosis. That justifies the necessity to promote public awareness educational campaigns to strengthen our national early detection program. Excluding the marital status, level of education and number of parity, there was no statistical difference regarding the impact of age on the demographic and clinical profiles of breast cancer among premenopausal versus postmenopausal Iraqi patients.
2. Bray F, McCarron P, Parkin DM. The changing global patterns of female breast cancer incidence and mortality. Breast Cancer Res. 2004;6:229–239.
3. Brinton LA, Gaudet MM, Gierach GL. Breast cancer. In: Thun MJ, Linet MS, Cerhan JR, Haiman CA, Schottenfeld D, Eds. Cancer Epidemiology and Prevention. 4th ed. New York, NY: Oxford University Press, 2018; pp. 861–888.
4. Annual Statistical Report 2016. Planning Directorate, Ministry of Health/Environment, Republic of Iraq, 2017. Available from: https://moh.gov.iq/upload/upfile/ar/513.pdf.
5. Annual Report. Iraqi Cancer Registry 2016. Iraqi Cancer Board, Ministry of Health and Environment, Republic of Iraq, 2018.
6. Alwan N, Al-Attar W, Eliessa R, Al-Midfaei Z, Nidhal F. Knowledge, attitude and practice regarding breast cancer and breast self-examination among a sample of the educated population in Iraq. East Mediterr Health J. 2012;18:337–345.
7. World Health Organization. Strategy for Cancer Prevention and Control in the Eastern Mediterranean Region 2009–2013, World Health Organization. Regional Office for the Eastern Mediterranean, 2010.
8. Alwan N. Iraqi initiative of a regional comparative breast cancer research project in the Middle East. J Cancer Biol Res. 2014;2:1016–1020.
9. Alwan NA. Breast cancer: demographic Characteristics and clinicopathological presentation of patients in Iraq. East Mediterr Health J. 2010;16:1059–1164.
10. Alwan NAS, Tawfeeq FN, Maallah MH, Sattar SA. The stage of breast cancer at the time of diagnosis: correlation with the clinicopathological findings among Iraqi patients. J Neoplasm. 2017;2:1–10.
11. Alwan NAS, Mualla F, Al Naqash M, Kathum S, Tawfiq FN, Nadhir S. Clinical and pathological characteristics of triple positive breast cancer among Iraqi patients. Gulf J Oncolog. 2017;1:51–60.
12. Alwan NAS. Breast cancer among Iraqi women: Preliminary findings from a regional comparative breast cancer research project. J Glob Oncol. 2016;2:255–258.
13. Alwan NAS. Tumor characteristics of female breast cancer: pathological review of mastectomy specimens belonging to Iraqi patients. World J Breast Cancer Res. 2018;1:1–3.
14. Alwan NAS, Kerr D, Al-Okati D, Pezella F, Tawfeeq F. Comparative study on the clinicopathological profiles of breast cancer among Iraqi and British patients. Open Public Health J. 2018;11:177–191.
15. NCCN Guidelines. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. V 1. 2016. National Comprehensive Cancer Network. Available from: http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
16. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, Eds. AJCC (American Joint Committee on Cancer) Cancer Staging Manual. 7th ed. New York, NY: Springer-Verlag, 2010; pp. 347–377.
17. Porter P. “Westernizing” women’s risks? Breast cancer in lower-income countries. N Engl J Med. 2008;358:213–216.
18. Tfayli A, Temraz S, Abou Mrad R, Shamseddine A. Breast cancer in low- and middle-income countries: an emerging and challenging epidemic. J Oncology. 2010;2010:490631.
19. Mehdi I, Monem EA, Al Bahrani BJ, Al Kharusi S, Nada AM, Al Lawati J, et al. Age at diagnosis of female breast cancer in Oman: issues and implications. South Asian J Cancer. 2014;3:101–106.
20. Ravichandran K, Al-Zahrani AS. Association of reproductive factors with the incidence of breast cancer in Gulf Cooperation Council countries. East Mediterr Health J. 2009;15:612–621.
21. Sweileh WM, Zyoud SH, Al-Jabi SW, Sawalha AF. Contribution of Arab countries to breast cancer research: comparison with non-Arab Middle Eastern countries. BMC Womens Health. 2015;15:25.
22. Kulhanova I, Bray F, Fadhil I, Al Zahrani A, El Basmy A, Anwar W, et al. Profile of cancer in the Eastern Mediterranean region: the need for action. Cancer Epidemiol. 2017;47:125–132.
23. Donnelly TT, Khater AH, Al-Bader SB, Al Kuwari MG, Al-Meer N, Malik M, et al. Arab women’s breast cancer screening practices: a literature review. Asian Pac J Cancer Prev. 2013;14:4519–4528.
24. Alwan N, Kerr D. Cancer control in war torn Iraq. Lancet Oncol. 2018;19:291–292.
25. Najjar H, Easson A. Age at diagnosis of breast cancer in Arab nations. Int J Surg. 2010;8:448–452.
26. World Health Organization. World Health Statistics 2017: Monitoring Health for the SDGs, Sustainable Development Goals, 2017. ISBN 978-92-4-156548-6.
27. Mehdi I, Monem EA, Bahrani BJ, Al Kharusi S, Nada AM, Al Lawati J, et al. Age at diagnosis of female breast cancer in Oman: issues and implications. South Asian J Cancer. 2014;3:101–106.
28. Dinger JC, Heinemann LA, Mohner S, Thai do M, Assmann A. Breast cancer risk associated with different HRT formulations: a register-based casecontrol study. BMC Womens Health. 2006;6:13.
29. Gramling R, Eaton CB, Rothman KJ, Cabral H, Silliman RA, Lash TL. Hormone replacement therapy, family history, and breast cancer risk among postmenopausal women. Epidemiology. 2009;20:752–756.
30. Alwan NAS. Clinical and pathological characteristics of familial breast cancer in Iraq. Chron J Cancer Sci. 2017;1:002.
31. Gabr A1, Razek K, Atta H, Elsabah T, Tamam S. Demographic characteristics and clinico-pathological presentation of breast cancer female patients in South Egypt Cancer Institute (2005–2012). SECI Oncol. 2016;1–6.
32. Velappan A, Shumugam D. Analysis of demographic characteristics and treatment outcome of breast cancer patients in a tertiary cancer centre. IOSR J Dent Med Sci. 2017;16:25–28.
33. Zitnjak D, Soldić Z, Kust D, Bolanča A, Kusić A. Demographic and clinicopathologic features of patients with primary breast cancer treated between 1997 and 2010: a single institution experience. Acta Clin Croat. 2015;54:295–302.
34. OECD. Health at a Glance: Europe 2012. OECD Publishing, 2013;24–26.
35. Al Alwan N. Establishing guidelines for early detection of breast cancer in Iraq. Int J Adv Res. 2015;3:539–555.
36. Sankaranarayanan R, Alwan N, Denny L. How can we improve survival from breast cancer in developing countries? Breast Cancer Manage. 2013;2:179–183.
37. Alwan NAS, Al-Attar WM. Evaluating the effect of an educational teaching model on the knowledge about breast cancer among female university students in Iraq. JJ Cancer Sci Res. 2016;2:026.
38. Alwan NAS, Al-Attar WM, Mallah N, Hassoun T. Baseline needs assessment for breast cancer awareness and management among paramedical health care providers in Iraq. Int J Sci Res. 2017;6:1515–1519.
39. Alwan NAS, Al-Attar WM, Al Mallah. Baseline needs assessment for breast cancer awareness among patients in Iraq. Int J Sci Res. 2017;6:2088–2093.
40. Chen HL, Zhou MQ, Tian W, Meng KX, He HF. Effect of age on breast cancer patient prognoses: a population-based study using the SEER 18 database. PLoS One. 2016;11:e0165409.
41. Ewertz M, Duffy SW, Adami HO, Kvale G, Lund E, Meirik O, et al. Age at first birth, parity and risk of breast cancer: a meta-analysis of 8 studies from the Nordic countries. Int J Cancer. 1990;46:597–603.
42. Babalou A. The association of parity and breastfeeding with breast cancer: a review. Health Sci J. 2017;11:1.
43. Huo D, Adebamowo CA, Ogundiran TO, Akang EE, Campbell O, Adenipekun A, et al. Parity and breastfeeding are protective against breast cancer in Nigerian women. Br J Cancer. 2008;98:992–996.
44. Palmer JR, Wise LA, Horton NJ, Adams-Campbell LL, Rosenberg L. Dual effect of parity on breast cancer risk in African-American women. J Natl Cancer Inst. 2003;95:478–483.