|Year : 2012 | Volume
| Issue : 3 | Page : 389-393
Clinicoepidemiological analysis of female breast cancer patients in Kashmir
Shaqul Qamar Wani1, Talib Khan2, Saiful Y Wani3, Abid H Koka4, Syed Arshad1, Liza Rafiq5, Lone M Mqabool6, Fir Afroz6
1 Department of Radiation Oncology, Government Medical College and Associated Hospitals, Karan Nagar, Srinagar, India
2 Department of Anaesthesiology, Intensive Care and Pain Management, Government Medical College and Associated Hospitals, Karan Nagar, Srinagar, India
3 Department of Medicine, 53 Battalion CRPF HQ, District Police Lines, Baramullah, India
4 Department of Orthopedics, District Hospital, Pulwama, India
5 Department of Obstetrics and Gynaecology, Government Medical College and Associated LD Hospital, Karan Nagar, Srinagar, India
6 Department of Radiation Oncology, Sher -I- Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||17-Nov-2012|
Shaqul Qamar Wani
Department of Radiation Oncology, Government Medical College and Associated Hospitals, Karan Nagar, Srinagar, Jammu and Kashmir - 190 010
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to analyze the demographic features, reproductive history and stage at disease presentation among the female breast cancer patients.
Design and Setting: The present prospective hospital-based study was conducted in Department of Radiation Oncology, University Teaching and Tertiary Referral Hospital.
Materials and Methods: After approval from the Institute's ethical committee, 132 female breast cancer patients surgically treated either by mastectomy or breast conserving surgery (BCS) and then referred to the department of radiation oncology for further management and/or follow-up as per the hospital protocol, were enrolled in the study (January 2010 to December 2011) after obtaining a written informed consent from the patients. The patients were diagnosed by histology [fine needle aspiration cytology (FNAC), true cut or excision biopsy], mammography and ultrasonography (USG). The patients were analyzed as per the demographic and reproductive history and the stage of disease at presentation. The data collected were expressed as percentage (%), mean, median and standard deviation (SD).
Results: The mean age at presentation was 46.6 ± 10.2 years. The majority of patients were from rural areas, married, multiparous and post-menopausal. The commonest stage at disease presentation was IIb.
Conclusion: In comparison to the rest of Indian scenario, more awareness related to breast cancer among post-menopausal and the rural females is needed. The role of peri-menopausal status, which represent 10% (n = 14) patients needs to be established in relation to breast cancer.
Keywords: Breast cancer, demography, reproductive history, TNM stage
|How to cite this article:|
Wani SQ, Khan T, Wani SY, Koka AH, Arshad S, Rafiq L, Mqabool LM, Afroz F. Clinicoepidemiological analysis of female breast cancer patients in Kashmir. J Can Res Ther 2012;8:389-93
|How to cite this URL:|
Wani SQ, Khan T, Wani SY, Koka AH, Arshad S, Rafiq L, Mqabool LM, Afroz F. Clinicoepidemiological analysis of female breast cancer patients in Kashmir. J Can Res Ther [serial online] 2012 [cited 2020 Jun 3];8:389-93. Available from: http://www.cancerjournal.net/text.asp?2012/8/3/389/103518
| > Introduction|| |
Cancer of breast is a disease that instills feeling of dread and fear in many women. Not only is it a life-threatening disease, but it affects a part of the body that is central to women's sense of womanliness and femininity. It is a complex disease with the causes not yet fully understood. It is most likely caused by a number of factors interacting with each other, rather than by any one factor.  Breast cancer is currently the top cancer in women worldwide, both in the developed and the developing world. The majority of breast cancer deaths occur in low-and middle-income countries, where most of the women are diagnosed in late stages due mainly to lack of awareness and barriers to access to health services.  The incidence of breast cancer is low in India, but rising. Breast cancer is the commonest cancer of urban Indian women and the second commonest in the rural women.  Breast cancer is the most common malignant neoplasm in women worldwide. Its incidence has been reported to be 105 cases per 100,000 women per year with a lifetime risk of 1 out of every 8 women. 
Breast cancer is the second most common cancer among women in India and accounts for 7% of global burden of breast cancer and one-fifth of all cancers among women in India. Over 90,000 new cancer cases are estimated to occur this year and over 50,000 women are estimated to die of it annually in India.  It is the number one cancer among women in urban areas of India. The incidence of breast cancer is approximately three times higher in urban areas compared to rural areas.  The age-standardized incidence rates vary between 9 and 32 per 100,000 women. An increasing trend in the incidence rates of the breast cancer has been reported from the various registries of National Cancer Registry Project. This malignancy accounts for 19% to 34% of all cancer cases among women nationally. While the epidemiological studies for breast cancer carried out in India have largely focused on risk factors, such as religion, age at menarche, menopause and reproductive history, not much attention has been paid on role of family history even though genetic predisposition is responsible for 5-10% of all breast cancers.  It was found that age at first marriage and birth of the first child as well as the number of abortions and parity adjusted for age at first birth were associated with the breast cancer risk, whereas lactation was not.  Although some cases of breast cancer occur in a familial pattern, the majority of breast cancer cases are sporadic and without any prior family history. Risk factors for the development of breast cancer include family history, increasing age, parity, age at which sexual activity is initiated, nulliparity, environmental factors, previous benign tumors of breast and emotional factors.  Contrary to the trend in India, cervical cancer is not a leading type of cancer in the Valley and is less frequent even than cancer of the breast in the women.  Breast cancer is the second most common malignancy in females following upper GI malignancies.  There is a sharp rise in the breast cancer cases in the Valley over the years. In fact, breast cancer has reached among the first five commonest cancers.  Breast cancer is emerging as a major concern in female populations of the Kashmir Valley with its incidence showing an increasing trend.  This led us to the concept to undertake the study titled "Clinicoepidemiological Analysis of Female Breast Cancer Patients in Kashmir" with following aims and objectives to analyze among the female breast cancer patients:
- Demographic features like age at presentation and dwelling.
- Reproductive history like marital status, age at marriage, age at first birth, parity, menopausal status.
- Stage of disease at presentation.
| > Patients and Methods|| |
The present hospital-based prospective study titled "Clinicoepidemiological Analysis of Female Breast Cancer patients in Kashmir" was conducted over the study period (January 2010 to December 2011) in Department of Radiation Oncology, University Teaching and Tertiary Referral Hospital.
After approval from the Institute's ethical committee, 132 female breast cancer patients treated surgically by mastectomy or breast conserving surgery (BCS) by surgical oncology department and then referred to the department of radiation oncology for further management and/or follow-up as per the hospital protocol were enrolled in the study after obtaining an informed written consent from the patients. The patients were diagnosed by histology [fine needle aspiration cytology (FNAC), true cut or excision biopsy], mammography and ultrasonography (USG). The patients were analyzed as per the demographics, reproductive history and the stage of disease at presentation. The data collected were expressed as percentage (%), mean, median and standard deviation (SD).
| > Results|| |
The age distribution among the breast cancer patients was ranging from the minimum of 27 to 73 years of age with mean ± SD years as 46.6 ± 10.2 years [Table 1]. The age at the time of marriage among the married studied subjects (n = 128) range from 13 to 32 years with mean ± SD as 22.4 ± 3.5 years [Table 1]. The age at the time of first birth was a year later after marriage 23.5 ± 3.5 years [Table 1].
|Table 1: Age distribution and age at marriage characteristics among breast cancer patients|
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The majority of the patients were from the rural area [59.9% (n = 79)] and the remaining from urban area [40.1% (n = 53); [Table 2]]. Among the studied subjects, 97% (n = 64) were married [Table 2]. Among the married subjects, 75% (n = 96) were multiparous [Table 3].
|Table 3: Parity characteristics among the married studied subjects of breast cancer|
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As far as the menopausal status is concerned, majority of the patients were post-menopausal [50% (n = 66)], followed by pre-menopausal [39.4% (n = 52); [Table 4]].
The commonest tumor (T) stage at presentation among the breast cancer patients was T2 [48.5% (n = 64)], followed by T3 [22.7% (n = 30), T4 [19.7% (n = 26)] and T1 [9.1% (n = 12)]. The commonest nodal (N) stage was N1 [54.5% (n = 72)] followed by N2 [30.3% (n = 40)] and N0 [15.2% (n = 20)]. The commonest metastasis (M) stage was M0 [95.5% (n = 126)], rest of the stage was M1 [4.5% (n = 6); [Table 5]].
As far as the TNM staging of breast cancer is concerned, IIb was commonest [34.84% (n = 46)] followed by IIIa [28.78% (n = 38)], IIIb [16.66% (n = 22)], IIa [12.12% (n = 16)], IV [4.54% (n = 6)] and I [3.03% (n = 4)] [Table 6].
| > Discussion|| |
The presenting age of breast cancer patients ranges from 27 to 73 years with a mean of 46.6 ± 10.2 years. This is in accordance with the study of Shahriari Ahmadi et al. , Saxena et al.  , Wani et al. , Fakhro et al. , Raina et al. and Majid et al. Breast cancer incidence rates increase with age throughout the lifespan in Western countries, although the rate of increase is greater up to the age of 50 years than after 50 years.  The peak age for breast cancer is between 40 and 50 years in the Asian countries, whereas the peak age in the Western countries is between 60 and 70 years.  The age of first marriage among the breast cancer patients was 22.4 ± 3.5 years. The age at the time of first birth was a year later after marriage (23.5 ± 3.5 years) among our subjects.
The majority of the patients were from the rural area [59.9% (n = 79)] and the remaining from urban area [40.1% (n = 53)]. The majority of female population lives in rural Kashmir to the tune of 73.51%, though 68.84% of the total Indian population is rural.  Now a days most of the rural areas have adapted urban lifestyle in Kashmir. In rest of the Indian states, the patients are usually from urban areas. The incidence of breast cancer is low in India, but rising. Breast cancer is the commonest cancer of urban Indian women and the second commonest among rural women.  India is rapidly stepping toward industrialization vis-à-vis urbanization resulting in change of lifestyle. These factors possibly contributed to a gradual increase in the incidence of breast cancer in the country. The burden of breast cancer will continue to grow not only in terms of the absolute number of cases but also in terms of incidence.  The majority of patients in our study [97 % (n = 128)] were married; higher percentage of married subjects were seen in the study of Shahriari Ahmadi et al.,  Fakhro et al. and Montazeri et al. 
As can be seen from one of the demographic reports, 94 percent females in the state were married, and 89 percent are co-residing with their husbands; the majority were married by the age of 25 to 29 years.  In Kashmir Valley, there is a trend of female marriage done before the age of 25 to 30 years. The mean ages at marriage of boys and girls in Jammu and Kashmir are 26.0 years and 22.2 years, respectively. 
However, in rest of India, the median age at first marriage for women aged 20 to 49 in rural areas is only 16 years, well below the legal minimum. The median age at first marriage is 2 to 3 years higher for urban women than for rural women in all age groups.  The majority of our patients had given first birth a year later to marriage.
The majority of patients in our study were multiparous 75 % (n = 96). The risk of breast cancer increased linearly with age at first live birth; women with a birth after age 30 showed 4- to 5-fold excess risks compared to those with a birth prior to 18, while the risk for nulliparous women resembled that for women whose first birth was in their late twenties. Age at first live birth explained most associations, but some residual reduction in risk was noted for multiparous women and those with several births at an early age. There was evidence that delays in birth after marriage increased risk, but this did not explain the high risk associated with late age at first birth.  From an etiological viewpoint, both parity and age at first birth have some independent effect on breast carcinogenesis. However, from public health viewpoint it appears that the importance of age at first birth is greater, since the trend is linear across subsequent age levels, while the protection of parity seems to be quantitatively relevant only for women with four or five births or more.  Studies have shown an increased breast cancer risk in women of low parity, those who have their first child late, and those who had used oral contraceptives and hormone replacement therapy for prolonged periods. In Norway, it has been found that high parity is associated with an overall reduced risk of breast cancer. Among women 20-29 years of age, however, the results suggested increased risk with increasing parity. The protective effect of high parity was particularly strong among women with first birth before the age of 20 years, and rather weak among those with first birth at the age of 30 years or more.  Nulliparity is related to an increased risk for breast cancer diagnosed after 40 years. Multiple full-term pregnancies decrease the risk of breast cancers diagnosed after 40 years regardless of the age at first birth.  The majority of the patients were post-menopausal [48.4% (n = 64)], followed by pre-menopausal [39.4 % (n = 52)] and peri-menopausal [10.6% (n = 14)], reflecting that 50% of the patients were post-menopausal. However, early age at menarche, late age at menopause and late age at first full-term pregnancy are linked to a modest increase in the risk of developing breast cancer.  The cause of these seemingly higher pre-menopausal breast cancer rates among Iraqi Kurds could not be related to parity or to an excessive familial risk.  The risk of at least one breast cancer history among subjects' first-degree relatives was relatively high among pre-as well as post-menopausal women. A protective effect of physical activity against breast cancer was observed among both pre- and post-menopausal women. Dietary control decreased the risk of pre-menopausal breast cancer. Current smoking and drinking elevated the risk of breast cancer in pre-menopausal women. Decreasing trends of breast cancer risk were associated with intake of bean curd, green-yellow vegetables, potato or sweet potato, chicken, and ham or sausage in pre-menopausal women, while in post-menopausal women a risk reduction was associated with more frequent intake of boiled, broiled and/or raw fish (sashimi). Further study will be needed to clarify the age group-and/or birth cohort-specific risk factors for breast cancer among the young generation. 
Breast cancer incidence decreased with an earlier age at menopause. Women with a menopausal age of 44 years or younger had a 34% lower risk of breast cancer, than women with a menopausal age over 54 years. The annual hazard of breast cancer incidence decreased by 2.6% per year reduction in age at menopause. The protective effect of an early age at menopause was stronger for women with a low body mass index (27 kg/m 2 ; reduction of 44%) than for women with a high body mass index (>27 kg/m 2 ; reduction of 24%), although this difference was not statistically significant. This study provides evidence of the protective effect of lower age at menopause on subsequent breast cancer risk. This protective effect may be even stronger in leaner women. 
The menopausal status, reproductive status, and joint effect of diet and family history are the important risk factors. Breast-feeding is a preventive measure against breast cancer. Furthermore, the risk of breast cancer is found to be increasing with age. The highest incidences among women were in the age group of 40 to 59. 
In our study, the commonest tumor (T) stage among the breast cancer patients is T2 [48.5% (n = 64)], followed by T3 [22.7% (n = 30)], T4 [19.7% (n = 26)] and T1 [9.1% (n = 12)]. The commonest nodal (N) stage was N1 [54.5% (n = 72)] followed by N2 [30.3% (n = 40)] and N0 [15.2% (n = 20)]. The commonest metastasis (M) stage was M0 [95.5% (n = 126)], rest of the stage was M1 [4.5% (n = 6)]. The majority of the patients presented in stage IIb [34.84% (n = 46)], followed by IIIa [28.78% (n = 38)], IIIb [16.66% (n = 22)], IIa [12.12% (n = 16)], IV [4.54% (n = 6)] and I [3.03% (n = 4)].
The majority of breast cancer deaths occur in low- and middle-income countries, where most of the women are diagnosed in late stages due mainly to lack of awareness and barriers to access to health services.  The reason for the patients being diagnosed at the earlier stage was due to the fact that majority of our patients were married which made these patients to seek the medical advice at earlier stage. The awareness of cancer was also the reason for earlier diagnosis. This finding was contrary to the incidence of breast cancer at presentation in Asian and Indian states where patients present at advanced stages. However, stage IIb was common in our study, which was in accordance with the study of Shahriari Ahmadi et al.
The advantage of marital bond was found in the study of Ali et al. wherein 45% were reported at early stages and 53% at late stages. Elevated risks for late stage reporting among breast cancer patients were observed for women who were unmarried, widowed/divorced, with lower education.  Also those who are married may have lower mortality because of protective effects of marriage or selection of healthy individuals into marriage. 
| > References|| |
|1.||Uddin S, Ullah A, Najma, Iqbal M. Statistical Modeling of the Incidence of Breast Cancer in NWFP, Pakistan. J App Quant Methods Med 2010;5:159-65. Available from: http://jaqm.ro/issues/volume- 5, issue-1/pdfs/uddin_ullah_najma_iqbal.pdf |
|2.||WHO Bulletin. Global Breast Cancer Awareness Month WHO. October 2011- Global. Available from: http://www.who.int/cancer/events/breast_cancer_month/en/index.html. |
|3.||Agarwal G, Ramakant P. Breast Cancer Care in India: The Current Scenario and the Challenges for the Future. Breast Care (Basel) 2008;3:21-7. |
|4.||Shahriari Ahmadi A, Ghavamzadeh A, Amiri N, Farnia V, Samadzadeh S, Malekniazi A. Clinical, Biological and Pathological Characteristics of Breast Cancer Patients at the Taleghani University Hospital in Kermanshah, Iran. IJHOBMT 2005;2;6-11. |
|5.||Boyle P, Howell A. The globalisation of breast cancer. Breast Cancer Res 2010;12:S7. |
|6.||Saxena S, Rekhi B, Bansal A, Bagga A, Chintamani, Murthy NS. Clinico-morphological patterns of breast cancer including family history in a New Delhi hospital, India--a cross-sectional study. World J Surg Oncol 2005;3:67-74. |
|7.||Soini I. Risk Factors of Breast Cancer in Finland. Int J Epidemiol 1977;6:365-73. |
|8.||Eppenberger-Castori S, Moore DH Jr, Thor AD, Edgerton SM, Kueng W, Eppenberger U, et al. Age-associated biomarker. Profiles of human breast cancer. Int J Biochem Cell Biol 2000;34:30-8. |
|9.||Dhar GM, Shah GN, Naheed B, Hafiza. Epidemiological Trend in the Distribution of Cancer in Kashmir Valley. J Epidemiol Community Health 1993;47:290-2. |
|10.||Ayub SG, Ayub T, Khan SN, Rasool S, Hussain M, Wani KA et al. Epidemiological Distribution and Incidence of Different Cancers in Kashmir Valley-2002-2006. Asian Pac J Cancer Prev 2011;12:1867-72. |
|11.||Only Kashmir. Breast cancer in Kashmir on rise. Available from:http://www.onlykashmir.com/2011 / 03/breast-cancer-in-kashmir-on-rise.html. |
|12.||Wani SQ, Khan T, Teeli AM, Khan NA, Wani SY; Ashfaq-ul-Hassan. Quality of life assessment in survivors of breast cancer. J Cancer Res Ther 2012;8:272-6. |
|13.||Fakhro AE, Fateha BE, al-Asheeri N, al-Ekri SA. Breast cancer:Patient characteristics and survival analysis at Salmaniya medical complex, Bahrain. East Mediterr Health J 1999;5:430-9. |
|14.||Raina V, Kunjahari M, Shukla NK, Deo S, Sharma A, Mohanti BK et al. Outcome of combined modality treatment including neoadjuvant chemotherapy of 128 cases of locally advanced breast cancer:Data from a tertiary cancer center in northern India. Indian J Cancer 2011;48:80-5. |
|15.||Majid RA, Mohammed HA, Saeed HM, Safar BM, Rashid RM, Hughson MD. Breast cancer in Kurdish women of northern Iraq: Incidence, clinical stage, and case control analysis of parity and family risk. BMC Women's Health 2009;9:33-9. |
|16.||Kelsey JL, Berkowitz GS. Breast cancer epidemiology. Cancer Res 1988;48:5615-23. |
|17.||Leong SP, Shen ZZ, Liu TJ, Agarwal G, Tajima T, Paik NS et al. Is breast cancer the same disease in Asian and Western countries? World J Surg. 2010;34:2308-24. |
|18.||Census of India 2011; Rural Urban Distribution of Population. |
|19.||Murthy NS, Chaudhry K, Nadayil D, Agarwal UK, Saxena S. Changing trends in incidence of breast cancer: Indian scenario. Indian J Cancer 2009;46:73-4. |
|20.||Montazeri A, Vahdaninia M, Harirchi I, Harirchi AM, Sajadian A, Khaleghi F et al. Breast cancer in Iran: Need for greater women awareness of warning signs and effective screening methods. Asia Pac Fam Med 2008;7:6. |
|21.||Background characteristics Of Respondents. Chap. 3. Available from: http://hetv.org/pdf/nfhs/india/indch3.pdf |
|22.||International Institute for Population Sciences (IIPS), 2010. District Level Household and Facility Survey (DLHS-3), 2007-08: India. Jammu and Kashmir: Mumbai: IIPS. Available from: http://www.rchiips.org/pdf/rch3/report/JK.pdf |
|23.||Brinton LA, Hoover R, Fraumeni JF Jr. Reproductive factors in the aetiology of breast cancer. Br J Cancer 1983; 47:757-62. |
|24.||La Vecchia C, Negri E, Boyle P. Reproductive factors and breast cancer: An overview. Soz Praventivmed 1989;34:101-7. |
|25.||Kelsey JL, Gammon MD, John EM. Reproductive factors and breast cancer. Epidemiol Rev 1993;15:36-47. |
|26.||Hirose K, Tajima K, Hamajima N, Inoue M, Takezaki T, Kuroishi T, et al. A Large-scale, Hospital-based Case-Control Study of Risk Factors of Breast Cancer According to Menopausal Status. Jpn J Cancer Res 1995;86:146-54. |
|27.||Monninkhof EM, Van der Schouw YT, Peeters PH. Early age at menopause and breast cancer: Are leaner women more protected? A prospective analysis of the Dutch DOM cohort. Breast Cancer Res Treat 1999;55:285-91. |
|28.||Ali R, Mathew A, Rajan B. Effects of socio-economic and demographic factors in delayed reporting and late-stage presentation among patients with breast cancer in a major cancer hospital in South India. Asian Pac J Cancer Prev 2008;9:703-7. |
|29.||Berntsen KN. Trends in total and cause-specific mortality by marital status among elderly Norwegian men and women. BMC Public Health 2011;11:537. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]