|Year : 2019 | Volume
| Issue : 5 | Page : 1087-1091
Epidemiological characteristics of breast cancer patients attending a tertiary health-care institute in the National Capital Territory of India
Nighat Yaseen Sofi1, Monika Jain1, Umesh Kapil2, Chander Prakash Yadav3
1 Department of Food Science and Nutrition, Faculty of Home Science, Banasthali Vidyapith, Rajasthan, India
2 Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
3 Epidemiology and Clinical Research Division, National Institute of Malaria Research, Indian Council of Medical Research, Ministry of Health and Family Welfare, Dwarka, New Delhi, India
|Date of Web Publication||4-Oct-2019|
Nighat Yaseen Sofi
Department of Food Science and Nutrition, Faculty of Home Science, Banasthali Vanasthali, Niwai - 304 022, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Limited data are available on the epidemiology of breast cancer (BC) in India.
Objective: To study the epidemiological characteristics of BC patients attending a tertiary care hospital in National Capital Territory of India.
Materials and Methods: A cross-sectional study was conducted and information from 320 women with confirmed BC was collected on a questionnaire for demographic profile, socioeconomic status (SES), reproductive risk factors, and family history of BC. Information on clinical presentation and staging of BC was recorded. Anthropometric assessment for body mass index (BMI) was done. Data were analyzed and presented as mean ± standard deviation and frequency tables.
Results: The mean age at diagnosis of BC was 47 ± 10 years. Fifty-three percent of patients were illiterate or only primary school education. About 74% of patients were from urban areas. Only 11% of patients were from upper SES and 26% from lower SES. Forty-seven percent of patients had stage II followed by 36% with stage III BC. About 15% patients had experienced early menarche (<13 years of age) and 15% of women had attained late menopause (>51 years of age). About 42% of patients had <3 children and 15% patients had a family history of BC. About 38% patients were overweight and 21% were obese.
Conclusion: Other than the established risk factors, other factors such as lack of education, SES, and higher BMI were present in our study. A higher percentage of women were diagnosed with BC at later stages. There is a need for educating women about BC, self-examination of breast, and screening programs for early detection of BC.
Keywords: Body mass index, breast cancer, epidemiology, risk factors, socioeconomic class
|How to cite this article:|
Sofi NY, Jain M, Kapil U, Yadav CP. Epidemiological characteristics of breast cancer patients attending a tertiary health-care institute in the National Capital Territory of India. J Can Res Ther 2019;15:1087-91
|How to cite this URL:|
Sofi NY, Jain M, Kapil U, Yadav CP. Epidemiological characteristics of breast cancer patients attending a tertiary health-care institute in the National Capital Territory of India. J Can Res Ther [serial online] 2019 [cited 2019 Nov 22];15:1087-91. Available from: http://www.cancerjournal.net/text.asp?2019/15/5/1087/243499
| > Introduction|| |
Breast cancer (BC) is the most commonly diagnosed cancer among women in India. With the advent of population growth, changes in the lifestyle, and migration from rural to urban areas, there is an increase in the incidence in BC in developing countries. In India, statistically significant increase in the trends of incidence of BC is noticed. The mortality rates associated with BC have also increased during the last two decades. The annual age-standardized rate for BC incidence in India is 25.8/100,000 with a high mortality rate of 12.7/100,000. BC is a multifactorial disease. In addition to the nonmodifiable risk factors such as genetic mutation, age, and family history of BC, the other risk factors include reproductive risk factors such as early age at menarche and late age at menopause, nulliparity, older age at first full-term birth, number of children, and duration of breastfeeding., Epidemiological characteristics such as sociodemographic profile, socioeconomic status (SES), and educational status have been associated with BC. The risk also increases with changes in lifestyle such as low physical activity and consumption of high-fat diet., There are limited studies available on the risk factors in BC from the National Capital Territory (NCT) of India. Hence, the present study was conducted to identify the epidemiological characteristics of the patients with BC in NCT of India.
| > Materials and Methods|| |
The present cross-sectional study included women (patients) attending a tertiary care hospital for treatment of BC in NCT. The patients were enrolled between 2014 and 2016. The study was conducted after explaining the purpose of the study and obtaining informed consent from each patient. Terminally ill and the patients who did not give their consent for participation were excluded from the study. A total of 320 patients with newly diagnosed BC confirmed by histopathological (biopsy) and cytopathological (fine-needle aspiration cytology) reports were included. Each patient was administered a questionnaire to collect data on sociodemographic profile such as age, educational status, and religion socioeconomic profile such as education, occupation, and family income. SES was determined using modified Kuppuswamy's socioeconomic classification system. Information about clinical presentation and criteria for the diagnosis of BC was also recorded. The data on known risk factors such as age at menarche, age at first childbirth, parity, duration of breastfeeding, age at menopause, family history of BC, and body mass index (BMI) were also collected. BMI was calculated from anthropometric assessment for weight (kg) and height (cm) using standard tools and techniques. The cutoffs provided by the Word Health Organization for defining overweight (25–25.9 kg/m 2) and obesity (>30 kg/m 2) were adopted. Data were analyzed and presented as mean ± standard deviation and frequency tables.
| > Results|| |
The mean age of patients at diagnosis of BC was 47 ± 10 years. Majority (88%) of the patients were in the age group of 35–65 years. The distribution parameters for BC patients are presented in [Table 1]. The sociodemographic profile revealed that 74% (n = 236) of patients were from urban areas. Majority of the patients (260, 81%) were from Hindu religious group. About 60% (n = 210) of patients were from nuclear families and 34% (n = 110) from joint families (nuclear family implied for individual living with spouse and unmarried children only, whereas joint family implied for individual living in a family composed of parents of spouse, children of the individual, and the children's spouses and offspring living in one household). Fifty-three percent (n = 170) of patients were illiterate or had received only primary school education. Forty-seven percent (n = 150) of patients had received education of high school and above. Seventy-five percent (n = 240) of patients had a sedentary lifestyle and 25% (n = 80) were moderate workers. About 11% (n = 34) of patients were from upper SES, followed by 28% (n = 91) from upper middle, 35% (n = 111) from middle, and 26% (n = 84) from lower SES.
|Table 1: Distribution of breast cancer patients according to sociodemographic profile and presence of risk factors|
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The common clinical presentation was that of a breast lump. The clinical presentation for BC revealed that 47% (n = 151) of patients had stage II, followed by 36% (n = 114) with stage III, 14% (n = 45) with stage I, and 3% (n = 10) with stage IV BC. BC was confirmed by histopathology for 54% (173/320) and cytopathology for 46% (147/320) of patients.
Information regarding the known risk factors for BC revealed that 46% (n = 148) of patients were premenopausal and 54% (n = 172) were postmenopausal. The mean age at menarche was 13.7 ± 1.3 years and 15% (n = 48) of patients had experienced menarche at <13 years of age. The mean age at menopause was 46 ± 5 years and 15% (n = 24) of women had attained late menopause at the age of 51 years and above. Only 4% (n = 11) of patients had their first childbirth at the age of 30 years and above. About 42% (n = 128) of patients had <3 children. About 93% of women had breastfed their children with a mean duration of 27 ± 14 months of breastfeeding to the youngest child. About 15% (49) of patients were reported to have a family history of BC. The BMI revealed that 35% (n = 113) of patients were overweight and 21% (n = 66) were obese. It was also found that 93% of patients had breastfed their children with a mean duration of 27 ± 14 months of breastfeeding to the youngest child. However, of 320 patients, 302 were parous with 4% of patients having their first childbirth at the age of 30 years and above.
| > Discussion|| |
The peak age of BC is 60–70 years in Western countries and 40–50 years in Asian countries. In India, BC incidence peaks among women at a younger age as compared to women from Western countries. Research studies conducted earlier in the country have observed age at diagnosis of BC between 45 and 50 years.,, We found similar results in the present study. Increased size of tumor, metastatic lymph node involvement, low hormone receptor status, and low survival rates in BC have been observed at younger age.,
Educational status reflects the SES of an individual through its association with occupation, total income, residential type, and life-style related factors. Research studies in developed countries have shown that cancer incidence varies between people with different levels of education., In our study, 53% (n = 170) of patients were illiterate or had received only primary school education. However, almost half of the study population (47%) of BC patients had a higher education status and were in working profession. Recent research study revealed that higher education status was associated with increased risk of BC. Another study has found the same results where BC was found to be less prevalent at the lower education level and the incidence increased with the education level. The sociodemographic profile revealed that majority (74%) of BC patients were from urban areas. With the demographic change, from rural to urban areas, the incidence of BC is likely to become more frequent even in rural areas in future.
Earlier studies reported that patients with BC were from low SES conditions. Results on SES from our study revealed that 11% (n = 34) of patients were from upper SES, followed by 28% (n = 91) from upper middle, 35% (n = 111) from middle, and 26% (n = 84) from lower SES. Hospital-based cancer registry from northern India also revealed that nearly two-thirds of patients with cancer belong to the lower or upper-lower SES. The substantial delay in detection and diagnosis of cancers in low- and middle-income countries is one of the key reasons for the difference in cancer outcomes between high-, middle-, and low-income countries.
The clinical presentation for BC in our study revealed that 47% (n = 151) of patients had stage II, followed by 36% (n = 114) with stage III, 14% (n = 45) with stage I, and 3% (n = 10) with stage IV BC. Previous research studies on stage of BC have reported that more than 50% of newly diagnosed patients are present with stage III or IV BC., Earlier studies have implicated the factors such as lack of awareness, lack of funding, lack of infrastructure, and low priority in public health schemes for detection of BC at earlier stage. Earlier studies have documented that in low- and middle-income countries, 20%–50% patients are diagnosed at earlier stages.
Early menarche results in definite exposure to hormones such as estrogens in the presence of other hormones such as progesterone, thereby increasing the risk of BC. Early age at menarche has been associated with an increased risk of BC. In the present study, 15% (n = 48) of BC patients had experienced menarche at <13 years of age. Late age at menopause in Indian women has been associated with an increased risk of BC. In our study, 15% (n = 24) of women had attained late menopause at the age of 51 years and above. Similar results were observed in other research study where the risk of BC was more for women who had menopause after 50 years compared to women who had menopause before 45 years of age.
The reproductive risk factors such as age at first childbirth and total number of children have also been found associated with BC. In the present study, only 4% (n = 11) of patients had their first childbirth at the age of 30 years and above. However, 42% (n = 128) of patients had <3 children. It has been found that older age at first pregnancy (>25 years) and having fewer children (1–2) had a positive association with BC., About 93% of women had breastfed their children with a mean duration of 27 ± 14 months of breastfeeding to the youngest child. In a multicentric case–control study on breastfeeding and risk of BC in India, it was found that lifetime duration of breastfeeding was inversely associated with risk of BC among premenopausal women.
Family history of BC increases the cancer risk by two or three folds.,, In the present study, familial history of BC was observed in 15% of patients. Similar results have been documented in earlier studies., BMI and its association with risk of BC is thought to be due to the greater number of irregular menstrual cycles, with decreased exposure to ovarian hormones in obese women. A positive association has been observed earlier between risk of BC and augmented anthropometric factors for both pre- and post-menopausal rural and urban women. We found that 35% patients were overweight and 21% were obese. Similar results were found by earlier research studies.,
| > Conclusion|| |
In India, BC incidence is increasing among women in many regions. Implementation of prevention strategies and early detection of BC should be a public health priority. Health awareness education about BC and training for breast self-examination will support the cause for prevention of BC.
Financial support and sponsorship
Department of Biotechnology, New Delhi.
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Mathew A. Cancer Registration with Emphasis on Indian Scenario in Basic Information for Cancer Registry Documentation. Trivandrum: Regional Cancer Centre; 2003. p. 11-7.
Dikshit RP, Yeole BB, Nagrani R, Dhillon P, Badwe R, Bray F, et al
. Increase in breast cancer incidence among older women in Mumbai: 30-year trends and predictions to 2025. Cancer Epidemiol 2012;36:e215-20.
Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al
. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86.
Rose DP, Vona-Davis L. Interaction between menopausal status and obesity in affecting breast cancer risk. Maturitas 2010;66:33-8.
Hemminki K, Försti A, Sundquist J, Mousavi SM. Preventable breast cancer is postmenopausal. Breast Cancer Res Treat 2011;125:163-7.
Mathew A, George PS, Arjunan A, Augustine P, Kalavathy M, Padmakumari G, et al
. Temporal trends and future prediction of breast cancer incidence across age groups in Trivandrum, South India. Asian Pac J Cancer Prev 2016;17:2895-9.
Danaei G, Vander Hoorn S, Lopez AD, Murray CJ, Ezzati M; Comparative Risk Assessment Collaborating Group (Cancers), et al
. Causes of cancer in the world: Comparative risk assessment of nine behavioural and environmental risk factors. Lancet 2005;366:1784-93.
Amadou A, Ferrari P, Muwonge R, Moskal A, Biessy C, Romieu I, et al
. Overweight, obesity and risk of premenopausal breast cancer according to ethnicity: A systematic review and dose-response meta-analysis. Obes Rev 2013;14:665-78.
Kumar Ravi BP, Dudala SR, Rao AR. Kuppuswamy's socio-economic status scale – A revision of economic parameter for 2012. IJRDH 2013;1:2-4.
Physical status: The use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1995;854:1-452.
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.
Agarwal G, Pradeep PV, Aggarwal V, Yip CH, Cheung PS. Spectrum of breast cancer in Asian women. World J Surg 2007;31:1031-40.
Saxena S, Rekhi B, Bansal A, Bagga A, Chintamani, Murthy NS, et al
. 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.
Sandhu DS, Sandhu S, Karwasra RK, Marwah S. Profile of breast cancer patients at a tertiary care hospital in North India. Indian J Cancer 2010;47:16-22.
] [Full text]
Pakseresht S, Ingle GK, Bahadur AK, Ramteke VK, Singh MM, Garg S, et al
. Risk factors with breast cancer among women in Delhi. Indian J Cancer 2009;46:132-8.
] [Full text]
Shavers VL, Harlan LC, Stevens JL. Racial/ethnic variation in clinical presentation, treatment, and survival among breast cancer patients under age 35. Cancer 2003;97:134-47.
Mathew A, Pandey M, Rajan B. Do younger women with non-metastatic and non-inflammatory breast carcinoma have poor prognosis? World J Surg Oncol 2004;2:2.
Hemminki K, Li X. Level of education and the risk of cancer in Sweden. Cancer Epidemiol Biomarkers Prev 2003;12:796-802.
Vidarsdottir H, Gunnarsdottir HK, Olafsdottir EJ, Olafsdottir GH, Pukkala E, Tryggvadottir L, et al
. Cancer risk by education in Iceland; a census-based cohort study. Acta Oncol 2008;47:385-90.
Swaminathan R, Selvakumaran R, Vinodha J, Ferlay J, Sauvaget C, Esmy PO, et al
. Education and cancer incidence in a rural population in South India. Cancer Epidemiol 2009;33:89-93.
Yeole BB, Kurkure AP. An epidemiological assessment of increasing incidence and trends in breast cancer in Mumbai and other sites in India, during the last two decades. Asian Pac J Cancer Prev 2003;4:51-6.
National Cancer Registry Program. Consolidated Report of Population Based Cancer Registries, 2004–2006. New Delhi: Indian Council of Medical Research; 2008.
Kulkarni BB, Kulkarni SS, Hallikeri UR, Patil BR, Gai PB. Decade of breast cancer-trends in patients profiles attending tertiary cancer care center in South India. Asian J Epidemiol 2012;5:103-13.
Puri SS, Ashat M, Goel N, Pandev A. Socio-demographic characteristics of cancer patients: Hospital based cancer registry in a tertiary care hospital of India. Aust Asian J Cancer 2013;12:107-13.
Sankaranarayanan R, Boffetta P. Research on cancer prevention, detection and management in low- and medium-income countries. Ann Oncol 2010;21:1935-43.
Chopra R. The Indian scene. J Clin Oncol 2001;19:106S-11S.
Akhtar M, Akulwar V, Gandhi D, Chandak K. Is locally advanced breast cancer a neglected disease? Indian J Cancer 2011;48:403-5.
] [Full text]
Porter P. “Westernizing” women's risks? Breast cancer in lower-income countries. N Engl J Med 2008;358:213-6.
Althuis MD, Fergenbaum JH, Garcia-Closas M, Brinton LA, Madigan MP, Sherman ME, et al
. Etiology of hormone receptor-defined breast cancer: A systematic review of the literature. Cancer Epidemiol Biomarkers Prev 2004;13:1558-68.
Rajbongshi N, Mahanta LB, Nath DC, Sarma JD. A matched case control study of risk indicators of breast cancer in Assam, India. Mymensingh Med J 2015;24:385-91.
Gilani GM, Kamal S. Risk factors for breast cancer in Pakistani women aged less than 45 years. Ann Hum Biol 2004;31:398-407.
Meshram II, Hiwarkar PA, Kulkarni PN. Reproductive risk factors for breast cancer: A case control study. Online J Health Allied Sci 2009;8:5.
Babita R, Kumar N, Karwasra RK, Singh M, Malik JS, Kaur A, et al
. Reproductive risk factors associated with breast carcinoma in a tertiary care hospital of North India: A case-control study. Indian J Cancer 2014;51:251-5.
] [Full text]
Iwasaki M, Otani T, Inoue M, Sasazuki S, Tsugane S; Japan Public Health Center-based Prospective Study Group, et al
. Role and impact of menstrual and reproductive factors on breast cancer risk in Japan. Eur J Cancer Prev 2007;16:116-23.
Gajalakshmi V, Mathew A, Brennan P, Rajan B, Kanimozhi VC, Mathews A, et al
. Breastfeeding and breast cancer risk in India: A multicenter case-control study. Int J Cancer 2009;125:662-5.
Carpenter CL, Ross RK, Paganini-Hill A, Bernstein L. Effect of family history, obesity and exercise on breast cancer risk among postmenopausal women. Int J Cancer 2003;106:96-102.
Colditz GA, Kaphingst KA, Hankinson SE, Rosner B. Family history and risk of breast cancer: Nurses' health study. Breast Cancer Res Treat 2012;133:1097-104.
Mathew A, Gajalakshmi V, Rajan B, Kanimozhi V, Brennan P, Mathew BS, et al
. Anthropometric factors and breast cancer risk among urban and rural women in South India: A multicentric case-control study. Br J Cancer 2008;99:207-13.
Oza J, Prajapati JD, Ram R. A study on awareness toward the early detection of breast cancer on nursing staff in civil hospital Ahmedabad, Gujarat, India. Healthline 2011;2:34-37.
Bala D, Gameti H. An educational intervention study of breast self examination (BSE) in 250 women beneficiaries of urban health centers of West Zone of Ahmedabad. Healthline 2011;2:46-9.