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ORIGINAL ARTICLE
Year : 2010  |  Volume : 47  |  Issue : 1  |  Page : 16-22
 

Profile of breast cancer patients at a tertiary care hospital in north India


1 Department of Surgery & Surgical Oncology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana - 124 001, India
2 Department of Internal Medicine, Post Graduate Institute of Medical Sciences, Rohtak, Haryana - 124 001, India

Date of Web Publication12-Jan-2010

Correspondence Address:
D S Sandhu
Department of Surgery & Surgical Oncology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana - 124 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.58853

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 » Abstract 

Background and Aims: We carried out this study in order to know the epidemiology and management strategies for breast cancer patients in our patient population. Settings and Design: The epidemiological data pertaining to demography and risk factors for carcinoma breast were analyzed retrospectively in patients admitted to a tertiary care hospital of North India. Materials and Methods: Hospital records of 304 patients admitted for over a period of five years (January 1998 to December 2002) were used for data analysis. Statistical Analysis Used: Paired T-test . Results: Mean age of our female breast cancer patients was found to be lower compared to the western world, with an average difference of one decade. A majority of the patients were from a rural background and had a longer duration of symptoms compared to urban patients. Lump in the breast was a dominant symptom. Familial breast cancer was uncommon. Left sided breast cancer was slightly preponderant. Screening by mammography and staging procedures such as bone scan, Computed Tomography (CT) scan, and Magnetic Resonance Imaging (MRI) were sparsely used. The most common histology was infiltrating duct carcinoma. Conclusion: Modified radical mastectomy was found to be a safe operative procedure. Breast conservative surgery, although considered the gold standard in early breast cancer, was found unsuitable for our patients, due to the social background and lack of intensive radiotherapy and chemotherapy backup. Infiltrating duct carcinoma was more commonly associated with positive lymph nodes compared to other histopathologies. Cases operated by surgical oncologists had better axillary clearance. Neoadjuvant chemotherapy was used mainly by surgical oncologists suggesting a more rational approach toward the management of breast carcinoma.


Keywords: Breast cancer, combined modality, epidemiology, surgery


How to cite this article:
Sandhu D S, Sandhu S, Karwasra R K, Marwah S. Profile of breast cancer patients at a tertiary care hospital in north India. Indian J Cancer 2010;47:16-22

How to cite this URL:
Sandhu D S, Sandhu S, Karwasra R K, Marwah S. Profile of breast cancer patients at a tertiary care hospital in north India. Indian J Cancer [serial online] 2010 [cited 2019 Jun 18];47:16-22. Available from: http://www.indianjcancer.com/text.asp?2010/47/1/16/58853



 » Introduction Top


The World Cancer Report issued by the International Agency for Research on Cancer (IARC), tells us that cancer rates are set to increase at an alarming rate globally. Cancer rates could increase by 50% to 15 million new cases in the year 2020. [1] Worldwide breast cancer is the most frequent cancer in women and represents the second leading cause of cancer death among women (after lung cancer). [2],[3] Presently, 75,000 new cases occur in Indian women every year. [4] This figure must be viewed against the backdrop that the National Cancer Registry and the Hospital-based Tumor Registries hardly sample 3% of the total population. Locally advanced breast cancer (LABC) constitutes more than 50 to 70% of the patients presenting for treatment. [4] The information on the epidemiology of breast cancer in India is very limited, except for a few reports on limited samples. [5]

Management of breast cancer is immunologically and histologically heterogeneous in character and requires multidisciplinary treatment. [3] Despite all the advances, the management of breast cancer is still a controversial topic. This obviously is the reason why it continues to be the focus of intense basic and clinical research. Hence, this retrospective study was carried out to know the epidemiology, clinical presentation, risk factors, and management strategies for breast cancer patients. The difference in breast cancer patients' management in the hands of surgical oncologists and general surgeons is also detailed out.


 » Materials and Methods Top


A total of 304 primary breast cancer patients admitted over a five-year period (January 1998 - December 2002), in different surgical and oncosurgery wards of a tertiary care center in North India, were taken up for study. The breast cancer patients already treated by mastectomy outside were excluded. A detailed retrospective analysis of patients was done according to a planned proforma. The required information was collected from the medical records deposited in the Central Registration Office (C.R.O.) of the institute.

A majority of the patients (65.8%) were in the age group of 31 - 50 years. The youngest patient was 28 and the oldest was 85 years old. Out of 304 patients, 300 (98.7 %) were females and four (1.3%) were males. The mean age was 47.39 ± 10.90 years for females and 56.5 ± 7.77 years for males. A total of 191 (62.8%) patients were from a rural background and 113 (37.2%) from an urban background, the ratio being 1.7:1.

[Table 1] depicts that 267 (87.9%) patients presented with a lump in the breast; 144 (47.4%) patients had a lump in the right breast and 157 (51.6%) cases had it in the left breast. Three cases (1%) had lumps in both breasts. [Table 2] shows that majority of the patients had lumps in the upper and outer quadrant. In 19 (6.4%) patients it was impalpable due to excision biopsy done prior to definitive surgery. The duration of presenting complaints as recorded in 301 (99.0%) patients is shown in [Table 3]. One hundred and eighty-eight (61.5%) patients presented with a history of more than three months' duration and only four (1.3%) patients presented with a history of less than 15 days duration. Of 108 female breast cancer patients, whose status regarding parity was mentioned in the records, 79.63% (n = 86) had less than three children, while 14.81% (n = 16) were nulliparous. Menstrual status was mentioned in records of 226 (75.3%) patients, of which 126 (55.76%) were postmenopausal and 100 (44.24%) were premenopausal. No patient had a positive family history of breast cancer. Fine needle aspiration cytology (FNAC) was done in 286 patients; it was positive for malignancy in 244 (85.3%) and either negative or inconclusive in 42 (14.7%) patients. These patients later on underwent trucut or excision biopsy for confirmation of diagnosis. Mammography was not a principle modality for diagnosis and was done only in 38 (12.5%) patients. The modalities for reaching final diagnosis of breast cancer are shown in [Table 4]. Seven (2.3%) patients were diagnosed to have metastasis in the lungs on a chest X-ray. In 278 (91.4%) patients, an ultrasound of the abdomen was done and 14 (4.6%) were found to have metastasis in the liver. Liver function tests (LFTs) were done in 68 (22.4%) patients, which included all the 14 patients with liver metastasis. Out of these 68 patients, 28 (41.2%) were with LABC, 26 (38.2%) were with early breast cancer (EBC), and 14 (20.6%) were stage IV. None of these patients had abnormal LFTs. Bone scan status was known in only 25 (8.2%) patients. Two of these 25 (8%) had metastasis in the bones and both were clinically LABC. Of the remaining 23 patients, 11 (47.8%) were LABC, three (13%) were stage IV, and nine (39.2%) were EBC. [Table 5] details the surgical treatment given to the patients. A total of 294 (96.7%) patients underwent surgery. Of the remaining 10 (3.3%) non-operated cases, six had stage IV disease and four patients were lost to follow-up after downstaging the disease by neoadjuvant chemotherapy. Out of the 294 operated cases, a majority (80.6%) underwent classical modified radical mastectomy (MRM). One hundred and nine (46%) of these were done in operable breast cancer (OBC) patients and 128 (54%) in LABC. A total of 14 (4.9%) toilet mastectomies were done out of which four (28.6%) were done in metastatic breast cancer (MBC) and 10 (71.4%) in LABC. All these patients had fungating masses. Simple mastectomy was done in one (0.3%) patient, despite being operable because of old age (85 years) and associated comorbidity. Thirty-three (11.2%) patients already had lumpectomy and MRM done and were categorized as completion MRM. In seven (2.4%) patients with stage IV disease, mastectomy was done as a surgical palliation, although they were not having fungating mass lesions and these were categorized as palliative MRM. One (0.3%) patient was subjected to wide excision of primary tumor with excision of eroded nipple areolar complex.

Out of 294 operated cases, 163 (55.4%) were operated by surgical oncologists while the remaining 131 (42.6%) were operated by general surgeons. Out of 237 patients who underwent classical MRM, 136 (57.4%) were operated in Surgical Oncology and 101 (42.6%) in General Surgery Units. Of the 33 patients who had completion MRM, 20 (60.6%) were operated in Surgical Oncology and 13 (39.4%) in General Surgery Units. A total of 14 toilet mastectomies were done, seven (50%) each in Surgical Oncology and General Surgery Units. However, all palliative MRMs were done in General Surgery Units. Breast conservation surgery (BCS) and simple mastectomy were done by Surgical Oncology Units. The only patient who underwent wide excision for OBC was operated upon by a general surgeon. Only six (2%) of 294 operated patients had a documented wound infection in hospital records. The axillary dissection was done in 292 cases and 74 (25.3%) patients had lymphorrhea. A majority of the patients, 162 (58.9%), received anthracycline-based chemotherapy with 143 (52.0%) receiving cyclophosphamide, adriamycin and 5-flurouracil (CAF), and 19 (6.9%) receiving cyclophosphamide, epirubicin and 5-flurouracil (CEF), respectively. One hundred and thirteen (41.1%) patients received cyclophosphamide, methotrexate and 5-flurouracil (CMF)-based chemotherapy and none received taxol-based chemotherapy. One hundred and forty-nine (49.0%) patients received hormone therapy in the form of tablets, Tamoxifen 20 mg daily. [Table 6] shows the final histopathology of 294 operated patients. Of 288 patients with invasive ductal carcinoma (IDC), 279 (96.9%) had NOS variety. In the final histopathology, three (1.0%) patients had medullary carcinoma, four (1.4%) had colloid carcinoma, one (0.3%) had sclerosing adenosis, and one (0.3%) had Paget's disease. Out of 292 cases of axillary dissection, no lymph nodes were isolated from the specimen in five (1.7%) patients. In 57 (19.5%) patients 1 - 5 lymph nodes were isolated, in 144 (49.3%) 6 - 10 lymph nodes, in 67 (23.0%) patients 11 - 15 lymph nodes, in 17 (5.8%) patients 16 - 20 lymph nodes, and in two (0.7%) patients more than 20 lymph nodes were isolated. Out of these 292 patients, 83 (28.4%) had no lymph nodes positive for carcinoma metastasis in the histopathology specimen. In 113 (38.7%) patients, 1 - 3 lymph nodes were positive. In 84 (28.8%) patients, the number of lymph nodes positive was in the range of 4 - 9. Only 12 (4.1%) patients had more than 10 lymph nodes positive in the final specimen. The final staging in a majority of patients was LABC (54.6%). One hundred and eleven (39.8%) patients were EBC, that is, stage II b or less, and 17 (5.6%) patients were in stage IV. Ten (3.3%) patients could not be staged due to previously done lumpectomy and their final histopathology revealed no evidence of primary tumor.


 » Discussion Top


The aim of this retrospective analysis was to study the epidemiology of breast cancer at a tertiary care hospital in North India. A majority of the patients (83.9%) were in the fourth to sixth decade of their life, as also reported in studies from India and other Asian countries. [4],[6],[7],[8],[9],[10] However, reports from the western world show that female breast carcinoma is predominantly seen in the fifth and sixth decade. [11],[12],[13] The incidence of breast carcinoma in males was found to be 1.3%, similar to other reports published in the literature. [14],[15],[16] Out of all the patients 62.8% were from a rural background and the difference was statistically significant. However, other reports from India as well as United States show higher incidence in urban population compared to the rural population. [4],[16] The difference is possibly due to the fact that women in rural areas face substantial barriers in receiving preventive health care services. [16] However, our hospital caters to maximum patients from rural area, thus accounting for higher number of rural breast carcinoma patients. Furthermore, the consolidated report of the Indian Council of Medical Research (ICMR) on Population Based Cancer Registry (PBCR) cites that 70 - 80% of India's population resides in rural areas and the currently available data is mainly from the urban registries, therefore, to estimate the load of cancer is difficult. [6] A majority of the patients (89.8%) were found to be of lower socioeconomic status and a similar finding has been observed in other studies. [17] Lump in the breast was the chief presenting complaint in a majority of the patients (87.9%), as reported in various studies. [18],[19] No patient presented with an isolated complaint of nipple discharge or pain in the breast.

However, in advanced western nations, diagnosis of breast cancer has undergone a dramatic evolution since the mid-1980s. Subsequent to the widespread availability of mammographic screening programs, a shift toward the diagnosis of clinically occult and nonpalpable lesions is noted. [4] In our study, women with breast cancer almost always detect their disease by themselves, by finding a lump in the breast, and thus it is important to educate the masses on self-breast examination. Moreover, the issue of exhaustive workup on isolated complaint of pain in the breast or nipple discharge should be re-addressed, as not even a single patient had such isolated complaints.

The incidence of breast carcinoma was more on the left side in the upper outer quadrant corroborating with the previous reports. [20],[21],[22],[23],[24] The possible explanations are that the left breast is bulkier and the upper outer quadrant has a relatively larger volume of breast tissue. [22],[24] Delayed presentation was possibly related to rural background and lack of education. Only 20.37% of the patients were nulliparous, whereas, others had three or more children. However, other reports indicate higher incidence of breast carcinoma in nulliparous females. [3],[25],[26] 92.9% of the patients had their menarche between the ages of 13 and 16, supporting reports that risk is higher with early onset of menarche. [7],[27],[28],[29] Incidence of breast carcinoma was more in postmenopausal patients and age of menopause was in the range of 41 to 50 years in most of the patients (93.56%). A similar finding of early age of menopause in Indian females in comparison to their western counterparts has been observed in the past. [30] The earlier published reports also show that the risk of breast carcinoma increases with increasing age of menopause, possibly because the women are exposed to hormones for a longer duration. [28],[29],[31]

For the diagnosis of breast carcinoma, FNAC was done in most of the cases (94.1%) and a positive predictive value of 85.3% was obtained. FNAC is a useful diagnostic tool because it is rapid and cost effective. [32] The use of core needle biopsy (CNB) and vacuum assisted biopsy with mammographic or ultrasonographic guidance is being increasingly used for nonpalpable tumors. [32] Unfortunately these techniques have not picked up in this part of the world, probably due to their inherent cost. Mammography is an important tool for breast carcinoma screening between 50 and 70 years, when the breast tissue content decreases and fat content increases. However, in studies from India, including our study, the maximum incidence of breast carcinoma is seen in the fifth decade. During this age, the breast tissue content is high and therefore it is likely to decrease the efficacy of mammography in detecting breast carcinoma during screening. Moreover, mammography is neither cost-effective nor easily available in developing countries. Thus, we suggest reconsidering the importance of mammography as a screening modality in our country.

As part of a metastatic workup, LFTs were done in 22.4% of the cases and most of them were with advanced breast carcinoma. However, none of the tested patients had abnormal liver functions, indicating the lack of usefulness of this investigation as a metastatic workup. 8.6% of the patients were not subjected to ultrasound examination in the General Surgical Units and most of these cases were LABC. A bone scan was ordered in EBC in as many as 39.2% cases, by general surgeons. Omission of abdominal ultrasound in LABC and performing bone scan in EBC were against standard recommendations and indicated irrational management of breast carcinoma in General Surgical Units. Literature also supports that a complete metastatic workup is unnecessary in a majority of the patients with newly diagnosed breast carcinoma, whereas, it may be indicated for specific patient categories, such as, those with stage III disease. [33]

Clinical TNM staging is an important clinical parameter of breast carcinoma, but it was ill documented in a majority of the records. The patients were grouped in three categories of OBC, LABC, and MBC. MBC patients were not admitted in surgical wards unless they needed surgical palliation or investigational workup. Surgery formed the principle mode of therapy, while chemotherapy, radiotherapy, and hormone therapy were used in the adjuvant setting. Popularity of BCS is increasing in the western world. [34],[35],[36] As per some recent reports, BCS has become the preferred method of treatment for many patients. [37],[38] The reasons supporting this conservatism are (1) earlier diagnosis through mammographic screening, (2) development of image-guided CNB, and (3) advent of state-of-the-art Radiotherapy Units. [35] However, in our study only one patient underwent BCS. The absence of a dedicated Radiotherapy Unit, patient ignorance, illiteracy, and poor follow up are the main reasons for a low rate of BCS. A one-time procedure of meticulous MRM leads to good locoregional control and still remains an important tool for managing breast cancer in India. Postoperative morbidity was seen in the form of lymphorrhea / seroma (25.3%), flap necrosis (4.8%), and wound infection (2%), which was comparable with the reports in the literature. [39],[40],[41],[42],[43],[44] The incidence of lymphorrhea, following axillary dissection in Surgical Oncology and General Surgery Units was 20.2 and 5.1%, respectively, and the difference was statistically significant (p < 0.001). Additionally on analyzing the number of positive lymph nodes with lymphorrhea, the difference was found to be highly significant (p < 0.001), which indicated better axillary clearance by surgical oncologists than general surgeons. Literature also supports that the major factor predicting lymphorrhea was the number of positive lymph nodes isolated and indirectly indicates a more complete axillary dissection, which is an important prognostic indicator in cases with breast carcinoma. [45],[46]

Neoadjuvant chemotherapy was given in 34.2% of the patients for downstaging the disease and a majority of these cases were managed in Surgical Oncology Units. 81.1% of the dropouts from chemotherapy were from the General Surgery Units and 18.9% were from the Surgical Oncology Units and the difference was statistically significant (p < 0.001). This could be attributed to better patient information and detailed management schedule planned in the Surgical Oncology Units. An increasing trend in the usage of anthracycline-based chemotherapy was noticed in the Surgical Oncology Units. Literature also suggests that anthracycline-based chemotherapy is more effective in terms of relapse-free and overall survival than a CMF-based regimen. [47]

Our study as well as reports from India and the western world indicate that IDC is the most commonly encountered histopathology. [17],[20],[22],[48],[49] Ductal carcinoma in situ (DCIS) accounts for over 20% of the breast carcinoma cases in the western world, due to early detection by screening. [23] However, in developing countries like India, most patients present late, due to lack of screening programs, leading to a very low incidence of DCIS. A majority of the patients (54.6%) present with LABC, in accordance with other reports from India. [4] LABC is a relatively uncommon presentation (5-20%) in economically developed countries, due to better public awareness and availability of medical resources. [50]

On correlating age with the stage of disease, it was found to be statistically insignificant (P > 0.05), showing no relation between age and stage of presentation, which is in accordance with other studies. [48],[51] Correlation of duration of symptoms and stage of breast carcinoma reveals a highly significant value (p < 0.001), indicating that patients with a rural background are more likely to present in late stages of the disease as compared to their urban counterparts.[52] Node positivity is correlated with various factors like sex, menstrual status, age, laterality, and histology. None of these parameters, except the histopathological diagnosis of IDC, is significantly associated with nodal positivity (p < 0.001). The previous reports show that apart from IDC, right-sided breast cancers are more commonly associated with lymph node positivity. [48]

In conclusion, the mean age of presentation for breast carcinoma is a decade earlier in our patients compared to patients from the west. Hence, mammography as a screening tool is less likely to be as effective, due to the following reasons:-

Higher density of breast tissue at younger age decreases the sensitivity of mammography.

Most patients in our set up are unable to afford mammography due to their poor socioeconomic background.

Thus there is a need for developing other cost-effective screening modalities for breast cancer in addition to propagating breast self-examination in masses, for early detection. Although BCS is gaining popularity worldwide, MRM still remains the gold standard for the management of breast carcinoma in the present circumstances, in most parts of India. In view of the rising incidence of breast carcinoma and the prevailing controversies in its management, it is recommended that they should preferably be managed by surgical oncologists for improvement in the patient's outcome.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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