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ORIGINAL ARTICLE
Year : 2010  |  Volume : 47  |  Issue : 2  |  Page : 194-198
 

TNM staging and classification (familial and nonfamilial) of breast cancer in Jordanian females


1 Department of Medical Laboratory Sciences, Hashemite University, Zarqa 13133, Jordan
2 Department of Clinical Nutrition and Dietetics, Hashemite University, Zarqa 13133, Jordan
3 Forensic Medicine Teaching Center, Jordan University of Science and Technology, Irbid, Jordan

Date of Web Publication5-May-2010

Correspondence Address:
M F Atoum
Department of Medical Laboratory Sciences, Hashemite University, Zarqa 13133
Jordan
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Source of Support: Hashemite University, Conflict of Interest: None


DOI: 10.4103/0019-509X.63022

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 » Abstract 

Purpose : Staging of breast tumor has important implications for treatment and prognosis. This study aims at pinpointing the frequency of each stage among familial and nonfamilial breast cancers. Materials and Methods : Ninety-nine Jordanian females diagnosed with familial and nonfamilial breast cancer between 2000 and 2002 were enrolled in this study All breast cancer cases were staged according to the TNM classification into in situ, early invasive, advanced invasive and metastatic. Results : Forty-three cases were familial breast cancer and 56 were nonfamilial. One female breast cancer was diagnosed with ductal carcinoma in situ (DCIS) cancer. Fifty cases were diagnosed in early stages of invasive breast cancer, of which 31 cases were familial, 29 cases were classified as advanced invasive, where 21 cases were nonfamilial and 19 cases were metastatic stage of breast cancer, with 16 nonfamilial cases. Stage 2b was the most common stage of early invasive cases and represented 48% of the early stage of breast cancer. On the other hand, among cases diagnosed with advanced invasive breast cancer, stage 3a was the most common stage and represented 89.6% of the advanced stage. Interestingly, all cases of stage 3a belonged to TNM stages of T2N2M0 and T3N1M0. The tumor size in all cases of Jordanian females diagnosed with advanced invasive breast cancer exceeded 2 cm in size due to selection bias from symptomatic women in our study. Conclusion : The incidence of nonfamilial breast cancer was slightly higher than that of the familial type amongst studied the Jordanian females studied. The early invasive stage of breast cancer was more common in the familial while the advanced invasive and metastatic breast cancer cases were encountered more often in the nonfamilial type. Our study was based on a small sample and symptomatic women. Therefore, more research with larger population samples is needed to confirm this conclusion.


Keywords: Breast cancer, BRCA1/2Jordan, TNM staging


How to cite this article:
Atoum M F, Hourani H M, Shoter A, Al-Raheem S N, Al Muhrib T K. TNM staging and classification (familial and nonfamilial) of breast cancer in Jordanian females. Indian J Cancer 2010;47:194-8

How to cite this URL:
Atoum M F, Hourani H M, Shoter A, Al-Raheem S N, Al Muhrib T K. TNM staging and classification (familial and nonfamilial) of breast cancer in Jordanian females. Indian J Cancer [serial online] 2010 [cited 2020 Oct 21];47:194-8. Available from: https://www.indianjcancer.com/text.asp?2010/47/2/194/63022



 » Introduction Top


Cancer becomes one of the most common diseases in our lives today, and breast cancer is now the most common female malignancy worldwide, with up to a million cases annually. Breast cancer affects almost every eighth women in the world and its incidence has been rising in both developed and developing countries. [1] Breast cancer could be either familial, due to numerous known and unknown genetic mutations, e.g. BRCA1, BRCA2, P53, or nonfamilial, linked to predisposing factors like obesity, early menarche, delayed or absent childbearing, age, use of hormone replacement therapy and/or unknown causes. [2],[3]

Tumors of the breast are believed to arise from terminal ductal lobular units and comprise two common morphological types: ductal and lobular neoplasia. [4] Other types include tubular, medullary, mucinous types and Paget disease. Staging and morphology of breast tumor has important implications for treatment and prognosis. [5] In the American population, the distribution of cancer stages has changed significantly: in situ and early stage of invasive cancer has increased while diagnosis of metastatic breast cancer has decreased. [6] This may be due to the implementation of a screening program and advanced screening technology, which allows detection of breast cancer at an early stage. It would be of interest to determine the relation between various morphological types and age of patient as well as to show the frequency of each stage among different age group and among familial and nonfamilial breast cancer. Very limited studies have correlated pathological staging and the presence of familial and nonfamilial types of breast cancer. Lakhani et al.[7] found that familial breast cancer related to BRCA1/2 has lower frequency of lobular morphology compared to nonfamilial breast cancer, but familial breast cancer unrelated to BRCA1/2 has not shown any significant morphological difference from all breast cancer types combined.

Among Jordanian females, Tarawneh and Nimri (2005) [8] reported that histopathological distribution of Jordanian female breast cancers showed that 80.6% were infiltrating ductal carcinoma, 5.3% were lobular carcinoma, 1.9% were adenocarcinoma and the remaining were other morphology. The previous study was helpful in describing the prognostic stages of breast cancer but did not highlight the incidence of both familial and nonfamilial cases among Jordanian females. The objective of this study was to categorize the breast cancer stages among Jordanian females according to the TNM staging (tumor-node metastasis) and to identify the average age of each pathological stage and, finally, to determine the frequency of familial and nonfamilial breast cancer cases among each stage.


 » Materials and Methods Top


Patients

Ninety-nine Jordanian females diagnosed with breast cancer were enrolled in this study to determine the incidence, the type (familial or nonfamilial) and the stages of breast cancer. Samples were collected over a 2-year period between 2000 and 2002 from females diagnosed with breast cancer attending the Al-Basheer Governmental Hospital for breast cancer diagnosis and treatment. The patient's age ranged from 22 to 73 years, with an average age of 50 years. The age of the familial breast cancer participants ranged between 22 and 73 years and the age of the nonfamilial breast cancer participants ranged between 35 and 69 years. A signed permission was obtained from every female enrolled in this study, and each female was interviewed directly about her family history of breast cancer. For all cases, pathological analysis was recorded over a 2-year period between 2000 and 2002.

Classification and pathological staging of breast cancer

Breast cancer cases were classified into familial or nonfamilial types. The criterion used to consider a particular patient with familial breast cancer was based on the fact that at least two of her relatives (first or second-degree relatives) were affected with invasive cancer at any age. [9],[10]

All breast cancer cases were staged at diagnosis from 0 to 4 [Table 1] depending on the combination of TNM (T: tumor size, N: cancerous node, M: metastases) category [Table 2]. This staging was defined by the NCI-NIH (National Cancer Institute-National Institute of Health), USA, and revised by the American Joint Committee on Cancer Staging System for Breast Cancer (AJCC). [6]

Statistical Analysis

Statistical analysis was carried out using the statistical package for social sciences (SPSS9.0.0; SPSS Inc., Chicago, IL, US America). Statistical significance was set at P < 0.05.


 » Results Top


Breast cancer stages of Jordanian females

Based on the staging criteria described in [Table 1], of the 99 Jordanian females with breast cancer, only one case was diagnosed with in situ cancer (DCIS) without any evidence of invasion of her breast tissues [Table 2]. Fifty cases (50.5%) were diagnosed in early stages of invasive cancer (stages 1 and 2). The remaining 48 cases (48.5%) were classified as advanced invasive and metastatic stage of breast cancer in 29 and 19 cases, respectively [Table 2].

According to the detailed TNM staging system, our study shows in [Table 2] that stage 2a and 2b were the most common stages among early invasive cases in Jordanian females. The majority of early invasive cases were T2N0M0 and T2N1M0, with the tumor size between 2 and 5 cm. On the other hand, among cases diagnosed with advanced invasive breast cancer, stage 3a was the most common stage, with 26 of 29 cases (about 90%). Interestingly, all cases of stage 3a belonged to either T2N2M0 (48%) or T3N1M0 (42%), and the tumor size in all cases exceeded 2 cm in size, which may be due to the fact that the majority of the women in our study were diagnosed at a clinically palpable stage. Metastatic cancer cases were shown to account for 19% of all observed cases.

Frequency of familial and nonfamilial breast cancer among Jordanian females

As shown in [Table 3], although the frequency of early invasive cases was higher in familial than in nonfamilial types (62% vs. 38%), the difference was not statistically significant. On the other hand, advanced invasive and metastatic cases were shown to be significantly (P < 0.05) higher in the nonfamilial type than in the familial type (72% and 84% vs. 28% and 16%, respectively).

Distribution of breast cancer stages among different age groups

Patients' age ranged from 22 to 73 years. Of the 99 enrolled females enrolled in our study, 19 women were aged below 41 years, 28 were aged between 41 and 50 years, 36 were aged between 51 and 60 years and 16 were aged above 60 years [Table 4]. Detailed determination of frequency of each breast cancer stage among the different age groups revealed that young females aged below 41 years of age were diagnosed with in situ in one case (5.2%), early invasive in five cases (26.3%), advanced invasive in six cases (31.6%) and metastatic in seven cases (36.8%) of breast cancer. In female age groups 41-50 and ≥61 years, no significant differences were observed among the frequencies of the different stages of breast cancer, as shown in [Table 4]. However, in the group aged 51-60 years, significant differences were observed among different stages (63.9%, 27.8% and 8.3% for early invasive, advanced and metastatic cancer, respectively).

Classification of familial and nonfamilial breast cancer by age in Jordanian females

Regardless of frequency among different breast cancer stages, breast cancer in our study was mostly of the nonfamilial type [Table 3]. In the age group <50 years, familial breast cancer was more frequent than nonfamilial breast cancer. However, in the age group 51-60 years and more than 60 years, nonfamilial breast cancer was more frequent than the familial type, as shown in [Figure 1].


 » Discussion Top


The most frequent stage of breast cancer observed in this study was the early stage invasive cancer, which accounts for 50.5% of our cases. This may suggest improvement in the health education program from governmental hospitals in Jordan, which allows detecting breast cancer at early stages when the treatment is less aggressive and better supported by the women, and they have a better prognosis. This reflects an increase in community awareness and early detection of breast cancer among Jordanian females. However, advanced stage invasive cancer and metastatic cancer made up about 49.5% of the breast cancer diagnosed cases in our study. Interestingly, the present data showed that stage 2b of early invasive cancer and stage 3a from advanced invasive cancer were the most common stages. This may be an important predictor of disease recurrence and impact on survival because nearly 70-80% of patients with negative node status survive around 10 years, the prognosis worsening with an increase in the number of positive nodes. [10]

Familial breast cancer occurs among patients with a family history of breast cancer, but only 5-10% of the cases are attributed to inheritance [10] of autosomal genes (BRCA1 and BRCA2). The results of this study showed that the incidence of advanced invasive and metastatic breast cancer was higher in the nonfamilial than in the familial type. Previous studies showed that familial breast cancer is relatively more aggressive and has a poor prognosis. [11] The pathology of non-BRCA1/2 cancers was different from the pathology of BRCA1/2 cancers, and even histological phenotypes of BRCA1 mutation cancers can be differentiated from BRCA2 cancers. [11],[12] Breast cancer in non-BRCA1/2 families was of lower grade, less mitosis and less lymphocytic infiltrate. [12] BRCA1 mutations are highly proliferative and poorly differentiated, [13] and more lymphocytic infiltrate, while cancer associated with BRCA2 exhibited a higher score for tubule formation and lower mitotic count. [7] Therefore, treatment of breast cancer can take a variety of forms, dependent on the histological type, the grade and the stage of the cancer and the family history. [14]

The literature on breast cancer in Arabian women is limited. The present study indicated that in women below the age of 41 years, the incidence of metastasis was the highest (36.8%). In females above 41 years of age, the incidence of early invasive cancer was the highest (50%, 63.9%, 50%) and of metastasis was the lowest (17.9%, 8.3%, 25%) among age groups 41-50, 51-60 and 60 years, respectively. In a comparative study by Barak et al. [4] between Arab and American females diagnosed with breast cancer, 54% of Arab females at the time of diagnosis of breast cancer were <50 years old, while 37% of the American women were under 50 years of age. Khatib and Modjtabi [10] reported that breast cancer was the number one cancer among women in the Eastern Mediterranean region. Unlike in the USA, Jordanian breast cancer is more commonly diagnosed in Jordanian women under the age of 50. This is because the population pyramid in Jordan shows that 90% of the females were below 50 years old [15] and not because of an increased risk among younger age groups. Patients younger than 35-45 years old at the time of diagnosis of invasive breast cancer have been found to have a worse prognosis than older patients, [16] and have a significantly increased risk of dying from breast cancer. [17],[18]

In conclusion, nonfamilial breast cancer frequency was slightly higher than that of familial breast cancer among breast cancer Jordanian females diagnosed with breast cancer in our study. The early invasive stage of breast cancer was observed in the familial type while advanced invasive and metastatic breast cancer cases were recorded in the nonfamilial type. Further research or study is still needed to clarify the actual status of breast cancer and the staging among breast cancer Jordanian females.

 
 » References Top

1.Althuis MD, Dozier JM, Anderson WF, Devesa SS, Brinton LA. Global trends in breast cancer incidence and mortality 1973 - 1997. Int J Epidemiol 2005;34:405-12.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Walker AR. Breast cancer- can risk really be lessened. Eur J Cancer Prev 2000;9:223-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Atoum MF, Al-Hourani HM. Lifestyle related risk factors for breast cancer in Jordanian females. Saudi Med J 2004;25:1245-9.  Back to cited text no. 3  [PUBMED]    
4.Russo J, Russo IH. Cellular basis of breast cancer susceptibility. Oncol Res 1999;11:169-78.  Back to cited text no. 4  [PUBMED]    
5.Lakhani SR, Gusterson BA, Jacquemier J, Sloane JP, Anderson TJ, van de Vijver MJ, et al. The pathology of familial breast cancer: Histological features of cancers in families not attribtable to mutations in BRCA1 or BRCA2. Clin Cancer Res 2000;6:782-9.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Singletary SE, Allred C, Ashley P, Bassett LW, Berry D, Bland KI, et al. Revision of the American joint committee on cancer staging system for beast cancer. J Clin Oncol 2002;20:3628-36.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Lakhani SR, Jacquemier J, Sloane JP, Gusterson BA, Anderson TJ, van de Vijver MJ, et al. Multifactorial analysis of differences between sporadic breast cancers involving BRCA1 and BRCA2 mutation. J Natl Cancer Inst 1998;90:1138-45.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Tarawneh M, Nimri O. Cancer incidence in Jordan. 2005. Ministry of health. Jordan cancer Registry.  Back to cited text no. 8      
9.Atoum MF, Al-Kayed SA. Mutation analysis of the breast cancer gene BRCA1 among breast cancer Jordanian females. Saudi Med J 2004;25:60-3.  Back to cited text no. 9  [PUBMED]    
10.Khatib O, Modjtabi. A Guideline for the early detection and screening of breast cancer. World Health Organization EMRO Technical Publications series; 2006.   Back to cited text no. 10      
11.Aaltonen K, Blomqvist C, Amini RM, Eerola H, Aittomδki K, Heikkilδ P, et al. Familial breast cancers without mutations in BRCA1 or BRCA2 have low cyclin E and high cyclin D1 in contrast to cancers in BRCA mutation carriers. Clin Cancer Res 2008;14:1976-83.  Back to cited text no. 11      
12.Eerola H, Heikkilδ P, Tamminen A, Aittomδki K, Blomqvist C, Nevanlinna H. Histopathological features of breast tumours in BRCA1, BRCA2 and mutation-negative breast cancer families. Breast Cancer Res 2005;7:R93-100.  Back to cited text no. 12      
13.Stoppa-Lyonnet D, Ansquer Y, Dreyfus H, Gautier C, Gauthier-Villars M, Bourstyn E, et al. Familial invasive breast cancers: Worse outcome related to BRCA1 mutation. J Clin Oncol 2000;18:4053-9.  Back to cited text no. 13      
14.Matloff ET, Shannon KM, Moyer A, Col NF. Should menopausal women at increased risk for breast cancer use tamoxifen, raloxifene, or hormone therapy? a framework for personalized risk assessment and counseling. J Cancer Edu 2007;22:10-4.  Back to cited text no. 14      
15.Jordan population pyramid for 2005. Available from: http://www.nationmaster.com/country/jo-jordan/Age-_distribution   Back to cited text no. 15      
16.Barak F, Zippin C, Awad EJ, Houser AR, Horn Y. Breast cancer at medical centers in Israel, the West Bank and the United states. Oncology 1988;45:354-9.  Back to cited text no. 16  [PUBMED]    
17.Vicini FA, Recht A. Age at diagnosis and outcome for women with ductal carcinoma in situ o breast: A critical review of the literature. J Clin Oncol 2002;20:2736-44.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Kroman N, Jensen MB, Wohlfahrt J, Mouridsen HT, Andersen PK, Melbye M. Factors influencing the effect of age on prognosis in breast cancer; population based study. BMJ 2000;320:474-9.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1]
 
 
    Tables

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

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