Middle East Journal of Family Medicine

Dr Ali Al Obose* FRCS
Dr Osama Abu Salem* MRCSI
Dr Maysoun Alrabayha**
Dr Khalid Alghzawi

*General Surgeon at RMS
**Histopathologist at RMS

Address correspondence to:
Dr Osama Abu Salem, Email: Osamaabusalem@hotmail.com
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ABSTRACT

Background: Data on the clinical profile of breast cancer from Jordan is scant, due to different factors such as lack of proper statistical centers, different lifestyle, and different socio-demographic structures.

Aim: To analyze the clinical presentation and outcome of Jordanian patients with breast cancer.

Materials and methods: Data from 184 patients registered and treated at different Royal Medical Services Hospitals in Jordan from January 2002 to December 2005 were analyzed. The analysis concentrates on age, site, lymph nodes status, grade and type of the breast cancer found in Jordanian patients.

Results: The median age was 52.5 years and 54% of patients were pre-menopausal. Ninety-six per cent (177) patients presented with a lump. Stages 1 (14/184), Stage 2 (111/184), and Stage 3 comprised (59/184). Right breast involved in breast cancer was (93 /184), left breast involvement (90/184) and one case had a bilateral involvement. Most patients who needed chemotherapy were prescribed Tamoxifen for 5 years. The majority (86.4%) had a lump size > two cm.

Conclusions:

The study's results indicated that breast cancer prognosis in Jordan remains poor, primarily due to late diagnosis.
Since breast conservation protocols yield results similar to mastectomy, its use should be extended. Search for biological prognostic indicators should continue for their potential use as guides for treatment decisions.
Tumor size, grade and year of diagnosis all have significant constant effects on disease-specific survival in breast cancer, while the effects of age at diagnosis and disease stage have significant effects that vary over time.
The histologic type is important to consider in the prognosis and treatment of women diagnosed with breast cancer.
Future studies of survival of node-negative patients should include information on co-morbidity and treatment

INTRODUCTION

Breast cancer is the most common cancer and the second leading cause of cancer death among women in general; annual breast cancer deaths are exceeded only by those for lung cancer. (1)
The traditional diagnostic approach to breast lumps include physical examination, ultrasound and a mammogram screening procedure. These diagnostic procedures have a relatively low sensitivity regarding definite malignant small breast lumps and have largely been replaced by cytological lump evaluation. Breast cancer is one of the most common malignancies in women and the incidence has been increasing. Cytology play an important role not only in the diagnosis of breast lesions, but also in keeping the benign -to -malignant biopsy ratio low, so that unnecessary surgery is not performed. However, breast carcinomas do not always show every feature of malignancy. The well- differentiated or low-grade carcinomas are often difficult to differentiate from benign cells .It may be helpful to consider the clinical and radiological findings.

Conservative treatment of multifocal breast cancers, which can be completely removed by a single lumpectomy, seems, when technically feasible, an alternative to mastectomy. The increasing prevalence of breast cancer in our society has produced an ever-greater demand for new diagnostic and therapeutic technologies. Today, patients ask not only that these new technologies offer improved diagnostic and treatment capabilities but also that the procedures are convenient, cost-effective, and less invasive than before. Other diagnostic tools, such as sonography, mammography, magnetic resonance imaging and scintimammography, are now available .The additional information afforded by these technologies is intended to limit the number of patients who need further evaluation with breast biopsy. Early-onset breast cancer may differ with respect to etiology, clinical features and outcome compared with breast cancer in older women.
Clinically most of the patients with malignant breast lump had a palpable mass, which signifies the role of routine self-examination and screening programs.

Late diagnosis is a major factor for increased mortality as the majority of the patients present in advanced or metastatic stage. This is primarily attributed to lack of access to medical facilities, virtually non-existent breast cancer screening programs, lack of awareness and social-cultural attitudes. . A recent meta-analysis of the breast cancer screening trials indicates that screening reduces the mortality rate by approximately 25% (2).

Data from 184 patients registered and treated at different Royal Medical Services Hospitals in Jordan from 2002 through 2005 were analyzed. The analysis concentrated on age, site, lymph nodes status, grade and type of the breast cancer, found in Jordanian patients.

Case records of all the female patients presented at the surgical Clinic in the Royal Medical Services Hospitals over a four-year period from January 2002 to December 2005, were retrieved. EBC (Early Breast Cancer) was defined as tumors of less than five centimeters (T1, T2), with either impalpable (N0) or palpable (N1) but not fixed lymph nodes, with no evidence of distant metastases (M0), corresponding to Stages I. Patients with tumors more than five cm (T3) were included if they had N0 M0 disease; Stage IIb. All EBC cases with pathological confirmation either by fine needle aspiration cytology or core biopsy and who had been treated by at least one mode of treatment (surgery, chemotherapy or radiotherapy) were included in the analysis.(Table 1.). Data from 184 patients was thus analyzed. All patients were followed up every three months after discharge from the hospital, following the initial treatment.

The median age was 52.5 years and 54% of patients were pre-menopausal. 5% have unknown menopausal status and 41% had a post menopausal status. Ninety-six per cent (177) patients presented with a lump. Stages 1 (14/184), Stage 2 (111/184), and Stage 3 comprised (59/184). Right breast involved in breast cancer was (93 /184), left breast involvement (90/184) and one case had a bilateral involvement. Most patients who needed chemotherapy were prescribed Tamoxifen for 5 years.

Median ages at menarche and menopause were 14 years (range 12-17 years) and 46 years (36-56 years), respectively. 177 (96%) patients presented with breast lump. The majority (86.4%) had a lump size > two cm. 77 (15.8%) had pain and 24 (4.9%) additionally had nipple discharge.

All patients underwent surgery; either a breast-conserving surgery (BCS) was carried out or simple mastectomy with axillary clearance was performed. Invasive ductal carcinoma was the commonest histology in 151 (82.1%) patients followed by invasive lobular carcinoma in 18 (9.7%), mixed type 12(6.5%) and medullary carcinoma in three (1.6%).

Adjuvant radiotherapy was given to some patients; indications included T3 tumor size, = 4 positive axillary nodes, (Table 2), positive margins, and BCS. Chemotherapy was administered to other women. Most of the patients were given CMF regimen at the oncology clinic.

Breast cancer is a major cause of cancer deaths in women and is increasing in incidence. There appears to be a leveling off in the incidence of breast cancer; previously the incidence had been increasing. A typical pathology report should indicate the type of breast cancer, the histologic grade, the size, and a comment on the surgical margins. In addition, depending upon the case, ancillary studies examining for estrogen and progesterone receptors may be ordered. The age-specific incidence rate curve for breast carcinoma overall increases rapidly until age of about 52 years, and then continues to increase at a slower rate for older women.

Breast cancer clinical research
An important goal is to analyze how factors are seen to affect the disease process. Meanwhile, the disease progression is not fully modeled using standard analysis since transitions between intermediate events such as local-regional recurrences or metachronous contra lateral breast cancer are not considered.

In the present study
Breast cancer was usually self-diagnosed and tumors were > 2 cm at presentation in some of the cases, suggesting the possibilities of a delay in diagnosis, more aggressive tumors or both. Menopause did not seem to have any effect on Breast carcinoma as evidenced by steadily rising rates at all ages.

The 3 known causes of human breast cancer, ionizing radiation, exogenous ovarian hormones and beverage alcohol, offer some preventive possibilities but do little to explain the epidemiologic features of the majority of cases of the disease that occur in their absence (3)

There is no evidence that detection bias plays a major role, and although the right breast is slightly larger, on average, than the left, there is little evidence that breast size is associated with breast cancer risk. The reason for the right-sided excess among women in our study remains unclear.

Breast carcinoma is an unpredictable disease in the sense that some patients may present with relatively early disease and die of widespread metastases within six months to one year, while others present with fairly advanced disease and yet survive longer (4). The various histologic types of breast cancer exhibit differences in regard to relative frequency, site pattern within the breast, and patient survival.

Young patients with breast cancer had the worst histopathological features and the worst survival rate compared to their older counterparts. Age was an independent significant prognostic factor for relapse. (5). Tumor size, grade, race of patient, and year of diagnosis all have significant constant effects on disease-specific survival in breast cancer, while the effects of age at diagnosis and disease stage have significant effects that vary over time. (6)

Younger patients as a group have more aggressive and advanced breast cancer at presentation compared with older patients. Considered in a multivariate model, together with other variables, age does not provide independent prognostic information and should not be used alone for management decisions (7). Young breast cancer patients have poorer outcomes, which are in part attributed to later stage disease, more aggressive tumors, and less favorable receptor status. There still appears to be other important factors that are contributing to the worse outcomes for these young patients, such as socio-economic status. Physicians need to have heightened awareness when evaluating this population, and increasingly efficacious adjuvant therapies need to be developed.
-The outcome of these patients may be improved by patient education and availability of better health care facilities

-Axillary ultrasonography is increasingly being used to improve the staging of breast cancer patients who have negative axillary lymph nodes on physical examination. (8) This approach has a number of advantages. First, node-positive patients identified with ultrasonography can be referred for axillary dissection, without the need for sentinel lymph node (SLN) staging. (9) The probability of death from breast cancer exceeded that from all other causes for patients diagnosed with localized disease before age 50 years, with regional disease before age 60 years, and with distant disease at any age. (10) There is little evidence that breast size is associated with breast cancer risk. (11)
Patient care decisions occur in the context of breast cancer and other age-related conditions. Co-morbidity in older patients may limit the ability to obtain prognostic information (i.e., axillary lymph node dissection), tends to minimize treatment options (e.g., breast-conserving therapy), and increases the risk of death from causes other than breast cancer. (12). In general breast cancer is a major public health problem in Jordan. Late presentation is a major concern, as large numbers of early breast cancer patients are still diagnosed in clinical Stage II. Patient preference for mastectomy is an important reason for the under-utilization of breast conservation therapy. Education/awareness campaigns, improvement of socio-economic conditions, better access to diagnostic resources, availability of higher standards of health care, use of breast self-examination, and screening mammography if implemented nationally would go a long way towards increasing early diagnosis and improved survival with a consequent possible rise in incidence of early cases as is happening in the West.

In our study there was no impact on recurrence of breast cancer with regard to size, age, menopausal status, nodal status, histologic subtype, adjuvant therapy, or extent of surgery.