|Year : 2017 | Volume
| Issue : 3 | Page : 93-97
Breast cancer mortality in a resource-poor country: A 10-year experience in a tertiary institution
Said Mohammed Amin1, Henry Azuh S Ewunonu1, Emmanuel Oguntebi1, Idris Mohammed Liman2
1 Department of Histopathology, National Hospital Abuja, Abuja, Nigeria
2 Department of Obstetrics and Gynaecology, National Hospital Abuja, Abuja, Nigeria
|Date of Web Publication||16-Jan-2018|
Dr. Said Mohammed Amin
Department of Histopathology, National Hospital Abuja, P. O. Box, 14247, Abuja
Introduction: Breast cancer is a major global public health problem accounting for massive morbidity and significant mortality worldwide. Factors contributing to breast cancer mortality have been a topic of intense research and discussion in the scientific world. There is, however, a dearth of information on the incidence of breast cancer mortality in most resource-poor countries including Nigeria. Available data from most African workers on breast cancer focused on incidence, risk factors, and complications rather than mortality. The unique ethnic heterogeneity of Abuja and its peculiar lifestyle (as compared to other Nigerian cities) provides added impetus for assessing breast cancer mortality in one of the Nigeria's fastest growing cities. This study is carried out in a 400-bedded public tertiary hospital in Abuja, the capital of Nigeria. Materials and Methods: A retrospective review of all breast samples in the department of histopathology over a decade is performed supported by clinical information from the medical record archives. Results: Of 2292 breast samples received in the department, 35.3% (n = 810) are malignant out of which 10.6% (n = 86) died. Breast cancer incidence increased from 29 in 2005 to 141 by 2013 while mortality declined from 11 to 9 over the same period. A crude fatality rate of 3.7% is observed. The ages of the decedents ranged from 20 to 90 years with a mean of 43.5 years. Infiltrative ductal carcinoma accounts for the largest mortality with 87.4%. Conclusion: Breast cancer is an important cause of mortality among females and efforts at early detection and treatment should be intensified.
Keywords: Associated risks, breast cancer mortality, Nigeria, patient demographics, tertiary hospital
|How to cite this article:|
Amin SM, Ewunonu HA, Oguntebi E, Liman IM. Breast cancer mortality in a resource-poor country: A 10-year experience in a tertiary institution. Sahel Med J 2017;20:93-7
|How to cite this URL:|
Amin SM, Ewunonu HA, Oguntebi E, Liman IM. Breast cancer mortality in a resource-poor country: A 10-year experience in a tertiary institution. Sahel Med J [serial online] 2017 [cited 2018 Sep 24];20:93-7. Available from: http://www.smjonline.org/text.asp?2017/20/3/93/223173
| Introduction|| |
Female breast cancer is a major global public health problem with an estimated 1,384,155 new cases worldwide and over 459,000 related deaths annually. Indeed the 2012 GLOBOCAN report indicates that 1.7 million women were diagnosed with breast cancer and 522,000 deaths recorded. Furthermore, this shows an increase of about 20% from the 2008 GLOBOCAN breast cancer incidence. The American Cancer Society estimated an average of 93,600 new cases of breast cancer annually in Africa with about 50,000 deaths.
While recording an observable increase in breast cancer incidence in almost all the European countries, noticeable decrease is seen in mortality in England, Wales, and Scotland. This may be attributable to efficient health-care delivery system with effective screening programs and novel therapeutic regimens.
The contribution of risk factors such as race, socioeconomic status, lifestyle, reproductive factors, diet, and socioenvironmental factors  to the morbidity and mortality of breast cancer has been acknowledged in various studies.
In Nigeria, female breast cancer is recognized as major cause of morbidity and mortality with incidence rate ranging from 36.3 to 50.2/100,000 live birth. Figures for breast cancer mortality are, however, scarce. This article presents the mortality from malignant breast cancer in a tertiary hospital in Nigeria.
The National Hospital Abuja (NHA) is a 400-bed tertiary public hospital located in the cosmopolitan city of Abuja, the capital of Nigeria. Its clientele is derived from the entire country but predominantly from the culturally and ethnically heterogeneous population of Abuja metropolitan city and nearby states.
| Materials and Methods|| |
This is a retrospective study of all breast lesions received in the Histopathology Department of the NHA from January 1st, 2004, to December 31st, 2013. Records of all breast samples received in the department within the period were retrieved from the request forms and departmental register. Slides made from such samples were reviewed and new slides made from the tissue blocks where necessary. Similarly, all records of clinic attendance and admission for surgical breast diseases were obtained from the Hospital Medical Record Department. Ward folders and Mortuary records were consulted where appropriate. Data are collated and analyzed using simple statistical methods with Microsoft Excel 2011.
| Results|| |
In the period from January 1st, 2004, to December 31st, 2013, a total of 2292 breast samples were received in the Histopathology Department of which 810 or 35.3% are malignant. Of the malignant cases, 86 patients (10.6%) died 2 of which are male. This provides a crude fatality rate of 3.7% for breast lesions and mortality rate of 10.6% for the period 2004–2013.
Malignant breast lesions constituted a significant proportion of the breast samples received over the years accounting for 26.6% in 2006 increasing to 67.5% in 2013. This is depicted in [Table 1].
|Table 1: The frequencies of breast lesions in National Hospital Abuja from 2004 to 2013|
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The ages range from 20 to 90 years with a mean of 43.5 years and a standard deviation of 11.17. Distribution of lesions according to age group reveals the most affected cohorts to be the 31–40 and the 41–50 years age group, as depicted in [Table 2]. Mortality from breast cancer, on the other hand, shows little change over the years and indeed declined in the latter year. [Figure 1] illustrates this finding.
|Figure 1: The annual frequency of breast malignancies and the mortality associated with them|
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The length of hospital stay (LOHS – number of days from the date of patient's admission to discharge or death as the case may be) ranges from 0 to 236 days with a mean of 25 days and standard deviation of 44.9. This is depicted graphically in [Figure 2].
In terms of histological diagnosis, the more common condition associated with breast cancer death is infiltrative ductal carcinoma consisting of over 87.4% (n = 708) followed by medullary and infiltrating lobular carcinoma with 4 and 3%, respectively. Others include mesenchymal tumors (sarcomas), tubular carcinoma, lymphoma, papillary, colloid, and cribriform carcinoma as well as granular cell tumor of the breast as depicted in [Table 3].
|Table 3: Histological diagnosis of breast malignancies seen in National Hospital Abuja in a decade|
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A greater proportion of the decedents are civil servants, housewives, businesswomen, and teachers, as depicted in [Figure 3].
|Figure 3: Distribution of occupation of deceased. CIVS: Civil servant; HWIF: Housewife; Business: Businesswomen; TEAC: Teachers; TRAD: Traders; NA: Not available; STUD: Student; RET: Retirees; NURS: Nursing|
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| Discussion|| |
This study shows breast malignancies increasing in absolute figures and also displaying an increasing trend over time. This is in concordance with the result of most studies worldwide. Breast cancer incidence has not only being remarkably high in most studies but also shows a progressive increase in Nigeria  and numerous other countries over the years. Indeed studies from Australia  and European countries such as Spain, Netherlands, Denmark, and Finland show a considerable increase in the breast cancer incidence over time. Breast cancer mortality, on the other hand, exhibits a different trend. In most centers, while the breast cancer incidence is on the increase, the mortality seems to either stabilize or even decrease with time.
The high frequency of breast cancer mortality in our study may give credence to the postulate that breast cancer is generally more aggressive and associated with higher mortality among non-Caucasian race, a discrimination that becomes more pronounced after menopause. This racial trend was more clearly highlighted by Russell et al. who demonstrated an 18% increase in breast cancer mortality among non-Caucasian with a 3% decrease among Caucasians over the same period in the USA. A possible contributing factor may be racial genetic differences in metabolism of commonly used drugs. Another explanation proffered by workers in Michigan is the p53 mutations in the 5–9 exons and adjacent introns common in black women than whites. A genome-wide association studies in women of African ancestry  suggest a significant number of common shared variant loci predisposing these women to breast cancer
Moreover, studies from European Community indicate that breast cancer mortality is influenced by various extraneous factors such as radiation,, parity, stage at presentation, geographical location, diet, systemic endocrine therapy, body build, age at detection, stage, and histologic grade of tumor . Adverse effect of alcohol consumption  and statistically insignificant effect of passive smoking  on breast cancer mortality have been reported by some studies. The role played by comorbidity  and hospice care  in the determination of the length of survival of patients with breast cancer is adjudged to be significant. Furthermore, some studies suggest that reproductive factors may contribute adversely to breast cancer, especially where parturition occurs within 2 years of diagnosis., Sighoko et al., however, looking at full-term pregnancies in women from Nigeria, Cameroon, and Uganda did not observe any increased risk in breast cancer causation from these factors.
The role of occupation in breast cancer mortality has been studied in different climes. In our study, a significant proportion of the women were civil servants, housewives, teachers, and businesswomen. A study in the US noted a slight increase in breast cancer mortality among women “executives” and “administrative support” staff. No significant relationship was observed in breast cancer mortality among teachers, nurses, sale girls, and servicewomen. A study in the US, however, suggested increased breast cancer mortality among women electrical workers. Another study suggested an increasing incidence of breast cancer mortality among Negroid women with increasing level of education  though a similar study in Norway failed to see any correlation.
A 22-year histologic study of breast cancer mortality looking at various parameters including age at diagnosis, histological type and grade, mitotic count, tumor margin, inflammatory cell reaction, extent of tumor necrosis, primary tumor size, axillary nodal status, DNA ploidy and index, S-phase fraction, and occurrence of the second primary breast cancer provided remarkable insight into the condition. A direct correlation was found between advanced age at diagnosis, second primary breast cancer during follow-up, and large primary tumor size to breast cancer mortality.
In our study, the LOHS among decedents was in most cases less than a week reflecting the severity of disease at the time of presentation in the majority of cases. Other factors contributing to LOHS attributable to the patient, physician, or hospital characteristics have not been studied in this work. Factors attributable to patients as expounded in the literature include older age, lack of immediate family support, low socioeconomic status, and severe comorbidity. Factors ascribed to the physician are mostly level of experience and competence. Hospital characteristics include protocol for breast cancer care
One key factor that, in our opinion, plays a crucial role in breast cancer mortality in our study is a late stage of presentation  often a consequence of poverty, ignorance, and/or inaccessible health-care facilities. Other studies have emphasized the importance of this parameter. Various workers attributed late-stage breast cancer to factors such as accessibility to health care and diagnostic services, availability and utilization of screening programs, biological aggressiveness of the disease, demographic and socioeconomic characteristics of the patient, and the utilization of health insurance.
Studies in England and Scotland showed quite remarkable reduction in breast cancer mortality by about 27% following screening with mammography and self-breast examination (SBE). Other workers obtained similar results regarding the positive effect of mammography in other countries., These further underscore the salutary effect of early detection and screening programs.
| Conclusion|| |
Breast cancer mortality poses a serious public health threat in Nigeria and indeed in most countries of the world. Early detection with the help of intense sustained screening methods such as mammography and self-breast examination might go a long way toward reducing this scourge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]