|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 2019 Sep 19];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|
Click here to view
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|
Click here to view
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|
Click here to view
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|
Click here to view
| 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.
| References|| |
Ferlay J, Shin HR, Ervik M, Dikshit R, Eser S, Mathers C, et al
. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon, France: International Agency for Research on Cancer; 2013.
Botha JL, Bray F, Sankila R, Parkin DM. Breast cancer incidence and mortality trends in 16 European countries. Eur J Cancer 2003;39:1718-29.
Lannin DR, Mathews HF, Mitchell J, Swanson MS. Impacting cultural attitudes in African-American women to decrease breast cancer mortality. Am J Surg 2002;184:418-23.
Lacey JV Jr., Devesa SS, Brinton LA. Recent trends in breast cancer incidence and mortality. Environ Mol Mutagen 2002;39:82-8.
Daling JR, Malone KE, Doody DR, Anderson BO, Porter PL. The relation of reproductive factors to mortality from breast cancer. Cancer Epidemiol Biomarkers Prev 2002;11:235-41.
Gaskill SP, McGuire WL, Osborne CK, Stern MP. Breast cancer mortality and diet in the United States. Cancer Res 1979;39:3628-37.
Dagatti MS, Poletto L, Maris Pezzotto S. Mortality rate trends for breast cancer in Rosario, Argentina. Association with socioeconomic factors. Ginecol Obstet Mex 2002;70:275-80.
Jedy-Agba E, Curado MP, Ogunbiyi O, Oga E, Fabowale T, Igbinoba F, et al.
Cancer incidence in Nigeria: A report from population-based cancer registries. Cancer Epidemiol 2012;36:e271-8.
Smith CL, Kricker A, Armstrong BK. Breast cancer mortality trends in Australia: 1921 to 1994. Med J Aust 1998;168:11-4.
Fregene A, Newman LA. Breast cancer in sub-Saharan Africa: How does it relate to breast cancer in African-American women? Cancer 2005;103:1540-50.
Flaws JA, Newschaffer CJ, Bush TL. Breast cancer mortality in black and in white women: A historical perspective by menopausal status. J Womens Health 1998;7:1007-15.
Russell A, Langlois T, Johnson G, Trentham-Dietz A, Remington P. Increasing gap in breast cancer mortality between black and white women. WMJ 1999;98:37-9.
Flaws JA, Bush TL. Racial differences in drug metabolism: An explanation for higher breast cancer mortality in blacks? Med Hypotheses 1998;50:327-9.
Blaszyk H, Vaughn CB, Hartmann A, McGovern RM, Schroeder JJ, Cunningham J, et al.
Novel pattern of p53 gene mutations in an American black cohort with high mortality from breast cancer. Lancet 1994;343:1195-7.
Feng Y, Stram DO, Rhie SK, Millikan RC, Ambrosone CB, John EM, et al.
A comprehensive examination of breast cancer risk loci in African American women. Hum Mol Genet 2014;23:5518-26.
Garland FC, Garland CF, Gorham ED, Young JF. Geographic variation in breast cancer mortality in the United States: A hypothesis involving exposure to solar radiation. Prev Med 1990;19:614-22.
Mohan AK, Hauptmann M, Linet MS, Ron E, Lubin JH, Freedman DM, et al.
Breast cancer mortality among female radiologic technologists in the United States. J Natl Cancer Inst 2002;94:943-8.
Tatalovich Z, Zhu L, Rolin A, Lewis DR, Harlan LC, Winn DM, et al.
Geographic disparities in late stage breast cancer incidence: Results from eight states in the United States. Int J Health Geogr 2015;14:31.
Toikkanen SP, Kujari HP, Joensuu H. Factors predicting late mortality from breast cancer. Eur J Cancer 1991;27:586-91.
Jain MG, Ferrenc RG, Rehm JT, Bondy SJ, Rohan TE, Ashley MJ, et al.
Alcohol and breast cancer mortality in a cohort study. Breast Cancer Res Treat 2000;64:201-9.
Wartenberg D, Calle EE, Thun MJ, Heath CW Jr., Lally C, Woodruff T. Passive smoking exposure and female breast cancer mortality. J Natl Cancer Inst 2000;92:1666-73.
Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage 2007;33:238-46.
Hou N, Ogundiran T, Ojengbede O, Morhason-Bello I, Zheng Y, Fackenthal J, et al.
Risk factors for pregnancy-associated breast cancer: A report from the Nigerian Breast Cancer Study. Ann Epidemiol 2013;23:551-7.
Sighoko D, Ogundiran T, Ademola A, Adebamowo C, Chen L, Odedina S, et al.
Breast cancer risk after full-term pregnancies among African women from Nigeria, Cameroon, and Uganda. Cancer 2015;121:2237-43.
Calle EE, Murphy TK, Rodriguez C, Thun MJ, Heath CW Jr. Occupation and breast cancer mortality in a prospective cohort of US women. Am J Epidemiol 1998;148:191-7.
Loomis DP, Savitz DA, Ananth CV. Breast cancer mortality among female electrical workers in the United States. J Natl Cancer Inst 1994;86:921-5.
Heck KE, Wagener DK, Schatzkin A, Devesa SS, Breen N. Socioeconomic status and breast cancer mortality, 1989 through 1993: An analysis of education data from death certificates. Am J Public Health 1997;87:1218-22.
Lund E, Jacobsen BK. Education and breast cancer mortality: Experience from a large Norwegian cohort study. Cancer Causes Control 1991;2:235-8.
Downing A, Lansdown M, West RM, Thomas JD, Lawrence G, Forman D. Changes in and predictors of length of stay in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of England: A population-based study. BMC Health Serv Res 2009;9:202.
Pruitt L, Mumuni T, Raikhel E, Ademola A, Ogundiran T, Adenipekun A, et al.
Social barriers to diagnosis and treatment of breast cancer in patients presenting at a teaching hospital in Ibadan, Nigeria. Glob Public Health 2015;10:331-44.
Dai D. Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit. Health Place 2010;16:1038-52.
Onitilo AA, Engel JM, Liang H, Stankowski RV, Miskowiak DA, Broton M, et al.
Mammography utilization: Patient characteristics and breast cancer stage at diagnosis. AJR Am J Roentgenol 2013;201:1057-63.
Verma R, Bowen RL, Slater SE, Mihaimeed F, Jones JL. Pathological and epidemiological factors associated with advanced stage at diagnosis of breast cancer. Br Med Bull 2012;103:129-45.
Campbell RT, Li X, Dolecek TA, Barrett RE, Weaver KE, Warnecke RB. Economic, racial and ethnic disparities in breast cancer in the US: Towards a more comprehensive model. Health Place 2009;15:855-64.
Kuzmiak CM, Haberle S, Padungchaichote W, Zeng D, Cole E, Pisano ED. Insurance status and the severity of breast cancer at the time of diagnosis. Acad Radiol 2008;15:1255-8.
16-year mortality from breast cancer in the UK trial of early detection of breast cancer. Lancet 1999;353:1909-14.
Andersson I, Aspegren K, Janzon L, Landberg T, Lindholm K, Linell F, et al.
Mammographic screening and mortality from breast cancer: The Malmö mammographic screening trial. BMJ 1988;297:943-8.
Barchielli A, Paci E. Trends in breast cancer mortality, incidence, and survival, and mammographic screening in Tuscany, Italy. Cancer Causes Control 2001;12:249-55.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Preimplantation genetic testing for breast cancer
| ||EuniceI Oribamise,OladapoA Ashiru,EbeleC Iloabachie,JumokeG Osumah,OladimejiO Moruf |
| ||Nigerian Medical Journal. 2019; 60(3): 99 |
|[Pubmed] | [DOI]|
||Effect of Sociodemographic Variables on Patient and Diagnostic Delay of Breast Cancer at the Foremost Health Care Institution in Nigeria
| ||Sunday O. Olarewaju,Emmanuel O. Oyekunle,Adebukola O. Bamiro |
| ||Journal of Global Oncology. 2019; (5): 1 |
|[Pubmed] | [DOI]|
||Transforming Screening Uptake in Low-resource and Underinformed Populations: A Preliminary Study of Factors Influencing Womenęs Decisions to Uptake Screening
| ||Judith D. Akwo,Akwa E. Erim,Valentine C. Ikamaise,Bassey Archibong,Ernest U. Ekpo |
| ||Journal of Medical Imaging and Radiation Sciences. 2019; |
|[Pubmed] | [DOI]|