SPECTRUM OF BREAST DISEASES IN A RURAL HIMALAYAN REGION OF WESTERN NEPAL: A HOSPITAL BASED STUDY

Results: Out of 110 cases, only 4 (3.96%) were male. Almost half 54 (49.09%) of the cases were in the age group of 21-30 years. Fibrocystic disease, Breast Abscess and fibroadenoma, and cracked nipple were 39 (35.45%), 38 (34.54%, 15 (13.63%) and 8 (7.28%) respectively. The benign diseases were seen mostly in the younger population while malignant breast diseases were seen in the older population. Mastalgia was mostly seen in the twenties (17.3%) and the thirties (10%) while Breast abscess was commonly encountered in the twenties (16.4%) and the teens (11.8%). The gynaecomastia were seen only in four males.


INTRODUCTION
The female breast, a specialized secondary sex organ undergoes various cyclical changes influenced by hormones at different stages of reproductive life. Although male breast is rudimentary and do not have any role in reproduction, it makes up 1% of all the malignancies. 1 Breast is more developed in females and its morphology keep changing throughout the life. The diseases of the breast include congenital, inflammatory, neoplastic, functional and others. 2,3 The benign lesion are common during the reproductive period while malignant lesions are common during postmenopausal period. 4,5 The breast cancer is one of the most common cancers in female worldwide and this causes a fear of its occurrence if any features of breast disease arises. 6,7 About 85% of the breast masses are identified by self-breast examination which are palpable when they attain the size more than 1 cm in diameter. Accounting the tumor doubling time, a single cell takes about 3 years to reach this size. 8 In Nepal, the majority of the rural women suffer from breast diseases but they cannot express because of the cultural inhibition and the deep-seated taboo prevalent therein. On the other hand, cancer phobia drives them to seek the medical and surgical services even for benign problems. This study was aimed to determine the spectrum of breast diseases prevailing in the rural Himalayan region of western Nepal.

METHODS
This was a retrospective study conducted in Department of General Surgery, Karnali Academy of Health Sciences (KAHS), Teaching Hospital from August 2019 to July 2020 AD (Shrawan 2076 to Ashar 2077 BS). An ethical approval was taken from the institutional review board (IRB) of the KAHS before starting the study (Ref. No. 2076/2077 The data from all the patients with breast disease were extracted from OPD records and filled into per forma. The demographic data including the age, sex, and ethnicity along with the diagnosis were recorded. The data were entered into the SPSS version 16, analyzed using descriptive statistics and presented in tables and figures.

RESULTS
Total 4110 patients visited the surgical OPD during the study period. Out of them, 110 (2.68%) were included in the study. Only 4(3.64%) of the total cases were male and the rest of the 106 (96.36%) cases were all female ( Figure 1).

Figure 2: Ethnicity wise distribution of breast diseases
Chettri (42.73%) was the most common ethnicity followed by Dalit, Brahmin and Janajati ( Figure 2).
The maximum number of cases were in the 21-30 years of age group (n=54, 49.09%) followed by 11-20, 31-40 years of age group and so on ( Table 1).
The highest number of the cases were Mastalgia/Fibrocystic disease (35.45%) and Mastitis/Breast Abscess (34.54%) among others which were then followed by fibroadenoma, cracked nipple and so on. The benign diseases were seen mostly in the younger population while the two of the total cases were carcinoma seen in the older population one in the 6 th decade and the other in the 7 th decade. Mastalgia was mostly seen in the twenties (17.27%) and the thirties (10%) while breast abscess was commonly encountered in the twenties (16.36%) and the teens (11.82%). The gynaecomastia were seen in four male out of them three were teens and one case was in his thirties ( Table 2).

DISCUSSION
The present study was conducted among 110 patients diagnosed with breast diseases presented in General Surgery OPD at KAHS during the study period.
Breast is one of the specialized organs of female with various functional and physiological properties. Breast cancer is one of the leading cause of death in Asia which has overcome cervical cancer. However, the benign diseases of the breast occur at higher frequency than the carcinoma in women. 9,10 Only 4(3.64%) of the total cases were male (gynaecomastia) and the rest of the 106 (96.36%) cases were all female which shows almost similar i.e. few results in the study done by Singh UR et.al in which male were 6.68%. 11 The chettri (42.73%) was the most frequent ethnicity followed by Dalit (36.36%), Brahmin (14.55%) and janajati (6.36%).
Although the chhetris (16.6%) and Brahmin (12.18%) are higher than dalit according to Nepal cencus 2011 AD the dalit suffered more than brahmin in our study. 12 The age which had the maximum number of the breast diseases was 21-30 years of age (n=54 i.e. 49.1%) These findings were almost similar to studies which also had more cases in the same 21-30 age group, Khazada et.al showing 44% 13 , and Bajracharya et al showing 33.6%. 14 Mastalgia (fibrocystic disease) or the breast pain was the most common diagnosis made in our study (n=39) i.e. 35.45% however it was second only after fibroadenoma in other studies; fibroadenoma (28.28%) fibrocystic diseases (21.71%) 11 and fibroadenoma (27%) fibrocystic diseases (21%) 13 . In our study fibroadenoma (13.63%) was only after breast abscess (34.54%) in the third position. This could be because of the pain related to fibrocystic disease which led early soughing of the problem as self-breast examination in not understood by the female in this part of the world because of lack of proper education which could have revealed painless fibroadenoma.
The benign diseases were seen mostly in the younger population while the two of the total cases were carcinoma seen in the older population one in the 6 th decade and the other in the 7 th decade. Mastalgia was mostly seen in the 3 rd decade (17.3%) and also the Breast abscess (16.4%). The fibroadenoma was also common in the third decade (16.4%). The gynecomastia were seen in four male out of them three were teens and one case was in his thirties. These findings are coherent with the other studies Chavan R et.al 15 and Hiremath BV et.al 16 that showed the diseases were mostly noted in the 3 rd decade.

CONCLUSION
Benign diseases of the breast were the most common problems in female of the reproductive age especially the younger age however carcinoma were few in number and also in older population. The four most common breast diseases were fibrocystic disease, mastitis/breast abscess, fibroadenoma and cracked nipple respectively. These diseases were most commonly encountered in the third decade. Few males suffered from the breast problems which were gynaecomastia in all the scenarios. The findings of this study would be helpful for surgeon as well as other health professional in better understanding the pattern of breast diseases.