A Retrospective Analysis of Breast Cancer at BPKMCH, Nepal

Introduction: Breast cancer is the most common cancer and also the leading cause of cancer related mortality in women worldwide which impact 2.1 million women each year. Breast cancer rates are increasing in nearly every


Introduction:
Breast cancer is a group of diseases in which cells in breast tissue change and divide uncontrolled, typically resulting in a lump or mass. Most breast cancers begin in the lobules (milk glands) or in the ducts that connect the lobules to the nipple. Breast cancer is the most common cancer and also the leading cause of cancer mortality in women worldwide. Approximately 1.38 million new breast cancer cases were diagnosed in 2008 with almost half of all breast cancer cases and nearly 60% of deaths occurring in lower income countries. 1,2 Globally, breast cancer impacting 2.1 million women each year, and also causes the greatest number of cancer-related deaths among women. In 2018, it is estimated that 627,000 women died from breast cancer -that is approximately 15% of all cancer deaths among women. While breast cancer rates are increasing in nearly every region globally. 1

Methods
This is retrospective study at Department of Pathology in B P Koirala Memorial Cancer Hospital effective from 15 April 2018 to 14 April 2019. This study included the patients who were operated at BPKMCH or referred cases from elsewhere, but the specimen was processed and reported at BPKMCH. All the data were retrieved and analyzed.

Results
Total 205 breast cancer cases were analyzed, among them 198 cases were females accounting 96.5 % and 7 cases were males accounting 3.5 %.
Among 205 cases, As per WHO Cassification 2019 4 , 182 (88.9%) cases were invasive breast Carcinoma of No Special Type, in addition histologic subtype 4 (1.9%) cases were of medullary pattern, 5 (2.4%) cases were malignant phylloides tumour, 4 (1.9%) cases were invasive lobular carcinoma, 4 (1.9%) cases were Metaplastic carcinoma, 3 (1.4%) cases were Paget's disease of nipple with ductal carcinoma in situ, 2 (0.9%) cases were mucinous carcinoma, 1 (0.4%) case was invasive papillary carcinoma.   According to the study carried by S Jamal et al, carcinoma of breast is one of the less frequent malignancies in males. In their study 50 cases of malignant tumours of male breast diagnosed during a 10 years period (1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989) were analysed retrospectively. One male breast was involved for every 33 female cases. The peak incidence was between 5th to 7th decade with mean age of 58.54 years. Histologically, the infiltrating duct carcinoma (grade III) was the predominant lesion. 6 According to our study breast cancer was most common in the age group 41-50 years (32.2% ). Similarly Chavan, R et al, encountered maximum breast cancer in the agegroup 40-50 years (38% ). 7 Shrestha JS et al did study, among 3270 total cancer patients, among them 5.59% (183 patients) had breast cancer. Age range 40 to 49 was the most affected age group comparable to WHO data on the Nepal breast cancer status. The minimum age was 22 years and the maximum was 82 years. Left sided breast (51%) cancer was more common, followed by right sided (44%) and bilateral (4%). This result is comparable to the result of the similar study done in India where left sided cancer was more common than right sided. 8 In our study minimum age was 23 years and the maximum age was 92 years. Left sided breast cancer cases were 111 (54.15%) and right sided breast cancer cases were 94 ( 45.85%). So our study revealed that left sided breast cancer was more common than right sided breast cancer.
Breast cancers can be classified into biologically and clinically meaningful subgroups according to histological grade. Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2/neu) are immunohistochemical markers of prognosis as well as predictors of response to therapy.9 Histological type, on the other hand, refers to the growth pattern of the tumours. The histological diversity of adenocarcinoma in the breast has long fascinated pathologists, who have identified specific morphological and cytological patterns that were consistently associated with distinctive clinical presentations and/or outcomes. These patterns are called 'histological types' . The commonest type of breast carcinoma is invasive ductal carcinomas not otherwise specified (IDC-NOS) or of no special type (IDC-NST). 3 In our study we did grading based on  fig.1,2)was the most common type of breast carcinoma, 84 cases accounting 75% of total cases. Carcinoma with medullary features was second most common (6 cases) comprising 5.4% cases followed by lobular, papillary, apocrine, mucinous and NST mixed types. Grade II tumors were most frequent grade observed in 76.79% cases followed by Grade I (12.50%) and Grade III (10.71%).

BPKMCH
Breast cancer has emerged as the second more prevalent malignancy in women in Nepal. But the hospital records show that Nepali women seek medical help when the disease is already in an advanced stage. 11 Factors responsible for the general delayed diagnosis are lack of knowledge, limited breast cancer screening programs, limited health care facilities and sociocultural barriers. The government should foster novel policies to establish effective nationwide cancer literacy programmes, as well as engagements with communitylevel, national and international organizations and the healthcare system. 12 In order to improve breast cancer outcomes and survival, early detection is critical. There are two early detection strategies for breast cancer: early diagnosis and screening. Limited resource settings with weak health systems where the majority of women are diagnosed in late stages should prioritize early diagnosis programmes based on awareness of early signs and symptoms and prompt referral to diagnosis and treatment.

Conclusion
Breast cancer is more common in females than in males. Most common affected age group was 41-50 years. Similarly, our study revealed that left sided breast cancer was more common than right sided breast cancer. Majority of cases was Invasive Breast Carcinoma, No special type with Nottingham grading system grade II. Most common histological type was invasive ductal carcinoma NST and mostly cases were in advanced stage. In order to improve breast cancer outcomes and survival, early diagnosis and screening should be done.