Frequency of breast cancer among sudanese patients with breast palpable lumps

Breast cancer burden in eastern Sudan: seven-year retrospective study

Background

Breast cancer (BC) is prevalent in Sudan, yet data on its epidemiology in Eastern Sudan is limited. This study aims to provide insights into the demographic and clinicopathologic features of BC patients treated at the East Oncology Centre (EOC) in Gadarif State, Eastern Sudan. Furthermore, we aim to identify the factors that contribute to a late-stage diagnosis.

Methods

This cross-sectional study included patients diagnosed with BC and treated in the EOC between 2016 and 2022. Data obtained from medical records were analysed using R software, with descriptive statistics and multiple logistic regressions applied to determine determinants of advanced-stage presentation. A p-value < 0.05 was considered statistically significant.

Results

Among the 394 patients studied, the majority were women (96%), married (66%) and from rural areas (43%). The peak years for BC diagnoses were 2018 and 2022, with a median age at diagnosis of 48 years. A family history of cancer was reported by 20% of patients. Clinical stages were distributed as follows: I (1.6%), II (17%), III (50%) and IV (32%). Twenty-five percent tested positive for human epidermal growth factor receptor 2, while 73% tested negative and 43% had triple-negative BC. Modified radical mastectomy was performed in 47% of patients, with 21% undergoing breast-conserving surgery. Treatment rates were 38% for radiotherapy, 84% for chemotherapy and 46% for hormonal therapy. Higher grade BC and lower education levels were associated with advanced-stage presentation, while a family history of cancer reduced the risk of advanced-stage disease (OR: 0.38, 95% CI: 0.18-0.78).

Conclusion

The study found that females in East Sudan often present at a young age and advanced stage, with a significant prevalence of triple-negative BC. Notably, family cancer history exhibited a protective effect against advanced-stage presentation, while grade 3 cancer was positively associated with advanced disease.

Diagnosis of idiopathic granulomatous mastitis in a sudanese woman

Idiopathic granulomatous mastitis (IGM) is a relatively rare specific chronic inflammatory process of unknown etiology, that diagnostically overlaps with common breast pathologies in Sudan, namely breast cancer (BC) and tuberculous mastitis (TBM). We report the case of a 34-year-old female who presented with a 1-month history of a painful lump in the lower outer quadrant of her left breast. A tru-cut biopsy showed features of granulomatous inflammation suggestive of IGM. Four months later, she presented with similar features and fine-needle aspiration cytology (FNAC) confirmed the presence of IGM and excluded the presence of both, BC and TBM. Histology once again confirmed the diagnosis of granulomatous mastitis with no evidence of breast cancer. Grocott's Methenamine Silver, Ziehl–Neelsen stain, and polymerase chain reaction were negative and accordingly the possibility of fungal infection and TBM were excluded. To our knowledge, this is the first case report of IGM in Sudan. FNAC helped in correct diagnosis of our case and importantly, conditions such as BC and TBM were both excluded as common mimickers of IGM. Although breast biopsy is the main golden approach in the diagnosis of IGM in addition to the usefulness of adjunct ancillary microbiological techniques, still further research is needed to establish whether FNAC can be a reliable tool in the diagnosis of IGM with the common practice of this diagnostic tool in Sudan.

Evaluation of Angiogenesis by Using CD105 and CD34 in Sudanese Breast Cancer Patients

&lt;b&gt;Background and Objective:&lt;/b&gt; Angiogenesis is a mechanism by which new blood vessels are developed in healing and tumour tissues, where it is necessary for regeneration growth, tumour cells survival and metastasis. This study aimed to assess the angiogenesis mechanism among Sudanese females with breast cancer using anti-CD34 and anti-CD105 markers. &lt;b&gt;Materials and Methods:&lt;/b&gt; Three hundred female representative Formalin-Fixed Paraffin-Embedded (FFPE) breast tissue blocks were included in this study. Of the 300 representative tissue blocks, 200 were breast cancer patient's tissues (confirmed cases) and 100 were normal breast tissues (controls). Their ages mean±SD, 47.3±12.9 years. &lt;b&gt;Results:&lt;/b&gt; The results showed the MVD of CD34 significantly increased in malignant lesions as compared to normal breast tissues. The mean of MVD CD34 and MVD CD105 showed statistical differences among different histologic types of breast cancer. Also, a strong positive correlation was detected between the manual and automated MVD counting methods. Also, the current study revealed no significant differences were observed in mean MVD counting for both markers and menopausal status or the age groups of the study population. &lt;b&gt;Conclusion:&lt;/b&gt; The MVD is a good tool for assessing prognostic markers. The CD105 marker has a high specificity to the new evolving tumour vessels and is a useful predictor for angiogenesis and breast cancer metastasis.

Fibroadenoma of the breast in a South African population -a pilot study of the diagnostic accuracy of fine needle aspirate cytology and breast ultrasonography

Background

The triple assessment of clinical breast exam (CBE), fine needle aspirate cytology (FNAC) and breast ultrasonography (US) is used in many settings for the diagnosis of fibroadenoma (FA). The diagnostic accuracy of FNAC and US for FA in South African (SA) women with palpable breast masses (PBM) is unknown.

Objective

To report the diagnostic accuracy of FNAC/US for FA in SA women with PBM.

Methods

We conducted a retrospective pilot diagnostic study of 91 women who presented with PBM to a SA regional academic hospital. Data for CBE, US, unguided FNAC, and open biopsies was collected from study participant medical records and analyzed using diagnostic accuracy tables.

Results

A total of 57/91 (62.6%) study participants had uninterpretable FNAC results. No study participants had uninterpretable US results. The overall diagnostic accuracy of FNAC for FA was 36.3% (95% Confidence Interval - CI: 27.1–46.5%). The overall diagnostic accuracy of US for FA was 83.5% (95% CI: 74.6–89.8%).

Conclusion

The yield of interpretable test results for FNAC was poor in our study. The diagnostic accuracy of US for FA appears to be superior to that of FNAC. Omission of FNAC from the triple assessment in our setting should be considered.

Demonstration of an algorithm to overcome health system-related barriers to timely diagnosis of breast diseases in rural Zambia

Background

Long delays to diagnosis is a major cause of late presentation of breast diseases in sub-Saharan Africa.

Aims

We designed and implemented a single-visit breast care algorithm that overcomes health system-related barriers to timely diagnosis of breast diseases.

Methods

A multidisciplinary team of Zambian healthcare experts trained a team of mid- and high-level Zambian healthcare practitioners how to evaluate women for breast diseases, and train trainers to do likewise. Working collaboratively, the two teams then designed a clinical platform that provides multiple breast care services within a single visit. The service platform was implemented using a breast outreach camp format, during which breast self-awareness, psychosocial counseling, clinical breast examination, breast ultrasound, ultrasound-guided biopsy, imprint cytology of biopsy specimens and surgical treatment or referral, were offered within a single visit.

Results

Eleven hundred and twenty-nine (1129) women attended the camps for breast care. Mean age was 35.9 years. The majority were multiparous (79.4%), breast-fed (76.0%), and reported hormone use (50.4%). Abnormalities were detected on clinical breast examination in 122 (10.8%) women, 114 of whom required ultrasound. Of the 114 who underwent ultrasound, 48 had identifiable lesions and were evaluated with ultrasound-guided core needle biopsy (39) or fine-needle aspiration (9). The concordance between imprint cytology and histopathology was 100%, when breast specimens were classified as either benign or malignant. However, when specimens were classified by histopathologic subtype, the concordance between imprint cytology and histology was 85.7% for benign and 100% for malignant lesions. Six (6) women were diagnosed with invasive cancer. Eighteen (18) women with symptomatic breast lesions had next-day surgery.

Significance

Similar to its impact on cervical cancer prevention services, a single visit breast care algorithm has the potential to overcome health system-related barriers to timely diagnosis of breast diseases, including cancer, in rural African settings.

Benign and Malignant Breast Disease at Rwanda's First Public Cancer Referral Center

BACKGROUND

Breast cancer incidence is rising in low- and middle-income countries. Understanding the distribution of breast disease seen in clinical practice in such settings can guide early detection efforts and clinical algorithms, as well as support future monitoring of cancer detection rates and stage.

PATIENTS AND METHODS

We conducted a retrospective medical record review of 353 patients who presented to Butaro Cancer Center of Excellence in Rwanda with an undiagnosed breast concern during the first 18 months of the cancer program.

RESULTS

Eighty-two percent of patients presented with a breast mass. Of these, 55% were diagnosed with breast cancer and 36% were diagnosed with benign disease. Cancer rates were highest among women 50 years and older. Among all patients diagnosed with breast cancer, 20% had stage I or II disease at diagnosis, 46% had locally advanced (stage III) disease, and 31% had metastatic disease.

CONCLUSION

After the launch of Rwanda's first public cancer referral center and breast clinic, cancer detection rates were high among patients presenting with an undiagnosed breast concern. These findings will provide initial data to allow monitoring of changes in the distribution of benign and malignant disease and of cancer stage as cancer awareness and services expand nationally.

IMPLICATIONS FOR PRACTICE

The numbers of cases and deaths from breast cancer are rising in low-income countries. In many of these settings, health care systems to address breast problems and efficiently refer patients with symptoms concerning for cancer are rudimentary. Understanding the distribution of breast disease seen in such settings can guide early detection efforts and clinical algorithms. This study describes the characteristics of patients who came with a breast concern to Rwanda's first public cancer referral center during its first 18 months. More than half of patients with a breast mass were diagnosed with cancer; most had late-stage disease. Monitoring changes in the types of breast disease and cancer stages seen in Rwanda will be critical as breast cancer awareness and services grow.

Incidence data for breast cancer among Yemeni female patients with palpable breast lumps

PURPOSE

To estimate the incidence of breast cancer in Yemeni female patients presenting with a breast mass.

MATERIALS AND METHODS

This retrospective study was carried out with 595 female patients with palpable breast lumps, attending to Alkuwait university hospital, Sana'a, Yemen. Triple assessment, including breast examination, mammography and biopsy (FNAC, core needle, or excision), for all patients were performed.

RESULTS

The incidences of benign and malignant lesions was calculated. Some 160 (26.9%) of 595 patients had malignancies; 213 (35.8%) were fibroadenomas; 12 (2.0%) were fibrocystic change; 143 (24.03%) were inflammatory lesions (including mastitis and ductectasia); 62 (10.4%) were simple cysts, while 5 (0.8%) were phyllodes tumors. The mean age of patients with malignant lumps was 44.3 years.

CONCLUSIONS

Among Yemeni female patients with palpable breast lumps, the rate of breast cancer is high, with occurrence at an earlier age than in Western countries. Improving breast cancer awareness programs and increasing breast cancer screening centers inb different areas of Yemen are needed to establish early diagnosis and offer early and optimal treatment.

Cytomorphology of palpable breast lesions: Diagnostic utility of FNAC in a developing country

BACKGROUND

Breast lesions including breast cancer represent a major public health issue in Sudan. Fine-needle aspiration cytology (FNAC) is an established, simple, highly accurate, minimally invasive, and cost-effective method of diagnosing most breast lesions. The aim of this study is to document the most common breast conditions diagnosed by means of FNAC over a two-year period in Atbara, a city in north Sudan.

METHODS

A retrospective, descriptive, cross-sectional, laboratory-based study in which records of all palpable breast lesions diagnosed by FNAC in the years 2012 and 2013 were reviewed and analyzed.

RESULTS

The total number of cases studied was 232; most subjects, 222 (95.7%), were females. The age range was 15-90 years (mean 38.2). Painless lump was the most common 190 (81.9%) clinical presentation. The left breast was affected more often than the right breast, 56.0% vs. 40.5%. Benign conditions were 167 (72%). Malignant neoplasms were 65 (28.0%). The most important associations with malignancy were female sex, age above 35 years, multiparity, painless lump at upper outer quadrant of left breast, lump size above 2 cm and the presence of an enlarged ipsilateral axillary lymph node at presentation.

CONCLUSION

In the northern part of Sudan, the prevalence of malignant breast lesions diagnosed by FNAC is more than one fourth of all cases presenting with palpable breast lumps. FNAC is a technique that is ideal for use in resource-limited health settings.

Part I: cancer in Sudan—burden, distribution, and trends breast, gynecological, and prostate cancers

Despite the growing burden of cancer worldwide, it continues to receive low priority in Africa, across the continent and specifically in Sudan. This is due to political unrest, limited health resources, and other pressing public health issues such as infectious diseases. Lack of awareness about the magnitude of the current and future cancer burden among policy makers play a major role as well. Although, the real scope of cancer in Sudan is not known, the reported cases have increased from 303 in 1967–6303 in 2010. According to Globocan estimates, the top most common cancers in both sexes are breast, non-Hodgkin lymphoma, leukemia, esophagus, and colorectum. This review is the first of four papers that focuses on cancer, its distribution and trend as well as the risk factors most common in Sudan. It is expected that cancer will increase in Sudan as a result of migration of people from rural areas to urban cities in the pursuit of a better standard of living, which has resulted in lifestyle and behavioral changes that include tobacco chewing and smoking, unhealthy dieting, and a lack of physical activity. These changes are further exacerbated by the aging population and have made the country vulnerable to many diseases including cancer. These reviews are meant to provide a better understanding and knowledge required to plan appropriate cancer-control and prevention strategies in the country.

Breast-cancer screening with trained volunteers in a rural area of Sudan: a pilot study

BACKGROUND

Breast cancer has a low cure rate in low-income and middle-income countries because patients often present with late-stage disease that has metastasised to other organs. We assessed whether the implementation of a cancer awareness and breast examination programme that uses local, volunteer women could increase the early detection of breast cancer in a rural area of sub-Saharan Africa.

METHODS

We did this pilot study in two counties in Gezira State, Sudan. We chose Keremet (56 villages) as the experimental county and Abugota (79 villages) as the control county. Female volunteers from villages in Keremet were trained in the detection of breast abnormalities. When trained, volunteers visited households in their village and screened women aged 18 years or older for breast abnormalities, referring women with suspected breast cancer for medical diagnosis and, if necessary, treatment at the district hospital. We also ran a cancer awareness programme for both men and women in study villages. Villages in the control population received no intervention. This study is ongoing.

FINDINGS

Between Jan 1, 2010, and Oct 10, 2012, 10 309 (70%) of 14 788 women in Keremet were screened. 138 women were identified as having breast abnormalities and were referred to the district hospital for diagnosis and treatment. 20 of these women did not report to the hospital. Of the 118 women who did report, 101 were diagnosed with benign lesions, eight with carcinoma in situ, and nine had malignant disease. After treatment, 12 of the 17 women with either carcinoma in situ or malignant disease (four had early breast cancer and eight had ductal carcinoma in situ) were disease-free and had a good prognosis. In the control villages, only four women reported to the centre: one was found to have a benign lesion while three were diagnosed with advanced disease.

INTERPRETATION

Our findings show that a screening programme using local volunteers can increase the detection of breast cancer in asymptomatic women in low-income rural communities. These findings can inform policy-makers' decisions in the design of cancer control programmes in Sudan and other similar areas in sub-Saharan Africa.

FUNDING

Sudan National Cancer Institute.

Incidence of invasive breast cancer in the presence of competing mortality: the Canadian National Breast Screening Study

Mortality due to causes other than breast cancer is a potential competing risk which may alter the incidence probability of breast cancer and as such should be taken into account in predictive modelling. We used data from the Canadian National Breast Screening Study (CNBSS), which consist of two randomized controlled trials designed to evaluate the efficacy of mammography among women aged 40-59. The participants in the CNBSS were followed up for incidence of breast cancer and mortality due to breast cancer and other causes; this allowed us to construct a breast cancer risk prediction model while taking into account mortality for the same study population. In this study, we use 1980-1989 as the study period. We exclude the prevalent cancers from the CNBSS to estimate the probability of developing breast cancer, given the fact that women were cancer-free at the beginning of the follow-up. By the end of 1989, from 89,434 women, 944 (1.1 %) were diagnosed with invasive breast cancer, 922 (1.0 %) died from causes other than breast cancer, and 87,568 (97.9 %) were alive and not diagnosed with invasive breast cancer. We constructed a risk prediction model for invasive breast cancer based on 39 risk factors collected at the time of enrolment or the initial physical examination of the breasts. Age at entry (HR 1.07, 95 % CI 1.05-1.10), lumps ever found in left or right breast (HR 1.92, 95 % CI 1.19-3.10), abnormality in the left breast (HR 1.26, 95 % CI 1.07-1.48), history of other breast disease, family history of breast cancer score (HR 1.01, 95 % CI 1.00-1.01), years menstruating (HR 1.02, 95 % CI 1.01-1.03) and nulliparity (HR 1.70, 95 % CI 1.23-2.36) are the model's predictors. We investigated the effects of time-dependent factors. The model is well calibrated with a moderate discriminatory power (c-index 0.61, 95 % CI 0.59-0.63); we use it to predict the 9-year risk of developing breast cancer for women of different age groups. As an example, we estimated the probability of invasive cancer at 5 years after enrolment to be 0.00448, 0.00556, 0.00691, 0.00863, and 0.01034, respectively, for women aged 40, 45, 50, 55, and 59, all of whom had never noted lumps in their breasts, had 32 years of menstruating, 1-2 live births, no other types of breast disease and no abnormality found in their left breasts. The results of this study can be used by clinicians to identify women at high risk of breast cancer for screening intervention and to recommend a personalized intervention plan. The model can be also utilized by a woman as a breast cancer risk prediction tool.

Basal-like phenotype in a breast carcinoma case series from Sudan: prevalence and clinical/pathological correlations

Basal-like breast cancer, an aggressive subtype associated with high grade, poor prognosis, and younger age, is reported frequently in Africa. We analyzed the expression of the basal cytokeratins (CKs) 5/6 and 17 in a case series from Central Sudan and investigated correlations among basal CK status, ER, PgR, and Her-2/neu, and individual/clinicopathological data. Of 113 primary breast cancers 26 (23%), 38 (34%), and 46 (41%) were, respectively, positive for CK5/6, CK17, and combined basal CKs (CK5/6 and/or CK17). Combined basal CK+ status was associated with higher grade (P < .03) and inversely correlated with ER (P < .002), PgR (P = .004) and combined ER and/or PgR (P < .0002). Two clusters based on all tested markers were generated by hierarchical cluster analysis and k-mean clustering: I: designated "hormone receptors positive/luminal-like" and II: designated "hormone receptors negative", including both basal-like and Her-2/neu+ tumors. The most important factors for dataset variance were ER status, followed by PgR, CK17, and CK5/6 statuses. Overall basal CKs were expressed in a fraction of cases comparable to that reported for East and West African case series. Lack of associations with age and tumor size may represent a special feature of basal-like breast cancer in Sudan.