INTRODUCTION
The stage of breast
cancer seen in an area to some extent, is a reflection of the blend of the
inherent characteristics of the tumor, socioeconomic standing, cultural values,
and the response/degree of development of the peoples’ health system. Hence variation in clinical staging of breast cancer is
observed across the globe. These same factors also conspire to influence
survival and mortality in patients with breast cancer in different regions. The
first worldwide study on this subject as far back as 2012 therefore reported
higher survival in breast cancer patients in Europe and the United States.1, 2 In Europe,
about 20 years ago, stage at diagnosis was 55% for locally advanced tumors, 18%
for metastatic disease, and the overall 5-year survival was 79%.3 In a Mexican report on 4411 patients, the average age at diagnosis was
53 years, stage at diagnosis was 36% for early stages and 45% for locally
advanced.4 In that report, triple negative tumors comprised 14.6% of all tumors. In
Iran, early breast cancer is seen in 65.5%-70.5% of cases, and the overall
survival rate was 72% as reported in a study published in 2018.5 In that study, the mean age at diagnosis was 49.84 years, and the
predominant histologic type was invasive ductal carcinoma. These Iranian observations
are further strengthened by the findings of other Iranian researchers,6 which contrast with those in Africa. A recent meta-analysis of studies
from 23 countries in the five regions of Africa reported that 58% of the
overall breast cancer occurred in patients who were less than 50 years of age,
only 2% had carcinoma in-situ, and 50% of the patients had stage III disease.7 It was observed in this study, that most of the advanced tumors
originated from studies conducted among patients in West African Sub-region.
Investigations
correlating clinicopathologic characteristics of
breast cancer with some demographic variables have been carried out in
different parts of the world with some differences in outcome. In the United
States, African Americans and premenopausal women are associated with triple-negative
breast cancer which has higher risk for brain and lung metastasis.8 In an Iraqi study, no correlation was found between demographic findings
(age of the patients, history of lactation or contralateral breast involvement)
and stage at diagnosis.9 However, a similar study done in year 2021 demonstrated significant
association between clinical staging and marital status, educational
status, history of hormonal intake,
contralateral breast involvement and familial cancer.10
Correlational studies between breast cancer staging and demographic
findings have also been done in few centers in Nigeria with variable outcomes.
A multi-center study had reported that level of educational, living in rural
areas, and not believing in cure of breast cancer were strongly associated with
late-stage disease, whereas, no such association was observed for age at
diagnosis, tumor grade and estrogen receptor status.11 However, a center-based
study demonstrated significant association between disease staging and age at
menarche, age at menopause, age at first pregnancy, and body index mass.12 This study aimed to determine the clinical
correlation between clinical staging and demographic characteristics (age at
diagnosis, age at menarche, age at menopause) of breast cancer patients who
were seen in a tertiary health facility from July 2016 to June 2019.
MATERIALS
AND METHODS
An analytical observational study was carried out
among patients who had breast cancer at the Surgery Department of the
University of Port Harcourt Teaching Hospital from July 2016 to June 2019. Total
population of the patients who attended the breast clinic were enrolled using a
proforma to extract data on clinical staging and
demographic characteristics (age at diagnosis, age at menarche, age at menopause), from the patients, clinic and ward registers. All the authors verified
the data before usage. The Statistical
Package for Social Sciences (SPSS) version 20.0 was used for statistical
analysis. Pearson’s correlation and simple linear regression equation were used
to explore the relationship between clinical staging and demographic
characteristics. The mean demographic characteristics were compared across clinical
staging using the one-way Analysis of Variance (ANOVA) to determine significant
differences. All statistics were tested at the 0.05 significant level.
RESULTS
Table 1 shows the
comparison of the mean demographics across the clinical staging of the disease.
The mean age of patients who had stage IV disease was 41.50±14.96 years,
relatively lower than the mean age of 50.00±0.00 years for stage I disease and
41.88±7.59 years for stage II disease. Similarly, the mean age at menarche of
14.20±1.30 years observed among patients who had stage IV disease, is lower
than the values of 14.50±0.70 years for stage I and 13.40±1.18 years for stage
II disease. Lower age at menopause was observed for stage II disease, while
relatively higher age was seen for II (51.43±3.51 years) and IV disease
(49.50±0.70 years). However, these were not statistically significant (p >
0.05).
DISCUSSION
It is already a known fact in academic research
that correlational studies do not address causality.13-15
However, it highlights association or relatedness of two or more variables of
interest, akin to the saying “show me your friends, and I will tell you who you
are”.16-18 We found an inverse
and rather weak relationship between disease “clinical staging” and the “age of
the patients”. The meaning of this is that the clinical stage of breast cancer tends
to be higher as the age of the patient decreases. Hence any delay in
presentation of breast cancer in a younger patient is likely to result in more
remarkable increase in the stage of the disease than in the older breast cancer
patient. This finding appears to agree with what is already known about breast
cancers that occur in younger patients which tend to be poorly differentiated
and hence exhibit a tendency for rapid transition to advanced stage of disease
within a short time.19 However, our findings differ from that of an Iraqi study where no
correlation was found, and also other similar studies.9, 20, 21 It is rather not surprising in this study, why relatively
younger mean age was associated with relatively advanced disease.
The relationship between disease “clinical staging”
and “age at menarche” was linear with the Pearson correlation coefficient, “r”,
being positive. Although this relationship was weak and has a small percentage
variation, it tends to suggest that the “clinical staging” increases in the
same direction as the “age at menarche”, i.e. the clinical stage will tend
increase as the age of menarche increases. Our finding is similar to the
observations in another study carried out in Lagos Nigeria where a significant
association was found between age at menarche and disease stage.12 We are unable to find a plausible explanation for this observation, as
the opposite observation is rather expected. The finding of lower mean age at
menarche observed among patients who had advanced disease is rather expected,
although the relationship was not statistically significant. Most studies
rather reported the correlation or association between age at menarche and
breast cancer risk, as seen in a
Taiwanese study which found a 6.47‑fold early‑onset increased risk of breast cancer for every
year of menarche younger.22
The disease “clinical staging” increases in
the same direction as the “age at menopause”, implying that patients who have
higher age at menopause are likely to have higher stage of disease. This
implies that breast cancer stage will tend to increase as the patients’ age at
menopause increases, although this relationship is weak and has very small
percentage variation. A Lagos Nigeria study also reported significant
association between age at menopause and the clinical stage of breast cancer.12 Otherwise, studies on this subject mostly dealt with the association
between age at menopause and breast cancer risk, and not stage of breast
cancer.
Study Limitations: The study population is small,
and the correlations between the variables of interest is weak. A larger study
population is need in another study to ascertain the findings of this study.
CONCLUSION
A trend was found in the relationship between
the “clinical staging” of breast cancer and the “age of the patients” in
inverse direction, and between the “clinical staging” and “age at menarche”/ “age at menopause” whose relationship was
linear (in the same direction). Additionally, younger mean age/lower age mean
age at menarche were associated with advanced disease. The percentage variation
in each case was however, small and the relationships were weak.
Recommendation: Occurrence of breast cancer in the younger patient requires more urgency
to ensure early diagnosis and commence proper treatment as the tendency for
rapid progression of disease is higher.
OTHER
INFORMATION
Acknowledgement: The resident doctors in the Breast Unit of the Hospital within the study
period assisted in data collection, and the Management of Eagles Watch Research
Centre analyzed the collected data, for which we are grateful.
Ethical Considerations: The
approval of the Research Ethics Committee of the University of Port Harcourt
was obtained. The personal details of the patients were excluded.
Source of Funding: The study was self-funded by the authors.
Conflict of Interest: None
declared
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