|Year : 2019 | Volume
| Issue : 1 | Page : 1-6
An audit of breast lumps detected during cancer screening: A report from Southwest Nigeria
Babatunde Adeteru Ayoade1, Henry O Ebili2, Olubunmi M Fatungase3, Collins C Nwokoro1, Babatunde A Salami1, Adeleke O Adekoya1, Abimbola A Oyelekan1, Bolanle O Adefuye4, Ayodeji A Olatunji5
1 Department of Surgery, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
2 Department of Morbid Anatomy and Histopathology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
3 Department of Anaesthesia, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
4 Department of Medicine, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
5 Department of Radiology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
|Date of Web Publication||15-Oct-2019|
Dr. Babatunde Adeteru Ayoade
Department of Surgery, Olabisi Onabanjo University Teaching Hospital, PMB 2002, Sagamu, Ogun State
Source of Support: None, Conflict of Interest: None
Background: In low-Human Development Index countries, population-based screening programs for breast cancer are virtually nonexistent, but there are occasional screening programs organized by nongovernmental organizations in these countries. This study aims to describe the clinical and histopathological characteristics and the prevalence of breast diseases detected by clinical breast examination (CBE) in a cohort of women who participated in a community-based breast screening program. Methodology: This is a retrospective cross-sectional study of women who were referred for assessment in our Breast Clinic following CBE during a breast cancer screening program. Palpable lesions were subjected to biopsy and histopathological examinations. Results: Of the 2450 women screened, 102 had breast biopsy. Twenty-one were malignant (20.6%) and 79 were benign (77.5%). The mean age for benign breast disease was 32 ± 14 years, whereas that for women with malignant breast lesions was 57 ± 11 years (P < 0.001). Sixty-three women (61.8%) were married, 59 (57.8%) had tertiary education, and 27 (26.5%) were petty traders. The mean lump size was 3.8 ± 3.9 cm for benign lumps and 6.2 ± 4.2 cm for malignant lumps (P = 0.014). Histopathological examination revealed that 20.6% of the lumps were malignant, 50% were benign neoplasm (fibroadenoma,) 17.6% were fibrocystic change and related conditions (fibroadenosis), 5.9% were sclerosing lesions, 2% were inflammatory lesions, 2% were benign proliferative breast disease, and 2% were inadequate sample. Two of the 12 breast lumps (16.6%) were detected for the first time at screening, of which two were malignant. This constitutes 1.9% (2/102) of all the lumps biopsied and 0.081% of all the women who had CBE. Conclusion: This study has demonstrated that CBE as a tool for early detection of breast cancer should be encouraged and applied. It confirms that fibroadenoma is the most common cause of clinically obvious breast lumps.
Keywords: Benign, breast lumps, clinical breast examination, fibroadenoma, malignant
|How to cite this article:|
Ayoade BA, Ebili HO, Fatungase OM, Nwokoro CC, Salami BA, Adekoya AO, Oyelekan AA, Adefuye BO, Olatunji AA. An audit of breast lumps detected during cancer screening: A report from Southwest Nigeria. Arch Med Surg 2019;4:1-6
|How to cite this URL:|
Ayoade BA, Ebili HO, Fatungase OM, Nwokoro CC, Salami BA, Adekoya AO, Oyelekan AA, Adefuye BO, Olatunji AA. An audit of breast lumps detected during cancer screening: A report from Southwest Nigeria. Arch Med Surg [serial online] 2019 [cited 2020 Jul 4];4:1-6. Available from: http://www.archms.org/text.asp?2019/4/1/1/269232
| Introduction|| |
The incidence of breast cancer is increasing in the low-Human Development Index countries (HDI) as is the mortality from the disease. The relative high mortality in those countries compared to what obtains in the high-HDI countries has been attributed to various factors which include late presentation, poor health facilities, poor socioeconomic status, and many sociocultural beliefs.
In high-HDI countries with effective screening programs, early detection and appropriate treatment have been shown to improve breast cancer morbidity and survival. In low-HDI countries, resource limitation due to competition from the highly prevalent communicable diseases makes it very difficult to institute screening programs for breast cancer. Therefore, population-based screening programs for breast cancer are virtually nonexistent. However, there are occasional screening programs organized by nongovernmental organizations (NGOs) in these countries. However, data from these efforts are also few.
Breast cancer screening methods include clinical breast examination (CBE), breast self-examination, ultrasonography, and mammography. Mammography is the gold standard for breast cancer screening in high-HDI countries, but this is out of the reach for patients in low-HDI countries on account of cost of equipment, inadequate personnel, and other competing demands. In recent times, there is increasing advocacy for the use of breast ultrasound as a screening method in low-HDI countries because it is readily available., CBE has been recommended for use in the developing world despite that it has been found not to affect breast cancer mortality in the developed world. CBE is advocated because it is cheap, is easily affordable, and can be easily integrated into primary health-care interventions; hence, it will promote early detection. Therefore, this method was employed by the Uplift Foundation (an NGO founded by the wife of executive of Ogun State Governor, Nigeria), in collaboration with the Medical Women Association of Nigeria (MWAN, an association of female medical doctors), to screen women following which those with breast diseases were referred for further investigation and treatment.
The aims of this study are (1) to describe the clinical and histopathological characteristics and prevalence of breast diseases detected by CBE in a cohort of women who participated in a community-based breast screening program organized by the Uplift Foundation, in collaboration with the MWAN, and (2) to add to the existing data of breast disease prevalence in our population. The secondary aim is to identify differences in the demographic and clinical characteristics of women with benign breast disease and women with malignant disease.
| Methodology|| |
The study was conducted in Olabisi Onabanjo University Teaching Hospital, Sagamu, a tertiary care facility with 290 beds, located midway between the two big cities of Abeokuta and Ijebu Ode in Ogun State, Nigeria. The facility has radiodiagnostic services equipped with computed tomography scan, ultrasonography, mammography machines, digital X-ray machines with facilities for screening, a surgical oncology unit, a well-established histopathology service, and well-equipped hematology and chemical pathology laboratories. The hospital offers diagnostic and therapeutic services for both solid and hematological malignancies.
This is a retrospective cross-sectional study of patients who were referred for further assessment in our Surgical OutPatient Breast Clinic following initial CBE during an early breast cancer detection program in the three senatorial districts of Ogun State, Nigeria, over a 1-month period (October 1–31, 2017). Data on the total number of women screened and total number referred were obtained from the MWAN. The initial CBE was done by members of the MWAN. The referred patients had routine assessment which consisted of history and clinical examination. In addition, those without palpable lumps upon breast examination had breast ultrasound if younger than 40 years, and a combination of ultrasound and mammography if above 40 years old. Breast lesions detected by palpation or ultrasound were subjected to tru-cut needle, excisional or incisional biopsy as indicated followed by histopathological examinations which were done at no cost as the Uplift Foundation bore the cost. The histopathological specimens were examined and then processed as routinely done. The slide sections were examined by three pathologists, and routine histopathology reports were produced. Furthermore, the diagnoses were categorized using a general histopathological breast lesion classification which was modified from Tumours of the Breast  and Breast in Ackerman's Surgical Pathology.
The records of the women were retrieved, and the data on demographic characteristics, (such as age, address, occupation, level of education, and marital status), site, size of lump, duration, clinical diagnosis, and histological diagnosis were extracted. The demographic and clinical characteristics were then examined for statistical association with the histopathological features. The results were analyzed with IBM SPSS software version 20 manufactured by International Business Machines Corporation Armonk, New York, United States of America and presented as descriptive statistics, and Chi-square test was used to assess association. P < 0.05 was considered statistically significant.
| Results|| |
A total of 2450 females were screened by CBE in the three senatorial districts. One hundred and sixty women (6.5%) were referred for further assessment, of which only 124 women (5.0%) reported at the Surgical Outpatient Clinic. Fourteen women were found to be normal after the clinical examination and radiological screening. One hundred and ten women (4.5%) had lesions which were planned for biopsy. However, only 102 (4.1%) women presented and had their biopsy done for histopathological review.
The age range of the women was 13–85 years, with a mean age of 37 ± 15 years. The mean age for women with benign breast disease was 32 ± 14 years, whereas that for women with malignant breast lesions was 57 ± 11 years (difference in the mean age was 25 years, P < 0.001). Fifty-two women (51%) were aged between 21 and 40 years, 63 (61.8%) were married, 59 (57.8%) had tertiary education, and 27 (26.5%) were petty traders. The details of the demographic features are shown in [Table 1].
|Table 1: Demographic and clinical characteristics and nature of breast lumps|
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Forty-eight (47.1%) women were multiparous, the lump was on the left breast in 45.1%, duration of symptoms was 1–3 months in 33.3% of women, and only 11.8% of the women (12/102) had their lumps detected for the first time during the screening and clinical examination. The lump size was <2 cm in 38.2% of women and 2–5 cm in diameter in 39.2% of women. The details of the clinical features are shown in [Table 1]. The symptom duration mean in women was 13 ± 20 months for benign lumps and 10 ± 15 months for malignant lumps (difference in symptom duration mean was 3 months, P = 0.512). The mean lump size was 3.8 ± 3.9 cm for benign lumps and 6.2 ± 4.2 cm for malignant lumps (difference in the mean size was 2.4 cm, P = 0.014).
Histopathological examination showed that 20.6% of the lumps were malignant, 50% were benign neoplasm (fibroadenoma and fibroadenomatoid change), whereas 27.5% were nonneoplastic lesions including inflammatory, cystic, sclerosing, and benign proliferative diseases. Two specimens submitted were inadequate for histopathological assessment of breast disease, and they are yet to have a repeat at the time of this report [Table 2].
Twelve lumps (16.6%) were detected for the first time at screening, of which two were malignant. This constitutes 1.9% (2/102) of all the lumps biopsied and 0.081% of all the women who had CBE.
| Discussion|| |
In the present study, 4.5% of the 2450 women screened had lumps which were planned for biopsy. This rate is similar to the findings in a study in Ghana in which 4.8% of 1419 premenopausal women had palpable breast lumps, and in a study in Lafia, Nigeria, by Ozoilo et al. in which 4.6% of 2095 women had palpable lumps.
In the present study, 22.5% of 160 women who were referred for further assessment did not show up for follow-up. Furthermore, 7.8% of 110 women who were booked for biopsy defaulted. This trend is common in low-HDI countries. For example, a breast cancer-screening trial employing CBE which was conducted in the Philippines was stopped because of poor follow-up attendance for biopsy and treatment despite offers of transportation and home visits. Similarly, in a pioneering effort at breast cancer screening using mammography in Egypt, only half of the 433 women who required further assessment and treatment showed up for follow-up visits. This situation is not peculiar to low-HDI countries, as it was observed in the USA that some women on prepaid insurance refused breast cancer confirmatory tests, the reasons for this being fatalism, denial, and avoidance. Compliance and participation are crucial to the success of a screening program, and many programs are affected by lack of compliance and low participation in which individuals refuse to show up for further intervention required because of fear of what may be found during the screening process.
The mean age, as well as the modal age bracket of the women screened in this study, was similar to those found by other workers., Fifty-one percent of the women were within 20–40 years' age, and this reflects the age structure of the population. As expected, the mean age of women with benign lumps was significantly less than those of women with malignant lumps. Furthermore, we observed that no malignant lump was found in the women who were <20 years of age. This is in keeping with the observation that malignancy tends to occur in older people, as shown previously by Ugwu-Olisa et al. However, the mean age of women with malignant lumps was a decade later than what is usually observed in our population. This may be due to the small sample size of women who eventually had histopathological review.
In our cohort of women, majority of them had tertiary education and were students and skilled professionals such as nurses and teachers. This has been observed in other studies as these groups of people are likely to respond positively to campaign to participate in screening programs. Moreover, the prescreening campaigns took place in the urban and semi-urban areas where most of the women are reasonably well educated. The level of education and occupation are surrogates for socioeconomic status, and they are known to affect the health awareness and attitude to breast screening. It was also observed that majority of the women studied were married (61.8%), of which 23.8% of them had malignant lumps. This observation is likely due to the fact that the age at which breast diseases occur coincides with age at which the women are expected culturally to be married in this environment.
Hormonal factors are involved in the development of breast cancer. In particular, prolonged exposure to estrogens has been implicated in the pathogenesis of breast cancer. Early menarche, late menopause, nulliparity, hormone replacement therapy, and absence of breastfeeding have all been implicated because they all lead to increased exposure of the breast to continuous estrogen stimulation. In our cohort, 18 of 59 women whose parity was above 2 had malignant lump, but only three cases of malignancy were observed in those women with <2 births. This suggests that pregnancy and parturition is not protective. This has been observed by other workers in our population. The possible reasons for this observation include the notion that the breast cancer in our population has different biological characteristics, adoption of Western lifestyle such as alcohol consumption, reduced duration of lactation, and increasing life span. Benign breast lumps are more common in premenopausal women, whereas malignant lumps are more common in postmenopausal women, as observed in this study.
The rationale for breast disease screening is to detect malignancy early and offer adequate treatment because the survival depends largely on the stage of presentation. Screening is defined as detection of a disease before the appearance of symptoms. In this study, 11.8% of lumps (12 of 102 lumps) were detected for the first time during CBE in which the patients were unaware of their presence and completely asymptomatic. Majority of the women were aware of their breast lesion; hence, they took advantage of the opportunity that was presented for free treatment. Most of the women also presented late. (Late presentation is defined as the presence of symptoms for >12 weeks before reaching a service provider.) This trend has been observed in other studies also. There is no statistically significant difference in the duration of symptoms between the benign and malignant lumps.
The lump size is of prognostic importance in breast cancer, as lumps <2 cm in size are associated with better prognosis. In our cohort, 38.2% of the lumps were <2 cm in size, and only four of these were malignant. Furthermore, 77.4% of the lumps were between 2 and 5 cm in size, and ten of these were malignant. The lump size so observed is less than those reported in other studies, which is not associated with early detection program because the patients present late. Overall, the malignant lumps were significantly bigger than the benign lumps because they grow more rapidly over the same period.
Biopsy technique, tissue handling including processing may adversely affect slide reporting, interpretation and consequently histopathological diagnosis. This may necessitate a repeat of the biopsy. Two biopsy specimens which were taken from the lumps with tru-cut needle without ultrasound guidance during the 3-day surgery program and which were <2 cm in size were reported as inadequate samples. This gives a documented failure rate of 1.9%. This is comparable with 2% failure rate observed by Cox et al.
Fibroadenoma is the most common benign breast lump in this study, and this is similar to the report of others,, whereas invasive ductal carcinoma is the most common type of malignant tumor. In all, 20.5% of the lumps and 0.85% of women who had CBE had malignant lumps. This is similar to the findings of Ozoilo et al.
The strength of the study is the demonstration of the usefulness of CBE in our setting. It encourages early detection of potentially life-threatening malignancy. Limitation of this study include the lack of demographic characteristics of the women who were found to be normal after CBE and small sample size, which made generalization of the findings impossible.
| Conclusion|| |
This study has demonstrated that CBE as a tool for early detection of breast cancer should be encouraged and applied. It has also confirmed further that fibroadenoma is the most common benign breast lump and invasive ductal carcinoma is the most common malignant breast lesion, and late presentation of breast lesion is common in our population. We advocate that breast cancer screening should be restricted to women who are 20 years and above.
We express our gratitude to the Uplift Foundation and the MWAN, Ogun State chapter, for supplying the data on the participants at the screening program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.
Nemesure B, Wu SY, Hambleton IR, Leske MC, Hennis AJ. Barbados National Cancer Study Group. Risk factors for breast cancer in a black population – The Barbados national cancer study. Int J Cancer 2009;124:174-9.
Weir HK, Thun MJ, Hankey BF, Ries LA, Howe HL, Wingo PA, et al.
Annual report to the nation on the status of cancer, 1975-2000, featuring the uses of surveillance data for cancer prevention and control. J Natl Cancer Inst 2003;95:1276-99.
Oche MO, Ayodele SO, Umar AS. Breast cancer and mammography: Current knowledge, attitudes and practices of female health workers in a tertiary health institution in Northern Nigeria. Public Health Res 2012;2:114-9.
Omidiji OA, Campbell PC, Irurhe NK, Atalabi OM, Toyobo OO. Breast cancer screening in a resource poor country: Ultrasound versus mammography. Ghana Med J 2017;51:6-12.
Galukande M, Kiguli-Malwadde E. Rethinking breast cancer screening strategies in resource-limited settings. Afr Health Sci 2010;10:89-92.
Bobo JK, Lee NC, Thames SF. Findings from 752,081 clinical breast examinations reported to a national screening program from 1995 through 1998. J Natl Cancer Inst 2000;92:971-6.
Anderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A, et al.
Guideline implementation for breast healthcare in low-income and middle-income countries: Overview of the breast health global initiative global summit 2007. Cancer 2008;113:2221-43.
Ellis IO, Lee AH, Pinder SE, Rakha EA. Tumors of the breast. In: Fletcher CD, editor. Diagnostic Histopathology of Tumors. 4th
ed. Philadelphia: Elsevier Saunders; 2013. p. 1057-145.
Ackerman LV, Rosai J. Breast. Rosai and Ackerman's Surgical Pathology. 11th
ed., Ch. 36. Philadelphia: Elsevier Mosby; 2018. p. 1463-542.
Naku Ghartey Jnr F, Anyanful A, Eliason S, Mohammed Adamu S, Debrah S. Pattern of breast cancer distribution in Ghana: A survey to enhance early detection, diagnosis, and treatment. Int J Breast Cancer 2016;2016:3645308.
Ozoilo KN, Misauno MA, Chukwuogo O, Ozoilo JU, Ojo EO, Yakubu AA. Breast cancer screening in a resource poor setting: A preliminary report. J Med Tropics 2014;16:14-8.
Anderson BO. Understanding social obstacles to early breast cancer detection is critical to improving breast cancer outcome in low- and middle-resource countries. Cancer 2010;116:4436-9.
Salem DS, Kamal RM, Helal MH, Hamed ST, Abdelrazek NA, Said NH, et al.
Women health outreach program; a new experience for all Egyptian women. J Egypt Natl Canc Inst 2008;20:313-22.
Weinmann S, Taplin SH, Gilbert J, Beverly RK, Geiger AM, Yood MU, et al.
Characteristics of women refusing follow-up for tests or symptoms suggestive of breast cancer. J Natl Cancer Inst Monogr 2005;(35):33-8.
Ugwu-Olisa AO, Anyanwu SN, Nwigwe CG, Iyare FE. Clinicopathologic study of breast lumps in Abakaliki, South Eastern Nigeria. Asian J Med Sci 2016;7:58-64.
Sarkar S, Lahiri A, Bandyopadhyay S, Das S, Chakraborty T. Benign and malignant lesions of the breast: Clinic-pathological perspective from a government teaching hospital in West Bengal. India Int Surg J 2018;5:3460-6.
Ayoade BA, Agboola AJ, Olatunji AA, Tade AO, Salami BA, Adekoya AO. Clinical characteristics and survival outcome of breast cancer in Southwest Nigerian women. Afr J Cancer 2014;6:79-84.
Pike MC, Spicer DV, Dahmoush L, Press MF. Estrogens, progestogens, normal breast cell proliferation, and breast cancer risk. Epidemiol Rev 1993;15:17-35.
Adebamowo CA, Adekunle OO. Case-controlled study of the epidemiological risk factors for breast cancer in Nigeria. Br J Surg 1999;86:665-8.
Agboola AJ, Musa AA, Wanangwa N, Abdel-Fatah T, Nolan CC, Ayoade BA, et al.
Molecular characteristics and prognostic features of breast cancer in Nigerian compared with UK women. Breast Cancer Res Treat 2012;135:555-69.
Khumucham R, Devi RB, Devi TS, Singh KA. Cytomorphological study of breast lesions in pre-menopausal and post menopausal women presenting in JNIMS Hospital, Manipur: A retrospective study. J Evolution Med Dent Sci 2016;5:5820-23.
Thomson CS, Forman D. Cancer survival in England and the influence of early diagnosis: What can we learn from recent EUROCARE results? Br J Cancer 2009;101 Suppl 2:S102-9.
Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richards MA. Factors predicting delayed presentation of symptomatic breast cancer: A systematic review. Lancet 1999;353:1127-31.
Michaelson JS, Silverstein M, Wyatt J, Weber G, Moore R, Halpern E, et al.
Predicting the survival of patients with breast carcinoma using tumor size. Cancer 2002;95:713-23.
Jedy-Agba E, McCormack V, Adebamowo C, Dos-Santos-Silva I. Stage at diagnosis of breast cancer in Sub-Saharan Africa: A systematic review and meta-analysis. Lancet Glob Health 2016;4:e923-e935.
Cox CE, Ross M, Salud C. Breast biopsy for benign disease. Opt Tech Gen Surg 2000;2:86-95.
[Table 1], [Table 2]