1 f Al Zahraa College of Medicine, Basrah, Iraq

2 Basrah Teaching Hospital, Basrah, Iraq

3 Dept. of Community Medicine, Al Zahraa College of Medicine, University of Basrah, Basrah, IRAQ.


Breast cancer is the most commonly diagnosed cancer among women around the age of menopause. With an advice from WHO, screening programs are encouraged globally for detection of the breast cancer in early stage using mammography imaging technique that is used to understand the breast health and early detection of breast lumps.The study aimed to determine the socio-demographic characteristics of breast cancer screened cases among women aged above 35 years in Basrah with studying the time trend of registered breast cancer cases in Basrah from 2014 to 2020. In addition, it also aimed to detect malignant cases among Breast Imaging Reporting and Data System (BIRADS) 1 & 2 breast cancer screened cases. This is a database descriptive study using mammography medical records of women attended to Basrah Cancer screening Center in Basrah Teaching Hospital. A total of 448 female patients who had histopathological result indicating breast cancer and were classified according to mammogram (BI-RADS) grading methodology in the period 2014-2020. The study found that above 55 years of age multipara women were the highest group affected by breast cancer. Most importantly, malignancy was detected in 20% of breast cancer cases that were categorized as BIRAD 1 & 2.In conclusion, women with BIRAD 1 & 2 should be included in active follow-up examinations to detect any little risk that the lesions are malignant.Key words: Breast Cancer, Basrah, BIRAD, mammography screen


Introduction reast cancer is one of the most in growing health issues that threats female globally and especially in the developing countries because of the poor facilities and low socioeconomic status. Basically the detection of breast cancer relies on the primary healthcare centers and specialized clinics for early detection of breast cancer1,2 . A new research stated that about 1.7 million new cases of breast cancers reported globally each year and 60% deaths of breast cancer or its complications happened in the developing countries3 . These countries depend on their national healthcare system in the screening process and early detection, which are poorly equipped, and need more training and experience4 . The most common risk factors of breast cancer are; nulliparity, using oral contraceptives, hormonal replacement therapy, low physical activity and family history5 . In addition, many studies show no difference in the incidence of breast cancer in rural and urban areas6 . An increased risk of breast cancer in women with a family history of breast cancer has been demonstrated by many studies using a variety of study designs. However, this depends mainly on the type of relative relationship, if more than one BBreast cancer among women in Basrah Hayder H Abdulsamad, Mazin H Al-Hawwaz & Rajaa A Mahmoud Bas J Surg,June, 27, 2021 52 relative were affected, in addition to the age of getting the cancer7 . World Health Organization along with nation cancer control centers advice and encourage the screening program for detection of the breast cancer in early stage using mammography8,9 . The mammogram is an imaging technique used to understand the breast health, although it gives no definitive diagnosis of malignancy, but the radiologist can help by describing the findings for the surgeons that may help in taking the decision for each patient10 . The extension of screening mammography has resulted in a decreased number of patients who dies from breast cancer, because mammography is sensitive for the detection of clinically occult breast cancer11,12 . Mammography is a highly sensitive screening test for breast cancer screening, with a positive predictive value (PPV) of 15%–30% for malignancy detection among non-palpable lesions13,14 . Breast Imaging Reporting And Data System (BIRADS) is commonly used by American College of Radiology14, and most commonly as a numerical scale15: Category 0: indicates an incomplete test (non-conclusive study), Category 1: indicates normal breast tissue , Category 2: benign finding, Category 3: probably benign (carry 2%) risk of malignancy, Category 4: subdivided into; A, carry (2- 9) % risk of malignancy, B, carry (10-49) % risk of malignancy, C, carry (50-95) % risk of malignancy. Category 5: indicates high suspicion of cancer (> 95% risk of malignancy), Category 6: malignancy proved with biopsy, used to compare mammography finding and the respond to treatment (surgical, chemotherapy, radiation). Although BIRADS 1 and 2, both denote an essentially zero chance of malignancy, BIRADS 1 is used in situations where the breast is completely unremarkable, and BIRADS 2 is used when the radiologist wants to remark on a benign finding16-19 . This study aimed to determine the general socio-demographic characteristics of breast cancer screened cases among women above 35 years in Basrah and to detect malignant cases among BIRAD 1 & 2 categorized cases who underwent mammography screening in Basrah during the period 2014-2020. This is a retrospective database descriptive study using mammographic medical records of women attended to Basrah Cancer Screening Center in Basrah Teaching Hospital. The lesions at the screening center are classified according BIRADS grading methodology. Patients and methods A total of 448 female patients who had a histopathological result indicating breast cancer and classified according to mammogram Breast Imaging Reporting And Data System (BI-RADS) grading methodology in Basra from 2014-2020. Inclusion criteria of the study sample: Symptomatic or asymptomatic visiting Basrah Cancer Screening Center, All cases who had FNA and or biopsy taken and proved malignant. Exclusion criteria: Any file missing the mammographic or FNA or histopatholgical report. The patient's medical files at the cancer screening centers that have been used during the study were usually written by radiologists and surgeons that considered as a part from the government program for early detection of breast cancer. Socio-demographic data of patients were sourced from the patient’s medical files. Cases with BIRAD 1 & 2 (which are considered to be normal and benign respectively), were investigated histopathologically for being malignant taking in consideration the patient age, parity and family history of CA breast. Statistical analysis of the data included in the study was done by using SPSS version 20 and Microsoft Excel sheets version 2010. To validate malignancy detection, the following statistical Breast cancer among women in Basrah Hayder H Abdulsamad, Mazin H Al-Hawwaz & Rajaa A Mahmoud Bas J Surg,June, 27, 2021 53 measures were used: Sensitivity and specificity of breast cancer malignancy detection. Positive predictive value (PPV) & Negative predictive value (NPV) of breast cancer malignancy detection among screened cases. The study was approved by the Clinical & Ethical Committee at Basrah Directorate of Health. Study limitations: Pandemic COVID-19 interrupted the study work especially after converting the study location to include only COVID-19’s patients with closure of all other departments, missing information registered in the patient's medical records especially for the variables: education, use of hormone therapy, use of oral contraceptives, age at first pregnancy, age of menarche and breastfeeding history.

1. Agarwal, Gaurav, et al. "Breast cancer care in developing countries." World journal of surgery 33.10 (2009): 2069-2076. 2. Anderson, Benjamin O., and Raimund Jakesz. "Breast cancer issues in developing countries: an overview of the Breast Health Global Initiative." World journal of surgery 32.12 (2008): 2578-2585. 3. Siegel, Rebecca, et al. "Cancer statistics, 2014." CA: a cancer journal for clinicians 64.1 (2014): 9-29. 4. da Costa Vieira RA, Biller G, Uemura G, Ruiz CA, Curado MP. Breast cancer screening in developing countries. Clinics. 2017 Apr; 72(4):244-53. 5. Fioretti F, Tavani A, Bosetti C, La Vecchia C, Negri E, Barbone F, Talamini R, Franceschi S. Risk factors for breast cancer in nulliparous women. British journal of cancer. 1999 Apr; 79(11):1923-8. 6. McPherson, Klim, CaMa Steel, and J. M. Dixon. "Breast cancer—epidemiology, risk factors, and genetics." BMJ 321.7261 (2000): 624-628. 7. Brewer, Hannah R., et al. "Family history and risk of breast cancer: an analysis accounting for family structure." Breast cancer research and treatment 165.1 (2017): 193-200. 8. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA internal medicine. 2014 Mar 1; 174(3):448-54. 9. Orel SG, Mendonca MH, Reynolds C, Schnall MD, Solin LJ, Sullivan DC. MR imaging of ductal carcinoma in situ. Radiology. 1997 Feb; 202(2):413-20. 10. Cardoso F, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rubio IT, Zackrisson S, Senkus E. Early breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2019 Aug 1; 30(8):1194-220. 11. Fracheboud, J., Otto, S., van Dijck, J. et al. Decreased rates of advanced breast cancer due to mammography screening in The Netherlands. Br J Cancer. April 2004; 91, 861–867 (2004). 12. Siu AL. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Annals of internal medicine. 2016 Feb 16; 164(4):279-96. 13. Cao, Haichao, et al. "Multi-Tasking U-shaped Network for benign and malignant classification of breast masses." IEEE Access (2020). 14. Baker JA, Kornguth PJ, Lo JY, Williford ME, Floyd Jr CE. Breast cancer: prediction with artificial neural network based on BIRADS standardized lexicon. Radiology. 1995 Sep; 196(3):817-22. 15. Orel SG, Kay N, Reynolds C et-al. BI-RADS categorization as a predictor of malignancy. Radiology. 1999; 211 (3): 845-5017. 16. Cardeñosa G. Clinical breast imaging: a patient focused teaching file. Lippincott Williams & Wilkins; 2006 Nov 1. 17. Wendie A Berg, MD, PhD, Athina Vourtsis, MD, PhD, Screening Breast Ultrasound Using Handheld or Automated Technique in Women with Dense Breasts, Journal of Breast Imaging, Volume 1, Issue 4, December 2019, Pages 283–296 18. Liberman, Laura, and Jennifer H. Menell. "Breast imaging reporting and data system (BI-RADS)." Radiologic Clinics 40.3 (2002): 409-430. 19. Magny SJ, Shikhman R, Keppke AL. Breast, imaging, reporting and data system (BI RADS). StatPearls Publishing. 2020 Jan. 20. Sharma GN, Dave R, Sanadya J, Sharma P, Sharma KK. Various types and management of breast cancer: an overview. J Adv Pharm Technol Res. 2010; 1(2):109-126. 21. Yip, Cheng‐Har, et al. "Guideline implementation for breast healthcare in low‐and middle‐income countries: early detection resource allocation." Cancer 113.S8 (2008): 2244-225. 22. Rasu RS, Rianon NJ, Shahidullah SM, Faisel AJ, Selwyn BJ. Effect of educational level on knowledge and use of breast cancer screening practices in Bangladeshi women. Health care for women international. 2011 Feb 18; 32(3):177-89. 23. Dey S, Soliman AS, Hablas A, Seifeldein IA, Ismail K, Ramadan M, El-Hamzawy H, Wilson ML, Banerjee M, Boffetta P, Harford J. Urban–rural differences in breast cancer incidence in Egypt (1999–2006). The Breast. 2010 Oct 1; 19(5):417-23. 24. Azzollini J, Fontana L, Manoukian S. Hereditary Breast Cancer: BRCA and Other Susceptibility Genes. InBreast MRI for Highrisk Screening 2020 (pp. 23-41). Springer, Cham. 25. Durham DD, Roberts MC, Khan CP, Abraham LA, Smith RA, Kerlikowske K, Miglioretti DL. Age at initiation of screening mammography by family history of breast cancer in the breast cancer surveillance consortium. Cancer Causes & Control. 2020 Oct 24:1-5. 26. Hsieh CC, Pavia M, Lambe M, Lan SJ, Colditz GA, Ekbom A, Adami HO, Trichopoulos D, Willett WC. Dual effect of parity on breast cancer risk. European journal of Cancer. 1994 Jan 1; 30(7):969-73. 27. Darbre PD. Recorded quadrant incidence of female breast cancer in Great Britain suggests a disproportionate increase in the upper outer quadrant of the breast. Anticancer research. 2005 May 1; 25(3C):2543-50. 28. Esserman LJ, Thompson IM, Reid B, Nelson P, Ransohoff DF, Welch HG, Hwang S, Berry DA, Kinzler KW, Black WC, Bissell M. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. The lancet oncology. 2014 May 1; 15(6):e234-42. 29. Chan HP, Wei J, Sahiner B, Rafferty EA, Wu T, Roubidoux MA, et al. Computer-aided detection system for breast masses on digital tomosynthesis mammograms: preliminary experience. Radiology. 2005 Dec; 237(3):1075–8. 30. Teertstra HJ, Loo CE, van den Bosch MA, van Tinteren H, Rutgers EJ, Muller SH, et al. Breast tomosynthesis in clinical practice: initial results. Eur Radiol. 2010 Jan; 20(1):16–24