Breast cancer among women in Basra, Iraq: A descriptive study in BIRAD 1 & 2 screened cases

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 20142020. 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.


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 cancer 1,2 .
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 countries 3 . These countries depend on their national healthcare system in the screening process and early detection, which are poorly equipped, and need more training and experience 4 . The most common risk factors of breast cancer are; nulliparity, using oral contraceptives, hormonal replacement therapy, low physical activity and family history 5 . In addition, many studies show no difference in the incidence of breast cancer in rural and urban areas 6 . 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 B relative were affected, in addition to the age of getting the cancer 7 . 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 mammography 8,9 . 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 patient 10 . 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 cancer 11,12 . 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 lesions 13,14 .
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 finding [16][17][18][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  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.

Results
The time trend distribution of the total number of breast cancer cases registered from 2014-2020 is shown in figure 1. The study results show a sharp decrease in the total number of the registered cases for the period between 2018 and 2020. In relation to age groups, table I shows that majority of the sampled population (80.4%) were above the age of 50 years. Above 55 years of age was also found by the study to be the highest group affected by breast cancer during the whole period from 2014-2020, while the age group of 35-40 years showed the least percentage of breast cancer cases ( fig.2).  In addition, being a housewife was the mostly registered cases among women with breast cancer as shown in figure 3.

Figure 3: Time trend distribution of study population according to occupation(%).
According to address of residence,   figure 4, which shows a 100% registration of the total cancer cases to be in 2020 in Basrah City Center with no case registered for the other places in the Governorate.    Table III shows that 54.7% of the total sampled population reported a positive family history of the disease. In regard to the family history & its time trend during the period 2014-2020, the results shows a fluctuated rates with a steady increase in the percentage of the disease occurrence for the period from 2017-2020 ( Figure 6).  According to parity, the study shows that the majority of the total registered breast cancer cases (84.6%) were multipara (Table IV) with a clear difference in the occurrence of the disease between nullipara and multipara with more percentage on the side of multiparity during the whole period between 2014-2020 ( Figure 7) and a highest percentage of the disease occurrence in 2020 (100%).

Discussion
Breast cancer is considered to be among the top of the most common cancers especially among women with an increasing trend to become a big burden on the health status of both developed & developing countries 20 . The early detection of the breast cancer through screening is increasing around the world, this increment because of the improvement in early detection and screening programs as well as the rising of educational level 21 . In our study we found a decrease in the total number of the registered cases in the time between 2018 and 2020, this might explained by increase in the number of private breast clinics in the governorate within the hospitals or the primary health centers, Regarding the year 2019-2020 the attendance to the screening clinic declining might be due to the Pandemic of COVID-19 which makes people aware about the attendance to hospitals and primary health centers to avoid get infection with SARS COV 2 virus, adding to that the public curfew. Educational level affect the detection of breast cancer, that those female aware about self-breast examination and attendance to health facility when they suspect breast health problem 22 , our study found that the most affected female are housewives which is not reflect the educational level of those females, because the education is not included in the patient files.
According to the residency, shows that Basrah city center is the main area with the highest percentage of the registered cases during the period 2014-2020. This is because the early detection clinics located in the center of the city. A study held in Egypt showing that the recorded cases from the city centers higher than that in the periphery residences 23 . In 2020, the time trend of the total cases in Basrah city center could be explained by the pandemic of COVID-19 and curfew that makes the attendance difficult for the people lives in the peripheries. Many studies all over the world proved a positive relation between breast cancer and family history which might be affected by age of the affected relative [24][25][26] . This is similar to what was found by the present study. Regarding tumor location, it's known that the upper lateral quadrant is more affected by breast cancer 27 . Screening for breast cancer with mammography aims at detecting breast cancer at an early and curable stage 28 . In our study, it was proved that mammography result was not 100% conclusive for malignancy detection & this might be explained by the fact that it's an operator dependent procedure in addition to being exposed to artifacts. On the other hand, in our study, cases with BIRADS 1 and 2 found to be malignant, which is opposite to what expected according to BIRADS in many of cases included in this study. A study attribute such results to the sensitivity of mammography in dense breast tissue can be limited due to the presence of overlapping fibroglandular tissue that reduces visibility of abnormalities 29 . The pattern of tumor growth is considered as another factor that affecting the BIRADS adequacy, some tumors not produce mass on growth which make it difficult to be detected by mammography 30 . Conclusion: We conclude that the women with BIRAD 1 & 2 should be included in an active follow-up examinations to detect any possibility of malignancy.