Profile of Breast Cancer in a Group of Women in a Developing Country in South Asia: Is There a Difference?

Demographic, tumour, and treatment characteristics of female patients with breast cancer in Sri Lanka; results from a hospital-based cancer registry

Background

Although breast cancer is the most common cancer among Sri Lankan women, there is little published data on patient characteristics and treatment in the local context. We aimed to describe disease characteristics and management in a large contemporary cohort of women with breast cancer at the National Cancer Institute of Sri Lanka (NCISL).

Methods

All women with invasive primary breast cancers diagnosed during 2016–2020 were identified from the NCISL breast cancer registry. The NCISL sees approximately 40% of all cancer patients in Sri Lanka. Cancer stage at diagnosis was defined according to the Tumour, Node, and Metastasis (TNM) staging system and the Estrogen (ER) and progesterone (PR) receptor status was determined based on the results of immunohistochemistry tests. Descriptive statistics were used to describe the study cohort and treatment patterns.

Results

Over 5100 patients were diagnosed with breast cancer during the study period at the NCISL. The mean age of the women was 56 (SD 12) years. Common co-morbidities were hypertension (n = 1566, 30%) and diabetes mellitus (n = 1196, 23%). Two thirds (66%) of the cancers were early stage (stage I & II) at diagnosis. ER/PR positivity rate was 72% and HER-2 positivity rate was 22%. Two thirds of the women had undergone mastectomy while 68% had undergone axillary clearance. The rate of chemotherapy delivery was 91% for women with node positive disease while 77% of eligible women (i.e., after wide local excision or with > 3 positive lymph nodes) had received adjuvant radiotherapy. Endocrine therapy was initiated in 88% of eligible women with hormone receptor positive disease while rate of trastuzumab use was 59% among women with HER2 positive breast cancer.

Conclusions

High percentage of advanced breast cancer at diagnosis and high prevalence of comorbidities are some of the major challenges faced in the management of breast cancer in Sri Lanka. Given that stage at diagnosis is the most important prognostic factor determining survival, greater efforts are needed to promote early diagnosis of breast cancer. Considerable lapses in the concordance between guideline recommendations and the delivery of cancer care warrants closer assessment and intervention.

Breast Cancer Survival in Sri Lanka

PURPOSE

In this study, we report survival data of the largest cohort of patients with breast cancer in Sri Lanka.

PATIENTS AND METHODS

All female patients with histologically confirmed breast cancer treated at a single unit at the National Cancer Institute of Sri Lanka between 1994 and 2006 were included in the study. Clinical records were reviewed and data obtained on the following clinical and pathologic factors: age, histology, stage at presentation, grade, and immunohistochemistry profile. Treatment details such as type of surgery and use of systemic chemotherapy, hormonal therapy, trastuzumab, and radiation therapy were also collected. In localized cancer, disease-free survival (DFS) was the primary end point, while in patients who presented with de novo metastases, progression-free survival (PFS) was the primary end point.

RESULTS

A significant proportion of patients presented with de novo metastases (14%) and locally advanced disease (18%). While 57% of patients had hormone-sensitive tumors, human epidermal growth factor receptor 2 overexpression was seen in 14%, and 29% had triple-negative tumors. Only 3% of patients with localized disease were treated with breast-conserving surgery, with the rest undergoing modified radical mastectomy. The 5- year DFS rate was 71.6% (95% CI, 69.2 to 74.0) in patients with localized disease. The median PFS in patients with metastatic disease was 20 months (95% CI, 18 to 22 months), while the median overall survival was 30 months (95% CI, 32 to 35 months). On multivariable analysis, immunohistochemical group and stage were prognostic factors in localized disease, while in patients with metastases, immunohistochemical group and tumor grade were associated with PFS.

CONCLUSION

More effective screening and early detection programs along with increasing breast-conserving surgery will improve breast cancer outcomes in Sri Lanka.

Serum sex hormone levels and hormone receptor status in identifying breast cancer risk in women

Background

The association of sex hormones with receptor status and breast cancer (BC) incidence is studied with inconclusive results. The present work assessed the serum estrogen, progesterone, and testosterone concentrations and estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status of newly diagnosed Sri Lankan BC patients and studied the possibility of risk assessment for BC using these parameters.

Methods

Serum estrogen, progesterone, and testosterone concentrations of newly diagnosed BC patients (n = 155) were assessed and compared with apparently healthy age-matched women (n = 75). Hormone concentrations were assessed with an enzyme immunoassay competition method with fluorescent detection (Biomerieux, France). Hormone receptor statuses were recorded from histopathology reports.

Results

Estrogen and progesterone concentrations were not significantly different according to the menstrual phase of premenopausal BC or healthy women or according to the menopausal status. Testosterone concentration of BC patients was significantly (P = 0.001) lower than in apparently healthy women. Estrogen and progesterone concentrations were not significantly different according to ER and PR status. However, progesterone concentrations of postmenopausal were significantly different (P = 0.021) among HER2 overexpressed women when compared to HER2-negative women. Postmenopausal women with progesterone level below 0.25 ng/mL were more likely to have HER2 overexpressed (P = 0.002).

Conclusions

Serum estrogen and progesterone concentrations of BC patients were not significantly different when compared with apparently healthy women. Women with testosterone level below 0.26 ng/mL demonstrated a higher risk of having BC. Serum progesterone concentrations of BC patients were significantly higher among HER2 overexpressed women compared to HER2-negative women.

Genetic Variants Associated with Clinicopathological Profiles in Sporadic Breast Cancer in Sri Lankan Women

PURPOSE

Several single nucleotide polymorphisms (SNPs) have been reported to be associated with clinicopathological profiles in sporadic breast cancer based on studies conducted on major population groups. The knowledge of the effects of these common genetic variants in South Asian populations remains limited. The present study aimed to investigate the association between a selected set of SNPs and the clinicopathological profiles in sporadic breast cancer in Sri Lankan women.

METHODS

A total of 350 postmenopausal women with histologically confirmed invasive breast cancer were genotyped for 58 SNPs located in 36 breast cancer related genes. The clinicopathological factors that were investigated included age of onset, tumor histologic grade, and lymph node involvement, as well as estrogen receptor (ER), progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status. Association testing was performed using logistic regression models adjusted for confounding factors.

RESULTS

Seven SNPs showed significant associations with clinicopathological profiles in breast cancer. The G allele of BRCA1:rs799917 (p=0.047; β [standard error; SE]=-1.069 [0.537]) and the G allele of NQO2:rs17136117 (p=0.040, β [SE]=1.901 [0.923]) were found to be associated with age of onset between 50 and 59 years. The C allele of CDH1:rs13689 (odds ratio [OR], 2.121; p=0.033) was found to be associated with ER-positive breast cancer. The A allele of AKT1:rs1130214 (OR, 2.095; p=0.011) and the C allele of NQO2:rs2071002 (OR, 1.632; p=0.045) were associated with HER2-positive breast cancer. The C allele of BRCA2:rs15869 (OR, 1.600; p=0.041) and the C allele of CCND1:rs7177 (OR, 1.555; p=0.041) were associated with high tumor histologic grade.

CONCLUSION

The common genetic variants identified in the AKT1, BRCA1, BRCA2, CCND1, CDH1, and NQO2 genes could serve as potential clinical and prognostic biomarkers in sporadic breast cancer patients. Further studies are required to validate our current findings in other populations.

Validity of St Gallen risk categories in prognostication of breast cancer patients in Southern Sri Lanka

Background

Although, there are many developments in the field of management, breast cancer is still the commonest cause of cancer related deaths in women in Sri Lanka. This emphasizes the need for validation of treatment protocols that are used in Sri Lanka for managing breast cancers. There are no published papers on treatment and survival of breast cancer patients in Sri Lanka. Hence this study was designed to determine the validity of St Gallen risk categories based on the survival outcomes of breast cancer patients in Southern Sri Lanka.

Method

This retro-prospective study included all female breast cancer patients who had sought the immunohistochemistry services of our unit from May 2006 to December 2012. Patients who had neo-adjuvant chemotherapy were excluded. Patients were stratified according to the St Gallen risk categories; low-risk (LR), intermediate-risk (IR) and high-risk (HR), which is used in deciding on the adjuvant treatment. IR category was subdivided based on presence/absence of 1–3 positive-nodes (absent-IR1, present-IR2) and HR on the number of positive-nodes(1–3 lymph nodes;HR1,> 3 lymph nodes;HR2). Kaplan-Meier and Cox-regression models were used in the survival analysis.

Results

This study included 713breast cancer patients (LR-2%, IR1–45%, IR2–10%, HR1–13%, HR2–30%). Five year breast cancer specific survival (BCSS)wasLR-100%, IR-91%, HR-66% and the recurrence free survival (RFS) was LR-85%, IR-84%, HR-65%. BCSS and RFS curves were significantly different between the three risk categories (p < 0.001).

No survival difference was evident between the IR1 and IR2 (BCSS-p = 0.232, RFS-p = 0.118). HR1 and HR2 had a distinctly different BCSS (p = 0.033) with no difference in RFS (p = 0.190).

Conclusion

This study validates the St Gallen risk categorization of female breast cancer patients in our setting. However, the HR includes two subsets of patients with a distinct difference in BCSS.

MicroRNAs and Their Impact on Breast Cancer, the Tumor Microenvironment, and Disparities

Breast cancer is a worldwide health issue as it represents the leading cause of cancer in women and the second-leading cause of cancer-related mortality in women, with an increasing incidence. Nothing speaks more clearly to the shocking breast cancer health disparities than the fact that African American (AA) women are as likely to get breast cancer as Caucasian American (CA) women, yet have a higher breast cancer death rate. It is becoming increasingly apparent that racial disparity in cancer exists due to molecular differences in tumor biology as well as, or in addition to, socioeconomic and standard of care issues (Albain, Unger, Crowley, Coltman, & Hershman, 2009). A greater understanding of the risk factors and biological links associated with breast cancer, will significantly impact AA communities due to the higher deaths associated with this disease in this population. microRNAs are small noncoding RNA molecules that were recently discovered as major players in the regulation of many diseases including cancer. Although, there are many studies that have investigated the role of miRNAs in breast cancer, few have investigated their role if any in breast cancer disparities. This review serves to summarize the current published literature that is involved in the study of microRNAs and their impact on breast cancer disparities.

Modulation of expression of heat shock proteins and apoptosis by Flueggea leucopyrus (Willd) decoction in three breast cancer phenotypes

Background

During the past few years, there has been an increasing interest among the Traditional and Folk medical practitioners of Sri Lanka in the use of a decoction prepared from Flueggea leucopyrus (Willd.) for treating various cancers including breast cancer. In the present study, the cytotoxicity of this decoction and its effects on Heat Shock Protein (HSP) expression and apoptosis were compared in three breast cancer phenotypes, to scientifically evaluate if a decoction prepared from F. leucopyrus (Willd.) is useful for the treatment of breast cancer.

Methods

Cytotoxic potential of the F. leucopyrus decoction was determined by evaluating its effects in MCF-7, MDA-MB-231 and SKBR-3 breast cancer cell lines, and MCF-10A (non-cancerous) breast cell line, by use of the Sulphorhodamine (SRB) assay. The effect of the decoction on HSP gene expression in the above cells was evaluated by (a) Real time reverse transcription PCR (RT-PCR) and (b) Immunofluorescence analysis of HSP protein expression. Effects of the decoction on apoptosis were evaluated by (a) fluorescent microscopic examination of apoptosis related morphological changes and (b) DNA fragmentation (c) Caspase 3/7 assay.

Results

F. leucopyrus decoction can mediate significant cytotoxic effects in all three breast cancer cells phenotypes (IC₅₀ values: 27.89, 99.43, 121.43 μg/mL at 24 h post incubation periods, for MCF-7, MDA-MB-231, SKBR-3 respectively) with little effect in the non-cancerous breast cell line MCF-10A (IC₅₀: 570.4 μg/mL). Significant (*P <0.05) inhibitions of HSP 90 and HSP 70 expression were mediated by the decoction in MCF-7 and MDA-MB-231, with little effect in the SKBR-3 cells. Clear apoptotic morphological changes on Acridine orange/Ethidium bromide staining and DNA fragmentation were observed in all three breast cancer cell lines. Caspase 3/7 were significantly (*P <0.05) activated only in MDA-MB-231 and SKBR-3 cells indicating caspase dependent apoptosis in these cells and caspase independent apoptosis in MCF-7 cells.

Conclusions

Modulation of HSP 90 and HSP 70 expressions is a possible mechanism by which the decoction of F. leucopyrus mediates cytotoxic effects MCF-7 and MDA-MB-231 cells. This effect appears to correlate with enhanced apoptosis in these cells. In SKBR-3 cells, mechanisms other than HSP inhibition may be utilized to a greater extent by the decoction to mediate the observed cytotoxic effects. Overall findings suggest that the decoction has the potential to be exploited further for effective treatment of breast cancer.

Clinicopathologic profile of breast cancer patients in Pakistan: ten years data of a local cancer hospital

Breast cancer is the most frequent cancer of women worldwide, with considerable geographic and racial/ethnic variation. Data are generally derived from population based cancer registries in the developed countries but hospital data are the most reliable source in the developing countries. Ten years data from 1st Jan 2000 to 31st Dec 2009 of a cancer hospital in Pakistan were here analyzed by descriptive statistics to evaluate the clinicopathologic profile of local breast cancer patients. Among 28,740 cancer patients, 6,718 were registered as breast cancer. The female to male ratio was 100:2. Breast cancer accounted for 23% of all and 41% of female cancers. Some 46% were residents of Lahore, with a mean age of 47±12 years. Less than 1% were at Stage 0 and 10%, 32%, 35% and 23% were at Stage I, II, III and IV respectively. Histopathology was unknown in 4% while 91%, 2% and 1% had invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC) and mucinous carcinoma respectively. Rare carcinomas accounted for the rest. Tumor grade 1, 2 and 3 was 11%, 55% and 34% among the known. Profile of breast cancer patients in Pakistan follows a pattern similar to that of other developing countries with earlier peak age and advanced disease stage at presentation. The male breast cancer accounts for higher proportion in the local population. Local women have higher frequency of IDC and lower frequency of ILC and DCIS, owing probably to a different risk profile. Use of hospital information systems and establishment of population based cancer registry is required to have accurate and detailed local data. Promotion of breast health awareness and better health care system is required to decrease the burden of advanced disease.

The pathologic characteristics of breast cancer in China and its shift during 1999-2008: a national-wide multicenter cross-sectional image over 10 years

In China, breast cancer is currently the most common malignancy and the sixth leading cause of cancer death in women. But, the characteristics of breast cancer in the whole population are not determined. The aim of this study was to perform a detailed study on pathologic characteristics of breast cancer representing the whole population in China during 1999-2008 and to compare the difference in invasive breast cancer between the Western and Chinese. We randomly collected 4,211 inpatient at seven hospitals in representative geographical regions of China during 1999-2008. All the hospitals had the ability of comprehensive cancer treatment. The pathologic characters including estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status were surveyed. The shift of pathologic characters was evaluated and the data from China were also compared with those of the Western, both using Chi-square test. We found as follow. (i) The median age of the patients was 48 years and showed the similar characters of Asia. (ii) Breast cancer in China showed more invasive ductal carcinoma with larger tumor size, later stage, lower ER and PR expression and higher HER2 overexpression than those in the Western (p < 0.001). (iii) Both tumor size and stage at diagnosis decreased year by year (p < 0.001). Breast cancer in China showed more aggressive behavior than those in western countries, although tumor size and stage at diagnosis decreased by year during 1999-2008. We addressed the urgent needs for employ race-specific breast cancer screen, diagnosis methods, and therapeutic models in China.

Systematic review of breast cancer biology in developing countries (part 2): asian subcontinent and South East Asia

There has been no systematic appraisal of ethnicity-based variations in breast cancer (BC) biology amongst women from developing countries. A qualitative systematic review was conducted of breast cancer size, stage, grade, histological type, extra-mammary involvement, hormone receptor status as well as patient demographics. This review includes patients from Africa, the Middle East, Eastern Europe, Mexico, the Caribbean and South America. BC in these regions present at an earlier age with large aggressive tumours. Distant metastases are frequently present at the time of diagnosis. African women have a higher frequency of triple negative tumours. Over half of Middle Eastern women have lymph node involvement at the time of diagnosis. Despite experiencing a lower incidence compared to the Ashkenazi Jewish population, Palestinian women have poorer five-year survival outcomes. The majority of women from Mexico and South America have stage two or three disease whilst over sixty percent of women from Eastern Europe have either stage one or stage two disease. The biological characteristics of BC in the Caribbean cannot be fully assessed due to a paucity of data from the region. BC amongst the developing world is characterised by an early peak age of onset with aggressive biological characteristics. Strategies that improve breast cancer awareness, address amenable risk factors and improve early detection are essential.