Increasing prevalence of breast cancer among Saudi patients attending a tertiary referral hospital: a retrospective epidemiologic study.
ABSTRACT To determine the pattern of breast diseases among Saudi patients who underwent breast biopsy, with special emphasis on breast carcinoma.
A retrospective review was made of all breast biopsy reports of a mass or lump from male and female patients seen between January 2001 and December 2010 at the King Khalid University Hospital, Riyadh, Saudi Arabia.
Of 1035 breast tissues reviewed, 939 specimens (90.7%) were from female patients. There were 690 benign (65.8%) and 345 (34.2%) malignant cases. In women, 603 (64.2%) specimens were benign and 336 (35.8%) were malignant. In men, 87 specimens (90.6%) were benign and 9 (9.4%) were malignant. All malignant cases from male patients belonged to invasive ductal carcinoma and the majority of malignant cases from female patients belonged to invasive/infiltrating ductal carcinoma. The proportion of malignancy was 18% in patients younger than 40 years and 63.2% in patients older than 60 years. The mean age of onset for malignancy was 48.6 years. The annual percentage incidence of malignant breast cancer steadily increased by 4.8%, from an annual rate of 23.5% in 2000 to 47.2% in 2007.
Among Saudi patients, there is a significant increase in the incidence of breast cancer, which occurs at an earlier age than in western countries. Continued vigilance, mammographic screening, and patient education are needed to establish early diagnosis and perform optimal treatment.
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ABSTRACT: Breast cancer is the most common cancer among Malaysian women. Nonetheless, in Malaysia there is a marked geographical difference in the incidence of breast cancer with advanced stage of presentation. The breast clinic in Kuala Lumpur Hospital diagnosed approximately 150 to 200 new cases of breast cancer a year. This number, however, represents only 12.0% to 15.0% of all breast disease seen annually in Kuala Lumpur Hospital. Between 1998 and 2001, of a total of 774 cases of newly diagnosed breast cancer in Kuala Lumpur Hospital, only 5.0% (40/774) were impalpable breast cancers. The peak age group for the three major ethnic distributions (Malay, Chinese, and Indian) ranged from 40 to 49 years. The mean tumor size at presentation was 5.4 cm (range: 1-20 cm), and the advanced stage of breast cancer is observed to be highest among the Malay ethnic group. Although it appears that the incidence of breast cancer in Malaysia is lower than in the developed countries, the difference may be attributable to the difficulty in getting accurate statistics and to underreporting of cases. Nonetheless, from the available data, it is clear that breast cancer continues to be the most common cancer among Malaysian women. The strongly negative social-cultural perception of the disease, made worse by the geographical isolation of many rural areas, accounts for the delayed diagnosis and the often advanced stage of disease at presentation. A prospective population-based study is called for to verify the demographic patterns of breast cancer, particular in Malaysia and other developing countries. The findings of such a study may have implications for future breast screening programs and for facilitating the understanding of differing risks of breast cancer among women around the world.World Journal of Surgery 09/2003; 27(8):921-3. · 2.23 Impact Factor
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ABSTRACT: Fibroadenomas are benign breast tumors that are commonly diagnosed in young women and are associated with a slight increase in the risk of breast cancer. These lesions vary considerably in their histologic characteristics. We assessed the correlation between the histologic features of fibroadenomas and the risk of subsequent breast cancer. We conducted a retrospective cohort study of a consecutive series of patients with fibroadenoma diagnosed between 1950 and 1968. Follow-up data were obtained for 1835 patients (90 percent of those eligible). Fibroadenomas with cysts, sclerosing adenosis, epithelial calcifications, or papillary apocrine changes were classified as complex. The rate of subsequent breast cancer among the patients was compared with the rates in two control groups, women listed in the Connecticut Tumor Registry and women chosen from among the patients' sisters-in-law. The risk of invasive breast cancer was 2.17 times higher among the patients with fibroadenoma than among the controls (95 percent confidence interval, 1.5 to 3.2). The relative risk increased to 3.10 among patients with complex fibroadenomas (95 percent confidence interval, 1.9 to 5.1) and remained elevated for decades after diagnosis. Patients with benign proliferative disease in the parenchyma adjacent to the fibroadenoma had a relative risk of 3.88 (95 percent confidence interval, 2.1 to 7.3). Patients with a family history of breast cancer in whom complex fibroadenoma was diagnosed had a relative risk of 3.72, as compared with controls with a family history (95 percent confidence interval, 1.4 to 10). Two thirds of the patients had noncomplex fibroadenomas and no family history of breast cancer and did not have an increased risk. Fibroadenoma is a long-term risk factor for breast cancer. The risk is increased in women with complex fibroadenomas, proliferative disease, or a family history of breast cancer.New England Journal of Medicine 08/1994; 331(1):10-5. · 51.66 Impact Factor
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ABSTRACT: Each year thousands of women present to general surgeons with palpable breast masses, some of which are clinically ambiguous and the majority of which are benign. In addition, surgeons are frequently faced with the question of whether to biopsy those palpable abnormalities in the setting of normal radiographic studies. One might propose that such lesions could be safely observed rather than immediately biopsied. If these lesions were not biopsied, how many cancers would escape detection? To address this issue, a population of patients with known, palpable breast cancer was retrospectively examined to determine the frequency of normal or benign findings on both mammography and ultrasonography. Between January 1998 and December 2001, 351 women with breast carcinoma presented initially with palpable tumors. The medical records of these remaining 351 cases were retrospectively reviewed to examine the radiographic characteristics of the palpable carcinomas. Of the 351 cases in the study group, 13 (3.7%) patients with palpable breast cancers had mammogram and sonogram examinations that were both normal, benign, or nonspecific in appearance. The results of this study indicate that nearly 4% of women with breast cancer who present with palpable lumps will have normal or benign findings on both mammography and ultrasonography. These data support prior studies of similar false negative rates and may provide some reassurance to surgeons and patients regarding clinical breast lumps, as the decision of whether to biopsy still rests in the surgeon's hands. However, inappropriate reliance on these tests for an evaluation of a palpable abnormality will result in a number of missed tumors.The American Journal of Surgery 06/2003; 185(5):416-9. · 2.52 Impact Factor
Aim To determine the pattern of breast diseases among
Saudi patients who underwent breast biopsy, with special
emphasis on breast carcinoma.
Methods A retrospective review was made of all breast bi-
opsy reports of a mass or lump from male and female pa-
tients seen between January 2001 and December 2010 at
the King Khalid University Hospital, Riyadh, Saudi Arabia.
Results Of 1035 breast tissues reviewed, 939 specimens
(90.7%) were from female patients. There were 690 benign
(65.8%) and 345 (34.2%) malignant cases. In women, 603
(64.2%) specimens were benign and 336 (35.8%) were ma-
lignant. In men, 87 specimens (90.6%) were benign and 9
(9.4%) were malignant. All malignant cases from male pa-
tients belonged to invasive ductal carcinoma and the ma-
jority of malignant cases from female patients belonged
to invasive/infiltrating ductal carcinoma. The proportion
of malignancy was 18% in patients younger than 40 years
and 63.2% in patients older than 60 years. The mean age
of onset for malignancy was 48.6 years. The annual per-
centage incidence of malignant breast cancer steadily in-
creased by 4.8%, from an annual rate of 23.5% in 2000 to
47.2% in 2007.
Conclusion Among Saudi patients, there is a significant
increase in the incidence of breast cancer, which occurs at
an earlier age than in western countries. Continued vigi-
lance, mammographic screening, and patient education
are needed to establish early diagnosis and perform op-
Ammar Al-Rikabi, Sufia
Department of Pathology, College
of Medicine, King Saud University,
Riyadh, Saudi Arabia
Received: August 1, 2011
Accepted: March 30, 2012
Ammar Cherkess Al-Rikabi
Department of Pathology
King Saud University, Faculty of
Medicine and King Khalid University
P.O. Box 2925
Kingdom of Saudi Arabia
Increasing prevalence of breast
cancer among Saudi patients
attending a tertiary referral
hospital: a retrospective
Croat Med J. 2012;53:239-43
Increased awareness and efficient breast cancer informa-
tion-dissemination campaign led to an increased num-
ber of diagnosed cases of breast cancer. According to
the American Cancer Society, about 1.3 million Ameri-
can women annually are diagnosed with breast cancer
and about 465 000 die from the disease (1). The number
of deaths has decreased since 1990, probably due to an
earlier detection and advances in treatment. According to
2000-2004 Saudi National Cancer Registry data, there were
127.8 per 100 000 women with breast cancer and mortality
rate was 25.5 per 100 000 (2).
Most palpable breast masses are benign; less than 30% of
women with palpable masses have a diagnosis of cancer
(3-5). Approximately 4% of breast cancers present with
a palpable mass without mammographic or ultrasono-
graphic evidence of the disease (6). Therefore, evaluation
of a breast mass should be done by taking into consider-
ation patient’s history, physical examination, imaging, and
biopsy. Definitive diagnosis in nearly all cases is established
by needle biopsy. Because of the low specificity of mam-
mography, many women undergo unnecessary breast
biopsy. As many as 65%-85% of breast biopsies are per-
formed on benign lesions (7), which subjects the patients
to avoidable emotional and physical burden.
Similarly to other countries, breast cancer in Saudi Arabia is
the most common cancer in women (7). The Saudi Nation-
al Cancer Registry reported a rising proportion of breast
cancer among women of all ages, from 10.2% in 2000 to
24.3% in 2005 (8). A significant majority of these breast
cancers (almost 80%) were of the infiltrating ductal type.
The average age at presentation of breast cancer in Arab
countries is 48 years, which is a decade earlier than in west-
ern countries (9). The median age of onset of breast cancer
among Saudi women is 46 years (8). Due to the increasing
incidence, several articles have been published on screen-
ing for breast cancer and on public awareness programs
initiated by the Saudi Arabian government and non-gov-
ernmental sectors (10-13). This study aims to describe the
epidemiological characteristics of breast mass lesions of
patients examined at the King Khalid University Hospital,
Riyadh, Saudi Arabia from 2001 to 2010.
MAteRiAlS And MetHodS
This retrospective study included histopathological re-
ports of all patients (including male patients) who had
undergone biopsy of breast masses or lesions between
January 2001 and December 2010 at the King Khalid
University Hospital, which is a large (1000 beds) tertiary re-
ferral hospital with a large patients catchment area cover-
ing the northern part of Riyadh. Data were extracted from
the hospital computer database and entered into an Excel
sheet. Demographic data included age at diagnosis and
sex. Histomorphological features were classified as benign
or malignant based on the 2003 World Health Organiza-
tion classification of tumors of the breast (14). Data were
analyzed using Predictive Analytical Software, version 18
(IBM, SPSS Inc., Chicago, IL, USA) and expressed as mean,
standard deviation, and percentages. Validation was per-
formed by random re-examination by the two authors of
15% of the histopathology slides representing the various
A total of 1035 breast tissue specimens were examined
between January 2001 and December 2010 at the Pathol-
ogy Department of the King Khalid University Hospital.
There were 939 specimens (90.7%) from female and 96
(9.3%) from male patients. Histopathology revealed 681
(65.8%) benign and 354 (34.2%) malignant cases. The av-
erage age at diagnosis of all patients with malignancy was
48.6 ± 11.6 years.
Among men, benign breast lesions mostly occurred in
patients younger than 40 years, while malignant lesions
occurred in patients aged 40 and older (Table 1). Among
women, benign breast lesions also mostly occurred in pa-
tients younger than 40 years and the majority of those
cases (more than 50%) were fibroadenomas. The medi-
an age of onset of breast cancer in our population was
48.0 years (range, 20-91 years). However, the proportion of
malignancy progressively increased from 18% in the age
group 20-39 years to 53.3% in the age group 40-59 years,
tAble 1. breast lesions detected in male patients with age
Age groups in years, n (%)
benign (n = 87):
Malignant (n = 9):
18 (90.0) 53 (88.3) 5 (50)
1 (5.0) 3 (5)
1 (5.0) 4 (6.7)
1 (16.7) 1 (1.0)
--4 (40) 5 (83.3) 9 (9.4)
Al Rikabi and Husain: Breast lesions among Saudi patients
and as much as 63.2% of patients were more than 60 years
old (Table 2).
The yearly percentage incidence of malignant breast neo-
plasms (in terms of percentage distribution) showed a
steady rise over the years, as compared to benign breast
lesions. In 2000, 76.5% of the tissues submitted for histo-
pathology were benign and only 23.5% were malignant.
From 2000 to 2007, there was a steady rise by a mean of
4.8% in the annual incidence of malignant breast lesions,
with the exception of 2003, when there was a slight de-
crease. The annual rate of a malignant breast lesions con-
firmed by histopathological examination ranged from
23.5% in 2000 to 47.2% in 2007. In contrast, after 2007,
there was a shift of the trend toward more benign cases
(Figure 1). There was, however, an overall increase in the
percentage of people diagnosed with breast cancer from
23.5% in 2000 to 34.5% in 2010.
In this study, the majority of breast lesions sent for histo-
pathology were fibroadenomas, constituting 423 of 1035
(40.9%) breast specimens received in our laboratory. This
finding is similar to other reports (1,2). Such patients were
predominantly young, with age range from 18 to 78 years
in women. Although fibroadenomas are not cancerous or
life-threatening lesions they can still be a source of signifi-
cant anxiety and concern to the patient.
Our study found a malignancy rate of 33.3% (ie, 345 out
of 1035 cases were malignant). It is a high rate, compared
to the rate reported in the literature that was lower than
30% (3-5). Furthermore, our incidence rate was significant-
ly higher than the incidence rate of 24.3% reported by the
Saudi National Cancer Registry in 2005 (8). This difference
may be explained by an increase in the use of mammog-
raphy, effectiveness of breast cancer awareness program
tAble 2. breast lesions seen in female breasts with age distribution
Age groups in years, n (%)
<2020-3940-5960 and abovetotal
benign (n = 603):
epidermal inclusion cyst
benign phyllodes tumor
Malignant (n = 336):
invasive ductal carcinoma
malignant phyllodes tumor
medullary breast cancer
mucinous colloid carcinoma
FiguRe 1. Annual percentage and distribution of benign vs
malignant cases of breast lesions over a period of ten years.
Rhomb – benign; square – malignant.
Croat Med J. 2012;53:239-43
that has been initiated by the government, the effective
campaign organized by various health authorities in order
to educate the public on early detection of breast cancer
through self breast examination, or sample bias (10-13). In
our study, infiltrating/invasive ductal carcinoma was the
most common malignant type of breast cancer (96.2%),
with a slightly higher rate than that reported by the Saudi
National Cancer Registry (8). Patients diagnosed with breast
cancer were in the age groups ranging from 28 to 78 years;
however most of the women were in the age group 40-59
years (97.3%) (8). The age of onset of breast cancer in our
patients was similar to that previously reported (9) but was
slightly higher than that reported by the Saudi National
Cancer Registry (8).
Although our findings did not substantially differ from
those in previous studies in terms of the age of presen-
tation of breast cancer, histopathological types, or even
the ratio of benign to malignant cases, we believe that it
is necessary to point out the steady rise in the incidence of
breast cancer since 2000, with a mean annual increase of
4.8%. This rate is higher than the reported annual increase
in the proportion of breast cancer of 2% in the UK (15) and
higher than the annual average increase of 0.4% in the
USA (16). This trend can be explained either by an effec-
tive awareness program and efficient patient education on
breast self-examination or by sample bias as our patients
came from only one referral center. It is also important to
emphasize that breast cancer remains the leading cause of
death among the Saudi women.
Furthermore, we noticed a changing pattern in the pro-
portion of breast cancer cases in the last 3 years (2007 to
2010). Before 2007, most of the breast specimens were be-
nign cases, with an increasing annual incidence of malig-
nant cases. However, after 2007, the trend shifted toward
benign cases. In our opinion, this is a reflection of an ef-
fective campaign of breast diseases awareness programs.
Nevertheless, this trend should not be a reason for com-
placency, since some of these benign cases, though not
cancerous, may indicate an increased risk toward the de-
velopment of pre-malignant conditions such as fibroad-
enomas (17). Another point of paramount importance,
highlighted in this and other studies (9,15), is that among
Saudi patients breast carcinoma occurs in relatively
younger age groups than is the case in Western patients.
This could be due to the demography of the Saudi pop-
ulation, which is characterized by a predominance of a
younger population (more than 60% of the population
is under 18 years) (8).
An important limitation of this study is its retrospective na-
ture and, although our study covered a large catchment
area, all the data were from one tertiary referral hospital,
which is why they might not be representative of the entire
country. There is a need for a larger study involving various
medical centers that would also examine other environ-
mental, genetic, and dietary factors that may contribute to
the incidence of breast diseases in this part of the world.
Acknowledgment The authors would like thank Miss Roxanne Alamares for
her excellent secretarial help and computer skills during the typing of this
ethical approval Not required.
declaration of authorship AA-R is the owner of the original idea and par-
ticipated in the discussion. SH participated in the discussion.
competing interests All authors have completed the Unified Competing
Interest form at www.icmje.org/coi_disclosure.pdf (available on request
from the corresponding author) and declare: no support from any organi-
zation for the submitted work; no financial relationships with any organiza-
tions that might have an interest in the submitted work in the previous 3
years; no other relationships or activities that could appear to have influ-
enced the submitted work.
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