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Risk Factors of Breast Cancer in Kerala, India - A Case Control Study
Abstract
Breast cancer is the most common malignancy among women in Kerala state of India. This study tried to determine the strength of association of known risk factors of Breast Cancer among women in Kerala. An unmatched Case control study was conducted at Regional Cancer Center, Thiruvananthapuram, among 660 newly detected breast cancer patients admitted for surgery during 2003-2004 and 920 controls selected from the hospital and community. Advancing age, delayed first child birth, nulliparity, history of previous breast biopsies and family history of breast cancer among first degree relatives were found to be associated with increased risk of breast cancer. History of breast feeding was found to reduce the risk. This study concludes that age and parity play a major role in the occurrence of breast cancer in Kerala. It also suggests that past history of breast symptoms requiring biopsy is associated with increased risk of breast cancer. Longer duration of breast feeding was found to be protective against breast cancer.
Keywords: Breast biopsy, Breast cancer, Breast cancer risk, Breast feeding, Cancer screening, Crude and adjusted odds ratios, Kerala
... Studies conducted by Balasubramaniam et al and Augustine et.al also found similar prevalence of breast cancer in these age groups. 5,6 This emphasize the need for attention toward the development of breast cancer in Indian women at their younger age. Most of the cases were from rural areas. ...
... Even though there are study reports showed high prevalence of breast cancer among patients from urban area, this difference may be explained through the regional variations in the study sites. 6 A few Indian studies have shown higher prevalence of breast cancer in rural areas. [7][8][9][10][11] Awareness, education, early detection, and screening of breast cancer are less in rural areas. ...
... Study reports from Augustine et al, Kamath et al, and Das et al from various parts of India found high prevalence breast cancer cases among the patients with low socioeconomic status.6,11,16 This difference in observations might be due to the variation of socioeconomic levels of the region selected for the study. ...
Background: Breast cancer is the most common diagnosed cancer in women. Regional assessment of risk factors may help to increase awareness and management of breast cancer. The aim was to evaluate the risk factors of breast cancer among women.Methods: A total of 210 women were included with 42 newly diagnosed breast cancer cases, and 84 women each as hospital and community controls. The data were analyzed using SPSS. Multinomial logistic regression and odd’s ratio was used to find the association of risk factors with breast cancer. The association between the risk factors and breast cancer was analyzed using chi-square test.Results: The most prevalent age-group was 41–50 years. Significant association was observed between breast cancer and area of residence, religion, education, occupation, type of family, socioeconomic status, attainment of menopause, and breastfeeding when compared among cases and community controls (p<0.05). Significant association was observed between breast cancer and education, occupation, socioeconomic status, attainment of menopause, age at first child, breast feeding, and body mass index among cases and hospital controls (p<0.05). The risk of breast cancer was more in illiterates, women who attained menopause, women in joint family, and high socioeconomic class women when compared among cases and hospital controls and community controls.Conclusions: The important risk factors of breast cancer include literacy level, occupation and socioeconomic status, attainment of menopause, and breastfeeding. There is a strong need for general public-awareness policies and programs to reduce the prevalence, risks, morbidity, and mortality.
... Study by Balasubraminum et al., and his group found 3.14 times risk with family history of any cancer [4]. Paul Augustine et al., mentioned around 2 times risk with family history of breast cancer itself [5]. Many other studies from different parts of the world reported significant risk in women with a positive family history [6][7][8][9][10]. ...
... Many studies found significant risk with early menarche out of which two were conducted in the eastern India [2,[12][13][14][15]. Some studies did not observe any significant risk with early menarche [5,11]. Surprisingly one study observed protective effect with early (< 11 years) menarche (OR = 0.321; 95% CI: 0.106-0.971) ...
... Balasubramanium et al., reported around 2 times higher risk with > 25 years age at first childbirth [4]. Study by Paul Augustine et al., also reported 1.85 times risk at 26 -30 years and 2.96 times at ≥ 30 years compared to < 25 years of age [5]. Two others studies also reported odds of 2 for first childbirth at > 21 years and > 30 years of age [3,15]. ...
... In the current study cases with age group of 46-55 years had higher chance than the younger ones. Our finding is consistent with other studies done in India and also among studies done in other parts of world [7][8][9][10] . The reason for the above difference could be due to the various ethnic, socio-demographic, geographical and life style factors that are associated with advancement in the age which needs further exploration. ...
... [11] The important risk factors include nulliparity, advancing age, and family history of breast cancer. [12] In our study, we found that all the breast cancer patients were above 30 years of age, and the prevalence increased in the fifth and sixth decades. In the study, 95% of the women were unaware of performing breast self-examination. ...
... [11] The important risk factors include nulliparity, advancing age, and family history of breast cancer. [12] In our study, we found that all the breast cancer patients were above 30 years of age, and the prevalence increased in the fifth and sixth decades. In the study, 95% of the women were unaware of performing breast self-examination. ...
Background:
The estimated incidence of cancer cases in Kerala for 2014 was 31,400 and the mortality associated with it was 13,816. Although the treatment of cancer has shown remarkable advances, it has come with increasing costs.
Objective:
The objective of this study is to estimate the economic burden of cancer in Vypin Block Panchayat at Ernakulam by analyzing the average total direct and indirect cost of cancer care, socioeconomic status, and cost of cancer care between government and private hospitals.
Materials and methods:
A cross-sectional study was conducted for 2 months from March to April 2018. The study was conducted by utilizing an annotated cost questionnaire for completion by patients. Total direct and indirect cost was estimated. Appropriate statistical tests were used.
Results:
Direct cost for cancer care contributed 75% toward the cost of illness and the remaining was found to be indirect cost. Loss of income (44%) contributed to the largest chunk of indirect cost. The average direct cost for cancer care was found to be Rs. 25,606 and the average indirect cost was Rs. 8772. The average total cost of cancer care was calculated to be Rs. 34,378. Significant statistical variation was found between the cost of cancer care in private and government hospitals. The economic burden of cancer in this Vypin Block Panchayat was found to be Rs. 218,256,977/.
Conclusion:
The ratio of average income to average cost in this study is skewed which indicates the lack of affordability for cancer care in this population. A very large gap, therefore, exits between income levels and cost of cancer care clearly indicating a vast gap between affordability and cost of treatment, which clearly necessitates the need for a definite policy and state intervention for a mass cancer care program.
... A case-control study was conducted at Regional Cancer Center, Thiruvananthapuram, to determine the usefulness of Gail Model Breast Cancer Risk Assessment Tool in identifying women at high risk for breast cancer proved that Gail Model cannot be used to predict highrisk women in Kerala. [22] Numerous mathematical models were also made using these risk factors to predict individual women's risk of developing breast cancer. There is a paucity of data regarding the risk factors in our society. ...
Background: With an estimation of every two women newly diagnosed with breast cancer one dies. It is accounted that 1 in 28 women is likely to develop breast cancer during her lifetime. Developing a risk prediction tool by assessing the prevalence of known risk factors in the community will be a welcoming approach in this regard.
Methods: A cross sectional study conducted among 18- 64 years old women to gather prevalence of breast cancer risk factors. In this multistage random number based cluster sampling study, the results were compiled, collated and analyzed in rates and proportions. Statistical conclusions were converted into ordinal values using modified Likert Scale and median was used to estimate central values. The test of significance was calculated using Crohnbach’s alpha (α).
Results: The analysis of 558 participants were performed for the known risk factors for breast cancer which included reproductive factors, nutritional intake and anthropometry. The estimated prevalence of these known risk factors were re-assorted for analysis and this re-assorted data was categorized into range of values across the communities. The community based risk prediction tool was developed with Crohnbach’s α score of medium internal validity.
Conclusions: A ten item questionnaire based scoring of community risk was developed by modified 5 point Likert scale with known risk factors of breast cancer. The Crohnbach’s alpha value of 45.5 indicated good internal validity. The risk assessment tool has collated most of the risk factors of breast cancer that are capable of being measured at community level.
... A case-control study was conducted at Regional Cancer Center, Thiruvananthapuram, to determine the usefulness of Gail Model Breast Cancer Risk Assessment Tool in identifying women at high risk for breast cancer proved that Gail Model cannot be used to predict highrisk women in Kerala. [22] Numerous mathematical models were also made using these risk factors to predict individual women's risk of developing breast cancer. There is a paucity of data regarding the risk factors in our society. ...
Background: Breast cancer is the second most common cancer in the world and, by far, the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers). The current study aims at assessing risk factors for breast cancer in the community.
Methods: A multistage random number based cluster sampling study was conducted among women in the age group of 20 – 64 years. The estimated sample size was 550 considering the prevalence of risk factors of non-communicable diseases as 15%, and the total sample size was further divided among urban and rural areas with 100 and 450 participants respectively.
Results: The rates for ten known risk factors were assessed for the study. This included age above 40 years (40.3%); women married 30 years or above (3.3%); women with age at menarche 13 years or below (44.1%); women with first childbirth at ≥30 years (4.8%) and women who had menopause at ≥49 years (64.4%); women who had ever conceived, had at least one abortion in the community (18%); average fat consumption in the district (2380Kcal/week); BMI of ≥25 (19.5%); prevalence of breast diseases including both benign and malignant in the community was 3.5% and positive family history of breast cancer was found to be 2.5%.
Conclusions: The risk assessment tool has collated most of the risk factors of breast cancer that are capable of being measured at community level. A risk assessment tool with scoring system can be used for community surveys for risk assessment and the validity of such assessment results may be taken based on the α Crohnbach’s value.
Breast health is extremely important for all women. However, the breast is another region of the human body that is susceptible to cancer. Breast cancer is becoming increasingly common these days, and it is now one of the leading causes of mortality globally. According to the World Health Organization, breast cancer is the most common disease among women worldwide, claiming the lives of hundreds of thousands of women each year and impacting nations at all stages of development. In fact, it is the most common cancer in women, with a significant incidence observed among those aged 30 to 50. The goal of the World Health Organization’s Worldwide Breast Cancer Initiative (GBCI) is to reduce global breast cancer mortality by 2.5 percent each year; As a result, 2.5 million breast cancer deaths will be avoided globally between 2020 and 2040. To achieve these goals, three pillars must be in place: health endorsement for early detection, suitable identification at the right time, and comprehensive breast cancer management. Because of advances in early detection and care, the incidence of women dying of breast cancer has decreased by 41% from 1989 to 2018. During that time, more than 403,000 breast cancer deaths were prevented.
Introduction: Inflammatory cell infiltrate in tumours may be
involved in immunosurveillance or tumourigenesis. Tumour
Infiltrating Lymphocytes (TILs; within the tumour) and peritumoural
lymphocytes (at the invasive margin) are associated with improved
prognosis and response to therapy.
Aim: To estimate the presence of peritumoural lymphocytes
and TILs in breast carcinoma, identify their subsets by
Immunohistochemistry (IHC) and assess the relationship between
them and tumour grade, lymphovascular emboli and axillary
lymph node metastasis.
Materials and Methods: This was a cross-sectional study with
a sample size of 75 done in the Department of Pathology,
Government Medical College, Kozhikode, Kerala, India from
November 2017 to April 2019 with the approval of Institutional
Ethics Committee. The demographic data of the patients were
collected and histopathological assessment of tumour type,
grade, lymphovascular emboli, nodal metastasis and lymphocytic
infiltrate was done on Haematoxylin and Eosin (H&E) stained
sections. Immunohistochemical evaluation was performed using
antibodies against Cluster of Differentiation 4 (CD4) and CD8
and cells were scored separately in the stromal and peritumoural
areas. The results were analysed by Analysis of Variance (ANOVA)
and Chi-square test. Association between the immune infiltrate
and histopathological variables were assessed separately in
stromal and peritumoural compartments. Association between
the score obtained on H&E and subpopulation score obtained on
IHC was also analysed in both the compartments.
Results: Total of 75 subjects were included and the mean
age was 52.31 years with a standard deviation of 9.774 years.
The degree of stromal TIL infiltrate ranged from 10% to 95%,
with a mean of 48.47%. High grade peritumoural infiltrate was
seen in 66.67% (50 out of 75 cases). The stromal TILs were
significantly higher in higher grade tumours and tumours
without nodal metastasis. The peritumoural lymphocytes were
also significantly higher in high grade tumours. The scoring of
the immune infiltrate on H&E sections and subpopulation score
on IHC showed significant association for both stromal and
peritumoural compartments.
Conclusion: Stromal TILs and peritumoural lymphocytes were
significantly higher in high grade tumours. Stromal TILs were
also significantly higher in tumours without axillary lymph node
metastasis. No significant association was found between the
lymphocytic infiltrate and lymphovascular emboli. The immune
infiltrate within breast carcinoma has association with tumour
grade and lymph node metastasis.
A variety of factors including tumor biology and distance of the tumor from the nipple have been associated with nipple areola complex involvement in patients with breast cancer. Preoperative understanding regarding these factors can help in modifying the surgical options including preservation of nipple areola complex (NAC) and breast conservation. Nipple sparing surgery (breast conservation surgery/skin sparing mastectomy with immediate reconstruction) for breast cancer has gained widespread interest with the aim of achieving oncologically safe and cosmetically acceptable outcome. To study the proportion of cases with nipple areola complex involvement in invasive carcinoma breast and to describe the variables predictive of nipple areola complex involvement in patients undergoing excision of tumor along with NAC for invasive carcinoma breast. A cross-sectional study was conducted among 136 patients who underwent mastectomy in Regional Cancer Center, Thiruvananthapuram. Tumor nipple distance was assessed preoperatively using mammogram and postoperatively by histopathological examination. Nipple involvement was seen only among 4.4%. Preoperative assessment of tumor to nipple distance, tumor size, location, and stage of the disease agrees with the histopathological examination. Only a small proportion of breast cancer has NAC involvement and preoperative assessment could help the surgeon in deciding on the feasibility of NAC preservation.
The validation of breast cancer risk models is important, and that by MacInnis et al (2013) of the BOADICEA model, which is based solely on family history, is very welcome. A recent development has been the identification of 67 breast cancer risk SNPs (Michailidou et al, 2013), whose main use will be together as a panel to identify women at increased risk of breast cancer. We investigated how a polygenic SNP score based on these SNPs would compare with classical risk factors including family history, and how much information it might add to risk assessment.
Introduction : Type 2 Diabetes is a lifestyle related disease and a major risk factor for Cardio Vascular Diseases (CVDs). A very limited number of published studies indicate high prevalence of Type 2 Diabetes in the state of Kerala. This study was done in the Neyyattinkara taluk of south Kerala by including
coastal, mid land and high land regions to make it representative of the geographical profile of the state. Objectives : To estimate the prevalence of Type 2 Diabetes and Prediabetes among adults (aged 30 years and above) residing in Neyyattinkara taluk of South Kerala and to identify the diabetes Case Detection Rates across different age groups. Methods: Study Design: Cross-sectional study by including all three geographic regions of Neyyattinkara taluk of Thiruvananthapuram district. Study Period: 9 Months (June 2009- February 2010). Study Subjects: Adults of age 30 years and above, residing in study area. Sample Size: 450. Sampling technique: Multi-stage sampling. Data Collection: by conducting house to house visits and doing interview using a structured questionnaire and blood sugar estimation using Glucometer. Results: Overall prevalence of Type 2 Diabetes was found to be 27.11% (95%CI 23-31.22) of which 18.44% were previously known cases and 8.67% were newly detected. Age standardized prevalence of Diabetes was 20%. Prevalence of Pre Diabetes was found to be 22.67% (95%CI 18.6-26.54). Diabetes Case Detection Rate was found to be 68%. Conclusions: Prevalence of Type 2 Diabetes among adults was found to be very high in the study area in comparison to state, national and global figures. Also, high prevalence of Prediabetes points towards further increase in diabetes prevalence, requiring urgent public health interventions.
Non-communicable diseases (NCDs) have emerged as a major public health challenge in India and more so in Kerala. Realizing this, NRHM conducted a pilot intervention programme in Neyyattinkara Taluk of Thiruvananthapuram district through the existing health system. A process evaluation of the pilot programme can bring out unbiased gaps in the implementation and necessary modification can be suggested.
Aims
To evaluate the NCD control pilot programme.
Methods
qualitative methods – Fifty-five in-depth interviews (IDI) and 8 Focus Group Discussions (FGD) were conducted.
Results
The programme proceeded with an action plan as there was no written programme document. Training was good in terms of clinical aspects; but sensitization regarding the programme was inadequate. The quality of data from the field surveys by Accredited Social Health Activists (ASHA) varied from place to place. The detection camps were overcrowded. Programme was well supported (Funds, Logistics) by NRHM, All patients who were examined by doctors were given medicines for one month and were kept under close follow up by ASHA, and enabled to gain confidence of the community.
Conclusions
The programme could change the attitude of community regarding health care delivery. The study points to the need for pro-activeness in program management and a clear programme guideline to all the supervisors and implementers. People should be made aware of the program services and benefits through social mobilization campaigns. Quality medicines & equipments should be made available for the detection camps. ASHA can play an important role in controlling NCDs at the community level.
Introduction:
The incidence of breast cancer is increasing in developing countries over three decades. Despite good health indicators breast cancer is a public health problem in Kerala with an annual incidence of 14.9/100000 population. Identifying the risk factors helps to reduce the incidence in future.
Method:
A Population based case control study was conducted among all the breast cancer cases in the Arpookara Panchayat of Kottayam district in Kerala. 20 cases of breast cancer were paired with age matched controls from the same geographic area (ratio 1:4) with a total of 100 study participants. Data were collected by interviewing the participants using a pre tested structured questionnaire. Analysis was done by the authors using SPSS version 16.0 RESULTS: Age group of participants ranged from 32-70 years with mean age of 49.7 + 10.39. Early menarche < 13 years [Odds Ratio =3.2, p= 0.03], being unmarried and single, family history of breast cancer [Odds Ratio = 3.5, p = 0.02], previous history of benign breast tumours [Odds Ratio =8.14, p= 0.04], breast feeding less than 2 years [Odds Ratio = 2.28, p = 0.01 ] were found to be the risk factors for the breast cancer and the birth of first child before 30 years [Odds Ratio =0.302, p = 0.03 ] was found to be a protective factor for breast cancer. 60% of cases belonged to lower socioeconomic status [Odds Ratio = 14.47, p = 0.03]. Despite high literacy status, significantly lower awareness about symptoms of breast cancer and self examination of the breast were noted [Odds Ratio =11.6, p= 0.03].
Conclusion:
Awareness about symptoms of breast cancer and self examination of the breast were lacking in the study population. Health care personnel should be trained to spread the awareness of breast cancer in the community and to identify the vulnerable groups at the primary care settings itself. The policy makers can consider encouraging community participation by involving the non-governmental organizations, women self help groups and Public Private Partnerships in spreading the awareness of breast cancer.
Women with a family history of breast cancer are at increased risk of the disease, but no study has been large enough to characterise reliably how, over women's lives, this risk is influenced by particular familial patterns of breast cancer. This report, on the relevance of breast cancer in first-degree relatives, is based on combined data from 52 epidemiological studies.
Risk factors included race and ethnicity, body mass index (BMI), physical activity, alcohol use, smoking, family history of breast cancer, breast density, prior breast procedures, and reproductive factors (age at menarche; parity; age at birth of first child; breastfeeding; oral contraceptive use; menopausal age, status, and type; and menopausal hormone therapy). We included studies meeting the following criteria: studies of risk factors for recent or current status that reflected exposure within 1 year of breast cancer diagnosis; studies of physical activity that reported categories of exercise descriptively (inactive, some, or regular) or quantified by metabolic equivalents; studies of alcohol use and smoking that reported use status (current, former, or never), recency, and amounts of use (drinks per week or packs per day); and studies of oral contraceptive and menopausal hormone therapy use that investigated any formulation (combination, progestin, or estrogen only) and used various definitions of ever and never use. We excluded studies of nonoral forms of contraception and those evaluating formulations not applicable to the target population (8).
We included data from the BCSC to supplement the systematic review because some risk factors were not reported in published studies. The BCSC is a national collaboration of 5 mammography registries and 2 affiliate sites in the United States that prospectively collects data on breast imaging, risk factors, and breast cancer outcomes (23). We analyzed BCSC data collected from 1994 to 2010 for women aged 40 to 49 years at the time of screening mammography. Risk factor data were obtained at the time of each screening mammography and reported in categories similar to those defined by the systematic review. Results for 380 585 women aged 40 to 49 years were provided in proportional hazards models adjusted for age, race, family history of breast cancer, and BMI and stratified by site. We used partly conditional Cox regression (24) to incorporate multiple observations per woman (allowing her to enter the analysis at each eligible screening mammography) and accounted for multiple observations per woman by using the robust sandwich estimator of the SE (25). Women were followed until they were diagnosed with invasive breast cancer; until they were censored at the first occurrence of ductal carcinoma in situ, death, age 50 years, or end of complete cancer follow-up or eligibility for her site; or for 5 years after the examination date. Mean length of follow-up was 3.3 years.
Cancer Medicine is the best known and respected work in the field of
oncology and was the first comprehensive textbook devoted to reporting and assessing
the rapid and continuous development in the diagnosis and treatment of cancer.
Cancer Medicine is widely recognized as a leading reference
resource for medical oncologists, radiation oncologists, internists, surgical
oncologists, and others who treat cancer patients. Cancer Medicine
e.5 continues this high standard while providing updated information in
all areas of oncology - including molecular biology, pathology, imaging
interventional radiology, endoscopy, surgical oncology, radiation oncology, and
medical oncology.
Recent estimates of global cancer incidence and survival were used to update previous figures of limited duration prevalence to the year 2008. The number of patients with cancer diagnosed between 2004 and 2008 who were still alive at the end of 2008 in the adult population is described by world region, country and the human development index. The 5-year global cancer prevalence is estimated to be 28.8 million in 2008. Close to half of the prevalence burden is in areas of very high human development that comprise only one-sixth of the world's population. Breast cancer continues to be the most prevalent cancer in the vast majority of countries globally; cervix cancer is the most prevalent cancer in much of Sub-Saharan Africa and Southern Asia and prostate cancer dominates in North America, Oceania and Northern and Western Europe. Stomach cancer is the most prevalent cancer in Eastern Asia (including China); oral cancer ranks as the most prevalent cancer in Indian men and Kaposi sarcoma has the highest 5-year prevalence among men in 11 countries in Sub-Saharan Africa. The methods used to estimate point prevalence appears to give reasonable results at the global level. The figures highlight the need for long-term care targeted at managing patients with certain very frequently diagnosed cancer forms. To be of greater relevance to cancer planning, the estimation of other time-based measures of global prevalence is warranted.
Breast cancer is the most common female malignant disease in the western countries where a woman's lifetime risk of developing the disease is more than 10%. Nulliparity or use of hormonal replacement therapy, strong family history, or a history of therapeutic thoracic radiation are considerable high risk factors for the development of breast cancer. Nowadays more new effective therapeutic agents have been developed for the intervention of the breast cancer, but prognosis is still remained poor in the metastatic disease. For the general population, screening mammography in women older than 40-45 years has been shown to be effective in identifying early-stage breast cancer and in decreasing the mortality rate. In randomized screening mammography trials for breast cancer, it has been established that screening mammograms reduced breast cancer mortality in women older than 50 years of age by 25 to 30%. This review article summarizes the risk factors for developing breast cancer, methods for risk assessment and the accepted screening guidelines.