Breast cancer in relation to gynecological risk factors among women in Southeast Nigeria

Uzoamaka Rufina Ebubedike; Brenda Chijioke I. Nwammuo; Eric Okechukwu Umeh; Chinekwu Skye Nwosu; Kelechi Collins Elendu; Chijioke Chukwuemeka Umeokafor

doi:10.4103/jrmt.jrmt_3_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 3 | Issue : 2 | Page : 57-62

Breast cancer in relation to gynecological risk factors among women in Southeast Nigeria

Uzoamaka Rufina Ebubedike, Brenda Chijioke I. Nwammuo, Eric Okechukwu Umeh, Chinekwu Skye Nwosu, Kelechi Collins Elendu, Chijioke Chukwuemeka Umeokafor
Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria

Date of Submission	22-Feb-2022
Date of Decision	14-Apr-2022
Date of Acceptance	21-Jun-2022
Date of Web Publication	17-Dec-2022

Correspondence Address:
Uzoamaka Rufina Ebubedike
Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrmt.jrmt_3_22

Abstract

Background: Breast cancer is a highly heterogeneous disease that is developed by mutual impact of genetic risk factors and environmental factors. Identification of these factors may enhance the ability to prevent the disease by permitting better-focused health education and other preventive strategies. Objectives: The objective of the study is to determine the association between breast cancer and gynecological risk factors. Methodology: One hundred and twenty consenting females who were referred from the Surgical Outpatient Department and underwent mammography in the Radiology Department of Nnamdi Azikiwe University Teaching Hospital, Nnewi, from 2018 to 2020. Women who were 40 years and above as well as those below 40 years with positive family history of breast cancer presenting with palpable breast mass were included in the study. Results: The mean age was 47.36 ± 10.67 years and the most frequent age range was 41–50 years while the least frequency fell in the above 70 years of age group. Women with age of menarche at 11–13 years had higher association with breast cancer than those whose menarche occurred at later age. Those who attained menopause at a later age had higher association with breast cancer. Women whose age at first confinement was 25 years or less had higher association too. Further, higher incidence of breast cancer was recorded in women with parity >3. Conclusion: No significant statistical difference was found between these gynecological risk factors as well as body mass index and breast cancer.

Keywords: Age at first confinement, breast cancer, body mass index parity, menarche, menopause

How to cite this article:
Ebubedike UR, I. Nwammuo BC, Umeh EO, Nwosu CS, Elendu KC, Umeokafor CC. Breast cancer in relation to gynecological risk factors among women in Southeast Nigeria. J Radiat Med Trop 2022;3:57-62

How to cite this URL:
Ebubedike UR, I. Nwammuo BC, Umeh EO, Nwosu CS, Elendu KC, Umeokafor CC. Breast cancer in relation to gynecological risk factors among women in Southeast Nigeria. J Radiat Med Trop [serial online] 2022 [cited 2023 Jun 3];3:57-62. Available from: http://www.jrmt.org/text.asp?2022/3/2/57/364178

Introduction

Breast cancer is the most common malignancy in women with over one million new cases reported globally annually. It accounts for up to 18% of all female cancers.^[1] The prevalence of breast cancer in Nigeria was 116/100,000, and 27,840 new cases were expected to develop in 1999.^[2] Agbo et al. reported a prevalence rate of breast cancer to be 10.4 cases/100,000.^[3] The incidence rate of breast cancer in Nigeria has steadily increased from 15.3/100,000 in 1976 to 33.6/100,000 in 1992.^[4] Reasons for increased incidence could be due to increased reporting and improved diagnosis. There is also a trend toward westernization in developing countries with the change in demographic profile and lifestyle, as well as the change in socioeconomic profile of the country.

The etiology of breast cancer is not fully understood.^[1] A variety of interrelated factors, such as genetics, hormones, environment, sociobiology, and physiology among others can influence breast cancer development.^[5] Breast cancer is a highly heterogeneous disease that is developed by mutual impact of genetic risk factors and environmental factors. Although epidermiological evidence highlights the presence of risk factors (such as age, obesity, alcohol use and exposure to estrogens in lifetime, and family history of breast cancer), gynecological factors also play a significant role.^[6]

In Nigeria, breast cancer is associated with high morbidity and mortality rates, and this is greatly attributed to late presentation.^[7] Early diagnosis has been proven to reduce mortality and improve survival.^[8],[9],[10] However, breast cancer remains one of the most preventable and manageable cancers.

With improved understanding of the etiology and predisposing risk factors, the management of breast cancer may be better addressed. Because the risk of breast cancer development varies in different races and population due to a lot of factors, there is need for each race or population to define the characteristics of the disease among its people and devise appropriate management strategy, hence the need to identify risk factors for breast cancer in Nigerian women. Identification of these factors may enhance the ability to prevent the disease by permitting better-focused health education and other preventive strategies.

Several studies on mammographic findings of breast cancer in Nigerian women as well as its clinical and pathological characteristics are found in the literature, but little is known about gynecological risk factors of the disease in this population.^{[10],[11],[12],[13],[14]}

This study is aimed at determining the association of breast cancer with parity, age at first confinement, age at menopause, age at menarche, nulliparity, and body mass index (BMI).

Methodology

A prospective study that involved recruitment of 120 consenting adult females with palpable breast lump referred for mammography examination from the Surgical Outpatient Department between October 2018 and November 2020 at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi. Ethical approval was obtained from the NAUTH Ethical Committee for this study. Women who were 40 years and above as well as those below 40 years with positive family history of breast cancer presenting with palpable breast mass were included in the study. Women with no palpable breast mass, with significant breast pain, or ulcerating palpable breast mass were excluded from the study.

Detailed history with regard to risk factors of breast cancer was taken; subsequently, the patient underwent mammography with two standard views; craniocaudal (CC) and mediolateral oblique (MLO), done for each patient on both breasts, with supplementary views done when required.

The general electronics performa mammography machine MGF-10 was used in this study. Participants were asked to remove clothing and possible source of artifacts from the region of the breast and axilla. Two standard views, CC and MLO, were done on both breasts. For the CC view, table height was set at the level of inframammary crease. The breast was kept in close contact with the film in a horizontal plane, and wrinkles or skin folds were smoothened out with the nipple in profile. Each patient was made to stand with the back straight and shoulders relaxed, arm at side, head turned away from the side being examined. After close collimation and compression were ensured, an exposure was taken with the central ray passing through the center of the base of the breast, perpendicular to film. For the MLO view, each participant was made to stand in the erect position with breast oriented in the oblique sagittal position and supported by the film holder in the same direction. The patient was rotated 45° with nipple in profile.

Mammograms were evaluated by at least two of the radiologists involved in the study. To check intraobserver variability, each radiologist had a double reading of each mammogram. Thereafter, independent interpretation and exchange of mammograms for reporting by two radiologists to check interobserver variability were done.

Patients subsequently underwent surgical biopsy, and the sample was taken for histology.

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]"> Results [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

Table 1: Age distribution of the study participants

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Table 2: Chi-square cross-tabulation analysis showing the association between parity and nulliparity with breast cancer (on the right breast)

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Table 3: Chi-square cross-tabulation analysis showing the association between age at confinement, and age at menarche with breast cancer (on the right breast)

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Table 4: Chi-square cross-tabulation analysis showing the association between age at menopause, and body mass index with breast cancer (on the right breast)

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Table 5: Chi-square cross-tabulation analysis showing the association between parity and nulliparity with breast cancer (on the left breast)

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Table 6: Chi-square cross-tabulation analysis showing the association between age at confinement and age at menarche with breast cancer (on the left breast)

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Table 7: Chi-square cross-tabulation analysis showing the association between age at menopause and body mass index with breast cancer (on the left breast)

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Discussion

This study sought to identify the relationship between the reproductive (gynecological) risk factors and breast cancer.

The mean age (47.37 years) recorded in this study as well as the age range with the highest frequency is similar to those recorded in previous literature.^{[10],[14],[15],[16],[17]}

Menarche and menopause are the markers of onset and cessation, respectively, of ovarian and related endocrine activity associated with reproduction. Early menarche and late menopause are known to increase women's risk of developing breast cancer despite inconsistencies in the literature.^[18] A 10% reduction in breast cancer risk has been reported for each 2 years increase in age at menarche.^[19]

Huo et al.^[20] in their study noted that breast cancer risk was increased among women with early menarche and late menopause. This is in accordance with what was gotten in this study where females who attained menarche at an earlier age (11–13 years) had a higher association with breast cancer than those who attained it later. In addition, those who attained menopause at a later age had higher association with breast cancer than those who attained menopause at an earlier age, though none of these factors were statistically significant in this study.^[21],[22]

A first pregnancy is linked to an increased short-term risk of breast cancer but a decreased long-term risk of breast cancer. The impact of these risks depends on a woman's age at the time of her first pregnancy,^[11],[12] and this is still a complex problem. It is estimated that the women having their first child before 18 years have only one-third of the breast cancer risk of those whose first birth occurred after 35 years or more.^[23]

Early first full-term pregnancy (FFTP, before 25 years of age) is believed to confer protection toward the development of breast cancer after menopause compared to the risk in nulliparous women but is also correlated with a transient increase in the risk of developing breast cancer soon after pregnancy (short term). On the other hand, a late first pregnancy (after 35 years of age) is believed to increase the risk of developing breast cancer after menopause, equating or increasing the risk compared to nulliparous women.^[24] This is contrary to what was documented by Sighoko et al.,^[25] who found a strong protective effect after FFTP, regardless of the age at pregnancy, and a strong protection resulting from pregnancy, regardless of the number of full-term pregnancies.

They suggested that the protective effect of parity is exhibited immediately after FFTP and that the transiently increased risk after pregnancy observed in previous studies may not be applicable to African populations.

This present study showed that more women whose age at first confinement was 25 years and below had breast cancer though not statistically significant.

Our finding could be attributed to majority of our patients (almost 65%) being in age groups less than age of menopause at which early age of first confinement confers protection.

Some studies, particularly in Caucasian populations, have demonstrated a protective effect of parity independent of age at FFTP on breast cancer risk. These were studies among the Nordic, Asian-American, and Nigerian (Mid-Western and South-Eastern) population, respectively.^{[22],[26],[27]} Kelsey et al.^[28] and Coldite et al.^[29] reported a lower risk of breast cancer in parous women compared to nulliparous. However, this was not the case in our study. This study recorded a high incidence of breast cancer in women with >3 children, though not statistically significant.

The influence of anthropometric measures on breast cancer risk has been the subject of many studies.^{[30],[31],[32],[33],[34]} Although fewer sample size was used in this study, there was no significant relationship between BMI and breast cancer. This findings is consistent with that of Ogundiran et al.,^[35] who conducted a case–control study in Ibadan using 1000 cases and 1000 controls. A cohort study in African-Americans showed that BMI was associated with reduced risk of breast cancer.^[36] On the contrary, another study showed that BMI was positively correlated with premenopausal breast cancer risk in low-risk societies including Japan and Taiwan.^[33] Chow et al. reported a positive correlation between BMI and postmenopausal breast cancer.^[37]

Factors such as breast feeding and surgical removal of the ovaries have been found to reduce incidence of breast cancer, while short intervals between menstrual cycles have been reported to increase breast cancer though they are not considered in this study.^[28]

Conclusion

Many of these gynecological factors have been suggested from previous studies to be the risk factors of breast cancer. However, none was found to be statistically significant in this study. Further studies with larger sample size may provide more findings in the relationship between gynaecological risk factors and breast Ca which could be useful to health authorities in planning intervention to reduce breast cancer incidence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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