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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 8-11

Survival rates among breast cancer patients from a hospital based cancer registry, Thrissur, Kerala, India


1 Department of Community Medicine, Amala Institute of Medical Sciences, Thrissur, India
2 Department of Community Medicine, Clinical Immunology and Rheumatology, Amala Institute of Medical Sciences, Thrissur; Currently, Clinical Immunology and Rheumatology, St. Joseph's Hospital, Kadukutty, Kerala, India
3 Department of Community Medicine, mala Institute of Medical Sciences, Thrissur, India

Date of Submission26-Nov-2020
Date of Acceptance06-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Catherin Nisha
Department of Community Medicine, Amala Institute of Medical Sciences, Thrissur - 680 555, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jssrp.jssrp_1_20

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  Abstract 


Introduction: Breast cancer is a biologically heterogeneous disease and patients with the same diagnostic and clinical prognostic profiles can have markedly different clinical outcomes. This difference is possibly caused by the limitation of our current taxonomy of breast cancers, which groups molecularly distinct diseases into clinical classes based mainly on morphology. Objectives: The study objective was to assess the survival rates of breast cancer patients of all immunohistochemical subtypes at a hospital-based cancer registry, Thrissur, Kerala. Materials and Methods: After obtaining Institutional Ethical Clearance we included 202 patients of histologically diagnosed breast carcinoma who had been diagnosed in the year 2016. Data was obtained from the patient files. Associations between tumor subtypes and survival rates were examined. Results: Of the 202 patients, 197 were females and 3 were males. The mean age of the study population was 55.9 ± 11.8 years. The survival rate at three years was 76.5%. Conclusions: It was found that the survival rate at three years for the study population was 76.5%. Community-based surveys will give a better outlook regarding the survival rates in the general population. More studies from developing countries like India are appreciated to understand the burden of disease.

Keywords: Breast cancer, hospital-based cancer registry, Kerala, survival rates


How to cite this article:
Iype RK, Vaz C, Nisha C. Survival rates among breast cancer patients from a hospital based cancer registry, Thrissur, Kerala, India. J Surg Spec Rural Pract 2020;1:8-11

How to cite this URL:
Iype RK, Vaz C, Nisha C. Survival rates among breast cancer patients from a hospital based cancer registry, Thrissur, Kerala, India. J Surg Spec Rural Pract [serial online] 2020 [cited 2021 Jan 22];1:8-11. Available from: http://www.jssrp.com/text.asp?2020/1/1/8/305918




  Introduction Top


Breast cancer is biologically a heterogeneous disease. Difference in disease progression and outcome of therapy can be attributed to its heterogeneity.[1] Decline in mortality rates have been observed in breast cancer patients in recent decades and this decline has been attributed to widespread mammography screening, systemic therapy and adjuvant endocrine therapy.[2]

Breast cancer patients with tumors that are (ER)-positive and/or (PR)-positive have greater survival advantage after diagnosis than (ER)-negative and/or (PR)-negative disease and the survival advantage is enhanced by treatment with adjuvant hormonal and/or chemotherapeutic regimens.[3],[4],[5],[6] HR6imensancer patients with tumors that are (ER)-positive and/or (PR)-positive have greater survival advantage after diagnosis than (ER)-negative and/or (PR)-negative disease and the survival advantage is eHowever, a significant proportion of a small subset of invasive cancers namely, adenoid cystic carcinoma and secretory carcinoma, are HRstic carci These tumours have an excellent prognosis with minimal regional recurrence.

In addition, not all poorly differentiated, HR-negative tumours behave poorly. Medullary-like cancers are reported in some series to have a relatively better prognosis than expected. All these features point toward the heterogeneous nature of a HR-negative subgroup of invasive breast cancers and may indicate the presence of more aggressive subgroups within these tumour types that can benefit from an aggressive therapy. HER2 is a major target for the development of new cancer therapies and is similar to the oestrogen receptor, which guides hormone therapy. Its greatest value as a predictive marker lies in the prediction of response to therapies that target HER2, such as trastuzuma (Herceptin). Although HER2essive th disease has a more favourable prognosis than HER2ease has disease, it lacks the benefit of using these targeted therapies. Previous studies have reported that HER2 status usually shows an inverse association with HR expression.[7]

Survival is a key index of the overall effectiveness of health services in the management of patients with cancer and survival patterns can be used to drive national cancer strategies, as have been used across several nations in the world.[8] Ethnic differences in breast cancer survival have been documented and their influence on survival rates in different parts of the world.[9] Same prognostic factors may not apply to a given race, for example, breast cancer survival for oestrogen receptor and progesterone receptor (ER/PR)-positive tumours in black patients was lower than similar tumours in Caucasian patients.[7] The objective of this study was to assess the survival rates of breast cancer patients of all immunohistochemical subtypes at a hospital based cancer registry, Thrissur, Kerala.


  Materials and Methods Top


Study design

A retrospective cohort study was designed to collect data.

Study setting

Hospital Based Cancer Registry in Kerala, South India.

Study population

Breast Cancer patients from hospital-based cancer registry centre in Kerala, South India whose IHC has been done in the year 2016. All cases in the cancer registry was identified by the coding system of the International Classification of Diseases for Oncology, 3rd Revision (ICD-03), from the World Health Organization.[10] In order to confirm the diagnosis of breast cancer and examine the changes on coding, we retrospectively collected and checked records of diagnosis and pathological reports of these cases.

Data collection

A total of 202 cases of invasive breast cancer had been recorded in the IHC register during the year 2016 and were included in the study. Prior permission was obtained from the management of the institution to collect required data from the patient data file. Permission was also taken from the Head of the Department of Pathology to access the data from the department register. The following variables were recorded at baseline for each patient including age, menopausal status, tumor grade, histological subtype, tumor size, nodal status, and metastatic involvement at presentation. Hormone receptor status including estrogen receptor (ER), progesterone receptor (PR) and Her-2 positivity were also documented. Type of surgery, chemotherapy received, be it neo-adjuvant, adjuvant or palliative, types of radiation received were also recorded. Development of locally recurrent disease and sites of distant metastasis were documented. In case if the data was not available, it was recorded as data not available. The observations were coded as numbers.

Estrogen receptor (ER), and progesterone receptor (PR) was defined according to Allred scoring as positive when the sum of proportion and intensity was two and above.[11] Her-2 positivity was defined as more than 10% strong complete membrane staining or positive with fluorescent in situ; hybridization technique (FISH).[12]

Data analysis

The data were entered in Microsoft Excel, and analysed using SPSS version 23.0. Mean and standard deviation was computed for continuous variables and proportions were reported for categorical variables. The purpose of the analysis was to report overall survival at three years. A P ;value of less than 0.05 was considered as statistically significant. Log rank test was assessed and Cox Proportional hazard ratios were computed to assess associations between survival and independent variables. The independent variables were menopausal status, tumor size, tumor grade, ER, PR, and Her 2 neu status, nodal involvement and disease stage. By applying non-parametric Kaplan-Meier survival curve technique, we estimated overall survival rate.


  Results Top


The hospital records containing IHC reports and biopsy report of 202 breast cancer patients who presented to this hospital in the year 2016 was obtained, which included representation from 10 districts of Kerala, India. Mean age of the study population was 55.9 with standard deviation 11.84. Majority were in the age group 46-55 (32.7%). The age distribution of the study population is depicted in [Table 1]. 199 cases in our study were females (98.5%) and 3 were males (1.5%). 191 (94.6%) of the cases was invasive breast carcinoma and regarding the nodal status 115 (56.9%) were node negative and 85 (42.1%) were node positive.
Table 1: Demographic details of study population

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[Table 2] depicts the marital status, parity, menopausal status and grade at diagnosis of the study population. The receptor status proportion is nearly equally distributed among cases. ER, PR and Her-2 status of the study population is depicted in [Table 3]. The proportion of cases receiving different modalities of treatment combinations, such as surgery, chemotherapy, radiation and hormonal therapy is given in [Table 4].
Table 2: Variables of study population

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Table 3: Receptor status of study population

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Table 4: Log rank test to assess the proportional hazard

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[Figure 1] shows the mean survival of total cases at three years which is 76.5% and [Figure 2] shows the mean survival of cases depending on the combination of treatment undergone, in which cases underwent surgery along with chemo radiation and hormonal therapy has better survival when compared to combination of other modalities.
Figure 1: Patient status with mean survival

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Figure 2: Mean survival based on the combination of treatment modality underwent. (1) Patients have undergone only surgery. (2) Patients who have underwent surgery and chemotherapy. (3) Patients who have underwent surgery and chemo radiation. (4) Patients who have underwent surgery, chemo radiation and hormonal therapy

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  Discussion Top


In women, breast cancer is the most frequently diagnosed malignancy and the leading cause of cancer death in both developed and developing countries.[13] Variation in incidence rates worldwide is thought to be due to differences in reproductive patterns and other hormonal factors as well as early detection.[14],[15]

This study comprised of 202 cases of breast cancer. The mean age of the study population is 55.6 years. A study conducted in Chennai in 2011 has a mean age of breast cancer patients as 53.8 years[16] and another study conducted in Saudi Arabia in 2014 also has a comparable mean age of breast cancer patients as 53.7 years.[17] Only 1.5% of the cases were males. The overall incidence of breast cancer in males is approximately 1/100th that of the rate in females and this is comparable to our study. We found the stage at diagnosis is late when compared to developed countries and previous studies from India shows the same.[18] Studies from US shows that they diagnose cases at an earlier stage[19] and its mortality rates have been steadily decreasing over the last 2–3 decades.[20]

Aside from age, sex, and family history, risk of developing breast cancer is largely related to woman's reproductive risk factor profile,[21] which is characteristic of exposure to sex hormones. Specifically, risk of developing breast cancer is increased by early menarche, late menopause, and nulliparity; whereas, risk is reduced by higher parity and lactation, but surprisingly we have very few nulliparous breast cancer cases in our study.

Regarding survival in breast cancer cases mean and cumulative survival is lower in cases who underwent only surgery and it is better and higher in case who had completed other treatment modalities along with surgery. Previous studies have shown combining surgery with chemo radiation and hormonal therapy have greatly improved the survival rate.[22] Large population-based study shows that there is greater negative effect in young age, among those not receiving adjuvant treatment and age did not have any significant effect.[23] The survival rate of our study is 76.5% which is comparable to study conducted by Vettuparambil &#et al.;[24] in Kerala (71.4%) and Raina &#et al.; in New Delhi (73%).[25]


  Conclusions Top


The mean survival rate of our study population was 76.5% at three years. In our study we found that stage of cancer at diagnosis is late which can be attributed to lesser screening practices and awareness among our study population. In our it was highlighted that cases who underwent other modalities of treatment in addition to surgery had better survival than cases who underwent only surgery. In the study population 147 (72.8%) were diagnosed at grade 2.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Munjal K, Ambaye A, Evans MF, Mitchell J, Nandedkar S, Cooper K. Immunohistochemical analysis of ER, PR, Her2 and CK5/6 in infiltrative breast carcinomas in Indian patients. Asian Pac J Cancer Prev 2009;10:773-8.  Back to cited text no. 1
    
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Harvey JM, Clark GM, Osborne CK, Allred DC. Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol 1999;17:1474-81.  Back to cited text no. 11
    
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Ambroise M, Ghosh M, Mallikarjuna VS, Kurian A. Immunohistochemical profile of breast cancer patients at a tertiary care hospital in South India. Asian Pac J Cancer Prev 2011;12:625-9.  Back to cited text no. 16
    
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Khabaz MN. Immunohistochemistry subtypes (ER/PR/HER) of breast cancer: Where do we stand in the West of Saudi Arabia? Asian Pac J Cancer Prev 2014;15:8395-400.  Back to cited text no. 17
    
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Agarwal G, Ramakant P. Breast cancer care in India: The current scenario and the challenges for the future. Breast Care (Basel) 2008;3:21-7.  Back to cited text no. 18
    
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Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 2012;367:1998-2005.  Back to cited text no. 19
    
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Elsawaf Z, Sinn HP, Rom J, Bermejo JL, Schneeweiss A, Aulmann S. Biological subtypes of triple-negative breast cancer are associated with distinct morphological changes and clinical behaviour. Breast 2013;22:986-92.  Back to cited text no. 21
    
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Sainsbury R, Haward B, Rider L, Johnston C, Round C. Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet 1995;345:1265-70.  Back to cited text no. 22
    
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Kroman N, Jensen MB, Wohlfahrt J, Mouridsen HT, Andersen PK, Melbye M. Factors influencing the effect of age on prognosis in breast cancer: Population based study. BMJ 2000;320:474-8.  Back to cited text no. 23
    
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Vettuparambil A, Chirukandath R, Culas TB, Vijayan SM, Rajan G, Kuttappan SV. Hormonereceptor expression and survival patterns in operat cases of female invasive ductal breast carcinoma in Kerala: A retrospective cohort study. World J Surg Oncol 2015;13:160.  Back to cited text no. 24
    
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