Locally advanced breast cancer in Saudi Arabia: high frequency of stage III in a young population

In the Kingdom of Saudi Arabia (KSA), breast cancer constitutes 18% of all cancers in Saudi women. Whilst locally advanced breast cancer disease is unusual in Western countries, it constitutes more than 40% of all non-metastatic breast cancer in KSA. The relative frequency of locally advanced disease among our breast cancer population and the lack of a uniform consensus in the literature about its optimal management have prompted this retrospective analysis of the medical records of patients with Stage III breast cancer patients seen at King Faisal Specialist Hospital and Research Center between 1981 and 1991. In all, 315 patients were identified. Their median age ±SD was 46±11.6 years which is distinctly different from the 60–65 years median age in industrial Western nations. Most patients were younger than 50 years (64%) and premenopausal (62%). Patients were approximately equally divided between Stage III A and Stage III B Patients received multimodality treatment, including surgery., adjuvant chemotherapy, tamoxifen, and adjuvant radiotherapy. Sixty-one patients were excluded from survival analysis as they were considered lost to follow-up. Of the remaining 254 patients, 73 (29%) were alive and disease free, and 18 patients (7%) were alive but, with evidence of the disease. The remaining 163 (64%) had died from breast cancer or its related complications. Their median overall survival (OS) was 54 months, (95%, Cl, 27 to 121 months) and the median progression-free survival (PFS) was 28.8 months (95% Cl, 14.2 to 113 months). Cox proportional hazard, model identified Stage III B and the number of positive axillary lymph nodes as poor predictors of OS and PFS. Radiotherapy was the only adjuvant modality that affected survival favourably. The prognosis of patients with Stage III disease remains poor despite the use of a multimodality approach. The overall young age of our patients may have contributed to the poor outcome. Moreover, the adverse effect of Stage III B disease (as compared with Stage III A) and axillary nodal status was evident. Whilst the favourable effect of radiotherapy on survival was demonstrated, the lack of independent efficacy of other modalities (adjuvant chemotherapy and tamoxifen) or the apparent deleterious effect of neoadjuvant chemotherapy should be addressed with discretion in such retrospective analysis. Optimal management of patients with locally advanced breast cancer disease should be appraised in well designed, prospective, randomised studies.     

Genetic testing in women with breast cancer: implications for treatment

Introduction: Mutations in either the BRCA1 or BRCA2 genes are responsible for approximately 42,000 cases of breast cancer annually. Identifying these germline mutations in a woman with breast cancer is important because it can influence her immediate and long-term management and has important implications for other family members.

Areas covered: This review highlights how treatment-focussed genetic testing for BRCA1 and BRCA2 mutations can potentially influence cancer treatment and secondary prevention decisions in women with breast cancer.

Expert commentary: Testing women with breast cancer for BRCA1 and BRCA2 germline mutations has the potential to decrease cancer burden and improve cancer outcomes. It can help optimise surgical and systemic therapy approaches. Clinicians should actively consider whether genetic testing is appropriate for each woman with breast cancer, and if so should instigate it early in the treatment trajectory when it can most influence cancer care.     

The present and the future of breast cancer burden in the Kingdom of Saudi Arabia

Background Despite the low cancer incidence in the Kingdom of Saudi Arabia (KSA), the country must be ready to face the challenge of foreseeable increase in cancer burden attributed to growth and aging of population. This work was designed to study female breast cancer as a model to assess future cancer burden and the impact on healthcare resources. Methods Cancer statistics for the KSA were compared with that for the USA. The Joinpoint regression program was used to identify changes in secular trends, while the GLOBOCAN 2002 software projected future incidence and mortality. Results In the KSA, the age-standardized cancer rate (ASR) is 61 per 100,000 population, while the median age at diagnosis is 54 and 49 years for men and women, respectively. Fitting the ASR for breast cancer did not show any significant trend over a 10-year calendar period (16.2–18.2 per 100,000), a pattern that was similar to that for the USA in the prescreening mammography era. Considering the growth and aging of population and using conservative estimates for the annual percent change in incidence (increase) and mortality (decrease) by 2025, incidence and mortality cases are expected to increase by about 350% and 160%, respectively. Conclusion In developing countries, future cancer rates could demonstrate a considerable increase and enormous demands on healthcare resources. The present work may provide an impetus to study other prevalent cancer types particularly in developing countries.     

Women's interest in genetic testing for breast cancer risk: the influence of sociodemographics and knowledge.

The objective of this study was to assess women's interest in genetic testing for breast cancer risk. Randomly selected samples of 761 women without breast cancer from the general population of British Columbia, Canada, and 260 women with breast cancer from the provincial cancer registry participated in a telephone survey that assessed interest in genetic testing for breast cancer risk, knowledge of hereditary breast cancer and genetic testing, and sociodemographics. Women with breast cancer did not possess superior knowledge of breast cancer genetics compared with women from the general population. Of the women with breast cancer, 30.8% reported interest in testing or had been tested, compared with 28.5% of women without breast cancer. Controlling for differences in age, education, personal history of breast cancer, and knowledge of genetics, women with at least one relative with breast cancer were 2.3 times more likely to express interest in genetic testing for breast cancer risk than those with no family history. There were significant interactions between breast cancer status and education and between age and knowledge of breast cancer genetics. Women without breast cancer and with a positive family history, who were between 20 and 40 years of age, were most likely to be interested in testing. The women with breast cancer who were interested in testing tended to be approximately 50 years of age, had a positive family history, and had more years of education. Women with a family history of breast cancer, well-educated women with breast cancer, and younger women, particularly those with knowledge of genetic testing, are important target audiences for community-based education on genetic testing for breast cancer risk.     

Women's attitudes toward preventive strategies for hereditary breast or ovarian carcinoma differ from one country to another: differences among English, French, and Canadian women

BACKGROUND: The authors investigated the acceptability to women of the preventive strategies available for dealing with hereditary breast/ovarian carcinoma in France, the United Kingdom, and Canada, countries selected because of their cultural differences. The authors aimed to discover the existence of specific factors that may affect acceptability of these preventative measures. METHODS: A cross-sectional, multicenter survey was conducted in Marseilles, France (n = 141), in Manchester, England (n = 130), and in Montreal, Quebec (n = 84). All of the women attending cancer genetic clinics for the first time because of a family history of breast-ovarian carcinoma completed a self-administered questionnaire before their clinic consultation. RESULTS: Variations in responses to different preventative options presented on the questionnaire were seen within the sample of patients considered as a whole. The highest levels of acceptability were obtained for mammographic screening (87%) and chemoprevention (58%). In contrast, prophylactic oophorectomy and prophylactic mastectomy were thought to be acceptable at an early age (before 35 years), an age associated with the highest prophylactic efficacy, by only 19% and 16% of the respondents, respectively. After multivariate adjustment, the statistical data showed that the British respondents were more in favor of oophorectomy (P < 0.0001) and more in favor of chemoprevention than the French (P < 0.001) and the Canadian respondents (P < 0.001). The British (overall adjusted response [OR(adj)] = 3.9; P < 0.001) and Canadian respondents (OR(adj) = 3; P < 0.01) were more in favor of prophylactic mastectomy than the French. The cumulated acceptability of mammography before the age of 40 years was found to be greater in the French (OR(adj) = 2.8; P < 0.01) and Canadian (OR(adj) = 3.1; P < 0.05) samples than in the British sample. CONCLUSION: These results demonstrated the existence of international variations in the acceptability of the preventive strategies available for women at risk for hereditary breast/ovarian carcinoma. Therefore, these results suggested that when establishing medical recommendations or planning public health interventions, physicians must integrate the population's perception of advantages and drawbacks with the patient's individual decision making.     

Cervical cancer prevention program in Jakarta, Indonesia: See and Treat model in developing country

Objective

The purpose of this study was to describe the implementation of single visit approach or See-visual inspection of the cervix with acetic acid (VIA)-and Treat-immediate cryotherapy in the VIA positive cases-model for the cervical cancer prevention in Jakarta, Indonesia.

Methods

An observational study in community setting for See and Treat program was conducted in Jakarta from 2007 until 2010. The program used a proactive and coordinative with VIA and cryotherapy (Proactive-VO) model with comprehensive approach that consists of five pillars 1) area preparation, 2) training, 3) awareness, 4) VIA and cryotherapy, and 5) referral.

Results

There were 2,216 people trained, consist of 641 general practitioners, 678 midwives, 610 public health cadres and 287 key people from the society. They were trained for five days followed by refreshing and evaluation program to ensure the quality of the test providers. In total, 22,989 women had been screened. The VIA test-positive rate was 4.21% (970/22,989). In this positive group, immediate cryotherapy was performed in 654 women (67.4%).

Conclusion

See and Treat program was successfully implemented in Jakarta area. The Proactive-VO model is a promising way to screen and treat precancerous lesions in low resource setting.     

Oral cancer in Saudi Arabia: the role of alqat and alshammah

The purpose of this retrospective clinical study is to look into the etiological role of alshammah and alqat consumption in the causation of squamous cell carcinoma of the head and neck (SCHN) in Arabia. Alshammah and alqat are traditional forms of chewable tobacco very commonly used in southern Saudi Arabia and Yemem. In a 2 year period 64 patients with histologically proven SCHN were found. Most of them were originally from southern Saudi Arabia and Yemen. Of these 64 patients 52 (81%) admitted alshammah consumption. Of these 52 patients 22 admitted alqat consumption in addition. Thirty-eight (59%) had oral cancer, while the rest had pharyngeal and laryngeal cancer. All the 38 patients with oral cancer either used alshammah alone (16 patients) or used both alshammah and alqat (22 patients). The median duration of alshammah consumption was 15 years and that of alqat was 12 years. Alcohol was not consumed among the group and only few were cigarette smokers. Most patients presented in the late stage of the disease. The evidence implicating alshammah and alqat in the causation of SCHN is only clinically based. Further controlled prospective clinical and experimental studies are needed to confirm the theory.     

Estimation of individualized probabilities of developing breast cancer for Japanese women

BACKGROUND: Projecting individualized probabilities of developing breast cancer is needed for counseling and chemoprevention for Japanese women, in whom breast cancer incidence has been rapidly increasing. METHODS: We calculated individualized probabilities of developing breast cancer within 10-20 years and until life expectancy for Japanese women by multiplying the relative risk for each risk factor combination by the cumulative risk for the reference group. The risk factors used were age at menarche, age at first delivery, family history of breast cancer, and body mass index (BMI) (in post-menopausal women). The relative risk by menopausal status for each risk factor combination was estimated from a case control study conducted at Osaka Medical Center for Cancer and Cardiovascular Diseases (OMCC), Japan. The cumulative risk of breast cancer for the reference group within 10-20 years and until life expectancy was estimated to divide the corresponding cumulative risk for Japanese women by the weighted average of the relative risk. The weight is an expected proportion of those who have each risk factor combination among the general population. The cumulative risk for Japanese women was estimated using a data file from the Osaka Cancer Registry (OCR). RESULTS: We obtained cumulative risks for any age women within a certain range according to various risk factor combinations by menopausal state. For example, the highest risk group had about a 5 times higher risk probability of developing breast cancer than the general population at initial age 40, within 10-20 years, and until life expectancy. CONCLUSION: The cumulative risk of breast cancer varied according to individuals' risk factors among Japanese women. The availability of concrete individualized risk estimation figures will be of use to health care providers in encouraging Japanese women to seek counseling and to adopt self-control of body weight as a primary preventive measure, as well as to have breast cancer screening.     

Psychological morbidity in women at increased risk of developing breast cancer: a controlled study

There has been an ongoing debate in the literature on the extent to which women with a family history of breast cancer are at risk of psychological morbidity. This study compares psychological morbidity in 557 women participating in a large Australian registry of high-risk breast cancer families (kConFab) with 2 age and education matched samples, 1494 general practitioner attendees and 158 members of a twin registry. Participants completed the Somatic and Psychological Health Report (SPHERE). There were no significant differences between the three groups on psychological distress (F(2, 670) = 1.77, p = 0.17). Unsurprisingly, GP attendees reported more symptoms of somatic distress than the kConFab group (t411 = 2.89, p = 0.004); there were no differences between the twins and the kConFab group on somatic distress (t174 = 0.40, p = 0.687). Clinically significant anxiety/depression, a combination of psychological and somatic distress, therefore was significantly higher in GP attendees (28%) than the kConFab and twin samples (both 20%). These results refute the hypothesis that women with a family history of breast cancer are at greater psychological risk.