Dear Readers,
T he Journal of Breast Health has received increasing number of articles from you, and become one of the peer review journal in Turkey
with your supports. In order to be an international journal, we funded an international editorial board, and invited very well
known experts from the world on breast health. There will be a professional redaction department of the journal, to review submissions
in english. As you know, our journal has both an electronic and hard copies, being reached to more than 2.000 readers(http://
www.memesagligi.dergisi.org). And, it has been accepted by The Scientific and Technological Research Council of Turkey (TUBITAK) and
EBSCO Publishing to site last year. Our next step is to site by Pub-Med and SCI Expanded. For this reason, we would like to have your submissions
both Turkish with english abstract and also in english. We will do redaction for your papers writing in english. Turkish Federation
of National Breast Societies will also support you for this aim.
In our new issue, I would like to give you some information on breast cancer incidence, screening, stages in the world. As a member of
The Breast Health Global Initiaitive (BHGI), results of previous three Global Summits will be given in this paper. National Breast Cancer
Registry Program has reached more than 11.000 patients, and new statistical results of the program will be shared with you.
With my warm regards,
Prof. Dr. Vahit Özmen
Editor-in Chief
BREAST CANCER IN THE WORLD AND TURKEY
Abstract
Background: Breast cancer is the most common cancer of women,
comprising 23% of all female cancers around the globe, with
an estimated 1.15 million cases diagnosed in 2002. Of the 411,000
breast cancer deaths around the world, 221,000 (54%) occurred
in low- and middle-income countries (LMCs). However, in most
low- and middle-income countries (LMCs), incidence rates are increasing
at a more rapidly than in areas where incidence rates are
already high. Breast cancer incidence and prevalence in western
part of Turkey in 1992 was 24.4/100.000 in 1992 and 0.3% respectively.
Distribution of breast cancer incidence in 2000s changes in
different regions of Turkey due to geographic, economic, social,
cultural factors. Breast cancer incidence in western part of Turkey
(50/100.000) is more than two times in eastern part of Turkey
(20/100.000) due to “Westernizing life” (early menarche, late menopause,
first birth >30 years, less breast feeding, etc.), and other
related factors.
Methods: Established in 2001, Turkish Federation of National
Breast Societies has National Breast Cancer Registry Programme including more than 11.000 breast cancer patients. These patients
were evaluated in February 2008, and statistical results will be presented
in this paper. The Breast Health Global Initiative (BHGI) created
an international health alliance to develop evidence-based
guidelines for LMCs to improve breast health outcomes. The BHGI
held three Global Summits in October 2002 (Seattle), January
2005 (Bethesda) and, October 2007 (Budapest) using an expert
consensus, evidence-based approach developed resource-sensitive
guidelines that define comprehensive pathways for step-bystep
quality improvement in health care delivery.
Results: Most of 11.208 breast cancers in the registry program
diagnosed at stage II (52.8%). Only 4.28% of patients had opportunistic
screening and non-palpable breast cancer, and 90% of patients
admitted to clinics with a complaint of mass in the breast.
Breast conserving surgery was applied in 35% of patients. Five
years mean overall survival was 86% in Istanbul Medical Faculty,
The Breast Unit. Half of the patients had a pathologic diagnosis
with fine needle aspiration or tru-cut biopsy, and diagnosis was
performed by excisional biopsy in 29.5% of patients. The BHGI
guidelines stratify resources into four levels (basic, limited, enhanced, and maximal), making the guidelines simultaneously applicable
to countries of differing economic capacities. The BHGI
guidelines provide a hub for linkage among clinicians and alliance
among governmental agencies and advocacy groups to translate
guidelines into policy and practice.
Conclusions: Breast cancer incidence has been increased in Turkey
in last decades, and there is not nationwide screening program. Its
frequency, stage at diagnosis, and treatment have heterogenity in
different regions of Turkey (earlier diagnosis and higher incidence
in western Turkey), due to social, cultural, educational economic
factors. These problems can be improved through practical interventions
that are realistic and cost-effective. Early breast cancer
detection and comprehensive cancer treatment play synergistic
roles in facilitating improved breast cancer outcomes. The most
fundamental interventions in early detection, diagnosis, surgery,
radiation therapy, and drug therapy can be integrated and organized
within existing health care schemes in Turkey and other
LMCs. The BHGI will study what implementation strategies can
most effectively guide health care system reorganization to assist
countries that are motivated to improve breast cancer outcome in
their populations.
Key words: breast cancer, incidence, Turkey, The BHGI, risk factors, lowmiddle
income countries
Breast cancer is the most common cancer of women, comprising
23% of all female cancers around the globe, with an estimated
1.15 million cases diagnosed in 20021. There is marked geographical
variation in incidence rates, being highest in the developed
world and lowest in the developing countries in Asia, Middle East,
and Africa. The age-standardized incidence in North America is
the highest, at 99.4 per 100,000, while the lowest is in central Africa
where it is 16.5 per 100,0001. However, in most low- and middle-
income countries (LMCs), incidence rates are increasing at a
more rapidly than in areas where incidence rates are already high.
Global breast cancer incidence rates have increased by about 0.5%
annually since 1990, but cancer registries in China are recording
annual increases in incidence of 3-4%.1
Incidence
A population-based cancer registry, covering the province of Izmir
(population 2.7 million, 1993-1994) in Western Turkey was
established in 19922. Overall cancer incidence was higher in
males than in females (age-standardised rates 157.5 and 94.0 per
100.000, respectively), as in previous non-population-based series.
The principal cancers in males were tobacco-related - lung (agestandardised
incidence rate (ASR) 61.6), bladder (ASR 11.0) and
larynx (ASR 10.6), consistent with the high prevalence of smoking,
and use of traditional high-tar tobaccos. In women, Breast cancer
incidence and prevalence are 24.4/100.000 in 1992 and 0.3%
respectively; cervical cancer was relatively rare (ASR 5.4)2. Distribution
of breast cancer incidence changes in different regions
of Turkey due to geographic, economic, social, cultural factors.
Breast cancer incidence in western part of Turkey (50/100.000) is
more than two times in eastern part of Turkey (20/100.000) due
to “Westernizing life” (early menarche, late menopause, first birth
>30 years, less breast feeding, etc.).
To the estimations of the Health Ministry resources (Tuncer, 2006,
www.saglık.gov.tr), the number of breast cancer patients in the
period of 2007-2012 has been seen in Table 1.
Prognosis
Prognosis from breast cancer is rather good, although globally it still
ranks as the leading cause of cancer mortality among women. Very
favorable breast cancer survival rates in the United States and other
developed countries have been attributed to early detection by
screening, and by timely and effective treatment3. For example,
women diagnosed with breast cancer between 1990 and 1992 and
reported in the population-based case series from the Surveillance,
Epidemiogy, and End Results (SEER) program (13,172 women) had
an 89% 5-year survival rate4. By contrast, age-adjusted survival
rates for breast cancer in developing regions average 57% and are
as low as 46% in India and 32% in sub-Saharan Africa.4 In addition
to heterogenity in incidence of breast cancer in Turkey, breast cancer
mortality also shows differences in different regions depending
on breast health awareness, diagnostic and therapeutic infrastructures.
In a study evaluating 1841 breast cancer patients from
Istanbul Medical Faculty, 5 years breast cancer mortality rate was
similar to rates for developed countries (86% and 85% for patients
with breast conserving surgery, and mastectomy respectively, median
follow up 76 months)5. This rate was low in Diyarbakır and
other cities in East Anatolia (around 60%) due to advanced stage
at diagnosis, lack of breast cancer awareness, and other social, educational,
cultural and economic barriers to early diagnosis and effective
treatment. Surgical procedure was MRM in 66%, and breast
conserving surgery in 34% of patients5.
Breast cancer screening and early detection
There is solid evidence supporting the value of diagnosing cancer
early, and guidelines on early detection are available6,7. The only
screening method that has been demonstrated to reduce mortality
from breast cancer is mammographic screening8,9. However,
mammography is expensive and requires manpower and technical
expertise that is not aff ordable in most Low-Middle income Countries
(LMCs). As a result, BHGI guidelines recommend that breast
health awareness (BHA) should be promoted to all women at the
basic level10. In addition to this basic facility, further development
will require training of relevant staff to perform clinical evaluation,
including taking a history and performing a clinical breast examination
(CBE) for both symptomatic and asymptomatic women.
Higher-level early-detection programs may include opportunistic
screening with CBE, trials of organized screening using CBE and/or breast self-examination (BSE), and finally feasibility studies of mammography
screening. There are sociocultural, educational, economic
barriers to breast cancer detection that need to be overcome
among women in Turkey. In some cultures, the woman’s decision
and actions are controlled by men who may be unaware of breast
screening as an effective, life-saving modality. According to Turkish
Breast Cancer Registry, breast cancer stages at diagnosis were
27% (StageI), 53% (StageII), 9% (StageIII), and 6% (StageIV) respectively
(http://www.mdkk.org/memekanseri/register.php). 90% of
patients admitted to the clinics with a complain of a painless mass
in the breast, only 4.28% of patients had an opportunistic screening
mammogram and non-palpable breast cancer.
The breast health global initiative
Evidence-based guidelines outlining optimal approaches to breast
cancer detection, diagnosis, and treatment have been well-developed
and disseminated in several high-resource countries11,12.
Even in some developing countries, there have been attempts to
develop clinical practice guidelines for the treatment of breast cancer
based on the resources available13. Most guidelines define
optimal practice, which have limited utility in developing countries
where resources are poor. Optimal practice guidelines may be inappropriate
to apply in LMCs for numerous reasons, including poverty,
infrastructure constraints, drugs, and cultural barriers. Hence,
there is a need to develop clinical practice guidelines oriented toward
countries with limited financial resources14. For these reasons,
the Breast Health Global Initiative (BHGI) was established in
2002. Cosponsored by the Fred Hutchinson Cancer Research Center
in Seattle, Washington, and the Susan G. Komen For The Cure in Dallas,
Texas, the BHGI is a program that strives to develop, implement,
and study evidence-based, economically feasible, and culturally
appropriate guidelines that can be used in LMCs with the aim of
improving breast health outcomes. The first evidence-based guidelines
were developed at the 2002 BHGI Global Summit, creating
guidelines for (1) early detection, (2) diagnosis, and (3) treatment.
These guidelines, published in 2003, are free and available on the
internet (http://www.fhcrc.org/science/phs/bhgi/). They outline
general principles for programmatic improvement in breast health
services as applied to LMCs15-18. The first BHGI Global Summit
adopted two axioms as principles for guideline development: 1.
All women have the right to have access to health care, although
considerable challenges exist in implementing breast health-care
programs when resources are limited, and 2. All women have the
right to education about breast cancer, but it must be culturally appropriate
and targeted and tailored to the specific population.
At the 2005 BHGI Global Summit, the guidelines were updated and
expanded into a flexible, fully comprehensive framework for improving
the quality of health-care delivery based upon outcomes,
cost, cost-effectiveness, and use of health-care services. Held
January 12–15, 2005, and hosted by the Office of International Affairs
of the U.S. National Cancer Institute in Bethesda, Maryland,
the 2005 BHGI Global Summit convened 67 international experts
representing 33 countries and 5 continents to define specific
“best practices with limited resources” and was expanded to include
medical ethics, international health, medical economics,
and sociology. Twelve national and international groups (including Breast Surgery International, International Union Against Cancer,
International Atomic Energy Agency, International Society of
Breast Pathology, and World Society for Breast Health) joined the
BHGI as collaborating organizations. In addition, the BHGI established
affiliations with three WHO programs: The Cancer Control
Programme, Health System Policies and Operations, and the Alliance
for Health Policy and Systems Research. The 2005 guidelines
addressed (1) early detection and access to care19, (2) diagnosis
and pathology20, (3) cancer treatment and allocation of resources21, and (4) health-care systems and public policy22.
The 2005 BHGI guidelines can be used to communicate programmatic
needs to hospital administrations, government officials, and/
or health-care ministries. The thesis of the BHGI is that these guidelines
create a framework for change by defining practical pathways
through which breast cancer care can be improved in an incremental
and cost-effective fashion23,24. However, guidelines do not
in and of themselves improve outcomes for women. Implementation
is the critical step by which the value of the guidelines can be
measured. The results of pilot research projects and demonstration
projects need to be studied and reported to determine the effectiveness
of the guidelines and to create evidence that will guide
and facilitate guideline implementation in other settings.
The Breast Health Global Initiative (BHGI) held its 3rd Global Summit
in Budapest, Hungary from October 1-4, 2007, bringing together
internationally recognized experts to address the implementation
of breast health care guidelines for early detection, diagnosis and
treatment in low- and middle-income countries (LMCs). A multidisciplinary
panel of experts addressed specifically the implementation
of BHGI breast cancer guidelines for early detection of disease
as related to resource allocation for public education and awareness,
cancer detection methods and evaluation goals. Public education
and awareness is a key first step, because early detection cannot be
successful when the public is unaware or has adverse misconceptions
about the value of early detection. The approach and scope of
any screening program will determine both the success of any early
detection program as measured by cancer stage at diagnosis, and
will also drive the breadth of resource allocation needed for program
implementation. The effectiveness and efficiency of screening
modalities including screening mammography, clinical breast
examination (CBE) and breast self-examination were reviewed in
the context of resource availability and population-based need.
Social and cultural barriers to breast cancer early detection must
be considered in any context where early detection programs are
being established. For each early detection category and tool, the
use of well-developed, methodologically sound quality indicators
is important to determine the effectiveness of early detection program
implementation success.
Breast cancer risk factors in Turkish women
In a survey conducted by Ozmen et al., breast cancer risk factors
in Turkish women were studied25. The survey was prospectively
conducted among women admitted to clinics of Istanbul Faculty
of Medicine for examination and/or treatment by using a questionnaire.
The women were selected from the waiting area of different
clinics without breast cancer by convenience sampling (n= 2167) whereas patients with breast cancer were either selected
from patients visiting our Breast Clinic for follow-up, or from our
breast cancer database (n=1492). The results suggested that, being
greater than or equal to age 35 years old, having induced
abortion, multiparity (≥1), late age at first birth (≥35 years old),
late age at menopause (≥50 years old), body mass index (BMI) ≥25
and having first-degree family history of breast cancer were risk
factors for breast cancer in Turkish women. Higher educational
level (high school), having miscarriages, cigarette smoking, oral
contraceptive usage, breast feeding more than one child (unrelated
to total period of breast feding) reduced breast cancer risk.
Factors including use of hormone replacement therapy for 5 years
or more and alcohol consumption are not found to be associated
with breast cancer risk.
Breast Cancer Patients’ Characteristics in Turkey
National Federation of Breast Societies of Turkey funded in
2001 and has a Breast Cancer Registry Programme since June
2005 (http://www.mdkk.org/memekanseri). In this registry programme,
11.208 breast cancer patients were recorded till February
200826. Patients’ registrations came from 13 breast centers
localized in 8 cities (İstanbul, Izmir, Ankara, Bursa, Kocaeli, Aydin,
Diyarbakir, and Adana) in Turkey.
According to statistical analyses of National Breast Cancer Registry
Programme26, mean age of breast cancer was 51.5 (12 to 97), and
20.2% of patients was ≤ 40 years of age. Breast cancer in women
under 35 years of age has been reported in the West to account for
2%–4% of all breast cancer cases27, and only 6.5% of all breast
cancers are detected in women under the age of 4028. Our rate
is similar to other Middle East, Asian countries29. Although this
finding may be partially due to the age structure of the population
in Turkey, age-adjusted incidence still found that a higher proportion
of young women who present with breast cancer in this locality.
There is also documentation that, although the Asian population
has a lower incidence of breast cancer, they have an earlier age at
maximal risk and less increase after menopause30. The full reason for the peak of onset of breast cancer at the age of 40 is still unclear.
This may be attributed in part to a more Westernized lifestyle,
refl ected by a significant difference in the mean age at first live birth
and mean age of menarche in this cohort31. Further studies on
the predisposition and gene-environmental interaction in this age
group may increase this understanding.
Breast cancer in Turkish women between 41-50, 51-70, and ≥70
years of age were 31%, 40.7%, and 8.2% respectively. 14.5 per cent
of patients had family history of breast cancer. Mean age of menarch,
and first birth were 13.2 and 22.5 respectively. Mean number
of deliveries and breast feeding duration in patients with breast
cancer were 2.67 and 18.5 months, respectively. History of previous
hormone replacement therapy and oral contraceptive usage
were positive in 9.3% and 11% of patients. The rate of menopausal
patients was 57%. All patients with breast cancer had diagnostic
mammography, and in 7% of patients, magnetic resonance imaging
was added to mammography and breast ultrasound.
Only 4.28% of patients with breast cancer and without any
symptoms came to the clinics with opportunistic screening or
from menopause clinics. A painless mass in the breast was only
symptom in 90% of patients (Table 2). Duration of symptoms was
less than 1 month in 40% of patients, but more than 6 months in
23.5%. This delaying to admission is mostly related with the belief
of Turkish women that a painless mass in the body is not cancer.
Click Here to Zoom |
Tablo 3: Clinical stages of patients with breast cancer at the first
presentation |
Fine needle aspiration biopsy (FNAB) and excisional biopsy were
performed in 39% and 29.5% of patients for histopathologic diagnosis,
respectively (Table 4).
Click Here to Zoom |
Table 4: Methods performed for histopathologic diagnosis in
patients with breast cancer. |
If we look at the surgical procedures, modified radical mastectomy
was the most common surgery (63%), and breast conserving surgery
was the second(36%). Only 1% of patients had radical mastectomy.
Histopathologic diagnoses were invasive ductal (70.7%),
invasive lobular(7.1%), and mixed type invasive cancer(5.8), respectively.
Medullar(2%), mucinous(2%), tubular1.5, and papiller(0.9%) types were other less frequently seen cancers. Tumor
sizes in 3664 patiens were seen in Table 5. Only 9.5% of patients
had tumor size less than 10 mm.
Estrogen, progesteron, and HER-2 receptors were positive in 67.4%,
51.9%, and 17.5% of patients. Only 4.5% of patients had Nuclear
grade 1 tumor (55.8% Grade 2, 39.7% Grade 3). Lymphovascular
invasion was positive in 52.3% of patients. Sentinel lymph node
biopsy was performed in 1233 patients, and sentinel lymph node
was positive 54.7% of patients. Blue dye (busulphan or methylen
blue) alone or combined technique(blue dye + radioisotope) was
used in 62% and 38% of patients.
Conclusions
Breast cancer is the most common female malignancy, and
consists of 24% of cancers in women. Incidence rate and
prevalance have increased three times in last decades in Turkey.
There are big differences regarding stage at diagnosis,
and effective treatments between eastern and western part of Turkey. Poorer survival in eastern part of Turkey is largely due
to late presentation of the disease which, when coupled with
limited resources for diagnosis and treatment, lack of breast
health awareness, social, cultural, and educational factors leads
to particularly poor outcome. The BHGI guidelines can be used
to communicate programmatic needs to hospital administrations,
government officials, and/or health-care ministries in
LMCs. The thesis of the BHGI is that these guidelines create a
framework for change by defining practical pathways through
which breast cancer care can be improved in an incremental
and cost-effective fashion.
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