Breast cancer in Saudi Arabia has been on the rise in acute form compared to the developed countries. Even women at younger age have been diagnosed with cancer. It is argued that lack of information and education has the reasons for it to spread at an early stage. Although breast cancer in Saudi Arabia is not as startling, but the situation is becoming a pressing public healthcare issue, for the reason that every fifth woman in the country is in danger of contracting this fatal disease.
Breast cancer can be considered to be the leading cause of death among women in Saudi Arabia. According to extrapolated statistics breast cancer amount to 19,441 per 25 million population . However, this statistical data is automated and does not take into account the genetic, cultural, environmental, social, racial or other features of the Saudi Arabia. Cancer Incidence Report 1999-2000 has mentioned that, between the period of January 1999 and December 2000, there were 1,157 official cases of female breast cancer in Saudi Arabia (NCR, 2000).
The report also states that breast cancer is considered the most common cancer among females accounting for 20.6 percent of all newly diagnosed female cancers (5,617), while the Age Standartised-Incidence rate (ASR) was 13.6/100,000 for the female population. According to the report, the mean age at diagnosis was 49 years. The five regions with the highest ASR were the Eastern region at 21.2/100,000, Riyadh region at 19.9/100,000, Madinah region at 16.9/100,000, Makkah region at 16.4/100,000 and Hail Region at 9.4/100,000 (NCR, 2000).
2.0 BREAST CANCER PREVALENCE IN SAUDI ARABIA
Breast cancer is considered to be a group of undifferentiated cells reproducing under extremely rapid rate in the area of the breast in women. The earliest changes usually appear in the epithelial cells of the terminal end buds of the breast milk system, where new cancer cells form tumors. If cancer cells are active, the tumor increases at significant rate and may result in metastasis. Being a complex process in which cells are separated from their initial tumors and supplied trough blood and lymph systems to other organs, metastasis spreads cancer throughout the body.
Ravichandran et al (2005) affirmed the statistics revealed prior in Cancer Incidence Report 1999-2000 that the rate of breast cancer among women in Saudi Arabia amounts to 19.8 percent. Ravichandran et al (2005) aimed to examine 5-year survival for all incidents of invasive breast cancer that occurred during 1994-96 in the province of Riyadh, Saudi Arabia. Ravichandran et al (2005) also determined that the survival probability of women with cancer during the first year had been almost 94 percent, and the percentage was down sloping with the time. At third and fifth year, it dwindled to 79 and 59.6 percent respectively.
The highest five year survival rate has been determined in the patient category of 40-49 years old, while the lowest one in women older than fifty. According to Ravichandran et al (2005) localized cases of breast cancer had much better prognosis and survival rate among 5-year patients comparing to regional and distant metastasis. Ezzat et al (1999) indicated that locally advanced breast cancer disease constitutes more than 40% of all non-metastatic breast cancer among Saudi women. Ezzat et al (1999) also demonstrated that radiotherapy represents the most favorable treatment of locally advanced breast cancer and the most contributing method of treatment to overall patient’s survival. Simultaneously, such methods as adjuvant chemotherapy, tamoxifen and neoadjuvant chemotherapy) have been recognized as ineffective or even deleterious (as in case with neo-adjuvant chemotherapy).
A study conducted by Millat (2000), which aimed to identify general, awareness of the disease among the secondary school’s students (18 years old) through self-examination. It was been expected, that the knowledge of general risk factors has been very low and over 80 percent of the students failed to answer the majority of questions. Millat (2000) indicates that those students who had been previously exposed to breast surgery had positive breast cancer history, or those who had undergone mammography showed higher awareness and higher knowledge levels about the disease. From the statistical viewpoint, only 40 percent of the study sample (6380 students) reported ever hearing of breast cancer, only 14 percent knew the correct frequency of disease, and only 7 percent were aware of its timing.
A similar case study conducted by Alsaif (2004) among Saudi female nursing students to examine young women’s breast cancer awareness rate and overall attitude to breast cancer. Comparing to study conducted previously held by Millat (2000), Alsaif’s survey included a smaller sample of 149 respondents but the overall results of study was more positive and encouraging. The study found out that 66 percent of surveyed students performed breast self-examination and majority of those performing self-examination indicated that they learned about breast cancer, its causes and prevention methods from their college curricula. Alsaif (2004) found significant relation between breast cancer awareness and self-examination and nursing specialization of the study sample.
3.0 MAIN RISK FACTORS
Medical specialists distinguish risk factors for breast cancer that individual can change and those that cannot be affected (Miller, 1996). There have been two major factors of breast cancer as described below (Oncology Resource Center, 2006)
3.1 Heredity and Genetic Factors
The heredity factors include, if some one in the family has the history of cancer, such as sister, aunt, mother with cancer history. In such families breast cancer have greater chance to develop. In majority of such cases women have a genetic abnormality, which is referred as BRCA1 or BRCA2 gene. Women with BRCA1 gene have 85 percent risk of developing breast cancer. Women with BTCA2 also have chance to develop cancer, but lesser than BRCA2. Similarly women with previous case history of cancer are also at risk. In addition, women with female fraternal twins (two eggs) also have greater chance of developing cancer (Miller, 1996).
3.2 Non-Genetic Factors
Other than genetic factors, early age menstrual cycle and late age menopause also increase the risk. Other factors include late childbirth, hormone replacement therapy, and extensive use of oral contraceptive, high fat diet and obesity. Some researchers have also mentioned a relationship between ovarian hormones and breast cancer. Smoking has also been mentioned as one of the reasons for developing breast cancer.
4.0 STRATEGIES TO PREVENT CANCER
In US two third of the cancer illness are related to poor diet, obesity and lack of exercise. The main causes of breast cancer are different; however overall poor diet and poor health can increases the risk factors. If habits are changed are preventive lifestyle and diet is followed, there can be reduction in cancer
4.2 Hormone replacement
It is proven that hormone replacement with estrogens or progestins increase the incidence of breast cancer, especially among the post-menopausal women. Even though there are benefits attached to hormone replacements and the number of breast cancers cases are slowing down, however the risk has to be weighed against the benefits of hormone replacement. Such preventive measure are a better safety procedure than the later age crisis.
4.3 Oral Contraceptives and Breast Feeding
As oral contraceptives are associated with increased risk of breast cancer, therefore it is essential to understand risks associated with use of long-term use of contraceptives. Breast-feeding has been proved to reduce risk of breast cancer as much as by 50 percent. The greater a woman feeds her child, the lesser are the chance of infected with breast cancer.
4.4 Early Screening and Treatment
Screening refers to the examination of the symptoms of cancer, which means to check risk factors, which are more likely to develop cancer in future. An awareness of these risk factors makes it essential to have early screening and detection. The common medical practice indicates that regular mammography screening allows the decrease and the mortality of breast cancer by 30 percent (Hart, 1999), which means that every woman should get a yearly mammogram starting from age 40 or even earlier.
During the mammography screening, the x-ray picture sometimes detects various substances in the breasts; which are sometimes not recognizable and may provoke unnecessary worrying for both patient and health professional (Hart, 1999). Young woman are recommended to have a compulsory clinical breast examination done by health professional. In addition, during the clinical examination, every woman has an opportunity to learn how to conduct self-examination.
4.5 Self Examination
One should not underestimate the value of clinical breast exams or self-examination as 15 percent of the tumors are felt, but cannot be detected by regular mammographic screening. Although a lump in the breast is the most common way women discover a breast cancer, younger women should understand that any change in the breast require further medical investigation. Among the clinical tests that are conducted in modern oncological clinics, some women are on a chance, if they have a chance of getting the disease by simply tracing back cases of breast cancer throughout the history of relatives.
Contemporary oncologists consider the following signs as a serious threat which require immediate attention from health specialist:
– Thickening or density in the breast or underarm;
– Ulcerated or inverted nipple;
– Puckered or dimple skin;
– Redness or swelling of the breast;
A lump near the breast including the underarm, collarbone and neck (Bostwick, 1998), if any of these abnormalities are detected, the individual should get immediate consultation (physical exam) from a health professional and get a mammogram, possibly an ultrasound, and visit a breast surgeon for complete examination.
Contemporary medicine possesses various treatment techniques for breast cancer; in particular, radiotherapy, toxic chemotherapy combinations, hormonal treatments and prophylactic mastectomies are used to treat early lesions. 20-year follow-up data from the NSABP B-06 trial (Hamid et al, 2004) have confirmed that radiation therapy clearly decreases the rate of locoregional recurrence in patients who undergo lumpectomy. Usually, radiation treatment is given after, rather than before, chemotherapy. Newer radiation techniques include partial breast irradiation, partial breast irradiation and brachytherapy, and interstitial brachytherapy.
These techniques are under investigation and, at this point, may be used in the context of a clinical trial. Another effective treatment of the disease, adjuvant treatment is defined as the use of systemic therapy for microscopic meta-static disease, which is normally taken after the surgical resection of the primary tumor. Chemotherapy and anti-estrogen therapy are the two major forms of adjuvant treatment, and patients may be given one or both. A meta-analysis conducted by the Early Breast Cancer Trialists’ Collaborative Group (Hamid et al, 2004) showed the benefit of adjuvant therapy in premenopausal and postmenopausal women and in women with node-negative and node-positive disease.
The risk of getting breast cancer is about 1:8, and the risk of dying from breast cancer is lower than 1:28; however, if preventive measures are taken many more people can survive; for which greater public awareness and change of attitude in Saudi Arabia is essential. There is an acute need of extensive education among Saudi youth, mothers and society at large. The program efforts should focus on creating breast cancer early detection and treatment awareness, which can be achieved by constant encouragement by professionals, who must indulge in extensive mammography screening and genetic testing for early detection and treatment.
There is also need for more cancer health centres and education in Saudi Arabia not among the physicians alone, but active participation from nurses and medical students is also vital for creating this awareness. The healthcare sector should also be provided with better and latest equipment so that it is possible to fight this fatal disease at an early stage.
Ezzat AA, Ibrahim EM, Raja MA, Al-Sobhi S, Rostom A, Stuart RK. Locally advanced breast cancer in Saudi Arabia: high frequency of stage III in a young population. Med Oncol. 1999 Jul; 16(2):95-103
Altaf FJ. Breast cancer screening. Saudi Med J. 2004 Aug; 25(8):991-7
Alsaif AA. Breast self-examination among Saudi female nursing students in Saudi Arabia. Saudi Med J. 2004 Nov; 25(11):1574-8.
Ravichandran K, Hamdan NA, Dyab AR. Population based survival of female breast cancer cases in Riyadh Region, Saudi Arabia.Asian Pac J Cancer Prev. 2005 Jan-Mar; 6(1): 72-6.
Milaat WA. Knowledge of secondary-school female students on breast cancer and breast self-examination in Jeddah, Saudi Arabia. East Mediterr Health J. 2000 Mar-May; 6(2-3):338-44.
The National Cancer Registry. Cancer Incidence Report Saudi Arabia 1999 – 2000. Available < http://www.kfshrc.edu.sa/NCR/> Accessed Oct 26, 2005
Hamid R. Mirshahidi, MD Jame Abraham, MD. (2004). Managing early breast cancer. Postgraduate Medicine. Minneapolis: Oct. 116(4), 23-27
Miller A.B. (1996). Fundamental issues in screening for cancer. In: Schottenfeld D., Fraumeni J.F. (ed.). Cancer Epidemiology and Prevention. 2nd ed. New York: Oxford University Press, 1433-52.
Hart D. (1999). Diagnosis and treatment of breast cancer. Plastic Surgical Nursing. Pitman: Fall.19(3): 137-145
Lauersen, N., & Stukane, E. (1996). The complete book of breast care. New York: Random House
Bostwick, J., (1998). A woman’s decision: Breast care, treatment and reconstruction. St Louis: Quality Medical Publishing, Inc.
Statistics by Country for Breast Cancer.( 2003)
Available < http://www.wrongdiagnosis.com/b/breast_cancer/stats-country.htm> Accessed Oct 26, 2005