SC 332: Epidemiology
Group Scholarly Paper
Submitted to: Ms. Noureen N. Karamali
The Aga Khan University School of Nursing and Midwifery
11th January, 2013
Word count: 1868
Cell is the smallest unit of life. Human body is made of millions of cells that reproduce and grows normally. However, disruption in cell growth results in cancer. One such type is breast cancer that has claimed the lives of million people. Moreover, breast holds great psychosexual and social significance for women. Threat to this organ dramatically shakes women identity which is important to address and also underlies our purpose of selecting this topic. This paper at paramount, attempts to elucidate the magnitude of breast cancer worldwide and in Pakistan. Moreover, it attempts to discuss the risk factors, treatment, possible prevention and recommendation with regards to breast cancer.
Breast cancer is defined as an uncontrolled division of normal cell inside the breast. It is the world’s most common cancer accounting for 41% of female cancers (Bhurgri et al., 2006). The developed countries like United Kingdom, Australia and USA have 30%, 27% and 26% patients of breast cancer among all females (Jemal et al., 2006). Moreover, amongst all Asian countries, Pakistan has highest margin of breast cancer (Banning, 2009). Additionally, the data from Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN) from the year 2000 to 2008 (Hanif et al., 2009) and Jinnah hospital Lahore from 1997 to 2001 (Aziz et al., 2008) also shows breast cancer to be the top most cancer accounting for 38% of all women. Furthermore, AKUH has identified case incidence of 336 women aged 30-35years between duration of 2011-2012.
Breast cancers have different types on basis of histopathology. First is lobular carcinoma in situ (LCIS) in which tumors are restricted to mammary glands. They neither produce lump nor does appear on mammogram and can progress to invasive breast cancer. Second is ductal carcinoma in situ (DCIS) that appears in milk ducts of breast. Unlikely LCIS, they produce lump and can identify on mammogram. 50% cases of DCIS progress to invasive breast cancer (IBC). According to American Cancer Society (2012), 226, 870 new cases of IBC are presented in United States women. At last, invasive ductal carcinoma (ICD) is a breast cancer that accounts for 85% of all cases. It begins in milk ducts and metastasizes to other body organs either through blood or lymphatic system. ICD grows as a hard lump and appears as spiked mass on mammogram (Gale, 2012).
Pathological changes in breast leads to clinical manifestation characterized by lump in breast or armpit, changes in size and shape of breast, discharge from nipple other than milk, nipple retraction, irritation, redness of breast skin and pain in lump or entire breast (Wax, n.d.).
Breast cancers are characterized by multifactorial approach of causation. Varying literature supports the inexistence of necessary cause where as several sufficient causes exist that contributes towards breast cancer which includes age, gender, family history, life style practices and hormonal factors. The most significant but non-modifiable risk factors are gender, age and family history. The prevalence of breast cancer in males is 1.2 whereas in females is 125.7 per 100,000 population (Susan, 2012). According to Harris et al. (2010) females have more breast tissues that are exposed to growth hormones resulting in increased proliferation thereby enhancing the probability of developing breast cancer. Besides gender, age is another important risk factor that has linear correlation with breast cancer. A woman aged 60yrs has a probability of 3.45% (1 in 29) as compare to women aged 30yrs who has 0.43% (1 in 232) probability of developing breast cancer (Alteri, 2012). Moreover, the risk of breast cancer doubles in an individual who has first degree relatives diagnosed with it. 60% mortality rate was identified among individuals having close blood relatives (Liede et al. 2002). In addition, the inheritance of mutated genes BRCA1 and BRCA2 that normally function as tumor suppressor gene, results in 80% probability of developing breast cancer at early age before menopause ("U.S. breast cancer statistics," 2012).
A subsequent risk factor in the development of breast cancer is life style practices which include diet, alcohol consumption, obesity and smoking. "A meta-analysis has found that moderate use of alcohol is associated with 4% increase in the relative risk of breast cancer" (Dixon, 2012). Intake of two alcoholic drinks per day increases the level of estradiol which contributes to the risk of breast cancer. (harris, lippman, morrow &osborne, 2010). In addition, obesity increases the risk of breast cancer in postmenopausal women. Adipose tissues become the essential source of estrogen after menopause. Due to excessive fats, high amount of estrogen is produce leading to rapid growth of estrogen-responsive breast tumors. The Women Health Initiative observational study of postmenopausal women weighing more than 82.2 kg has a relative risk of 2.85 (95% CI: 1.81-4.49) ("National cancer institute," 2012). Additionally, diet also contributes to the risk of breast cancer. A meta-analysis of 45 studies has concluded that the high fat intake increases the risk by 13% ("Cancer research UK," 2009). Furthermore, health cohort study has analyzed positive relationship between smoking and cancer. They have elaborated that in adolescence breast tissue are highly sensitive to carcinogens. Hence, initiation of smoking in early age has a relative risk of 1.48 (95% CI: 1.03-2.13) whereas this increased risk was not observed for women who continued smoking for 20years or initiated smoking after their first child birth (Harris et al., 2010).
In addition, third significant risk factor in the etiology of breast cancer is hormonal exposure. Estrogen and progesterone are the two significant hormones that regulate the growth and proliferation of breast tissue. Marie Martin, & L. Weber (2000) stated that prolong exposure to these hormones elevate the risk of breast cancer. Increase number of menstrual cycles, early age of menarche, nullparity and late onset of menopause contributes to prolong endogenous hormonal exposure and has a relative risk of 1.1-2.0 (Alteri, 2012). After menopause, long term use of estrogen and progesterone in combine hormonal replacement therapy (CHRT) has resulted in excess breast tumors as compare to women who never used CHRT. According to National cancer institute (2012), 26% increase in incidence rate of IBC was identified after using CHRT. However, the cohort study by cancer registry of Schleswig-Holstein concluded that cessation of HRT therapy for 1-4 years results in 8.8% decline in the incidence rate of breast cancer among women aged 50-60 years (Katalinic & Rawal, 2007).
Preventive measures for breast cancer are best described at primary, secondary and tertiary level. At primary level, prevention is done at mass level and high risk level which is accomplish by running awareness campaigns and educating overall population. It has been identified that Pakistani women are presented at late stage of breast cancer mostly due to lack of awareness. A survey by Lahore hospital analyzed 25% to 35% women was presented in metastatic stage of cancer (Gillani and Akhter, 2003). Health care providers give awareness regarding prevention of controllable risk factors that includes regular exercise, controlling body weight, low fat intake, avoiding alcohol and smoking. Public health nurse should also encourage breast feeding as it serves as protective factor against breast cancer. In a case study presented by Navod (2012), 1,665 pairs of women with a mutated BRCA1 (n = 1,243 pairs) were selected. They give breast feeding to their children’s for at least one year which reduces the risk by 32%. (CI: 95%) that proves breast feeding to be protective against BRCA1. Moreover, public health nurse should emphasize on screening for early detection for example every women aged 40 years and above should go for yearly mammography. Furthermore, celebration of breast awareness month (October) by organizing seminars and workshops was one of the Pakistan’s government steps towards primary prevention.
After that, interventions at secondary level are done to prevent the secondary effects of breast cancer by early detection and cure. It does not prevent breast cancer but attempts to minimize its impact or severity. Early detection includes screening which is done through self and clinical breast examination, mammography and ultrasound. It is recommended that every woman above age of 40 should be screened for breast cancer every year. According to Fogel, C. I., & woods, N. F (n.d.), community health nurses teaches breast self-examination (BSE) with a purpose of making client more aware of own breast changes. This is achieved by demonstrating BSE, giving feedback on technique performed by client and reinforcing continuation of client’s efforts. Despite of knowledge women are often reluctant to perform BSE due to low confidence and feeling of susceptible to breast cancer. Nurse attempts to overcome these barriers by providing facts and anticipatory guidance. Moreover, mobile mammography was launched on 31-march-2012 by pink ribbon Pakistan with an aim of providing facilities to poor people at their doorstep. (Free Mobile Mammography Screening Service, n.d.). After, screening and confirmation of diagnosis early treatment is initiated to prevent complications and reoccurrence. The treatment comprises surgery (lumpectomy and mastectomy), hormonal therapy, radiation therapy and chemotherapy.
Treatment started at secondary level is continued to tertiary level. In tertiary prevention, intervention such as rehabilitation is done to prevent further complications, functional limitation and disability. Furthermore, interventions are done to improve the quality of life. Women experiencing breast cancer often undergo psychological trauma and ends up with the feelings of altered body image, worthlessness, sexual anxieties and isolation. Hence, in such critical situation aim shifts towards improving self-esteem of patients by offering surgeries such as breast reconstruction. Agarwal et al. (2011) identified that 76% women were satisfied with their life after undergoing breast reconstruction.
It is recommended that development of prevention awareness campaigns should be done that anticipates the enhancement of community wakefulness of breast cancer as Zhu and Hu, (2010) has identified that women still exhibit knowledge deficiency regarding various aspects of breast cancer prevention, screening and diagnosis. Moreover, screening and early detection programs should be run throughout Pakistan to address high risk individuals and to ensure the continuity and quality of actions. Ongoing educational seminars regarding early recognition and diagnosis, pertinent to assessment are needed to be arranged for health care providers. Supporting this point, Huay-ben, (2013) signifies assessment as central component in diagnosing breast cancer as under assessment can delay the treatment and over assessment can increase financial burden. Fogel et.al, (n.d.) supports that duration and thoroughness of CBE has positive relation with accurate lump detection. In addition, public health schemes should be more intensive on patients with low individual socio economic status in command to lessen the health discrepancies. Furthermore, future research should be done to identify root cause of breast cancer. Effective strategies should be developed to detect breast cancer at its very early stage. Improving quality of life of breast cancer survivors necessitates the development of therapeutic interventions.
In conclusion, breast cancer is a sensitive issue that has ruined the life of millions of women and has posed challenges to women’s reproductive health. The prevalence and mortality rate of breast cancer is increasing worldwide and nationally. A step towards awareness regarding primary, secondary and tertiary prevention, thorough screening including SBE, CBE, ultrasound and mammogram, early diagnosis and multiple treatment options greatly influences the women health thereby affecting the disease burden of breast cancer. Moreover, intervention of recommendation will greatly influence the future of women having risk and diagnosed with breast cancer there by affecting the epidemic of breast cancer.
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