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Background: Breast cancer metastatic to the gastrointestinal tract or peritoneum is rare. We reviewed the natural history of ductal and lobular carcinoma in women with breast cancer metastatic to the gastrointestinal tract, peritoneum, or both.
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Methods: We performed a retrospective review of all patients (1985-2000) with a pathologic diagnosis of breast cancer metastatic to the gastrointestinal tract or peritoneum. Patients were categorized into three groups: those with gastrointestinal metastasis, carcinomatosis, or both.
Conclusions: Gastrointestinal metastasis occurred more often in patients with invasive lobular carcinoma. Surgical intervention did not significantly extend overall survival but may be considered in a select group of patients.
Background: Breast cancer incidence is increasing in low- and middle-income countries (LMICs). Mortality/incidence ratios in LMICs are higher than in high-income countries, likely at least in part because of delayed diagnoses leading to advanced-stage presentations. In the present study, we investigated the magnitude, impact of, and risk factors for, patient and system delays in breast cancer diagnosis in Rwanda.
Materials and methods: We interviewed patients with breast complaints at two rural Rwandan hospitals providing cancer care and reviewed their medical records to determine the diagnosis, diagnosis date, and breast cancer stage.
Conclusion: Patients with breast cancer in Rwanda experience long patient and system delays before diagnosis; these delays increase the likelihood of more advanced-stage presentations. Educating communities and healthcare providers about breast cancer and facilitating expedited referrals could potentially reduce delays and hence mortality from breast cancer in Rwanda and similar settings.
Implications for practice: Breast cancer rates are increasing in low- and middle-income countries, and case fatality rates are high, in part because of delayed diagnosis and treatment. This study examined the delays experienced by patients with breast cancer at two rural Rwandan cancer facilities. Both patient delays (the interval between symptom development and the patient's first presentation to a healthcare provider) and system delays (the interval between the first presentation and diagnosis) were long. The total delays were the longest reported in published studies. Longer delays were associated with more advanced-stage disease. These findings suggest that an opportunity exists to reduce breast cancer mortality in Rwanda by addressing barriers in the community and healthcare system to promote earlier detection.
Third world breast cancer is characterized by late presentation, occurrence at relatively young ages and dismal mortality. This poor outcome has encouraged patients to patronize quacks and alternative healers. Public control measures have targeted mainly public education and provision of screening facilities. Recent reports from the developed world indicate a high association with obesity, tobacco and alcohol, habits which though not currently very popular in the third world are nevertheless increasingly accepted.
A prospective study initiated in 1985 for all breast cancer patients attending 4 hospitals located in the Eastern Nigeria heartland where the author practiced. On attendance to hospital detailed epidemiological data including social habits were collected from patients.
There is need to take another look at cancer public health campaign mechanisms in the face of competing demands from HIV. Public control measures should include among others teaching of Breast Self Examination [BSE] to patients, Clinical Breast Examination [CBE] to health workers and opportunistic CBE to all patients. Strenuous efforts should be made to break the vicious cycle of late presentation, poor treatment outcome and reluctance of patients to present to health facilities because of poor outcome.
Eighty-eight percent of patients were married, separated, widowed or divorced at time of presentation. Mean age at menarche was 13.67 years [SD 1.61, SEM 0.15], 43% were menopausal at time of initial consultation; mean age at menopause was 46.34 years [SD 4.73, SEM 0.43]. Mean parity was 4.28 [SD 3.00, SEM 0.28], range 0 to 10; 17% were nulliparous. All parous patients had breastfed their babies, the total duration ranging from 5 to 216 months. Ninety-two percent of the patients had never used oral contraceptives, of the few that used, usage was occasional in most.
Ten percent gave a positive family history of breast cancer with the sister more often affected followed by cousins. Past history of breast cancer was obtained in 2 patients, the longest haven been treated 10 years previously. Sixty percent of the patients had a minimum of high school education.
Forty nine percent each occurred in left and right breasts respectively while 2% were bilateral. Three percent of the patients presented with Stage I, 11% in Stage IIA, 14% with Stage IIB, 32% with Stage IIIA, 36% with Stage IIIB and 4% with obvious distant metastasis in Stage IV as shown in Fig. 3. Of course under-staging is possible as only clinical methods with supportive radiology was utilized. Clinical lymph node positivity was noted in 72%. There were no mammographically diagnosed cases.
Elderly patients and those from poorer social classes presented at later stages. Whereas public health education has resulting in significant down-staging of breast cancer in other parts of the world, the results from our study when compared to previous studies from the same environment show very marginal improvement (Fig. 4).
The commonest histologic diagnosis was infiltrating ductal carcinoma in 80% followed by intraductal carcinoma in 7%, mucinous in 4%, lobular in 2% and others including a case each of malignant phylloides tumour and squamous cell carcinoma.
Compared to our previous series[13] there has been a significant increase in hospital incidence of breast cancer. This is in line with other reports from the third world and from global incidence studies[2, 4, 5]. However whether this increase is due to increasing awareness as suggested by some workers or reflects a global trend will need population based studies to elucidate. The only population based study in Eastern Nigeria[14] indicate a prevalence rate of 0.22% in nuns aged 20 to 68 years. The mean age at presentation has shown some [non-significant] increase from 44 years in our previous series to 46.9 years, a figure that is approaching the Asian and Middle Eastern population mean of 50[15, 16] but still a decade younger than the Western mean. Our findings indicate that the slight increase in mean age is due more to a higher representation of patients aged above 70 than in previous studies. This higher representation of above 70 age group is probably due to hospitals being nearer most communities or by better care by their children.
Coupled with delays in presentation is non-improvement in the clinical stage at presentation despite the above 60% literacy level in the society when compared to our previous studies[9, 13, 18, 19]. With more than 70% presenting with Stages III and IV and 72% with lymph node positivity curative therapies become elusive. This gloomy picture reinforces the negative perception of the disease in the public and maintains the vicious cycle associated with cancer in the third world. Unlike parts of Asia[15] where a small number of cases present early with mammographic diagnosis, such was not the case in this study. While mammograms are available in some centres, awareness and necessary skills in interpretation are lacking.
Current studies confirm earlier reports of falling age at menarche, falling parity and increasing age at menopause[13]. These factors have been implicated in breast cancer increase in other societies. Although the risk associated with oral contraceptives and abortion are still the subjects of considerable dispute[20] both are uncommon in the breast cancer population of Nigeria. On a happier note however other risk factors like alcohol intake, tobacco and obesity are still uncommon in the breast cancer population in this study.
Breast cancer still presents late in the third world with a widening of the 'mortality gap' Public health enlightenment measures for cancer seem to have fallen victim to the global war on HIV/AIDS. Radical policies including public campaigns with emphasis on BSE and CBE should be encouraged, while deleterious societal mindsets should be tackled. It may be wise to set targets for earlier detection to encourage curative and breast conservation measures.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Young age remains a controversial issue as a prognostic factor in breast cancer. Debate includes patients from different parts of the world. Almost 50% of patients with breast cancer seen at the American University of Beirut Medical Center (AUBMC) are below age 50.
Young age at presentation conferred a worse prognosis in spite of a higher than expected positive hormone receptor status, more anthracycline-based adjuvant chemotherapy and equivalent adjuvant tamoxifen hormonal therapy in younger patients. This negative impact on survival was seen in patients with positive lymph nodes and those with positive hormonal receptors. 152ee80cbc
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