Epidemiology and Histology Aspects of Breast Cancers of Women in Ivory Coast

doi:10.4236/jct.2012.325098

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Journal of Cancer Therapy, 2012, 3, 782-786

http://dx.doi.org/10.4236/jct.2012.325098 Published Online October 2012 (http://www.SciRP.org/journal/jct)

Epidemiology and Histology Aspects of Breast Cancers of

Women in Ivory Coast

Justin N’Dah Kouame1, Emile Troh1, Emmanuel Koffi Kouakou2, Brahima Doukouré1,

Arthur Didier Kouame3, Alain Didier Abouna1, Benjamin Ahoua Effi4, Mohenou I. Diomandé1

1Department of Pathology of the University Teaching of Cocody, Abidjan, Ivory Coast; 2Department of Pathology of the University

Teaching of Treichville, Abidjan, Ivory Coast; 3Department of Gynecology of the University Teaching of Cocody, Abidjan, Ivory

Coast; 4Department of Pathology of the University Teaching of Bouake, Abidjan, Ivory Coast.

Email: [email protected]

Received August 6th, 2012; revised September 9th, 2012; accepted September 20th, 2012

ABSTRACT

Breast cancer is a major public health problem both in developed countries, where it represents the first female cancer,

and in developing countries, where its incidence is increasing. Purpose: The authors report the results of a study whose

objective was to describe the epidemiological and pathological features of women’s breast cancers in Ivory Coast. Ma-

terial and Methods: This is a retrospective descriptive study on breast cancer histologically confirmed and made from

the records of pathology laboratories of the University Hospital in Abidjan. The study period was 24 years (1984-2007).

The parameters studied were: frequency, age, risk factors, the macroscopic and histological aspects. Results: Women’s

breast cancer was the second cancer among women (13.69%) after cervical cancer and represented 6.51% of cancers.

The average age was 45.21 years ranging from 10 years to 85 years. Subjects from 35 to 44 years were the most af-

fected (30.7%) and 8% of patients were under 30 years (n = 61). Multiparity (53.55%) and lower socioeconomic level

(79.63%) were associated. At the macroscopic level nodular aspects represented 47.62% of cases (n = 301). Carcinomas

were 92% (n = 710) of histological types with 94.36% (n = 692) of invasive carcinomas. Sarcomas (5.7%), lymphoma

(2.1%) and Paget’s disease (0.3%) were also observed. With regard to prognostic, the grading of Scarff-Bloom and

Richardson showed 26.75% (n = 156) grade I, 60.64% (n = 354) grade II and 12.52% (n = 73%) grade III. Conclusion:

In consideration of prognosis of advanced forms, an effort should be made for diagnosis and early treatment of

women’s breast cancer in Ivory Coast.

Keywords: Cancer; Breast; Epidemiology; Pathology; Ivory Coast

1. Introduction

Breast cancer is the most common cancer of women

worldwide and represents approximately 16% of all

female cancers. According to WHO, 519,000 women

died in 2004 and 69% of cancer deaths are from breast

[1]. This is a complex disease influenced by many risky

factors. We distinguish the genetic, environmental and

demographic factors on the one hand. And on the other

hand, the hormonal factors and those related to re-

production, lifestyle and eating habits. Clinically, it

manifests itself as a breast lump sometimes associated

with mastodymia, nipple discharge and retraction with

axillary nodes affected in advanced forms.

In developed countries, screening by imaging and

needle biopsy allow the diagnosis of cancerous lesions to

be earlier and as a result terrible prognosis [2]. In

developing countries, incidence rates are low but rising

steadily with a tendency to become a public health pro-

blem. The prognosis is bleak because of the lack of

appropriate strategies in most of these countries [1]. In

Ivory Coast, the advent of infectious diseases (HIV/

AIDS, malaria and endemic and epidemic diseases) and

their corollaries on the ivorian population, has put in the

background women’s breast cancer [3]. For decades, the

laboratory of pathological anatomy of Hospitals and

University of Cocody and Treichville were the only ones

in the Ivory Coast to perform examinations of patho-

logical anatomy until the 1990s. A study conducted in

those laboratories between 1974 and 1983 by Diomandé

et al. showed that cervical cancer was the first cancer of

women and breast cancer was the second with a fre-

quency of 10.52% of cases [3]. According to an ex-

haustive study of the first results from the cancer registry

of Abidjan carried out by Echimane et al., breast cancer

of women has an incidence of 24.5 cases per 100,000

women [4]. The aim of our study was to clarify the epi-

demiological and pathological features of breast cancers

Epidemiology and Histology Aspects of Breast Cancers of Women in Ivory Coast 783

of women in order to adopt an adequate strategy of care

in our Ivorian context.

2. Material and Methods

This is a retrospective descriptive study conducted from

registers of pathological anatomy laboratory of the Uni-

versity Hospital of Cocody and Treichville from 1984 to

2007. These laboratories were the main structures of

registration and diagnosis of breast lesions in Ivory Coast.

Databases reported in the records included the patient’s

identity (name, surname, age, sex and address). The cli-

nical, personal and family history, place of origin, the

type of sample, and histological types were recorded.

They stem mainly from pathologic examination bulletins

prefilled by the requesting physician or from the service.

Initially, samples were fixed in 10% formalin and under-

went the usual techniques of paraffin embedding, micro-

tome cutting, staining with hematoxylin-eosin staining

and additional colorations were absolutely necessary to

refine the diagnosis. In our study were included all cases

of breast cancers diagnosed on biopsy specimens of breast

and pieces of partial or total mastectomy with or without

cleaning out the axillary ganglia and histological exami-

nation confirmed. The results of breast needle biopsy

unconfirmed in the pathologic examination were not con-

sidered. Multiple registrations of the same patient were

considered only once. Statistical processing and data

analysis were performed using SPSS software.

3. Results

3.1. Epidemiology

3.1.1. Freq uency

From 1984 to 2007, we have worked in 139,542 samples

and diagnosed 11,854 cancers, wich was a frequency of

8.5 % of cases. Breast cancers of women represented

13.69% (n = 772) of cancer among women and 6.51% of

all cancer patients together (men and women). The an-

nual incidence was 30.33 cases with a peak in 2001 (50

cases). The frequency breaking down by year is illus-

trated in Figure 1.

3.1.2. A ge

The average patient age at the moment of the diagnosis

was 45.21 years ranging from 10 years to 85 years. The

breaking down of ages is illustrated in Figure 2. The

peak incidence was noted with patients from 35 to 44

years with a percentage of 30.7% (n = 237). The subjects

under 30 years represented 7.9% (n = 61), those from 30

to 64 years 79.53% (n = 614) and aged patients 12.57%

(n = 97).

3.1.3. Personal and Family History

These personal and family histories are reported in Table

1. There was a high multiparty (53.55%) among breast

cancer patients. Precocious puberty was observed in

11.29% of patients (n = 27), exclusive breastfeeding in

10.46% (n = 25) and family history of breast cancer

based only on data of the interview in 8.78% of cases (n

= 21). The first pregnancy after age 30 years old repre-

sented 4.18% (n = 10) and late menopause after 50 years

old in 1.25% of cases (n = 3). The average age of meno-

pause was 50.3 years ranging from 45 to 52 years.

3.1.4. Socio-Ec onomic

The subjects with low socioeconomic status (housewife

and tradeswomen) represented 79.63% of cases (n =

559).

Officials, pupils and students and the retirees had a

frequency of 20.37% (n = 143).

Different socio-economic values are reported in Table 2.

3.2. Pathology

3.2.1. Macrosco pic Aspec ts

Macroscopic aspects were performed with 632 patients.

These were nodular (47.63%), ulcerative (29.9%), in-

filtrative orange peel (13.45%), scirrhous (8.07%) and

calcifications (0.95).

Figure 1. Distribution of frequencies by year.

Figure 2. Distribution of breast cancer by age.

Epidemiology and Histology Aspects of Breast Cancers of Women in Ivory Coast

784

Table 1. Different types of personal and family history.

Histories Effective Percentage

Precocious puberty 27 11.29

Nulliparity 8

Pauciparity 17

Party

Multiparity 128

64.01

First child after age 30 10 4.18

Exclusive breastfeeding 25 10.47

Late menopause after age 50 3 1.25

Family history of breast cancer 21 8.78

Table 2. Different socio-economic levels.

Socio-economic Effective Percentage

Pupils and students 23 3.28

Officials 107 15.24

Housewife 307 43.,73

Retired officials 13 1.85

Traders 252 35.9

Total 702 100

3.2.2. Histological Asp ec ts

Their frequency is reported by Table 3.

Carcinomas represented 92% (n = 710) of histological

types including 94.36% (n = 672) of invasive carcino-

mas.

Among these patients with carcinoma, 6.33% (n = 45)

were under 30 years, 80.56% (n = 572) were aged be-

tween 30 and 64 and finally 13.1% were over 65 years.

There were also 20 cases of medullary carcinoma

(2.59% of cases) with an average age of 39.7 years. Sar-

comas were observed in 5.7% of cases of histological

types (n = 44), 79.5% (n = 35) of Kaposi’s sarcoma,

9.1% (n = 4) of malignant phyllode tumor, 6.8 % (n = 3)

liposarcoma and 2.3% (n = 1) of malignant heman-

giopericytoma and fibrosarcoma.

Patients under 30 years accounted for 15.9% (n = 7),

whose age is between 30 and 64 years were observed in

75% (n = 33) and 9.1% (n = 4) for patients over 64 years.

As for lymphomas, their incidence was 2.1% (n = 16)

of histological types. We distinguished 11 cases of

Burkitt lymphoma (68.75%), 3 cases of large cell NHL

(18.75%) and 2 cases of NHL mixed with small and large

cells (12.5).

These lymphomas were diagnosed in 50% of cases (n

= 8) among patients under 30 years and also in 50% of

cases among patients from 30 to 64 years olds.

Paget’s disease of the nipple was observed in 0.3% (n

= 2) of histological types and in one case it was associ-

ated with infiltrating ductal carcinoma.

3.3. Prognosis

3.3.1. Classification of Scarff Bloom Richardson

Prognosis

It was performed on 583 breast carcinomas. The grade I

(3,4,5) represented 26.75% (n = 156 cases), grade II (6.7)

60.73% (n = 354) and grade III 12.52% of cases (n = 73).

3.3.2. pT NM Classifi cation of Breast Carcinom a

Their frequency is reported in Table 4. Lymph node

metastases were observed in 86.44% of cases (n = 593).

The average tumor size was 3.75 cm and ranged from 0.5

cm to 10 cm.

4. Discussion

In Ivory Coast, for decades, cancer has been overshad-

owed by the importance of tropical infectious diseases.

The country has only two laboratories of pathology lo-

cated in Abidjan (economic capital). Inside the country

the infrastructures to support the cancer patients do not

exist and the absence of a pathologist contributes further

to aggravate the prognosis. The subjects are referred to

the only oncology department located in Abidjan. Sam-

ples from within the country are increasingly rare be-

cause of the increasing poverty of the population, which

greatly influences the running of the single cancer Regis-

try established in 1994 in Abidjan. Since the 1970s, the

pathology laboratories of the University Hospital of Co-

cody and Treichville allowed to appreciate assess the

impact of cancer. Although the values of these two la-

boratories only partially reflect the reality on the Ivorian

breast cancer, they allow to notice the importance of this

cancer that is increasing in our country (13.67% in 2010

in our compared study to the series of Diomandé

(10.52% in 1988) [3]. This increased incidence is due to

the improved diagnostics and especially the advent of

mammography that few patients have access in Ivory

Coast. We treated an average of 30 cases/year of breast

cancer in our series. However, the absence of prevalence

study is a real problem for the accurate assessment of this

disease. An exhaustive study archived with the first re-

sults of Abidjan’s cancer registry by Echimane et al. re-

ported a standardized incidence of 24.5 per 100,000

women [4]. The average age at the moment of the diag-

nosis is earlier (45.21 years). Indeed about 8% of cancers

occurred among patients under 30 years, 30% of patients

were aged between 35 to 44 and about 12% of patients

were over 64 years (older women). This distribution of

slices ages is similar to that found in West African coun-

tries where the population is predominantly young [5,6].

The average age of our patients is identical to that ob-

Epidemiology and Histology Aspects of Breast Cancers of Women in Ivory Coast

785

Table 3. Distribution of histological types according to age.

Age histological types 0 - 14 15 - 2424 - 3435 - 4445 - 5455 - 64≥65 Total %

IDC - 6 35 128 85 88 78 420

DCIS - 1 3 3 2 1 - 10

ILC - 3 38 76 57 59 14 247

LCIS - - 2 5 1 - - 8

MC - 1 3 8 2 5 1 20

Carcinoma

ACC - - - 1 2 2 - 5

Sarcoma 1 3 12 11 5 8 4 44 5.7

Lymphoma 5 1 5 4 - 1 - 16 2

Paget’s desease - - 1 1 - - - 2 0.3

Total 6 15 99 237 154 164 97 772 100

Note: IDC = Infiltrating ductal carcinoma; ILC = Infiltrating lobular carcinoma; MC = Medullary carcinoma; ACC = Adenoid cystic

carcinoma; NHL = Non-Hodgkin lymphoma; DCIS = Ductal carcinoma in situ; LCIS = Lobular carcinoma in situ.

Table 4. Distribution of breast cancer according to the

pTNM.

Nods

tumor pN0 pN1 pN2 pN3 pNx Total Percentage

pT1 12 2 1 - 10 25 3.65

pT2 27 41 30 15 17 130 18.95

pT3 31 47 80 27 42 227 33.09

pT4 15 48 57 24 57 201 29.3

pTx 8 33 17 19 26 103 15.01

Total 93 171 205 85 152 686 100

% 13.55 24.93 29.88 12.39 22.15 100

served by Najjar et al. [7] (45.4 years) and different from

data given by Rahasolo in Madagascar (47.5 years) [8],

Traore in Mali (48.2 years) [5] and European and US

averages (60 to 65 years) [9]. In general, the everage age

for diagnosis of breast cancer in developing countries is

lower than in western countries with an increasing trend

in all African series [5,6,8]. Thus, many genetic risk fac-

tors, environmental, demographic, sanitary and hormone

have been incriminated in breast carcinogenesis. The

early menses, associated with early and prolonged expo-

sure to hormonal impregnation, is not frequent in our

study and would be related to eating habits and require-

ments of the westernization of urban populations [10].

Exclusive breastfeeding, long practiced in developing

countries, permitted to reduce considerably the develop-

ment of breast cancer through the resting ovaries [10].

Unfortunately, the present context of modernization of

Ivorian society explains the gradual forsaking of this type

of plan in favor of mixed feeding and artificial and is

actively involved in the occurrence of breast cancer the

woman. Family history of breast cancer is often linked to

major genes (BRCA1, BRCA2) and other genes such as

TP53, PTEN, which are responsible for the Li-Fraumeni

syndrome and Cowden disease [11]. Although, they have

not been confirmed at the cytogenetic and molecular bi-

ology, familial breast cancers are not a significant entity

in our series (8.78%). The rate of menopausal women in

our study remains low as reported in other low-incidence

countries [5,6,10]. Most patients have significant physi-

cal activity (housewives and traderswomen). But ac-

cording Friedenreich et al., physical activity has an in-

fluence on the risk of breast cancer by decreasing estro-

gen production and maintaining energy balance [12]. But

the lack of strategy against breast cancer and lack of

knowledge of breast cancer in a large majority of women,

even urban, could explain this paradox. At macroscopic,

the tumor nodules and ulcerated tumors formed the basis

of macroscopic aspects, with an average size above than

3 cm in diameter. According to pTNM classification

(2003) used in our study [13], 29.3% of patients had tu-

mors larger than 5 cm in diameter and lymph node in-

volvement was observed in 86.44% cases. These values

reflect the advanced stage of breast cancer in our country.

Indeed, patients are seen in consultation in the context of

advanced cancer very often after approximative diagno-

sis and generally often traditional treatment with herbal.

Histologically, the predominance of epithelial tumours is

similar to literature data [5,6,14,15]. Invasive carcinomas,

which constitute the essential cancers, reflect the impact

of the late diagnosis of this disease in Ivory Coast. The

poor prognosis of these tumors is conformed with the

african literature [5,6,8]. Breast sarcomas (5% of all his-

tological types) are mainly Kaposi's sarcoma (79.5%

Epidemiology and Histology Aspects of Breast Cancers of Women in Ivory Coast

786

sarcomas) in our country. This is a situation due to the

impact of the virus HIV/AIDS, most often responsible

for carcinogenesis of tumor whose incidence remains

high in Ivorian society [16]. Primitive non-Hodgkin lym-

phomas have also been identified; the most common is

an endemic Burkitt lymphoma (68% of cases). Indeed,

the incidence of lymphoma B is high in African countries

located under the Sahara. In Coast Ivory, it particularly

affects children and adolescents and represents for 30 to

60% of childhood cancers with a predominant localiza-

tion in the mandible [17]. These locations extra-atypical

mandibular and abdominal are rare in the literature and

could be due to a spreading of tumor cells from an un-

known site to the mammary vessels. The high rate of

breast cancers among patients under 30 years observed in

our study is related to the impact of these two endemic

diseases in Ivory Coast.

5. Conclusion

Breast cancer is a common disease in the Ivory Coast and

is therefore a major public health problem. It is a disease

that primarily affects young individuals and is most often

diagnosed at an advanced stage. In consideration of the

poor prognosis of breast cancer of women in our country,

an effort should be made for the setting up of information

programs and training of women (breast self-examina-

tion), health workers and medical practitioners (gyne-

cologists) throughout the territory. The effectiveness of

such a public health program must take into account both

the training of specialists in pathology, and the creation

of a radiotherapy and oncology equipped structure as part

of a real testing policy of precancerous lesions and their

management.

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