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Title- Breast cancer in Saudi Arabia: The social anatomy of metastasis
Name of author-
Dr Tabinda Hasan

Breast cancer in Saudi Arabia: The social anatomy of metastasis.
Summary: Breast cancer is a fast emerging killer of women today. The unique vascular and lymphatic anatomy of the breast, aided by the racial and socio-biological make-up provide a fertile environment for metastasis. The stigma attached to breast cancer takes a new turn when it comes to Arab females. The differences in environmental and genetic factors are in part, responsible for different demographics and primary tumor characteristics; but there is an even bigger contributing factor lurking behind the thick curtains of society and traditions. The present article tries to unveil some of these closely guarded secrets in addition to bringing to the forefront, the current demographic status of breast cancer in the Arab world.
Introduction-
Breast cancer is the second leading cause of death among females around the world. It is a cause of morbidity not only for the female, but also for the family unit as a whole. Cancer invasion into neighboring tissues and metastasis to loco-regional lymph nodes or to distant organs is responsible for most of the cancer deaths. The demographics of breast cancer in the Arab world reveals an overwhelming metamorphosis as the incidence and course of the disease presents an uphill course which requires rapid socio-biological intervention.
Discussion-
Breast cancer related metastasis may occur via blood or lymphatics or through both routes. The most common places for the metastasis to occur are the lungs, liver, brain and bones. Although the etiology of breast cancer is unknown, numerous risk factors may influence the development of this disease including genetic, hormonal, environmental, socio-biological and physiological factors. Differences in life style and genes play a pivotal role in creating the "metastasis friendly" microenvironment. This has been proved time and again by studies showing that blacks continue to have a disproportionately higher cancer burden than whites. Experimentally, differential tumor cell adhesion to organ-derived micro vessels and organ parenchymal cells, appear to be important determinants in explaining the organ preference of metastasis and may eventually be used to predict and explain the unique metastastic distributions in breast cancer malignancies. It has been proposed that the genetic state of the primary tumor reflects the ability of that cancer to metastasize1. The body resists metastasis by a variety of mechanisms, through the actions of a class of proteins known as metastasis suppressors of which about a dozen are known2. Studies on breast cancer show that solitary skeletal metastasis has a different anatomical distribution and is an independent prognostic factor in patients with skeletal metastasis 3. Among patients with one to three positive axillary nodes, survival in case of internal mammary involvement has been found to be significantly lower than without internal mammary involvement .4 Also, the upper outer quadrant of the breast appears to be the most common site of malignancy .5 The descriptive epidemiology of breast cancer has demonstrated a rapid increase in the incidence rates in developing countries.6,7 Identification of the contributing factors for the increasing rate would help substantially in our understanding of the epidemiology of breast cancer.6 Environmental factors as well as genetic factors have been considered as the reason for variation in breast cancer rates among countries.7
Over the past few decades, while the risk of developing breast cancer has increased in both industrialized and developing countries by 1%–2% annually, the death rate from breast cancer has fallen slightly. Researchers believe that lifestyle changes and advances in technology, especially in detection and therapeutic measures, are in part responsible for this decrease. The statistics from the WHO reveal that more than 1.2 million women are diagnosed with breast cancer annually worldwide. In the next quarter-century, an estimated 25 million women around the world will be diagnosed with breast cancer," In developed countries, most patients (> 80%) with breast cancer present with operable disease that can apparently be entirely resected surgically. Unfortunately, about half of these patients eventually relapse.
Upon reviewing the aforementioned data one can well acknowledge the fact that medical literature is full of extensive researches on the various aspects of breast cancer; ranging from risk factors and treatment modalities to diagnosis and management. Unfortunately, we haven’t found an absolute cure even today.
Moreover, most of the previous studies have been conducted upon Caucasians, Pacific Islanders, Hispanics, and African females. Asia, despite being a vast continent has received surprisingly little attention. The available literature comes from Far East Asia and Russia. The rest of Central Asia, South East Asia and the Arab world remain blotted out of the picture.
Amongst an array of other factors, the unique "socio-cultural make up" of the Arabs has posed a hindrance towards a better exploration of the subject in this part of the world. The disparities in screening behavior contribute to worse outcomes for vulnerable women .Early detection is important, when a cure is most likely. Late-stage diagnosis in Saudi females has been linked to a number of structural and institutional barriers to care, including inadequate access to care, lack of access to health information, belief systems, cultural differences, language barriers, limited literacy, knowledge deficits and misconceptions.
It is a well documented fact that cancer cells thrive in a specific internal body environment (the seed and soil theory by Stephen Paget-1889). Racial disparities can influence both, the magnitude of malignancy and resistance to therapy. Yet our knowledge of the "cancer trends" among the Arabs is minuscule.
Here is a bird's eye view of the cancers diagnosed in the Saudi population.
Male
Leukemia 276 (9.6%) Liver 242 (8.4%) NHL 230 (8.0%) Colo-rectal 222 (7.7%) Lung 169 (5.9%) Prostate 156 (5.4%) Skin 143 (5.0%) Hodgkin Disease 137 (4.8%) Bladder 129 (4.5%) Nasopharynx119 (4.1%) Total=2875
Female
Breast 545 (19.9%) Thyroid 254 (9.3%) Colo-rectal 216 (7.9%) NHL 190 (6.9%) Leukemia 179 (6.5%) Ovary 101 (3.7%) Skin 100 (3.6%) Cervix uteri 92 (3.4%) Liver 81 (3.0%) Corpus uteri 78(2.8%) Total= 2741
We can see breast cancer topping the charts at a whopping 20%.
The demographics of breast cancer in Saudi Arabia during the past years are as follows:
Several studies have shown an upward trend in the incidence of breast cancer in Saudi Arabia.8,9,10,11 Breast malignancy had the highest relative frequency in the eastern region of Saudi Arabia during 1981–83 in relation to previous studies .This shows an upward trend in that region as it rose from the third most common cancer during 1952–60 to the second most common in 1962–73.8 However, it is the sixth most common malignancy in the southern region.9 For females in general, it is the most common cancer.10 The number of breast cancer cases registered at King Khalid University Hospital, Riyadh were 47, 48 and 107 during the periods 1985–87, 1988–90 and 1990–93 respectively and breast cancer was the second most common malignancy among females in that hospital.11 Data suggests that breast cancer in Saudi Arabia occurs in a relatively younger age group compared with industrialized countries. The mean age of Saudi women with breast cancer is 47 years as compared with 54 years in Western Europe and America.8 The number of reported cases of breast cancer in Saudi Arabia in 1999–2000 was 1157 (out of a female population of 7 788 754).12 There is no available data showing the number of deaths that can be attributed to breast cancer in Saudi Arabia. A significant positive association was found between risk of breast cancer and intake of dietary fats, protein and calories13.The calorie rich food habits of the locales support the findings. Whilst locally advanced breast cancer disease is unusual in Western countries, it constitutes more than 40% of all non-metastatic breast cancer in KSA.14 This retrospective analysis of the medical records of patients with Stage III breast cancer patients was done at King Faisal Specialist Hospital and Research Center between 1981 and 1991 .Most patients were younger than 50 years (64%) and in premenopausal (62%) years which is distinctly different from the 60-65 years median age in industrial Western nations. Patients were approximately equally divided between Stage IIIA and Stage III B.
Treatment modalities in breast cancer exhibit a wide diversification. First there was surgery, then chemotherapy and radiation. Now, doctors have come up with a fourth way to fight cancer; using the body's natural defender, the immune system. This is a novel approach in the battle against cancer but it has yet to prove its mettle. Even though neoadjuvant or preoperative induction chemotherapy has a high response rate and allows more conservative surgery, it is less apparent if survival is improved. Clinical trials are under way to see if genetic information collected from tumors can help predict which women will benefit from adjuvant chemotherapy.15 Still, the prognosis of patients with Stage III disease remains poor despite the use of a multimodality approach.
The rather high rate of breast cancer in Saudi Arabia is shared with most of the other Arab nations as well. If one observes the above mentioned data, many interesting facets of the disease reveal themselves here in Saudi Arabia.
Unlike the history of breast cancer in the US, majority of the women here are diagnosed in late stages of cancer .The mortality rate is higher here than in the other parts of the world. This is due to late detection and therapeutic intervention owing to ignorance about breast cancer, cultural stigmas regarding cancer and taboos on being vocal about this aspect of "womanhood". (Both the males and females share this view point.) Another interesting aspect is that the society here permits male polygamy. The Saudi female faces a unique unspoken fear of loosing her man to another woman if she isn't "feminine enough". So her physical "flaw" must be hidden in order to retain her husband for a longer time. This may partially contribute to the late stage presentations.
Compared to the West, where breast cancer mostly hits women in their fifties, Saudi women are afflicted by it in their forties. Genetic and environmental makeup may in part be held responsible for this.
Another unique issue pertaining to women with breast cancer in this society is that the man holds the power to decide over his woman's medical treatment to some extent. He can simply deny or delay her treatment because he is her "Kafil" or her legal guardian. Women have little power in that. This is because most men are ignorant about breast cancer themselves and consider it an "alien phenomenon".
What is more shocking is that many a times the doctor's attitude prevents good care when it comes to female patients. There is this overwhelming idea here that women in this culture are over dramatic and so should not be taken seriously even by their own doctors. Worth special mention is the case of a woman (identity confidential upon request) who went to her doctor, telling him that she felt "something wrong" with her breast. He noted her behavior as "over dramatic and attention seeking" and sent her on her way home. Until finally, she was diagnosed with cancer, two years after telling her doctor about her forebodings. She knew her own body; but the doctor simply felt that he knew the best and thought that women in this culture should be handled differently. (Do note she is now cancer free and faced all of her treatments like a champ, far from being "over dramatic".)
In theory, Saudi women should be able to detect breast cancer earlier than women in other parts of the world because health care is free for them. But in reality, cultural issues often prevent this from happening. Recently there were efforts on behalf of the government to make screening tools available to the locals in suburban areas .Mobile mammography vans patrolled, urging the females to come out and screen themselves. Surprisingly enough very few of the women ventured out of the safe sanctuary of their homes "without their male escorts". So we see that what works best in most countries of the world, may not necessarily work any wonders over here.
The Saudi government has made treatment for cancer patients free, as are other medical treatments, for its citizens. There are some great oncology units in Saudi Arabia, particularly King Faisal Hospital and Research Center in Riyadh and Jeddah .They offer a sanctuary for victims of this dreaded disease. However, treatment for non- Saudi patients is not free here. Although medical expenses here are very low compared to the rest of the world, out of pocket expenses for a prolonged cancer battle can run into some baffling financial troubles. Not all cancer medications are available in Saudi Arabia and many patients ultimately resort to the West. Saudi Arabia uses its own screening process before allowing the influx of any sort of medication. All are aware of the capital punishment imposed upon drug traffic here. So it may take some tedious screening time when it comes to introduction of new drugs that are placed on the American or European market. But the medications here are substantially cheaper than the US (about one fourth in cost price)
For the past several years the US has been working in collaboration with Saudi Arabia to tackle this disease effectively. Women have been sent abroad for education in order to learn how to promote breast cancer awareness in the Kingdom. The Kingdom of Saudi Arabia is the third country to join the groundbreaking U.S.-Middle East Partnership for Breast Cancer Awareness and Research. This has had its affects; the numbers of earlier detections are increasing a bit. Riyadh's King Faisal Specialist Hospital now includes a new breast cancer research unit that studies risk factors and develops treatments. The Saudi Cancer Society is a non-profit, charitable organization supervised by the Ministry of Social Affairs. The Society's mission is to minimize the effects of cancer on the Kingdom's community. To accomplish this, the Society supports detection and treatment programs, encourages scientific research to identify the causes of cancer in the Kingdom, and contributes to the support of cancer awareness and prevention. In February 2008, King Abdullah University (KAU) Hospital hosted a breast cancer awareness campaign organized by the Saudi Cancer Society. The campaign took place in Riyadh, Jeddah, Qassim and Dammam regions of Saudi Arabia. In 2010; there was a call for government funded research proposals from educational institutions all over the Kingdom with an aim to know more about this dreaded disease.
Conclusion-
The Saudi government is taking commendable steps in fighting the battle against breast cancer but there are still many social stigmas that are part and parcel of this disease, even more so with women, and breast cancer remains an occult woman killer today which needs rigorous intervention at all levels. All Saudi women need to be proactive in fighting the battle against breast cancer.
Recommendations-
We need more organized scientific researches here that will fulfill the following goals and objectives:
- A better understanding of patient demographics, primary tumor characteristics, tumor biology and metastasic distribution pattern to elucidate "cancer trends" in the Saudi population.
- Co relating the metastatic pattern of breast cancer with the therapeutic response. This way we can get a clue as to "what works best "for a Saudi female.
- A better analysis of the anatomical relationship between primary tumor and metastatic sites. The unique vascular and lymphatic anatomy of the breast is a decisive factor in the implantation of metastasis. This novel anatomico-clinical approach will benefit both the clinical oncologists and researchers.
- Improving the access to information and care in breast cancer to help women make informed decisions about their own health.
-Some socio- cultural parameters need to be modified as well. The society here needs to deal with taboo issues in a frank and supportive manner.
After all, intervention comes only after functional education. A practically feasible and socially acceptable Health communication strategy for breast cancer awareness and prevention needs to be adopted.
Workshops on "Breast Cancer Screening Guidelines" must be organized in educational institutions and various public and private sectors. This should include individualized guidance on "Breast Self Examination", Ideal Mammogram intervals and "Basic Screening Recommendations".
Through community education and active collaboration between health systems, educational institutions and general public, this ominous disease trend can be encountered and deterred from its destructive course.
References:
[1] - Ramaswamy S, Ross KN, Lander ES, Golub TR (January 2003). "A molecular signature of metastasis in primary solid tumors". Nature Genetics 33 (1): 49–54. doi:10.1038/ng1060. PMID 12469122
[2]-Yoshida BA, Sokoloff MM, Welch DR, Rinker-Schaeffer CW (Nov 2000). "Metastasis-suppressor genes: a review and perspective on an emerging field". J Natl Cancer Inst. 92 (21): 1717–30. doi:10.1093/jnci/92.21.1717. PMID 11058615. http://jnci.oxfordjournals.org/cgi/content/full/92/21/1717.
[3]- M. Koizumi, M. Yoshimoto, F. Kasumiand E. Ogata epartments of Nuclear Medicine, Breast Surgery and Internal Medicine, Cancer Institute Hospital, Tokyo
[4]- Veronesi U, Cascinelli N, Bufalino R, Morabito A, Greco M, Galluzzo D, Delle Donne V, De Lellis R, Piotti P, Sacchini V, et al. Risk of internal mammary lymph node metastases and its relevance on prognosis of breast cancer patients.Acta Oncologica 1988, Vol. 27, No. 6, Pages 715-719
[5]- Paul J. Borgstein, , Sybren Meijer, Rik J. Pijpers, and Paul J. van Diest, Functional Lymphatic Anatomy for Sentinel Node Biopsy in Breast Cancer Ann Surg. 2000 July; 232(1): 81–89. 2000 Lippincott Williams & Wilkins, Inc
[6] - Kelsey JL, Horn-Ross PL. Breast cancer: magnitude of the problem and descriptive epidemiology. Epidemiologic reviews, 1993, 15(1):7–16.
[7]- . Ziegler RG et al. Migration patterns and breast cancer risk in Asian–American women. Journal of the National Cancer Institute, 1993, 85:1819–27.
[8] - Rabadi SJ. Cancer at Dhahran health center, Saudi Arabia. Annals of Saudi medicine, 1987, (4):288–93.
[9] - Tandon P et al. Cancer in the Gizan Province of Saudi Arabia: an eleven year study. Annals of Saudi medicine, 1995, 15(1):14–20.
[10] - Koriech OM, Al-Kuhaymi R. Profile of cancer in Riyadh Armed Forces Hospital. Annals of Saudi medicine, 1994, 14(3):187–94.
[11] - Ajarim DD. Cancer at King Khalid University Hospital, Riyadh. Annals of Saudi medicine, 1992, 12:76–82.
[12] - National Cancer Registry. Cancer incidence report 1999–2000. Riyadh, Ministry of Health, 2000.
[13]- Alothaimeen, A. Ezzat, G. Mohamed, T. Muammar and A. Al-MadoujDepartment of Biostatistics, Epidemiology and Scientific Computing, Nutrition Research; Department of Oncology, Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
[14]-Ezzat AA, Ibrahim EM, Raja MA, Al-Sobhi S, Rostom A, Stuart RK.Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.3- BMC Cancer. 2007 Dec 5; 7:222. Epub 2007 Dec 5. [BMC Cancer. 2007
[15] Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: An overview of the randomised trials. Lancet 2005; 365(9472):1687–1717.