This retrospective study was intended to give a general picture of the breast diagnoses made at a histopathology laboratory at a tertiary hospital in a Sub-Saharan African country. The study looked at breast records for ten years that is 2005–2014 inclusive.
2510 breast records were obtained for the entire period of study thus averaging about 250 records per year which seems to be small for such a population that has grown by several millions in a decade. Kampala alone where the laboratory is located has close to two million inhabitants. The low number maybe due to lower numbers of clinicians requesting for the service as evidenced by the referral hospital running only four breast clinics in a month, one per week. The burden of histopathology requests may also have been reduced by private laboratories within and around Kampala. However, the picture of sex distribution at this center does not differ from what is observed in many other studies and from the epidemiology of the disease. The greater occurrence of breast disease in females (97.1%) we observed concurs with the fact that male breast disease is generally lower than female breast disease [5].
Benign breast diseases were notably the commonest accounting for 68% of the diseases diagnosed in the ten years and this is similar globally [6]. It is known that benign breast disorders comprise the majority of presentations of breast disease at a breast clinic worldwide [6]. We did not however identify any of the patients earlier diagnosed with benign diseases later being diagnosed with cancers although it is known that some of the benign lesions may be pre-cancerous and that benign breast disease (BBD) generally poses a risk for breast cancer, which can develop later in either of the breasts [7]. We found a cancer prevalence of 31.2% of all the breast lesions diagnosed, this means that every 3 of 10 cases of breast diseases at the lab would end up as cancerous.
Most of the breast disease diagnosed in the country for the decade under study was benign, consistent with the fact that BBD is the most common form of breast disease worldwide [4].
Over the duration of study, fibroadenoma followed by fibrocystic breast disease were the most commonly diagnosed benign breast diseases overall. This was consistent with studies done in Uganda and Nigeria over the last 15 years [7,8,9]. This finding however was more evident in females since in males, gynaecomastia was the more predominant BBD being at least twice more common than either of fibroadenoma or FBC. Gynaecomastia is the most common male breast mass and because men generally lack lobular breast development, they are rarely diagnosed with fibroadenoma, FBC or other lobular breast condition [10].
We observed a consistent predominance in frequency of fibroadenoma over FBC throughout the decade which is different from findings in the western world and particularly the USA [11] where FBC has been documented to be more predominant than fibroadenoma. In parts of the Asia-pacific region [12], the two diseases have been noted to exchange predominance. Our findings may attest to the fact that the black race has been noted to have a racial predilection to fibroadenoma [13].
The most diagnosed breast cancer that we observed over the duration of study was infiltrating ductal carcinoma (326 cases, 55.6% of cancerous cases). This is consistent with findings in Africa, Europe and the world at large for the most frequently diagnosed breast cancer type [14, 15]. The fact that a considerable amount of records we retrieved were diagnosed or concluded only as either “adenocarcinoma” or “breast malignancy”, may explain why we observed less IDC compared to the documented 70–88% elsewhere [16,17,18]. More ancillary diagnostic techniques or better tissue harvest may be necessitated to counter this.
Nevertheless, we observed a pattern of increase in the frequency of diagnosis of breast cancer in the country, which was more profound in the last half of the study period. It has been noted as well that over the last 20 years, cancer incidence rates in older adults have been on the rise in Uganda, with breast cancer showing the largest increase (5%) in older adult females [19]. The increase we observed in occurrence of breast cancer by more than double from 21.2% in 2010 to 50.5% of all diagnosed breast disease in 2014 may nonetheless be reflective of a possible increase in the population’s utilization of laboratory diagnostic services. This may have been encouraged by a rise in specialized breast clinics especially in the private health sector, public health breast disease awareness campaigns, the several volunteer surgical camps within the districts and the increasing use of minimally invasive techniques like ultrasound guided core needle biopsy and breast disease screening using fine needle aspiration and cytology in both private and public health care settings. Furthermore, findings from breast cancer research projects running over the study period could potentially have been implemented in the communities pushing for better community health seeking behavior and clinical vigilance to improve early breast disease diagnosis and intervention resulting in increased breast clinic attendance and eventual increase breast cancer diagnosis rate represented by the observed positive trend in breast cancer diagnosis over the study duration.
Notwithstanding, the observed increase in breast cancer diagnosis may also be a clear reflection of increasing incidence of breast cancer in the country. It is of note that most majority of women in Uganda do not participate in breast cancer down-staging practices despite receiving breast cancer education, rather showing reference for breast health messaging from their health care providers [20]. This of course implies that where there is less health access across the country, most breast disease will be picked up in advanced stages, making referrals to the MakCHS Lab arrive as advanced breast disease. Moreover, the increasingly western lifestyle of the country’s populace cannot be overlooked as a modifiable role player in the observed trend in breast cancer incidence [21, 22].
The relatively low male breast cancer (MBC) rates we observed in Uganda over the study period (low male to female breast cancer ratio of 1:48), stand in agreement with the global picture where it has been observed that MBC, even though it has been noted to be increasing, comprises only about 0.8% of all the world’s diagnosed breast cancer [23]. Our findings showed a little less MBC in comparison with previous conclusions made about MBC rates in East Africa where male to female breast cancer ratios have been documented to range between 1:20–1:45 [24,25,26]. These observed rates though, are comparatively higher than those noted in Nigeria, West Africa 24 where the male to female breast cancer ratios approximated 1:70.
We further observed MBC in the country to occur just above a decade and a half (16 years) later in males than in females over the study period. Different parts of the world seem to show different comparative durations of onset for male versus female breast cancer. For instance, Nigeria [27] and Bangladesh [28] respectively show two decades and one decade for the median age of occurrence of MBC later than female breast cancer. All in all though, our findings and the findings of most of the studies worldwide agree to the occurrence of breast cancer later in males than in females. Most men may be seeking breast health care services later in life because of poor awareness about breast disease, stigma of male breast disease or other socio-cultural reasons [29].
Notwithstanding the above observations for breast cancer in the country, we observed breast disease in general, regardless of type, to largely occur at a young overall median age of 27 years. Our observed predominance of BBD in those under 35 years of age was similar to observations in the Asia-Pacific region, where for instance in China [30] and Japan [31], BBD has been increasingly diagnosed in the younger (less than 40 years) population. Much less breast disease was observed in individuals above 65 years of age. The modal age group we observed for a breast cancer diagnosis being 45 to 54 years means that most of the individuals diagnosed with breast cancer may have theoretically succumbed to the disease within or slightly above the observed modal age group. This alludes to the fact that Sub-Saharan Africa and Africa at large have been noted to have cancer survival rates that are generally poorer than for those individuals in higher income countries [32]. The average age range for a breast cancer diagnosis in Sub-Saharan Africa and the lower-income countries is 42 to 53 years [33]. The country’s low life expectancy (approximately 59 years) [34] may have an independent role leading to the observed discrepancy. Other reasons may also play a part in holding back the elderly from seeking services for breast health care and assessment such as; socio-cultural tendencies and related attitudes, cost of health care and stigma of breast disease.
Although each region of the country registered mostly benign breast diseases, the Western region showed the highest proportion of cancerous breast lesions for a single region (90 out of 203 cases, 44.3%). Most people from this region, notwithstanding the other regions of the country, may have accessed the MakCHS lab as a referral from a local regional health unit with breast disease that had already progressed from a pre-cancerous stage whereas those affected by benign breast disease may have been managed from local regional health units needless for referral. In some instances, individuals may have autonomously stayed home conscious of having breast disease, especially BBD, just like it has been observed in some other communities [35]. However, this does not eliminate the possibility of an environmental, dietary or genetic factor in the Western region of Uganda that allows modification of outcome of breast disease so that the likelihood of it progressing to a cancer is increased.
The Northern region had the lowest breast disease rates of any breast pathology type over the entire duration of study. This may be because of a comparatively less westernized dietary behavior or lifestyle in this region thus lowering an individual’s relative risk for having breast disease. The impact of the devastating war in the Northern region of Uganda, which fueled by the rebel Kony’s Lord’s Resistance Army for most of the period 1987 to the early 2000s resulted in massive loss of lives and gross retardation in the region’s health care delivery, service and referral systems, cannot be understated. These amongst other reasons may offer explanation for the observed breast disease rates in the Northern region. However, from this noted background, the region may benefit from multi-modal education efforts in radiological diagnosis of breast disease to augment early breast cancer detection using the comparatively less available but present radiologic modalities like breast ultrasound [36].
Overall however, the variations in regional distribution of breast disease may be reflective of the uneven distribution of breast disease diagnostic facilities or services throughout the country since arguably the greatest presence of these resources is found in the country’s Central region.
