Determinants of Advanced Stage at Initial Diagnosis of Breast Cancer in Pakistan: Adverse Tumor Biology vs Delay in Diagnosis

Background: Breast cancer is the most frequent cancer of women in Pakistan with the majority presenting with stage III or IV lesionsat initial diagnosis. Patient and health system related factors are well known determinants of delay in presentation and diagnosis. Additionally, breast cancer being a heterogeneous disease, the various molecular subtypes featuring different aggressiveness also need to be considered. The present study evaluated the association of stage at initial diagnosis of breast cancer with these two factors in local women at a tertiary level health care facility in Lahore, Pakistan. Materials and Methods: Patient and tumor features were recorded separately during diagnostic workup in Breast Clinics at INMOL and at Services Hospital, Lahore. Data were entered in MS Excel and analyzed by descriptive statistics and Chi-Square test. Results: Among the 261 patients, 64% were staged as late breast cancer (LBC), the mean age was 46.8 with standard deviation of 13 years. Some 92% had invasive ductal carcinoma (IDC), 61% had luminal types (LT) of non-aggressive tumor while 39% had the non-luminal types (NLT) of of HER2-enriched or basal aggressive tumors. While 70% of patients presented within one year of symptomatic disease (early report group "ERG"), 30% reported after a mean delay of 4 years with a standard deviation of 3.75 years. The stage distribution among ERG patients was not statistically different from those reporting late (P=0.123). Statistically larger proportion of patients with NLT presented as LBC as compared to the LT (P =0.034). Among the ERG, statistically different stage distribution of disease was observed for the NLT versus LT (P=0.047). Among those presenting late, this difference was insignificant (P=0.416). Conclusions: Breast cancer is a distinct disease in Pakistan with a high frequency of aggressive molecular types affecting younger women, with the majority presenting as LBC. Association of NLT with higher stage at diagnosis is statistically significant whereas time delay in diagnosis is not. Further research is required to define the risk profile and features in local patients. The burden of LBC can be reduced by promoting breast health awareness and by establishing easily accessible dedicated breast care set ups in the hospitals.