Therapeutic management of breast cancer patients at Kenyatta National Hospital

Abstract

Background: The incidence of breast cancer (BC) has been reported to be lower in resource poor regions, with patients generally presenting with late stage disease at diagnosis. These patients have poorer prognosis. It is important for low and medium resource countries to collect BC data to assess their individual needs and therefore have evidence based approach to the management of BC. Such data is limited in our setup. Objective: To describe the management strategies that have been used in the treatment of BC at KNH and the clinical outcome associated with the different treatment modalities. Method: This was a hospital based retrospective study. Patients diagnosed with BC and who were registered at the Radiotherapy clinic during the five year period of study between January 1998 and December 2002 were identified from the patient registers. A total of 384 patient files were sampled using systematic random sampling. Data were entered into a pre -designed data collection tool then entered into Microsoft Excel worksheets. Analysis was done using Microsoft excel and Stata software. Results: The median age at diagnosis was 45 years while the range was 17 to 90 years. The overall mean age was 46.94 (95% CI: 45.57, 48.31). The mean age for the male patients was 68.83 (95% CI: 57.23, 80.43). The mean age for female patients was 46.59 (95% CI: 45.23, 47.94). There was significant difference in mean age between the males and the females (p-value < 0.00 I). Forty percent of the patients were aged between 31 - 45 years. However when age distribution is observed across the years, it was observed that for 1999 and 2000 more of the patients were aged between 46- 60 years but this trend changes in 2001 and 2002 where we observe that more of the patients were aged between 31- 45 years. It was also observed that there was significant difference in mean age between mean age for year 1999 and mean age for year 2002 (p-value = 0.001). Majority (91 %) of the patients did not have their tumours graded. Many of the patients who had grade recorded had tumour grade III. This was 6% of all the patients studied and 67% of the patients who had the tumour grade recorded. The available information indicated that a significant number of the patients had stage III or IV disease at diagnosis with 110 (28.65%) of patients in this group. ER and PR status was hardly done with only six (1.6%) patients having had these test done and reported. Nodal status was not reported for 201 patients accounting for 53% of the patients. Forty five percent of the patients had metastasis to regional lympnodes at the time of diagnosis. Of the patients who had menopausal status recorded, 43% were premenopausal. The commonest histologic type of BC for patients seen at KNH was IDC with 70% of patients. ILC accounted for 1%. Surgery was the commonest modality of treatment followed by endocrine therapy, chemotherapy and radiotherapy in that order. CAF regimen was the most commonly used first line chemotherapy regimen. Gemcitabine combined with carboplatin or cisplatin was the most commonly used second line chemotherapy. Hypertension was identified as the most common co -- morbidity. Skeletal metastasis was the most common site of metastasis. Only 61 (15.89%) patients were followed up for five or more years. The tumour grade and stage of disease at diagnosis correlated significantly with the follow up period (p values: 0.028 and < 0.001 respectively). The year of diagnosis, breast affected, histology, regional lymphnode metastasis and the chemotherapy regimen given did not correlate significantly with follow up period (p values: 0.5, 0.3, 0.3, 0.3 and 0.8 respectively) Conclusion: This study shows that KNH is operating at the limited resource level in management of BC as defined by BHGI guidelines. There is opportunity to improve BC management at KNH and Kenya in general by improving strategies for early detection, patient education and establishing standard treatment guidelines. Women between 31 and 45 years were found to be an important cohort.