Epidemiological Pattern of Breast Diseases among Females in the South-Western Region, Saudi Arabia

Background: Breast diseases cover several conditions. The majority of breast diseases are noncancerous. Some of these lesions are clinically unremarkable, which needed minimal intervention. However, some symptoms may be of clinical value and attract the attention of both the patient and the attending physician, especially when they become persistent. The study aimed to assess the prevalence, pattern, types, and clinical profile of breast diseases among females in the South-western region, during the period from 2018-2020. Methods: A retrospective record-based descriptive approach was used through reviewing medical records of all cases with breast disease attended King Khalid Hospital during the period from January 2018 to January 2020. Data extracted throng pre-structured questionnaire. Results: The study included 211 cases whose ages ranged from 18 to 58 years old with a mean age of 28.9 ± 12.8 years. Breast mass was the most recorded complaint (95.1%) followed with breast pain (32%), skin changes. Benign findings based on the final pathology report were recorded


Background
Breast diseases make up several conditions. The majority of breast diseases are noncancerous [1] [2]. Breast lesions are mainly recorded among females. The most recorded cause of breast problems in females is a benign breast disease, which is 10 times more common than breast cancer in most countries [3]. Some of these lesions are clinically unremarkable, which needed minimal intervention.
However, some symptoms may be of clinical value and attract the attention of both the patient and the attending physician, especially when they become persistent. The main item behind that concern is the possibility of the occurrence of breast cancer, which is usually asymptomatic in the early stages during which it is curable [4]. Benign breast diseases are mainly prevalent during the reproductive age as the incidence is common mainly in the second decade with realization on its peak at fourth and fifth life year's decade [5]. Benign breast diseases include many and variable histological patterns categorized into non-proliferative breast lesions, proliferative breast lesions without atypia, and proliferative breast lesions with atypia [6] besides fibroadenoma, fibrocystic change, and breast abscess are the most recorded benign lesions in the literature [7]. Certain types of benign breast lesions were recorded as a significant risk factor for developing breast cancer [8]. Women with benign proliferative or atypical breast lesions consume a two-fold risk of developing breast cancer in western populations [9].
The literatures covered the histopathological pattern of breast diseases with less attention for the clinical perspectives [10] [11] [12]. Surgical evaluation of the symptomatic patients by triple assessment, namely, clinical examination of the breast, mammography, and breast biopsy for definitive histological diagnosis is required in many patients [13].
The current study aimed to assess the prevalence, pattern, types, and clinical profile of breast diseases among females in the South-western region, during the period from 2018-2020.

Methodology
Retrospective record-based descriptive approach was used through reviewing medical records of all cases that were admitted and have breast disease (benign or malignant breast masses) in King Khalid Hospital during the period from January 2018 to January 2020. Records with missing data were included. Data extracted through pre-structured questionnaire including patient's bio-clinical data, initial clinical presentation of the breast disease, radiological assessment findings. Also, the final pathological findings were extracted besides the nature

Statistical Analysis
After data were extracted, it was revised, coded, and fed to statistical software IBM SPSS version 22 (SPSS, Inc. Chicago, IL). All statistical analysis was done using the two-tailed test. A P-value of less than 0.05 is considered being statistically significant. Descriptive analysis based on frequency and percent distribution was done for all variables, including demographic data, breast disease nature, and types, clinical presentation, and surgery outcome.

Results
The study included 211 cases whose ages ranged from 18 to 58 years old with a mean age of 28.9 ± 12.8 years. Exact of 59 (72%) of the females were married, and all of the sampled females started menstruation at the age of 18 years with regular menstrual cycle. Ten (67%) of the females are still menstruating. Only one (10%) of the study females had the first pregnancy before the age of 20 years and 10% above the age of 30 years. As for gravidity, 3 (10.3%) of the females had no pregnancy, while 31% had four pregnancies or more. Considering co-morbidity, diabetes mellitus was recorded among 5 (9.6%) of the females and 8 females (15.4%) had hypothyroidism (Table 1). Concerning clinical data of recorded breast diseases (Table 3), breast mass was the most recorded complaint as recorded for 196 females (95.1%) followed with breast pain which was among 66 females (32%), skin changes (11; 5.3%), and nipple discharge (8; 3.9%). The symptoms = appeared for less than one month among 23.5% of the cases while lasted for more than 6 months among 52 females (39.4%). As for the affected side, the right side was dominant among 84 females (41.2%) of the cases while it was bilateral among 19 (9.3%). The breast mass measured less than 2 cm among 60 (37.5%) of the cases while it was more than 5 cm among 21 females (13.1%) of them. Margins of the breast mass were irregular among 46.2% of the cases, and the mass was soft among 59 of the patients (54.1%). Skin changes were recorded for 28 (22.2%) of the cases, and 53 cases (34.9%) had positive Axillary lymph nodes on physical examination.
Considering radiological and biopsy findings among the cases, Table 4

Discussion
Researchers reported wide variability in the frequency and distribution of breast  [25]. It was estimated that worldwide over 508,000 women died in 2011 due to breast cancer [26]. Breast cancer survival rates vary greatly worldwide, ranging from 80% or over in North America, Sweden, and Japan to around 60% in middle-income countries and below 40% in low-income countries [27].
The current study aimed to assess the pattern of different breast diseases recorded for females in the south-western region, Saudi Arabia, during the period from January 2018 to January 2020. Also, the study aimed to assess the type of diagnostic and management methods with the clinical outcome. The study revealed that the majority of cases aged below 30 years and were married and still menstruating. Many risk factors for having breast diseases were recorded, including receiving oral contraceptive pills, hormonal therapy, positive family history, and irregular breast examination, especially at the age above 40 years.
Breast mass was the most frequent complaint with breast pain with its size ranging from 2 -5 cm in most cases and irregular margins in nearly half of the cases associated with Axillary lymph nodes in about 1 out of each 3 cases. Final pathology after a biopsy revealed that lesions were benign among two-thirds of the cases especially fibroadenoma, which is the most benign breast lesion. Regarding surgical intervention, modified radical mastectomy was needed for 1 out of each 5 cases, while only 11% of the cases undergone lumpectomy as the lesions were benign. Most of the cases had no post-operative complications less than 10% had seroma.
Generally, these findings were consistent with most of the literature. A study was conducted to assess benign breast lesions (BBD) in an African population [28] and recorded an increasing incidence of these benign lesions. The overall mean age for BBD was 27.5 years, SD ± 11.3, with an age range of 9 -84 years and a peak age occurrence in the third decade. The single most common lesion was fibroade- When local breast disease distribution patterns are known, skills related to diagnosis and management can be made with a sound degree of certainty. In addition, resource allocation and planning can be better allied. This is true mainly in low income countries where a large population of individuals may not afford diagnostic and management costs.

Conclusion and Recommendations
In conclusion, benign breast diseases (BBD) were the most recorded among Najran females, especially fibroadenoma, with low post surgical complications. The better reporting system should be initiated, and well training for the physicians is mandatory to improve the quality of available data, and research based on these data and achieve better and more realistic conclusions for planning and resource allocation.

Ethical Considerations
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics and Research Committee of the College of Medicine of Najran University.

Limitations of the Study
Irrespective of the variety of collected clinical data in the current study, but there were two main limitations. The first is the sample size, which was due to reviewing only 2 years' cases, but this was due to a poor recording system, which somewhat primitive. The second was the high missing rate in the data for the cases, which also related to the primitive recording system and lack of physician's experience regarding these cases management guidelines.