Management of Inflammatory Breast Cancers in Subsaharian Africa Context

Objective: To report the experience of Gynecology Department of the University Hospital of Treichville in the management of the inflammatory breast cancers. Methodology: We conducted a retrospective and descriptive study on cases of the inflammatory breast cancers managed in the Gynecology Department of the University Hospital of Treichville, from January 2011 to December 2015. Results: We collected 44 cases of inflammatory breast cancer representing 17.9% of all breast cancers. The average age of patients was 46.5 years (32 70 years) and among them, the majority had inadequate socioeconomic level (90.9%). The risk factor for cancer found in the majority of patients was the age of first menstrual periods before the age of 12 years (52.3%). The average consultation time was long (10 months) and several patients had extensive inflammatory signs (38.6%), with lymph node involvement (84.1%) and metastases (36.4%). At the histological analysis, the most common type was invasive ductal carcinoma (81.8%), SBR grade III (54.5%). Regarding treatment, mastectomy according to Patey associated with a chemotherapy was performed in 22.7% cases. The evolution has been marked by an overall 5-year survival of 20%. Conclusion: The management of inflammatory breast cancers was late and incomplete in our service making poor prognosis.

forms, called inflammatory breast cancers (IBC) are easily recognizable by the visualization of skin lesions of inflammatory type.Furthermore the IBC are worse prognosis than nodular forms, and must be considered immediately as metastatic cancers and treated as such [1].
Indeed the prognosis of inflammatory breast cancer is to be feared, with a median survival of 18 to 24 months in case of exclusive locoregional treatment.
The use of chemotherapy, in particular neoadjuvant chemotherapy, combined with radiosurgical treatment, has improved the prognosis that is still reserved, with a 5-year recurrence-free survival between 30% and 50% [2].
In Western countries where IBC are uncommon, representing 3% to 5% of breast cancers [2], their management is optimal thanks to an efficient technical equipment.But in our African countries, the technical equipment is limited making the management of IBC difficult.In these countries, there is also little publication on the management of IBC.We report through this study our experience in the management of IBC in our service with the objectives to describe the epidemiological, clinical, and therapeutic characteristics of patients.

Methodology
This is a retrospective and descriptive study conducted from 1 st January 2011 to 31 st December 2015 (5 years) in the gynecology department of the University Hospital of Treichville (CHUT), on patients managed for breast cancer.
Were included all the patients with inflammatory skin lesions of the breast with a histologic confirmation of invasive cancer.
The patients having inoperable cases were excluded from the study.
The parameters studied were the epidemiological, clinical, therapeutic characteristics and survivals.Survivals were evaluated from the date of diagnosis of certainty until the occurrence of death, by the Kaplan-Meier method.
Data were collected on a standardized survey form, from patient records, chemotherapy registers, operative report registers and phone calls.Data analysis was done using Epi info version 7 software.

1) Epidemiological characteristics -Frequency
During the study period, breast cancer diagnosis was confirmed in 246 patients including 44 cases of IBC, a frequency of 17.9%.

-Socio-demographic characteristics
The economic level of the patients was assessed according to their capacity to honor the various prescriptions made within the framework of the exploration and treatment report.Thus patients classified as low economic level were those who failed to meet more than 50% of prescriptions.Those who have honored between 50% and 80% have been classified as medium level and those who have honored more than 80% have been classified as high level (Table 1).Open Journal of Obstetrics and Gynecology The average age of the patients was 46.5 years (32 -70 years) and among them, 61.3% were under 50 years.
In addition, 81.8% of patients had an insufficient level of education (not educated or primary) and 90.9% insufficient economic level (low or medium) -History The risk factor for cancer found in the majority of patients was the age of first menstrual periods before the age of 12 years (52.3)(Table 2).

2) Tumor characteristics -Clinical characteristics
The average delay between the first signs and first consultation was 10 months (extreme: 1 month -36 months) and 22 patients (50%) consulted within the 6 months following the first signs (Table 3).
-Histological characteristics Only 19 patients have performed immunohistochemistry which helped determine the Ki 67, the hormonal receptor status (HR) and HER2 (Table 4).
3) Carcinological treatments performed (Table 5) -10 patients underwent a mastectomy (according Patey) with axillary removal, associated with a neoadjuvant chemotherapy, then adjuvant -9 patients with metastases underwent a palliative chemotherapy -19 patients have the benefit of an additional targeted therapy with surgery and chemotherapy

4) The survival -Global survival
The overall survival at 5 years was 20% with 19 deaths.
-Survival according the treatment Table 1.Distribution of patients according to their socio-demographic characteristics.The survival at 5 years was zero in untreated patients and 27% in patients who received for carcinological treatment.

1) Epidemiological characteristics -Frequency
In this series IBC (Figure 1, Figure 2) represented 17.9% of all breast cancers, close to the rate found by N'Koua-Bon [3] in Congo (15.2%).In North Africa and the developed countries, on the contrary, different authors report much lower rates, less than 10% [4]- [9].This higher frequency in our Sub-Saharan Africa could be explained by the fact that some non-inflammatory cancers diagnosed late at locally advanced stages can be taken for IBC.Indeed the diagnostic Open Journal of Obstetrics and Gynecology   delays are common in our countries, confirmed in several studies [3] [10] [11].
And face to a breast cancer with inflammatory skin lesions (Figures 3-5), only "time" criterion permits to distinguish the IBC from locally advanced noninflammatory breast cancers.By definition in the IBC, inflammatory signs appear in less than six months [1].However in our countries, insufficient educational level of some patients does not allow them to specify the exact duration of disease progression.some authors report that it is more frequent in women under 50 [6] [12] [13] [14].
In this study the average age was 46.5 years and the majority of the patients (61.3%) were actually less than 50 years old.Elsewhere in Africa, some authors have even reported series with a lower average age, close to 40 years [15] [16].
o Socio-economic characteristics In our study the majority of patients had a low socioeconomic level: Low educational level (81.8%), insufficient economic level (90.9%).In Africa, several authors also found a high frequency of breast cancer in patients of low socioeconomic level [10] [11].In many African countries there is no breast cancer screening program or social policy for the management of cancer which remains expensive.These two parameters are factors of delay in the consultation which could explain that some patients may neglect a noninflammatory initial tumor up to the appearance of inflammatory phenomenon.o History The usual risk factors of breast cancers are found in many of our patients: nulliparity (2.4%), absence of breastfeeding (11.4%), history of hormonal contraception (4.5%), late menopause (18.18%), first menstrual period before 12 years (52.3%),family history of cancer (6.8%).
In the literature, reported risk factors for IBC are common to those of all breast cancers [2] [17].Nevertheless some authors reported that pregnancy and hispanic and black races are special risk factors for IBC [18] [19] [20].
2) Clinical characteristics -Consultation period Touré found that in our country about 80% of breast cancer patients consulted late due to lack of financial means, the use of traditional medication and diagnostic errors [10].
In our series, the average delay between the first signs and the first consultation was also long (10 months), and half of the patients waited more than 6 months before consulting.These long delays could alter the memory of patients on the exact start of their illness.Indeed these patients are usually of low education level, making unreliable the information about the exact duration of the disease progression and the chronology of the appearance of skin lesions.
-Site of the tumor In this study, the IBC concerned the 2 breasts without significant difference: the right breast was affected in 52.3% and the left breast in 47.7%.Several authors had made the same remarks and concluded that there is no preferential site for the IBC [21] [22] [23].
3) Histological characteristic Open Journal of Obstetrics and Gynecology -Histological type In our series, histology found that the majority of IBC were IDC (81.8%) and had lymph embol (63.6%).However, the IBC does not correspond to a specific histological entity, and all the usual types of invasive carcinoma of the breast (ductal, lobular, medullary, or small cell cancer) may be manifested in an inflammatory form [2].Regarding the lymphatic embols, their presence in the deep dermis or hypodermis confirms the inflammatory nature of this cancer but are found only in 2/3 cases of the clinical diagnoses [2] [17].

4) Therapeutic characteristics
In the study population, the majority of patients (56.8%) has not benefited from a carcinologic treatment (surgery, radiotherapy, chemotherapy, hormonal therapy, targeted therapy) for 2 main reasons: either by medical indication-cons, or for lack of financial means to meet the prescribed care.In our country are the carcinologic treatments are expensive and are the responsibility of patients because there is no health coverage.
Moreover no patients received radiotherapy because it is unavailable in our country showing the limits of our technical equipment.

5) Survival
The survival at 5 years was low: it was 20% in the overall population, zero in untreated patients and 27% in patients who received carcinologic treatment.
The prognosis of IBC is daunting.In developed countries where radiotherapy is possible, the prognosis is better than in our countries but it is still reserved, with disease-free survival at 5 years less than 50%, an overall survival at 5 years from 30% to 75% [2] [30].

Conclusion
This study allowed us to find that the IBC were relatively frequents in our country, especially affecting women of low socioeconomic level.The consultation delays were late and the management was limited by an incomplete technical equipment (no radiotherapy) darkening the prognosis.Therefore, in order to improve the prognosis, it is important to focus on the screening program practice in our country.

Figure 1 .
Figure 1.Survival curve in the overall population.

Figure 2 .
Figure 2. Survival curve according to the concept of treatment.

Figure 5 .
Figure 5. Breast cancer with skin lesions, making difficult to distinguish the IBC from locally advanced non inflammatory breast cancers.

Table 2 .
Distribution of patients according to their history.

Table 3 .
Distribution according to clinical features.

Table 4 .
Distribution according to the histological characteristics.
IDC: Infiltrating Ductal Carcinoma, ILC: Infiltrating lobular Carcinoma.Open Journal of Obstetrics and Gynecology

Table 5 .
Distribution of patients according to the carcinological treatment performed.