Breast Cancer in Middle Euphrates Region of Iraq: Risk Factors, Presenting Symptoms and Time to Medical Help-Seeking

Background: Breast cancer is the most frequently occurring tumor and the first cause of death in females. Low level of understanding early symptoms leads to a late diagnosis and high mortality rates. Aims: To describe presenting symptoms, risk factors, and medical care delays among breast cancer patients in Iraq. Materials & Methods: A retrospective, descriptive study conducted in Al-Hussein center in Karbala province of Iraq between February 2012 and August 2020. Results: There were 101 female patients with breast cancer, median age was 45 years. Most of our patients diagnosed incidentally and only 17.82% of our patients were performing breast self examination. Lack of physical activity was the most common risk factors in more than 74% of patients. Painless breast lump was the most frequent symptom in 85.14% of patients. Majority of our patients 58.42% asked medical help within six months. Limited knowledge about symptoms was the common barriers for early diagnosis in 43.94% of patients. Conclusion: Lack of knowledge about breast cancer had a major concern in our region. Increasing awareness about early symptoms and risk factors is very important for early diagnosis and proper management.


Introduction
decrease mortality from breast cancer by about 20%-35% in women aged 50 to 69 years. In young age with high risk magnetic resonance imaging and ultrasound are being tested, but are not approved for screening the general population [10].
In this study, we investigated breast cancer risk factors, most common presenting symptoms and barriers of early diagnosis among Iraqi patients. It can help to provide basic information and to develop future treatment strategies in our country.  [11][12]. We selected 101 female breast cancer patients, they were asked directly and all the information were recorded through their regular visits to our center. The questionnaire included: Section A, section B and section C. Section A dealt with socio-demographic details including: Age, marital status, number of pregnancies, family history, level of education and family income. Regarding income, we divided our patients into: low monthly income less than 500,000 Iraqi Dinars (IQD), middle monthly income within 500,000 -1,000,000 IQD and high income over 1,000,000 IQD per month [13].

Materials and Methods
In Section B, the questions were on presenting symptoms, stage, barriers and duration for seeking medical help. In section C, the questions raised about risk factors for breast cancer in our patients.
Patients with non-conclusive results were excluded from this study. Collected information was kept confidential. This study was approved by review ethical committee of Karbala teaching hospital, Iraq.

Socio-demographic data
There were 101 women enrolled in our study. Median age was 45 years, range was (25-70) years. Majority of our patients were married in 91 patients (90.09%) and 35 patients (34.65%) were illiterates. Only 13 patients (12.87%) had family history of breast cancer. Other data are explained in (Table 1).
Most of our patients 74.26% diagnosed incidentally after developing symptoms, while 17.82% performed BSE and only 7.92% had opportunity to screening mammography ( Figure 1).

Discussion
Cancer patients tend to present with heterogonous presentations and complications making treatment of those patients as a serious issue. Detection of the disease in its early stages before the appearance of signs & symptoms improve outcomes dramatically [14][15][16][17][18][19][20]. This study was carried out to understand risk factors, presenting symptoms and barriers to urgent medical help among breast cancer patients in Middle Euphrates region of Iraq.
Median age in our study was 45 years, this younger than median age in other parts of Iraq (49 years), Turkey (51 years) and US (62 years) this may be explained by our small sample size and short follow-up period [21][22][23].
Majority of our patients diagnosed incidentally, 17.82% performed BSE and only 7.92% performed screening mammography. Same results from Africa where majority of patients diagnosed incidentally after symptoms development. Unfortunately, our screening results revealed low compliance comparing to previous studies in other parts of Iraq, US, Saudi Arabia, Turkey

Presenting stages
The most common presenting stage in our patients was stage III in 40 patients (39.60%) followed by stage II in 32 patients (31.68%), stage IV in 22 patients (21.78%) and stage I in 7 patients (6.93%) as shown in (Figure 3).
Unhealthy life style was the main risk factor in our patients same results among Indian and Jordanian women [31][32]. But in Europe the use of hormone therapy, older age at the first birth and smoking were common risk factors [33]. On other hand about 12.8% of our patients had family history of breast cancer. This lower than previous studies in Iraq (18.7%) Turkey (15.8%) but it is higher than in India (4.2%) [22,[34][35].
Breast painless lump was the most reported symptom among our patients, same results in previous studies in Iraq, India, Turkey and UK [22,34,36]. Our patients tend to present in late stages, this was agreed with results in previous studies in Iraq and Africa where most of patients presented in advance stages. However, European women are more likely to present when the disease is still in its early stages [37][38].
Most of our patients asked medical help within six months after observing symptoms. This is longer than time in neighboring and high-income countries where the median time for medical consultation was 7-16 days only [39][40]. The most frequent barrier for early diagnosis in our study was limited knowledge about symptoms and neglect which is same in neighboring and African countries [26,40].
In conclusion, most of our patients diagnosed incidentally after appearance of symptoms. Unhealthy life style was the most common risk factor and breast lump was the most frequent symptom. Our patient tends to present in advance stages and majority of them wait 1-6 months before final diagnosis. Limited knowledge about symptoms and neglect were the main barriers for early diagnosis. Our findings show the need for community awareness and education programs about breast cancer signs, symptoms and treatment options among Iraqi women.