The Pattern of Breast Diseases at Kenyatta National Hospital
E.S. Otieno, MBChB, MMed (Surg), PGDRM (UoN), Lecturer, Department of Medical Physiology, College of Health Sciences, University of Nairobi, S.K. Kimende MBChB, MMed (Surg), Lecturer, Department of Surgery, College of Health Sciences, University of Nairobi and J. Micheni, MBChB. MMed (Surg), Consultant Surgeon, Kenyatta National Hospital.
Dr. E.S. Otieno, P. O. Box 30197-00100, Nairobi, Kenya, Email: firstname.lastname@example.org
Objective: To determine the pattern of breast diseases. Design: Retrospective descriptive study.
Setting: Kenyatta National Hospital (KNH), a University Teaching and National Referral Hospital.
Patients: One thousand one hundred and seventy two patients records were reviewed.
Results: An average 469 new patients per year or 11 new patients per clinic visit were reviewed over a two and a half year period. Females predominated (98.9%). The mean age of the patients was 34.71 years (range 1 to 96 years). The average age at menarche was 14.49 years and the mean duration of symptoms was 6.86 months. Only 2.6% of 843 patients had a positive family history of breast disease. Fibroadenoma was the commonest diagnosis made (33.2%) followed by ductal carcinoma (19.7%). Gynaecomastia was the most common lesion seen in males. Two thirds of patients presenting with lumps had masses measuring more than 5cm. Overall, five conditions (fibroadenoma, ductal carcinoma, breast abscesses, fibrocystic disease and mastalgia) accounted for over 85% of all breast ailments. Surgery formed the mainstay of care in over 80% of patients.
Conclusions: The pattern of breast diseases at KNH closely mirrors those reported in literature. This study indicates that a large proportion of patients presenting with breast diseases are treated initially by surgery. It may be wise to consider other alternative forms of therapy where appropriate.
Epidemiological studies reveal wide disparities in the frequency and distribution of breast ailments across the world (1-3). When local breast disease distribution patterns are known, generalizations pertaining to diagnosis and management can be made with a reasonable degree of certainty. In addition, resource allocation and planning can be better managed. This is particularly so in resource poor countries where a large population of individuals may not afford all the forms of diagnostic modalities available.
Breast diseases afflict women more than men, the prevalence rate in males ranging from 0 to 5.8% in most series (1-3). Majority of male breast afflictions are benign with gynaecomastia occupying the top slot (1,2,4). Among females, the distribution of pathology varies widely depending on age and geographical location. Benign lesions predominate at all ages accounting for 48.9% to 57% with a mean age of occurrence being 28.5 years (1,2,6,7). Benign lesion prevalence rates can peak 99% in those younger than 30 years (7). Fibroadenoma is the most common lesion at prevalence rates between 34.7 to 67% of all breast lesions with a peak mean age incidence of 16-25 years (1-4, 6, 10-13). Malignancy or inflammatory lesions come second in frequency to fibroadenoma (2, 6,11,12). Benign diseases thus, constitute the major work load in any breast clinic, although some studies have shown that malignant conditions predominate (4,6), yet others have found inflammatory lesions to be the most common disease entity (15). This study undertook to examine the pattern of breast pathology presenting at KNH.
Materials and methods
The breast clinic’s records and case files of all patients managed for breast diseases between 1st September 2000 to March 31st 2003 were retrospectively reviewed. The KNH breast clinic was set up in 2000 for the purpose of optimizing the care of breast diseases. It is held once a week and run by consultant surgeons and surgical residents in training. All patients seen at the clinic during the study period with a clinically and/or cytologically, histologically, radiologically diagnosed breast ailment were included in the study. Patients who presented with previously treated or recurrent lesions were excluded.
The age, sex, duration of symptom, pathological diagnosis and treatment methods were evaluated for each patient. Also abstracted from the medical records were the age at onset of menarche for female patients, family history of breast disease and the initial method of establishing the diagnosis. The data were analysed to calculate frequencies, means and standard deviations. Permission to do the study was granted by the Kenyatta National Hospital Research and Ethics Committee.
A total of 1172 new cases were seen at the KNH breast clinic over the two and a half year period, an average of 469 patients per year or 11 new patients per clinic visit. The mean age of these patients was 34.71 years with a range of 1 to 96 years. Table 1 below gives some descriptive demographic characteristics.
Click to view table 1
Malignant breast lesions accounted for 22% of all breast diseases. The most common malignancy was ductal carcinoma constituting 91.7% of all cancerous breast diseases followed by lobular carcinoma at 2.8% (Table 2a). The majority of patients (78%), had benign conditions, fibroadenoma being the single most common diagnosis made. It accounted for up to 40.2% of benign conditions (Table 2b) and 33.2% of all breast ailments put together. Five disease conditions: fibroadenoma, breast abscess, fibrocystic disease, mastalgia and chronic mastitis accounted for 83.4% of all benign lesions and formed the main work load at the clinic. Out of the 22 patients with chronic mastitis, eight had confirmed tuberculosis of the breast. Males constituted less than 1% in this series and gynaecomastia was the most common lesion seen in this group (Table 3).
Nine hundred and four patients presented with lumps. In two thirds of this group, the lumps measured more than 5cm in their widest diameters. Fine needle aspiration cytology (FNAC) was used in the initial definitive diagnosis in 46.1% of all cases. Excisional and incisional biopsies were utilised for only 8.6 and 3.0% of cases respectively. Patients diagnosed purely on clinical assessment comprised 40.0% (Table 4). Over 80% of patients seen at the KNH breast clinic were operated upon (Table 5).
Click to view table 2a
Click to view table 2b