Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 2, 2003, pp. 178-181

Indian Journal of Surgery, Vol. 65, No. 2, March-April, 2003, pp. 178-181

Profile of benign breast diseases in urban India

Uma Krishnaswamy

Department of General Surgery, Apollo Hospitals, Chennai
Address for correspondence Dr. Uma Krishnaswamy, 3, T.A Street, Ramakrishna Nagar, Chennai 600028 Email: umaks@vsnl.com

Paper Received: August 2002, Paper Accepted: January 2003. Source of Support: Nil

Code Number: is03031

ABSTRACT

Background: Literature on benign breast disorders and diseases in India is scanty. Mastalgia which is the most common problem seen in the West, finds little mention in our country. The purpose of this study was to profile benign breast problems amongst urban Indian women in general and highlight mastalgia in particular. Material and methods: A cross-sectional analysis of 1786 women undergoing a routine health check-up was done for this purpose. Results: 216 out of the 1693 (12.75%) Indian women studied were found to have benign breast problems. Pain was the most common breast related complaint and mastalgia was the most common clinical problem (62.5%) occurring in the 3rd decade of life. Conclusion: Benign breast disorders and diseases are common in urban India as is mastalgia.

KEYWORDS: Breast diseases, benign, cyclical mastalgia, non-cyclical mastalgia

How to cite this article: Krishnaswamy U. Profile of benign breast disorders and diseases in urban India. Indian J Surg 2003;65:178-81.

INTRODUCTION

Benign breast disorders and diseases (BBD) are at least 10 times more common than breast cancer in the West¹ and mastalgia is the most common problem encountered in both general practice and in hospital surgical outpatient settings.^2,3 References to BBD, in particular to mastalgia, are scant in Indian surgical literature. A tendency to negate or trivialize benign breast problems by the medical profession^4-6 together with a reluctance on the part of the patients to complain about breast pain⁷ are universal phenomena and have led to this neglect both in India and elsewhere. Moreover, Indian literature tends to profile the spectrum of BBD only by histopathological examination.^8,9 And mastalgia, which is essentially diagnosed clinically, is therefore overlooked. The purpose of this study was to profile the incidence and spectrum of BBD amongst urban Indian women examined on an outpatient basis and without a biopsy for a more realistic appraisal of its incidence.

MATERIAL AND METHODS

A cross-sectional analysis of 1786 women undergoing a routine health check-up under the care of the author from 1990 to the year 2000 was done. 93 foreign nationals (from adjoining countries such as, Nepal, Maldives and Bangladesh) were excluded from the study. This data of 1693 Indian patients was analyzed to determine the frequency and statistical significance of BBD, the geographical location of the patients, age range, breast related complaints, duration of complaints, past history of breast disease (benign or malignant) and breast surgery, clinical diagnosis as well as menstrual and obstetric profiles.

The parameters of data gathered reflect "breast-specific history taking", clinical examination of the breasts and clinical diagnosis as recorded solely by the author to eliminate variations in clinical assessment by multiple observers. Information from mammography, fine needle aspiration cytology, old operation notes and histopathological reports were utilized, when available, to corroborate clinical diagnosis. Breast lumps that were clinically suspicious of malignancy were flagged and channelled into a mandatory triple assessment.

RESULTS

The 1693 Indian women in this study came from urban locations in 25 States and Union territories. 216 (12.75%) of these patients had BBD and only 6 (0.35%) gave a past history of breast cancer (Table 1).

Clinical Diagnosis: 123 (56.9%) patients in this group of 216 had mastalgia, 78 (63.4%) had cyclical mastalgia and 45 (36.58%) had non-cyclical mastalgia (p= < 0.01). In the latter group 1 patient had costochondral pain. 32 (26%) patients with mastalgia had accompanying nodularity of the breasts. 20 (25.64%) of these patients belonged to the cyclical mastalgia group and 12 (26.66%) to the non-cyclical mastalgia group. 38 (17.6%) other patients had painless nodularity of the breasts and only 15 (6.9%) had fibroadenomas (Table 2).

Age: The range of age of patients with cyclical mastalgia was 23 49 years (mean 35.88, median 36 years). The range of age in non-cyclical mastalgia was 2568 years (mean 39.16, median 38 years). Thus patients with cyclical mastalgia were younger than those with non-cyclical mastalgia (p = 0.02) (Table 3).

Breast-related complaints: 123 patients (56.9%) complained of pain in the breasts (p = < 0.1), 28 patients (13%) complained of a lump in the breast, 4 patients (1.9%) of cosmetic problems and 3 patients (1.4%) of a nipple discharge. 58 patients (26.9%) had no breast related symptoms.

Duration of symptoms: The duration of pain in patients with cyclical mastalgia ranged from 1 to 180 months (mean 34.4, median 12 months) and in the non-cyclical mastalgia group from 1 to 240 months (mean 30.14, median 12 months) (Table 4).

Past history of breast disease and/or surgery: 2 patients in the cyclical mastalgia group and 2 patients in the non-cyclical mastalgia group gave a history of breast surgery for benign disease.

Family history of breast disease: 3 patients in the cyclical mastalgia group gave a family history of breast cancer in their mothers and all these had occurred over the age of 50 years.

Menstrual and obstetric profile: 18 patients (14.63%) with mastalgia gave a history of menstrual irregularity. The majority of patients with mastalgia (94.3%) were premenopausal. Only 3 patients in the non-cyclical mastalgia group had undergone a hysterectomy. The majority of patients with cyclical mastalgia (92%) as well as those with non-cyclical mastalgia (88.9%) had one or more children. (Figure 1). The majority of patients with cyclical mastalgia (60.3%) gave a history of 1 or more abortions (spontaneous or medical termination) while the majority of patients with non-cyclical mastalgia (64.4%) gave no history of abortions (Figure 2).

DISCUSSION

The cyclical perimenstrual changes that occur in the breast are so often accompanied by discomfort that they are dubbed as normal. However, if the intensity of the pain or the duration of pain interferes with the quality of a woman's life, then mastalgia is placed in the category of an aberration as per the Aberration in Normal Development and Involution (ANDI) classification¹⁰ of BBD. In the rare instances when mastalgia is severe or resistant to treatment it is placed under the category of a disease within the ANDI framework.

For reasons referred to earlier, namely the attitudes of both doctors and patients, mastalgia continues to be ignored in the non-Western populations.^11-14 This is true of India as well, with a few notable exceptions. Shukla¹⁵ and later Khanna and colleagues¹⁶ from Varanasi have drawn attention to the significant incidence of mastalgia. The latter estimated it to account for 70% of all BBD. Both found cyclical mastalgia to be more common than non-cyclical mastalgia with the majority of patients being in the 2^nd and 3^rd decades of life respectively.

In the current study, the incidence of BBD has been 12.75%. This figure is not comparable to figures currently obtained in Indian literature due to the fact that this sample deals exclusively with patients in an outpatient setting. However, it does alert one to the possibility of a higher current incidence or even a rising incidence in BBD in urban India.

This study also finds mastalgia to be a significant problem accounting for 56.9% of all BBD and shows that cyclical mastalgia is certainly more common than non-cyclical mastalgia. However, in this study, the mean age of patients with both cyclical as well as non-cyclical mastalgia falls into the early and late 3^rd decades respectively. Thus the pattern vis-à-vis the woman's age is closer to that seen in the Western countries¹⁷ (Table 5). An interesting detail to emerge from this study is the low incidence of fibroadenoma (6.9%). The incidence of fibroadenoma has been variously described at approximately 56% in a study in 1983,⁸ 40% in 1988,^9,15 and 17% in 1997.¹⁶ The implication of this downward trend over the years needs evaluation.

The present study emphasizes the fact that BBD in general and mastalgia in particular can no longer be ignored. Much work needs to be done to collect comprehensive data about the incidence and prevalence of BBD in India.

ACKNOWLEDGEMENTS

The author wishes to thank Dr.B.W.C.Sathiyasekaran, Professor,
Department of Community Medicine, Sri Ramachandra Medical College and Research Institute, Porur, Chennai.

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