CHAPTER 1

INTRODUCTION

1.1  Background

                  Breast cancer is the most common malignancy amongst women worldwide [1]. Amongst women it is the second most common cause of death worldwide with 626,679 deaths annually [2]. Recent data from the World Health Organization (WHO) reports show that  2.3 million women were diagnosed of having breast cancer with 685,000 deaths recorded globally in the year 2020 [3].At the end of 2020, there were 7.8 million women alive who were diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer [3]. Increased use of screening, dedicated research to improve understanding of the underlying biology of the disease, and the availability of new therapeutic agents have all contributed to the improved outcome of patients, especially in high income countries.

            Inflammatory breast cancer (IBC) is defined as a separate clinico-pathologic entity with erythema and edema occupying at least one-third of the breast, which can extend to the whole breast and across to the contralateral breast involving the mediastinum, upper extremities and neck area [4]. IBC is a rare and aggressive entity of breast cancer, it represents 1 – 6% of all cases of breast cancer [5]. The first description of IBC in scientific literature was published in 1814 by Sir Charles Bell [6].

         The new cases of IBC vary considerably in different regions around the world. Studies have shown that IBC is more common in North Africa than in other parts of the world; the most recent estimates suggest that it represents 5- 7% of all breast cancers in Tunisia [7], 4- 5 % in Morocco [8], while in Egypt it has a rate of 11% [8]. IBC is also characterized by rapid progression and higher metastatic potential [6].

               It is important to distinguish two clinical types of IBC that are commonly cited in literature. The term “primary IBC” is used to describe the de novo development of IBC in a previously normal breast in contrast, to “secondary IBC” which describes the development of inflammatory skin changes that mimic primary IBC either in a breast that already had cancer or on the chest wall after a mastectomy for non-IBC [9]. Clinical presentations vary but common findings include; erythema on the affected breast, oedema causing a characteristic peau d’orange (orange peel) appearance of the skin, these skin changes may progress quickly to nodules and ulceration [9].

              To have a better outcome, treatment is a multidisciplinary approach. Robertson and collaborators [9] carried out a study that led to the consensus that patients with primary IBC should receive systemic chemotherapy (including trastuzumab and hormonal therapy when indicated), followed by surgery and radiation therapy.

1.1.Problem Statement

           IBC does not have a classical presentation, mimicking its differentials (like breast abscess, mastitis etc.) As a result, we have a lot of misdiagnoses which causes late treatment hence poor outcome. Limited research present in Africa and especially in Cameroon gives limited awareness on the pathology amongst health practitioners.

1.2.Rationale

            Inflammatory breast cancer is an aggressive type of breast cancer though uncommon, it accounts for 1-5 % of all breast cancers in the United States [10]. Prior to 1974, IBC survival rate was a death sentence, with a 5-year survival rate of <5% and a median survival time of 1.2 years [11]. Nevertheless, some studies showed that a multidisciplinary approach can improve both local control and survival, with about 30% of patients living for 5 years [12]. But with the advent of tri-modality treatment, current overall 5-year survival rates range from 30- 70% [4].  

           Despite the increase prevalence of IBC worldwide, no study has been published in Cameroon to the best of our knowledge. This study titled ‘‘epidemiological, clinical and therapeutic options of Inflammatory Breast Cancer at the Yaounde General Hospital’’ will pave the way in understanding the pathology. More so, this information is vital to help in the diagnosis and treatment of patients with IBC. This can provide early warning signs and peculiar clinical presentation to the treating physician to pay attention to cases with IBC and with its associated poor outcomes. This will guide the allocation of limited health care resources to cases that need it and hence improve on the outcomes.

1.3. Research Questions

• What is the proportion of inflammatory breast cancer (IBC) at the Yaounde General Hospital (YGH)?
• What are the factors associated with occurrence of IBC?
• What are the therapeutic approaches used at YGH?
• What are some associated factors that influence patient outcome?

1.5. Research Objective

1.5.1. General Objective

            To study the proportion, clinical features, therapeutic options and patient outcome of IBC at YGH

1.5.2. Specific Objectives

• To determine the proportion of women diagnosed with IBC amongst other types of breast cancer.
• Describe the population socio-demographic characteristics.
• Identify factors associated with IBC
• To determine therapeutic options practiced at YGH
• Identify factors associated with patient outcome.