Background
There has been an increasing prevalence of breast cancer among females around the world [
1]. In Saudi Arabia, the recent statistics regarding women diagnosed with breast cancer are shocking. Even with the current advancements in the healthcare system and the breast cancer awareness campaign, the latest prevalence published by the Saudi Health Council in 2014 showed that breast cancer accounted for 29% of all the cancer types diagnosed in women. Unfortunately, few women present with early stages of the disease, compared to a substantial proportion of women who present in the late stages of breast cancer, when the tumour has become metastatic [
2].
Previous studies have reported that there are several common factors present in women diagnosed with breast cancer, such as their ages, ages at menarche and menopause, family histories, lifestyles and oral contraceptive usage [
3,
4]. However, the presentation of these factors varies among different populations of women. A greater number of breast cancer diagnoses have been linked to variances in the lifestyle patterns and socioeconomic factors. From the point of view of epidemiological studies, exploring the predominant risk factors in a selected population of women can help to direct the perspective of breast cancer prevention [
4].
The population of women in the region of Makkah is diverse, with different lifestyle patterns, economic statuses and breastfeeding practices. These factors play significant roles in influencing the overall health conditions and make it an area of interest for investigating the determinants of breast cancer in this specific population. Furthermore, postmenopausal women were more likely to have breast cancer than premenopausal women [
5]. Therefore, the aim of this study was to explore which of the socioeconomic factors, health-related characteristics, menstruation starting and ending ages and breastfeeding histories were determining factors for postmenopausal women diagnosed with breast cancer.
Methods
Study design and setting
This case-control study was conducted from June 2014 through November 2016 at King Abdullah Medical City Hospital (KAMC) in the Makkah region of Saudi Arabia. This hospital is the only centre that provides cancer screening and treatment for residents in Makkah region.
Participants
A total of 432 female participants (214 cases and 218 controls) were recruited for this study. We included postmenopausal Saudi women of Arabic ethnicity aged > 45 years from the Makkah region who were newly diagnosed with breast cancer that was biopsy confirmed by a cancer pathologist in KAMC. Studies have showed that factors associated to breast cancer differs in racial groups [
6,
7]. Therefore, we excluded women of any other nationality and African-Asians ethnicity. We also not included any breast cancer women diagnosed with any other type of cancer and who had a metastatic (stage IV) and/or recurrent breast cancer. Any woman stopped her menstrual periods within the last 12 months was defined as postmenopausal. The women in the control group were made up of hospital workers and the patients’ companions and friends. The controls were selected from the same region of cases and matched on a single year of age for both groups. Based on the above exclusion and inclusion criteria, 214 out of 229 cases were included in this study. However, some patients and healthy individuals were not recruited in this study due to; non-Saudi nationality (
n = 7 cases and 12 controls), African-Asians ethnicity (
n = 3 cases and 4 controls), premenopausal women and/or aged < 45 years (
n = 2 cases), metastatic breast cancer diagnosis (
n = 1 case), recurrent breast cancer (
n = 1 case), and diagnosis of multiple cancer types (
n = 1 case).
Data collection
Convenience sampling was used to collect the data for this study. As a routine work in the hospital, all newly diagnosed cancer patients should meet a registered dietitian to evaluate his/her nutritional status. During this evaluation, a self-administered questionnaire was completed by each of the participants via a face-to-face interview. The socioeconomic factors, health-related characteristics, menstrual histories as well as breastfeeding duration tested in this study were part of a previously validated questionnaire developed by Wilson et al. (2013) [
8] that focused on well-known determinants associated with breast cancer in postmenopausal women. Each participant’s body mass index (BMI; kg/m
2) was calculated after measuring the weight and height in the hospital and at the time of the data collection. Any participant with a BMI < 18.5 kg/m
2 was classified as underweight, normal weight was 18.5–24.9 kg/m
2, overweight was 25–29.9 kg/m
2 and obese was > 30 kg/m
2.
Statistical analysis
All of the statistical tests were completed using IBM SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, NY, USA), and a P-value < 0.05 was set for the significant differences. The Kolmogorov-Smirnov normality test was used to determine the normality of distribution. The P-value for each parameter was determined using a suitable test, which is mentioned as a footnote in each table. In order to ascertain the differences between the cases and the controls, the data from the participants was stratified using a case-control status. A chi squared test and t-test were conducted for the parametric and nonparametric variables to determine the differences in the socioeconomic factors, health-related characteristics, menstrual histories and breastfeeding durations.
To determine the possible risk factors related to breast cancer, the odds ratio (OR), 95% confidence interval (95% CI) and β-coefficient were determined by using a logistic regression test. All of the variables were adjusted for potential confounders; age (continuous), BMI (continuous), employment, family income, education, family size, marital status, physical activity, smoking, family history of breast cancer, other health problems, contraceptive use, age at menarche, age at menopause, and breastfeeding duration.
Results
An overview of the socioeconomic characteristics of the participants is presented in Table
1. The participants’ ages ranged from 45 to 75 years old, and the mean ages for the case and control groups were 57 ± 7.3 years old and 56.9 ± 8.6 years old, respectively. The results showed significant differences regarding some of the socioeconomic factors (
P < 0.001), such as employment, income, education and family size.
Table 1Socioeconomic characteristics of the study groups
Number [n (%)] | 218 (50.5%) | 214 (49.5%) | 0.847 |
Age (year) | 56.9 ± 8.6 | 57 ± 7.3 | 0.526 |
Employment |
Yes | 178 (81.7%) | 56 (26.2%) | < 0.001 |
No | 40 (18.3%) | 158 (73.8%) |
Family income |
< 5000 SRa | 21 (9.6%) | 94 (43.9%) | < 0.001 |
5000–10000 SR | 85 (39%) | 88 (41.1%) |
10000–20000 SR | 80 (36.7%) | 24 (11.2%) |
> 20000 SR | 32 (14.7%) | 8 (3.8%) |
Education |
Illiterate | 2 (0.9%) | 32 (15%) | < 0.001 |
Primary | 3 (1.4%) | 96 (44.9%) |
Intermediate/secondary | 23 (10.6%) | 38 (17.8%) |
Postsecondary | 190 (87.1%) | 48 (22.3%) |
Family size |
5 or less | 114 (52.3%) | 40 (18.7%) | < 0.001 |
6 or more | 104 (47.7%) | 174 (81.3%) |
Marital Status (Married) |
Yes | 191 (87.6%) | 204 (94.1%) | 0.087 |
No | 27 (12.4%) | 10 (5.9%) |
The highest employment status percentage in both groups was 81.7% employed participants in the control group, with 73.8% unemployed in the case group. Nearly one-half of the participants in the case group (43.9%) fell in the low-income category of < 5000 Saudi Riyal (SR) of monthly income (~ 1333.17 American Dollar) when compared to the control group (9.6%). Both groups had low percentages in the highest income category of > 20,000 SR (~ 5332.70 USD): 14.7% for the control group and 3.8% for the case group.
The illiteracy rate was higher among the cases (15%) when compared to the control group (0.9%). All of the participants in both groups reported varied results in obtaining an education, with a higher result for postsecondary education of 87.1% for the control group, compared to 22.3% for the case group for the same level of education. Having a large family size (6 or more family members) was more common in the case group (81.3%), while the control group showed no noticeable difference in the percentages of having small or large family sizes (52.3 and 47.7%, respectively). There were no significant differences in the marital statuses in either group (P > 0.05); the percentages of married participants were fairly high in both groups (87.6% for the controls and 94.1% for the cases).
With regard to the health-related characteristics for the participants in this study (Table
2), the BMI (
P < 0.001), regular exercise (
P = 0.009), cancer awareness (
P < 0.001), smoking (
P < 0.001), diabetes (
P < 0.001), hypertension (
P < 0.001) and the use of contraceptives (
P < 0.001) were significant when testing the differences between the groups. Based on these results, it was clear that there was a higher BMI (obese category) percentage of 63.6% among the cases when compared to the control group (24.3%). It was also evident that regular exercise was practiced among few of the participants in both the control and case groups (37.2% vs. 26.2%, respectively). Overall, high percentages of the participants were aware of cancer (98.2% for the control group and 81.3% for the case group). Although the results of having a family history of breast cancer were not significant (
P > 0.05), the family history results of the patients with breast cancer were higher in the cases (17.8%) than in the participants in the control group (6%). The smoking status showed that 17.8% of the participants in the case group were smokers, compared to 1.4% being smokers in the control group.
Table 2Health-related characteristics of the study groups
Weight (kg) | 69.5 ± 14.7 | 88.5 ± 17.5 | < 0.001 |
Height (cm) | 158.6 ± 7 | 157.7 ± 6.7 | 0.637 |
Body Mass Index (BMI) (kg/m2) | 27.7 ± 6.3 | 35.4 ± 10 | < 0.001 |
BMI categories |
Underweight | 1 (0.4%) | 0 | < 0.001 |
Normal | 69 (31.7%) | 22 (10.2%) |
Overweight | 95 (43.6%) | 56 (26.2%) |
Obese | 53 (24.3%) | 136 (63.6%) |
Cancer awareness |
Yes | 214 (98.2%) | 174 (81.3%) | < 0.001 |
No | 4 (1.8%) | 40 (18.7%) |
Regularly exercise |
Yes | 81 (37.2%) | 56 (26.2%) | 0.009 |
No | 137 (62.8%) | 158 (73.8%) |
Family history of breast cancer |
Yes | 13 (6%) | 38 (17.8%) | 0.072 |
No | 205 (94%) | 176 (82.2%) |
Smoking |
Yes | 3 (1.4%) | 38 (17.8%) | < 0.001 |
No | 215 (98.6%) | 176 (82.2%) |
Diabetes |
Yes | 17 (7.8%) | 72 (33.6%) | < 0.001 |
No | 201 (92.2%) | 142 (66.4%) |
Hypertension |
Yes | 33 (15.1%) | 104 (48.6%) | < 0.001 |
No | 185 (84.9%) | 110 (51.4%) |
Hyperlipidemia |
Yes | 28 (12.8%) | 40 (18.7%) | 0.062 |
No | 190 (87.2%) | 174 (81.3%) |
Contraceptive use |
Hormonal | 55 (25.2%) | 94 (43.9%) | < 0.001 |
Not-hormonal | 31 (14.2%) | 32 (15%) |
Don’t use | 132 (60.6%) | 88 (41.1%) |
Additionally, the percentage of breast cancer patients diagnosed with diabetes was higher (33.6%) than the diabetic participants in the control group (7.8%). Similarly, hypertension was higher in the cases when compared to the control group (48.6% vs. 15.1%, respectively). The screening for positive hyperlipidaemia results showed no significant difference between the two groups, but the percentage was low in the participants in the control group (12.8%) when compared to the cases (18.7%). The use of hormonal contraceptive types was higher in the cases (43.9%), whereas the highest percentage in the control group (60.6%) included those participants not using any contraceptive methods.
The results of the menstruation histories and breastfeeding durations are shown in Table
3. Both groups reported higher menstruation percentages at the ages of 11–14 years old; 70.1% of the cases and 89.9% of the control group began menstruation around this age. High percentages in both groups exhibited breastfeeding histories, with the results showing that most of the cases (70%) breastfed for a duration of 6–12 months, while most of the participants in the control group breastfed for a duration of less than 6 months. The results of the age of menopause showed no statistical difference between the groups. The highest percentage was 46 years old and older for 67.3% of the cases and 56.4% of the controls.
Table 3Menstrual history and breastfeeding duration of the study groups
Age of started menstruation |
< 10 years old | 1 (0.5) | 25 (11.7%) | < 0.001 |
11–14 years old | 196 (89.9%) | 150 (70.1%) |
> 15 years old | 21 (9.6%) | 39 (18.2%) |
Age at menopause |
< 35 years old | 2 (0.9%) | 8 (3.7%) | 0.271 |
36–40 years old | 25 (11.5%) | 16 (7.5%) |
41–45 years old | 68 (31.2%) | 46 (21.5%) |
> 46 years old | 123 (56.4%) | 144 (67.3%) |
Breastfeeding duration |
No | 51 (23.4%) | 40 (18.7%) | 0.052 |
Yes | 167 (76.6%) | 174 (81.3%) |
< 6 months | 76 (45.5%) | 48 (27.6%) |
6–12 months | 42 (25.1%) | 70 (40.2%) |
> 13 months | 49 (29.4%) | 56 (32.2%) |
The correlations between the potential dependent variables for breast cancer are shown in Table
4. With regard to the socioeconomic factors, the results showed that being unemployed had an increased positive association with breast cancer (β = 1.89, OR = 6.56, 95% CI = 3.83–11.37,
P < 0.001). This was similar to the results of being in the low-income category of < 5000 SR (~ 1333.17 USD) (β = 3.69, OR = 39.88, 95% CI = 11.11–143.16,
P < 0.001). Additionally, the results showed a positive association between having a large family size (6 members and more) and breast cancer (β = 0.8, OR = 2.23, 95% CI = 1.15–4.3,
P = 0.017). Moreover, having a primary level of education had a positive association with breast cancer (β = 4.07, OR = 58.56, 95% CI = 16.9–202.82,
P < 0.001).
Table 4Potential significant predictors related to breast cancer
Body Mass Index (BMI) (continuous) | 0.1 | 1.11 | 1.07–1.14 | < 0.001 |
BMI categories |
Underweight | ND | ND | ND | ND |
Normal | 0 | 1 | | |
Overweight | 0.41 | 1.5 | 0.77–2.93 | 0.234 |
Obese | 1.39 | 4 | 2.07–7.74 | < 0.001 |
Employment |
Yes | 0 | 1 | | |
No | 1.89 | 6.56 | 3.83–11.37 | < 0.001 |
Family income |
< 5000 SRa | 3.69 | 39.88 | 11.11–143.16 | < 0.001 |
5000–10000 SR | 2.07 | 7.88 | 2.45–25.4 | 0.001 |
10000–20000 SR | 1.36 | 3.89 | 1.09–13.88 | 0.036 |
> 20000 SR | 0 | 1 | | |
Education |
Illiterate | 2.98 | 19.7 | 4.33–89.54 | < 0.001 |
Primary | 4.07 | 58.56 | 16.91–202.82 | < 0.001 |
Intermediate-secondary | 1.71 | 5.52 | 2.75–11.09 | < 0.001 |
Postsecondary | 0 | 1 | | |
Family size |
5 or less | 0 | 1 | | |
6 or more | 0.8 | 2.23 | 1.15–4.3 | 0.017 |
Regularly exercise |
Yes | 0 | 1 | | |
No | 0.72 | 2.06 | 1.16–3.67 | 0.014 |
Cancer awareness |
Yes | 0 | 1 | | |
No | 1.87 | 6.47 | 1.84–22.77 | 0.004 |
Smoking |
Yes | 1.85 | 6.36 | 1.56–26 | 0.01 |
No | 0 | 1 | | |
Diabetes |
Yes | 0.5 | 1.65 | 0.81–3.35 | 0.165 |
No | 0 | 1 | | |
Hypertension |
Yes | 0.51 | 1.67 | 0.91–3.04 | 0.097 |
No | 0 | 1 | | |
Contraceptive use |
Hormonal | 1.91 | 6.78 | 3.42–13.44 | < 0.001 |
None-hormonal | 1.23 | 3.43 | 1.54–7.65 | 0.003 |
Don’t use | 0 | 1 | | |
Age of started menstruation |
< 10 years old | 1.61 | 5 | 1.12–22.29 | 0.035 |
11–14 years old | 0 | 1 | | |
> 15 years old | 0.54 | 1.57 | 0.79–3.13 | 0.197 |
The health-related characteristics, such as the BMI, exhibited positive correlations to breast cancer (β = 0.1, OR = 1.11, 95% CI = 1.07–1.14, P < 0.001), which was significant in the obese BMI category (β = 1.39, OR = 4, 95% CI = 2.07–7.74, P < 0.001). Additionally, having an awareness about breast cancer and the smoking status were significant factors correlated with breast cancer. Having no awareness was positively associated with breast cancer (β = 1.87, OR = 6.47, 95% CI = 1.84–22.77, P = 0.004), while being a smoker showed an increased risk of breast factor in this study (β = 1.85, OR = 6.36, 95% CI = 1.56–26, P = 0.01). Moreover, the use of both types of contraceptive methods, hormonal and nonhormonal, increased the risk of breast cancer. In fact, the higher risk was involved in using a hormonal type of contraception (β = 1.91, OR = 6.78, 95% CI = 3.42–13.44, P < 0.001).
Beginning one’s menstruation cycle at an early age (10 years old or less) increased the risk of breast cancer, according to the results of this study (β = 1.61, OR = 5, 95% CI = 1.12–22.29, P = 0.035). The not significantly identified variables by regression test; overweight, diabetes, hypertension and age of stated menstruation > 15 years old, were not included in this study as determinants of breast cancer.
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