Some Medical and Social Aspects of Diagnosis and Treatment of Advanced Breast Cancer in the Republic of Tajikistan

The dissertation is devoted to the medical and social aspects of diagnosis and treatment of advanced forms of breast cancer in the Republic of Tajikistan. The research is relevant due to the steady increase in breast cancer morbidity in the country — during the period from 1970 to 2002 it increased nearly fourfold, and the share of advanced forms at first referral exceeded 90%. The work is based on a sufficiently large clinical material and is aimed at studying the causes of late patient referral, the structure of hospitalized morbidity, and the clinical features of advanced disease forms, including tumor localization and distant metastases.

During the study, the effectiveness of diagnostic and treatment methods is evaluated, and the main causes of advancement are identified — low socio-economic level and awareness among the female population, insufficient preventive examinations, and health education work. On the basis of the data obtained, recommendations for early detection of breast cancer have been developed, a graphic scheme for breast imaging has been proposed for monitoring disease dynamics, and the results have been used in the formulation of national programs and methodological recommendations for oncologists and family physicians.

Relevance of the Problem. Prevention and prophylaxis of malignant tumors is one of the priority tasks of clinical oncology (11.53.54.93.102), while it is well known that over the past two decades the leading problem in oncology for the female population of many countries has been breast cancer (BC). Approximately 1 million new cases of BC are diagnosed annually worldwide. According to morbidity forecasts, by 2010 this figure will reach 1.45 million cases. Over the course of a lifetime, one in eight women in the United States suffers from this disease, and one in ten in Canada. In Russia, the morbidity rate for breast cancer increased by nearly 70% from 1980 to 1999. In the structure of morbidity among the female population, starting from 1977, breast cancer ranked second by standardized morbidity indicators, and in 1982 it took first place [1,13,54].

By morbidity level, Uruguay and the United States lead, followed by European countries and Canada, while relatively low indicators are observed in Asian and African countries. The incidence of BC increases by approximately 1.5% each year. In this regard, Tajikistan is no exception. Thus, the morbidity rate for breast cancer from 1970 to 2002 increased nearly fourfold [58,59].

According to WHO data, by the end of the century, approximately 750 thousand women annually will suffer from breast cancer, which may become the leading cause of mortality among women aged 40 to 55. It is currently known that breast cancer occurs 3 to 5 times more frequently in association with benign breast diseases and 30 to 40 times more frequently in nodular forms of mastopathy with epithelial proliferation of the breast glands. Despite the accessibility of the breast for examination and the apparent simplicity of diagnosis, even women of reproductive and perimenopausal age rarely undergo timely screening by a gynecologist, to whom they first seek help when experiencing various reproductive system problems.

According to S.S. Mirzoeva (2003), in the Republic of Tajikistan there is a trend of steady growth not only in breast cancer morbidity but also in mortality among women from this pathology. In connection with the rise in advanced-stage cancer rates, which in 1996 amounted to 64%, and by 2001 had increased to 72%. To reduce mortality among the female population of the Republic of Tajikistan, it is important to study the causes of breast cancer advancement [4,7,58,59].

To date, insufficient research has been conducted in the Central Asian region on the causes of breast cancer advancement, and there are no unified approaches to diagnosis and treatment at advanced stages of breast cancer. Over the past 20 years in Tajikistan, only a few studies on this problem have been completed: candidate dissertations "Retrograde Endoductal Polychemotherapy in Patients with Breast Cancer Stages III–IV" (Rasulov S.R., 1998) and "Sectoral Resection with Urgent Histological Examination in the Diagnosis and Treatment of Breast Cancer" (Mirzoeva D.S., 2002). Despite the sufficient clinical material available, there are no targeted studies on the medical and social aspects of diagnosis, causes of advancement, and late referral of breast cancer patients in Tajikistan, which determined the choice of the present study, in which the causes of breast cancer advancement are studied and scientifically developed measures for prevention and timely detection of this disease are recommended from new medical-organizational perspectives.

Aim of the Study. To study the causes of breast cancer advancement and to find ways of timely diagnosis, optimization of treatment, and prevention in the Republic of Tajikistan.

Research Objectives:

1. To study the causes of breast cancer advancement in the Republic of Tajikistan by referral patterns.

2. To study the features of clinical manifestation of advanced forms of breast cancer.

3. To determine the effectiveness of radiological diagnostic methods for advanced forms of breast cancer.

4. To evaluate the possibilities of various treatment methods for advanced breast cancer.

5. To develop measures for prevention and timely detection of breast cancer in Tajikistan.

Main Propositions for Defense.

1. In Tajikistan, more than 90% of breast cancer patients at their first referral to oncological institutions have a locally advanced or advanced neoplastic process.

2. Due to the low level of awareness among the female population of the country about the clinical manifestations of BC, as a result of the socio-economic level of living, more than 40% of patients suffering from BC engage in self-treatment, and only 10% seek help from oncologists in a timely manner (within one month).

3. At present, preventive examinations are practically not conducted in Tajikistan. In rare cases, when preventive examinations are organized at large enterprises, due to the insufficient number of apparatus (only one functioning mammograph in the entire country, mammographic and ultrasound examinations are not performed).

Scientific Novelty. For the first time in the Republic of Tajikistan, the medical and social aspects of diagnosis, treatment, and causes of advancement of breast cancer have been studied in a sufficiently large clinical material. It has been established that the main causes of late referral for specialized help in the Republic of Tajikistan are: low socio-economic level of the female population; low level of awareness among women about BC (50%); lack of knowledge of breast self-examination technique (97%); absence of preventive examinations and an insufficient level of health education in the country.

It has been found that every third woman among breast cancer patients had metastases, the most common being lung metastases — 13.5±2.3 and liver metastases — 8.0±1.9.

It has been established that more than 30% of breast cancer patients die within the first two years after diagnosis.

It has been determined that BC in Tajikistan shows a trend toward a younger age group. The peak of morbidity falls at the age of 40–44, meaning that women of reproductive age are more frequently affected.

A graphic scheme of the breast has been developed, allowing the dynamics of the disease and the effectiveness of ongoing treatment to be tracked.

Recommendations have been developed for early and timely detection of breast cancer; the necessity of screening programs and the organization of preventive examination rooms has been demonstrated.

Practical Significance. The data obtained as a result of the study formed the basis for the development of individual fragments of the National Breast Cancer Program in Tajikistan, as well as methodological recommendations for oncologists, family physicians, and physicians of the general healthcare system, and can be used for the organization of specialized care for breast cancer.

Publications. Based on the dissertation materials, 10 articles, 1 educational and methodological manual have been published, and 2 certificates for rationalization proposals have been obtained.

Defense of the Work. The dissertation materials have been reported at the annual conference of TIPPMK (2002), the conference of the Republican Clinical Oncology Center (RCO) of Tajikistan (2004), and the 690th session of the Association of Surgeons of the Republic of Tajikistan (2004).

Structure and Volume of the Dissertation. The dissertation is written in Russian on 116 pages, consisting of an introduction, a literature review, a description of material and research methods, and 4 chapters of original research. It is illustrated with 23 tables and 22 figures. The reference list includes 183 sources, of which 105 are in Russian and 75 are in foreign languages.