Delineating Breast Cancer in Asia: Exploring Regional Risk Factors and Screening Practices in a Comprehensive Study

Rakesh Nagamathan, Kovida Vupputuri, Nikhil Vundela (Equal Contribution), and Dr Lopamudra Das Roy

Published: October/2023

Abstract

The present research paper offers a comprehensive examination on the impacts and effects of breast cancer in Asia, along with insight on certain factors that could play a part in the discrepancies within the data. The paper refers from numerous sources: PubMed, National Institute of Health, and the World Health Organization, to investigate the breast cancer scenario. Additionally, through the resources provided by multiple experimental studies, this research paper offers recent data with multiple conclusions for further research. As the largest continent in the world, Asia has many diversities and disparities within its borders. When considering the impact of breast cancer, it is crucial to view the statistics presented with an open mindset. Risk factors and screening practices in the Asian continent vary regionally. To accommodate this diversity, the paper incorporates specific data from each area. Furthermore, specific countries were highlighted to emphasize the variety in research, population, and treatment information. This data was then analyzed and interpreted, while focusing on specific factors that have been considered to change the populations that suffer from breast cancer, such as ethnicity, socioeconomic status, etc. The objective of the paper is to inform the public about region-specific risk factors and screening practices in Asia that can assist in early detection and prevention of breast cancer.

Introduction

Breast cancer is a complex and widespread global health issue, affecting millions of people annually. The survival rates of breast cancer are highest in Japan (84.7%), China (82%), South Korea (82.7%), and are lowest in Bangladesh (50%) [1]. Japan has the highest survival rate for breast cancer in Asia because their diet consists of high amounts of isoflavones, plant-based compounds linked to a reduced risk of breast cancer [2]. Additionally, the mortality rates of breast cancer in Pakistan are 23% and 20% in India[1] [3]. In the vast and diverse continent of Asia, this challenging disease has become a major concern, capturing the attention of healthcare professionals, researchers, and policymakers. As the largest and most populous continent in the world, Asia, presents a unique landscape where breast cancer rates, occurrences, and treatment outcomes vary significantly from one area to another. To gain a fundamental understanding on the breast cancer scenario through Asia, the paper throughly examines the regions that comprises Asia: Central Asia, South Asia, Southeast Asia, East Asia, Western Asia, and Northern Asia. In this in-depth investigation, the paper aims to explore the various aspects of breast cancer in Asia, shedding light on the factors that contribute to its prevalence, regional differences, cultural impacts, and the ongoing efforts to combat and manage this illness.

Breast Cancer Screening Guidelines in Asia

The screening process for breast cancer plays an integral role in treating cancer. When abmormalities like tumors are found early on through the screening process it becomes easy to treat cancer. A common screening practice conducted in Asia to test for breast cancer are mammograms. Mammograms are essentially pictures of the breast. In this process, the breasts are compressed between two support plates to capture a black and white image through utilizing x-rays. High density regions in the image produced by the mammogram are depicted by areas of white or gray that denote abnormalities such as tumors [4]. Several countries enforce guidelines for the recommended age individuals should take the mammogram. To illustrate, in India 40 years old is the suggested age where one should start the mammography screening [5]. Additionally, in China the suggested age for one to start the screening process for breast cancer is 40-44 years [6].

To observe the cost effectiveness and the benefits of the screening practices, a study was conducted in the Republic of Kazakhstan. This study was conducted by cross referencing screened and unscreened women who developed breast cancer. According to this study, it is determined that the screening practice, mammography, is cost effective to the people of Kazakhstan. In the study, the individuals who were screened and developed breast cancer yielded 1,253 more life years and 790 quality adjusted life years (QALY). Additionally, it was determined that the cost effectiveness ratio was 3,157 United States dollars to one quality adjusted life year. These results corroborate and emphasize individuals to be screened for breast cancer as it could be treated early on making it cost effective [7].

In spite of the breast cancer screening process being effective, several individuals continue to not undergo the screening process. A study in Kathmandu Valley, Nepal observed the factors that were related to the low screening rates. The study observed five hundred women using a questionnaire to analyze their intentions of having a mammography twice a year, a clinical breast examination, and a self examination monthly. The results concluded women with a positive attitude towards breast cancer and with high subjective norms were more than likely to undergo the three screening practices, however, women with high fatalistic beliefs were less likely to go through with the clinical breast examination. To increase the individuals who undergo screening practices the study notes that it is vital to improve individuals’ attitude towards breast cancer and increase the availibility of screening practices [8].

Unfortunately, China has more than 30% of new breast cancer cases and almost 25% of breast cancer deaths in 2020. Due to this rising number of cases in China, they developed a free breast cancer screening intiative to all women in the country [9]. With this new screening program, a number of women were determined to be prone to breast cancer. Despite the new screening program, the breast cancer screening rates in China continue to be lower than needed; while, the rates of individuals being susceptible to breast cancer continue to increase. The China CDC considers this proportion to be inadequate and multiple factors can account for the low rates of screening: socioeconomic barriers, cultural impacts, and cancer fatalism [10]. Ultimately, the study proves there are multiple screening procedures and expansions taking place, but the number of Chinese women being screened are not increasing.

Cancer cases in Southeast Asia have increased by over 2 million, and deaths by almost 1.5 million. Most of these cases reported have been breast cancer [11]. However, it is crucial to note that while breast cancer is the most prevalently reported cancer, it is also the cancer that is usually left untreated for the longest. There are multiple screening methods for breast cancer, including mammography and self-examination, which have proved to be useful in detecting cancer at its early stages. Furthermore, mammography can provide inaccurate results in some scenarios, healthcare providers also employ ultrasounds and MRI (Magnetic Resonance Imaging) to address this issue [12]. In all cases, treatment for breast cancer typically involves surgical removal of the cancerous cells, usually in the form of a mastectomy or lumpectomy[13]. While it may be lifesaving, women in highly urbanized countries with westerninzed beauty standards choose not to receive surgery at all, due to the proposed risk of loss of femininity, and scar tissues.

Ethnicity

In a region like Southeast Asia, where the rural population makes up over 75% of the total population of over 650 million, tracking the true proportion of female individuals affected by breast cancer is extremely difficult [14]. Additionally, due to the lack of resources, educational supplements, and medical aid being offered to those in rural Southeast Asia, it becomes even more difficult to treat those who suffer from breast cancer. However, in a city-state like Singapore, where 100% of the population lives in an urban setting, tracking individuals who possess symptoms is easy. Singapore has reported the highest number of women affected by breast cancer in Southeast Asia in the past 30 years [15] . Multiple factors account for this, many directed at the rapid urbanization and Western lifestyle that many Singaporeans are adapting to. An increase in smoking and alcohol abuse in Singaporean women can lead to higher chances of breast cancer. However, another reason involves the lack of data in other countries. While the data in Singapore may be high, every citizen is accounted for and tested, so the data depicts a low margin of error to the true proportion of females with breast cancer. However, most of the population is rural and unaccounted for in countries like the Philippines and Indonesia. The only data that nations like these are able to present are those from occupants in urban, country capitals like Manila or Jakarta. Apart from interregional differences in data, Singapore reports that ethnic differences are not a factor when understanding the impact of breast cancer, as all three main ethnicities: Chinese, Malya, and Indian have very similar rates of breast cancer.

The impact of ethnicity is widely disputed, especially in Asia. While over 45% of breast cancer cases worldwide are from Asia, ethnic differences within regions and countries vary heavily. In research conducted in Singapore and Japan, it is highly emphasized that ethnicity plays little to no role in the diagnosis of breast cancer [16]. However, when comparing ethnicites within the continent, certain factors can be noticed. Specifically, South Korean women tend to have a higher prevalence of hormonal factors such as early menarche (onset of menstruation), late menopause, and a shorter duration of breastfeeding, which suggests that ethnicity could be a potential factor when considering the spread of breast cancer in Asia. Nevertheless, there is very little disparity between the rates of breast cancer in South Korea and other countries. However, a study in Isreal offered revolutionary data that contradicts research suggested by other Asian studies. The study revealed that the ethnic Ashkenazi group of Isreal were at a much higher risk of contracting the BCRA1 mutation when compared to Isreali Arabs and other minor ethnicities in the country. This offers evidence that there are some clear differences in ethnicity. Other conclusions from this study include the survival and omrtality rates when comparing major ethnicities in Isreal. The Israeli Jewish ethnicity has a 90% survival rate, compared to the Isreali Arab ethnicity’s survival rate of 84%. Also, when looking at the mortality rate of the two ethnicities, the Jewish ethnicity has faced a downward trend from 1996 to 2019, while the Arab ethnicity has remained constant within that same time period [17]. Additionally, research on foreign born Asians revealed that Chinese and Filipina women born in the United States had a significantly higher chance of getting invasive breast cancer variants, and estrogen positive breast cancer rather than foreign born Chinese and Filipina Women. Due to this, there is a general acceptance that breast cancer plays a minimal role within the continent’s borders. However, when Asian women are born in a foreign continent, such as the United States, ethnicity plays a much larger role in the effects of Breast Cancer. Due to these disparities, the data on the Asian minority with breast cancer in Europe and the United States most likely has a great variance from the data with the same minorities in the Asian continent.

Socioeconomic Status

While ethnicity is a disputed reason for a spread in breast cancer cases, socioeconomic status is one of the most unanimous factors. In countries where poverty rates are low, such as Singapore and Japan, researchers argue that socioeconomic status plays very little role. However, in countries with a high rural and poor population, such as Thailand, there are more disparities within socioeconomic statuses. In Thailand, due to the high percentage of rural residents, there is a higher amount of women who simply do not receive any screening or treatment. Additionally, those in rural areas are more susceptible to preconceived opinions of western healthcare, which can also lead to a decrease in population receiving care. In Russia, factors such as delayed childbirth, fewer pregnancies, shorter breastfeeding duration, and hormonal factors associated with reproductive choices can influence breast cancer incidence. Russia has regions with high industrial activity and nuclear facilities, which may increase the exposure to potential carcinogens. In some regions of Russia, access to quality healthcare services, including breast cancer screening and early detection programs, may be limited.

Middle eastern Countries such as Egypt were heavily affected by socioeconomic factors, just like Thailand. Ancient Egyptians were among the first to describe breast cancer in the Edwin Smith Surgical Papyrus [11]. Yet, breast cancer is the prevailing cancer among Egyptian women. Late screening plays a massive role in this. Screening for cancer is not heavily inforced or talked about, so many people who could have prevented this, take it to the later stages, where it isn’t preventable. Most Egyptian women wait till they are ill to get screened, and 77% of them choose not to have a mammogram unless requested by their doctor. Breast cancer is also higher in Egypt for those who have less income, education, or areas of lower socioeconimic status [18].

In Japan, newer, less invasive treatments have been considered to be valuable when considering womens’ health and recovery. Chemotherapy, endocrine therapy, and radiation therapy were all research thoroughly in Japan’s breast cancer registries. Additionally, in a study conducted to understand environmental risks and breast cancer incidences in Japan, it has been heavily emphasized that socioeconomic and ethnic differences have no genetic or scientific effect on cancer incidences. However, they are much more susceptible to be exposed to poor health conditions and environmental toxicantss, making them more likely to be impacted by breast cancer [19].

Lifestyle/Environmental Factors

In Thailand, where there is a wide variety of both urban, rural, and suburban regions, the country as a whole has a scattered pattern of treatment. Breast cancer cases in Thailand are incredibly heterogeneous, with certain groups receiving care, and others without acknowledgment. Those in rural areas rarely get the care they need, and those in urban areas mainly refuse to get care. Incidence rates are heterogeneous as well, with the lowest region having 19.4 cases per 10,000 women, and the highest having 32.4 cases per 10,000 women. Khon Kaen, the largest province, tested to have the highest number of breast cancer cases per 10,000 women. To analyze the trends, multiple studies were conducted on the Khon Kaen region, with a major trend seen in age. The research concluded that those in their late 40’s to early 50’s are at most risk of getting breast cancer according to the trends seen in Khon Kaen.

Breast cancer is officially the most common cancer among all Korean women. When considering the number of people that get cancer in South Korea, we must also consider all the factors that play into it. Looking into the demographics, there is an increase in older individuals, with 71.46% of the population being as old as 15-64 years [20]. South Korea has a Westernized diet which can also be a leading cause for an increase in breast cancer. The westernized diet has a high intake of saturated fats like red and processed meat which is linked to an increase in breast cancer due to the high estrogen levels that come from eating hormone treated meats . It has a low intake of vegetables and fruits eliminating the vitamins and antioxidants that help prevent cancer that comes from fruits. It has heavy calorie foods which can cause obesity, which is a known cause of breast cancer. The processed carbohydrates and sugars that come with the diet, leads to insulin resistance which increases the chance of breast cancer, especially in postmenopausal women.

Iraq was in a state of multiple wars; causing damage to healthcare facilities [21]. This causes things like obesity and smoking, due to inadequete monitoring, lack of medical care and health education. These are all risk factors for cancer. Iraq already has a high incidence rate of breast cancer;the rate of cancer went from 44.58 to 67.87/100000 from 2008-2016. Some other reasons for this include low fruit/vegetable intake and a family history of breast cancer. Iran already has a high incidence of breast cancer, but it went up by 15.2 percent. Societal changes can also play a major role in breast cancer, whether it's good or bad. Increased urbanization, and increased education for women can change lifestyle like diets and physical activity.

Family History

Healthcare providers examine a patient’s family history to determine if the patient is at a higher risk for a disease. Additionally, genetic risk factors are an influential risk factor for breast cancer. Genetic risk factors are defined as inherited factors that pass down from parents to the child through genes, and these risk factors could predispose an individual to a certain disease [22].

The BRCA 1 (Breast Cancer Gene 1) and BRCA 2 (Breast Cancer Gene 2) are genetic mutations that are specifically tumor suppressor genes. Approximately, 45% of women with theBRCA mutation are susceptible to breast cancer [23]. In regions of Central Asia, genetic risk factors concerning their population are under-researched. To better gain a fundamental understanding of the correlation and the contributions of genetic risk factors to breast cancer, studies are being conducted to educate individuals. To further research the BRCA contributions to breast cancer in Uzbekistan, a pilot study was conducted. In this pilot study, it was determined that roughly 4.5% of samples of the individuals with breast cancer tested positive for the 5382insCBRCA1 mutation. This finding suggests that in Uzbekistan the 5382insCBRCA1 mutation can be attributed to breast cancer, and it is imperative to conduct further studies to examine and research the impact of this mutation on breast cancer in Uzbekistan. Furthermore, this study outlines and sets a beginning of incorporating the 5382insCBRCA1 mutation test in screening processes for breast cancer [24]. The heredity of breast cancer is best displayed in the Han population in China. While the ethnic population does not have a very high rate of breast cancer, the BRCA 1 and BRCA 2 mutations are the ones that are most hereditary in the population. These mutations frequently appear as a false negative during screenings for breast cancer [25]. However, researchers in China are currently attempting to formulate a model that captures the mutation for BRCA 1 and BCRA 2. Additionally, researchers are currently testing multiple ways to understand the hereditary mutations, and occurrences when major mutations occur in the Chinese population.

The partner and locator of the BRCA2 gene is the PALB2, which specifies the sequences of the BRCA protein [26]. A study identified that women who carry the PALB2 gene are 35% susceptible to being diagnosed with breast cancer. Based on these findings, a study conducted in Pakistan aimed to research the PALB2 gene mutation in early-onset and breast cancer patients [26]. The study was conducted on 370 Pakistanis, who were early-onset breast/ovarian cancer patients or cancer patients, and were tested negative for BRCA1/2, TP53, CHEK2, and RAD51C mutations. DNA sequencing and splice prediction algorithms were utilized to test if PALB2 was a factor for the patients to develop breast cancer. The results of the study yield four possible pathogenic PALB2 mutations and one novel pathogenic mutation signifying PALB2 mutations play a significant role for breast cancer susceptibility in Pakistan.

To gain an insight on the correlation of the XRCC1, TP53 and MDM2 genes with breast cancer in the female population of Kyrgyzstan, a preliminary study was conducted. The polymorphic markers determined in this study, signify a genotypic difference between individuals depicted through the marker sequence differences. The results of this study indicated and corroborated that XRCC1, TP53 and MDM2 genes found in these individuals are prone to developing breast cancer. Ultimately, this study identifies the molecular markers of risk to breast cancer that can facilitate early detection, prevention, and to recognize individuals with high risk to breast cancer [27]. Ultimately, these prelimary studies conducted throughout Asia aimed to conduct research on specific genetic mutations concerning the specific country’s popoulation.

Discussion

The findings provide an encompassing overview of breast cancer throughout the continent Asia, by representing and comparing several risk factors to different regions that form Asia. The results indicate factors like family histories, ethnicities, socioeconomics, and lifestyle/environmental factors can influence an indivdual to develop breast cancer. As throughout the continent rates of breast cancer continue to rise, it is imperative to implement screening processes throughout. Screening practices like self examination, mammography, and in addition to ultrasounds or MRI if the individual has a dense breast are proven to detect individuals with breast cancer and can identify abnormalities before it becomes a disease. Researchers emphasize individuals to undergo screening practices, unfortunately, some individuals with fatalistic beliefs do not participate in the screening practices. To overcome this belief, it is imperative to improve the attitude towards breast cancer screening practices and the availibilty and affordibility of screening practices. If the cancer is caught in its early stages it becomes easier to treat. Ultimately, these findings are based on previous research studies that aim to bring awareness to breast cancer, to educate the population on risk factors and preventive measures that should be considered.

Conclusion

In conclusion, the findings in this research paper discuss several factors that play an integral role in the susceptibility of breast cancer throughout Asia: ethnicity, socioeconomic factors, lifestyle/environmental factors, and genetic/family history. Specific genetic mutations, pregnancies, and political issues play a key role for individuals to develop breast cancer. Additionally, there are prevention methods and treatments that can help prevent these risk factors. While certain factors are beyond control, such as gender or race, it is crucial for individuals to take proper precautions, such as getting screened, and raising awareness, can reduce the burden of breast cancer in Asia, and promote better health for affected populations.

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BCHDev DevelopOctober 13, 2023