The Description of Non-Genetic Risk Factors in Breast Cancer Patients at Haji Adam

Malik General Hospital Medan 2017

Daniel Ivan Sembiring1, Mega Sari Sitorus2

1
Medical Student, Faculty of Medicine, University of North Sumatra
2
Lecturer Department of Anatomy, Faculty of Medicine, University of North Sumatra

ABSTRACT
Introduction. Breast cancer is the second most common cancer in Indonesia. The existence of
this cancer is closely related to risk factors, especially non genetic factors. These risk factors can
be modified and some can’t be modified. The important thing to know is the number of breast
cancer incidence based on these risk factors especially on the risk factors that can be modified,
with the aim is to be able to take preventive action case of cancer prevention. Aim. To know the
description of non-genetic risk factors such as previous medical history, smoking history, alcohol
consumption, physical activity, work environment, hormonal history, reproductive history, and
dietary patterns at RSUP Haji Adam Malik Medan. Methods. This research use descriptive
method with cross sectional design. Methods of collecting data by interview using Aichi Cancer
Center Research Institute's lifestyle and health questionnaire, Baecke physical activity
questionnaire, and Horn-Ross alcohol consumption questionnaire. Sampling using consecutive
sampling technique with a sample size of at least 100 respondents. Results. the results of
research is the majority of respondents in the age group 46-55 years amounted to 42%(42/100),
last education at high school 63%(63/100), house wife 44%(44/100), married 84%(84/100),
passive smoker 76%(76/100), less active 56%(56/100), sleep duration >7 hours/day
66%(66/100), age of menarche ≤12 years old 48%(48/100), pre menopause status 61%(61/100),
age of first childbirth at the age of 21-25 37%(37/100), multiparous 51.7%(45/87), duration of
breastfeeding 19-24 months 42.7%(35/82), consumption of hormonal contraceptive
47%(47/100), consumption of fatty food 63%(63/100) . Conclusion. From the research that has
been done, smoking, alcohol consumption, physical activity, stress factors, reproductive factors,
hormonal drug consumption, and dietary patterns are factors that can be modified to prevent
breast cancer.

Key words. Risk Factors, Breast Cancer, Questionnaire

INTRODUCTION
Breast cancer is a malignant epithelial tumor with characteristics capable of invading
surrounding tissue and has a tendency to metastasize to other organs. Most breast cancers begin
in the ducts or in the lobules of the breast gland. .(Kumar et al., 2010)
Breast cancer is one of the leading causes of death from cancer in the world other than lung,
liver, colon, and stomach cancer. The number of breast cancer patients in the world in 2015 who
died from breast cancer reached 571,000 people. (WHO, 2017)
Breast cancer cases in Indonesia ranks second with prevalence rates reaching 0.05% of all
cases, whereas the prevalence of cervical cancer accounts for 0.08% of all cases.(Badan
Penelitian dan Pengembangan Kesehatan, 2013)
 Etiology of breast cancer, associated with the presence of risk factors that can trigger cancer.
These risk factors include a family history of breast cancer, age, previous cancer history, history
of benign breast tumors, early menarche age, and long age of menopause included in non-
modifiable risk factors. Other factors such as the use of hormonal therapy, oral contraceptives,
pregnancy history and breastfeeding, lifestyle that includes alcohol consumption, physical
activity, and obesity are factors that can be modified to avoid the occurrence of breast cancer.
(Howell et al., 2014)
One of the factors that can not be modified is the genetic factor. In normal cell
circumstances, the BRCA1 and BRCA2 genes help prevent cancer by making proteins that can
help keep the cells from growing abnormally. However, if a family-derived mutation makes this
gene unable to stop abnormal growth. Research conducted by fentiman (2001), found that 5%
risk factors for breast cancer caused by a history of breast cancer in the family.
Nulliparitas, early menarche, old menopause, are factors that can increase the risk of breast
cancer. It is associated with prolonged exposure to estrogen and progesterone hormones. (Kelsey
and Bernstein, 1996) In addition, the use of exogenous hormones in the form of oral
contraceptives and hormonal therapy can also increase the risk of breast cancer. Overall evidence
suggests a breast cancer risk of about 25% higher in oral contraceptive users. The risk appears to
decline with age and time since the cessation of contraception. (Marchbanks et al., 2012)
Cases of breast cancer increased with age, found in 1.5 cases per 100,000 women aged 20-24
years, while 421.3 cases per 100,000 in women aged 75-79 years. Breast cancer cases generally
occur in women aged 40 years or older. The average age of women at the time of diagnosis of
breast cancer is 61 years. (WHO, 2017)
In lifestyle, regular physical activity with a time of 1 hour to 2.5 hours per week can reduce
the risk of breast cancer by 18%, while high-fiber dietary patterns such as grains, fruits, and
vegetables, low in saturated fat, and also low alcohol is a protective factor against the incidence
of breast cancer. (Holmes and Willett, 2004)
From previous studies that have been done on breast cancer risk factors, this study is
intended to see more broadly the picture of factors that affect the incidence of breast cancer,
especially non-genetic factors such as reproductive and hormonal factors, history diseases, and
modifiable factors such as lifestyle, obesity, and physical activity.

METHOD

This research is a descriptive research using cross sectional approach, where this study aims
to know the description of non-genetic risk factors in breast cancer patients in Poly Oncology
surgery in Haji Adam Malik Hospital Medan. The inclusion criteria in this study are patients who
have been diagnosed with breast cancer through histopathologic examination and are willing to
be interviewed by signing informed consent. Based on a large formula of descriptive sample
categorical obtained as many as 97 respondents minimal. The method of selecting the subjects of
the study was conducted by non-probability sampling using consecutive sampling, in which all
breast cancer patients who had met the study criteria were included in the study. The data of this
study were collected by direct interview technique to the research sample using Aichi Cancer
Center Research Institute and lifestyle questionnaire, Baecke physical activity questionnaire,
alcohol questionnaire Horn-Ross.(Strumylaite et al., 2013).
 Data obtained, collected and processed using Statistical Product and Service Solution (SPSS)
program and then distributed descriptively using the frequency distribution table and conducted
the discussion of data obtained

RESULTS AND DISCUSSION

Characteristics of Age

Age (Year) Frequency Percentage (%)

<26 0 0
26-35 8 8
36-45 28 28
46-55 42 42
56-65 20 20
> 65 2 2

It was found that the majority of respondents as much as 42% suffer from breast cancer at the
age of 46-55 years or enter the category of early elderly. The incidence of breast cancer,
especially at the age of less than 30 years is more due to hereditary factors. According to Chen et
al (2016) half of the total respondents had mutations in BRCA1, BRCA2, and TP53. Only 10%
are not of heredity. While at age> 40 years relative caused by hormonal factor and environmental
factor

Demographic Data

Demographic Data Frequency Percentage (%)

Residence
 Big City 38 38
 Subburb/ Small Town 54 54
 Village
8 8
Last Education
 Primary School 11 11
 Junior High School 12 12
 Senior High School 63 63
 University 14 14

Average Family Revenue Per Month

 <1,5 Million 14 14
 1,5-3 Million 23 23
 3-5 Million 29 29
 >5 Million 34 34

Work
 Housewife 44 44
 Government Employees 12 12
 Entrepreneur 30 30
 Farmers 14 14
Marital Statues
 Not Married 13 13
  Married 84 84
 Divorce 3 3

Based on the residence, it was found that the majority of patients came from the suburbs /
small town, that is as much as 54%. This happens because the average regional hospital (outside
Medan city) does not have adequate facilities for treatment of breast cancer patients. So the
patient should be referred to the Haji Adam Malik General Hospital which is the final referral
hospital, with the territory covering all areas of North Sumatra and Aceh.
Based on the average family income per month, 34% of cases were found in families with
income> 5 million per month.
Based on recent education, it was found that the highest number of patients with high school
education was 63%.
Based on the work of respondents, the majority of patients as much as 44% are housewives,
entrepreneurs as much as 30%
Based on marital status, the number of respondents who are married as many as 84% and
unmarried as much as 13%.
Similarly, Rosner et al (2000) found an increased risk of breast cancer in both unmarried and
married women who had no children compared with women with children.

Respondent's Disease History

Disease History Frequency Percentage (%)

Disease History Data
Disease Ever / ModerateGangguan Lambung
 Thyroid disease 21 21
 Hypertension 2 2
 Diabetes 18 18
 Breast Malignant Tumor 11 11
14 14
Part of Breast Cancer Affected
 Right 40 40
 Left 39 39
 Right and Left 21 21
Chemotherapy History
 Yes 68 68
 No 32 32
Radiotherapy History
 Yes 36 36
 No 64 64

In a study conducted by Liao et al (2011) with metaanalysis methods found increased risk of
breast cancer in diabetics by 23%, especially in post menopausal women. In addition to
increasing the risk of breast cancer, diabetes can also increase mortality rates in breast cancer
patients. This increased risk is associated with an increase in insulin and insulin-like growth
factor 1 (IGF-1).
Based on research metaanalysis conducted by Han et a l (2017) found a relationship between
hypertension disease with incidence of breast cancer. It is at risk of 15% especially in
postmenopausal patients.
 In a study conducted by Dupont et al (2000) suggesting that there is an increased risk of
breast cancer in women with a history of fibroadenoma disease, an increased risk of
fibroadenoma complex is compared with simple fibroadenoma. Risk can increase breast cancer
1.5 to 2 times greater after a follow up for 20 years since the biopsy.
Based on the history of chemotherapy, as many as 68% have received chemotherapy and 36%
have never got treatment radiotherapy.

Family History

Family History Frequency Percentage (%)

Yes 12 12
No 88 88

This is comparable to a study by Hirose et al (2001) in which 6.9% of premenopausal

patients had a family history of cancer, and 6.7% in postmenopausal patients.
Based on the American cancer society, it is explained that only 5% -10% of cases of breast
cancer have a family history of cancer. The genes that most commonly cause breast cancer are
inherited are the mutated BRCA1 and BRCA2 genes. If a mutated BRCA1 gene is obtained, the
risk of breast cancer rises to 80%, but the BRCA2 gene mutation may account for 45% of the
cancer.

Smoking History

Smoking History Frequency Percentage (%)

Active Smoker
 Yes 14 14
 No 86 86
Passive Smoker
 Yes 76 76
 No 24 24
Characteristic of Passive Smoker
Expose Place
 Home 53 69.7
 Work Place 9 11.9
 Home and Work Place 14 18.4
Exposure (Year)
 1-15 21 27.6
 15-25 26 34.2
 ≥26 29 38.2

According to a study by Gaudet et al (2013) using the cohort and meta-analysis method found
that in the cohort study, there was an increased risk of breast cancer in women smokers
especially in women who had smoked before the first birth. While the metaanalisis method of the
relationship between smoking and cancer is not too strong. The same is true of Catsburg et al
(2014) in which breast cancer risk increases with age and cigarette consumption
In a study conducted by Li et al (2015) found a significant relationship between passive smoking
and breast cancer risk in pre menopausal and post menopausal women. The increased risk is also
proportional to the length of exposure and the number of cigarettes spent in a day. The study
illustrates that women exposed to tobacco smoke more than 16 years have a high risk for breast
cancer.

History Of Alcohol Consumption

Alcohol Consumption Frequency Percentage (%)

 Yes 6 6
 No 94 94

Based on history of alcohol consumption, found 6% active drinking alcohol. Research

conducted by Gao et al (2013) with the type of metaanalysis research, found that there is no
significant relationship between alcohol consumption and breast cancer risk. Conversely, in the
study of Horn ross et al (2004) by using the cohort method, found the relationship of alcohol
consumption with breast cancer risk.

Physical Activity of Respondents

Physical Activity Frequency Percentage (%)

Respondents Exercising
 Yes 17 17
 No 83 83
Physical Activity Index
 Very Active 0 0
 Active 11 11
 Enough Active 22 22
 Less Active 56 56
 Very Inactive 11 11

A total of 17 respondents regularly exercise, with the most common type of exercise is
jogging or gymnastics.
Based on the summation between the job index score, the sports index, and the activity index
at leisure time. the index category of physical activity was obtained. From these results obtained
as much as 56% of respondents fall into the category of less activity. Respondents with active
category as much as 11%.
Based on research Kim et al (2013), strong physical activity to moderate can reduce breast
cancer risk. The same thing in the study Rockhill et al (1998) where there is a decreased risk of
breast cancer, if exercise at least 10 hours per week.

Hormonal History

Hormonal History Frequency Percentage (%)

Menarche (Age)
 ≤ 12 48 48
 13-14 38 38
 ≥15 14 14
Menstrual Regularity
  Reguler 87 87
 Irreguler 13 13
Menopause Status
 Pre-Menopause 61 61
 Post-Menopause 39 39
Hormonal Contraception
 Yes 47 47
 No 53 53
Duration of Hormonal
Contraception Use (Month)
 <1
 2-6 13 27.7
 >6 14 29.8
20 42.5
Hormone Replacement
Therapy
 Yes 6 6
 No 94 94

Based on hormonal factors, 48% of menarche respondents were found at age ≤12 years.
Judging by the regularity of menstruation, there are 13% of irregular menstrual respondents.
According Clemmescen (2012) there is no relationship between early menarche with breast
cancer. Unlike Apter (2010), women with early menarche at <12 years of age have high serum
estradiol levels, low testosterone and dehydroepiandrosterone compared with normal menarche
women, leading to prolonged exposure to estrogen hormones, thus increasing the risk of breast
cancer .
Based on menopausal status, 61% of pre menopausal respondents and 39% post menopause.
According Clemmescen (2012) increased risk of breast cancer in women pre menopause
compared with post menopausal women reached 40%. In addition, there were no significant
results on increased risk of breast cancer in the old menstruation, new risk seen at the age of
menopause> 54 years of 1.1 compared with women aged menopause <50 years. This increased
risk occurs due to prolonged exposure to estrogen and progesterone.
Based on the use of hormonal contraception, 47% of the respondents had used hormonal
contraception, and 20% of the respondents took it for more than 6 months. Based on a study by
Marchbank et al (2002), the association between the use of hormonal contraceptives and breast
cancer was not significant, the risk increased to 1.32 compared with those who did not take
hormonal contraceptives. Similarly, Hunter et al's (2010) study suggests an insignificant
association in hormonal contraceptive consumption <1 year with the incidence of breast cancer,
but a higher association was found if hormonal contraceptive use was more than 10 years.

Reproduction History

Reproduction History Frequency Percentage (%)

Age of First Childbirth (Age)
 ≤20
 21-25 5 6.1
 26-30 37 45.1
  >30 26 31.7
14 13.1
Total 82 100
Parity
 Nulipara 5 5.7
 Primapara 13 14.9
 Scundipara 23 26.4
 Multipara 45 51.7
 Grandemultipara 1 1.1
Total 87 100
Breastfeeding (Month)
 ≤8 13 15.8
 9-12 19 23.2
 13-18 11 13.4
 19-24 35 42.7
 >24 4 4.9
Total 82 100
Abortion or miscarriage
 Yes 5 5
 No 95 95
Total 100 100

Based on the reproduction factor, the first age gave birth to the majority at the age of 21-25
years as many as 37 respondents (45.1%). Based on the results of the study Ewertz et al (2000)
found that in women with the first gestational age> 25 years had a higher risk compared with
groups less than 25 years, and also found that in women aged 35 years at first birth has a risk of
cancer breast to 40% when compared to women aged 20 years at first birth.
Based on the number of children, the majority of respondents multipara or have children
amounted to 3-4 as many as 45 respondents (51.7%). A study by Helmrich et al (2000) suggests
a decreased association of breast cancer risk in women with children over 5 compared with
women with 1 or 2 children with relative risk being 0.7. Similarly, the study of Huo et al (2008)
suggests that breast cancer risk is increased in women with children <2 compared with women
with 3-4 children.
Based on the duration of breastfeeding, the majority of respondents breastfeed each child
during 19-24 months as many as 35 respondents (42.7%). According to a study conducted by
Pakseresht et al (2009) with a case control approach, states a protective relationship to breast
cancer with the duration of breastfeeding. Similarly, Gajalakshmi et al (2000) stated that there is
a decreased association of breast cancer risk with a long history of breastfeeding. The risk
reduction is 4.3% every 12 months of breastfeeding, so the protective effect can be seen if longer
breastfeeding. According to the American Cancer Society, there is a decreased risk of breast
cancer if breastfeeding a child for 1.5 to 2 years, this is because if women breastfeed it will
reduce the number of menstrual cycles.
CONCLUSION

Based on the results of research that has been done in RSUP Haji Adam Malik Medan in 2017
with a total of 100 respondents, the conclusions can be drawn from the results of this study is:
1. Based on Age of respondents, 42% of respondents aged 46-55 years.
2. Based on respondents' demographic data, 54% of respondents came from suburban /
small town, 63% of senior high school education, 34% of respondent family> 5 million,
44% work as housewife, 84% have married status.
3. Based on the history of the disease 21% of respondents suffered from stomach upset,
18% hypertension, 40% of the cancer was in the right breast, 68% had undergone
chemotherapy, 36% had undergone radiotherapy.
4. Based on a family history of cancer, there were 12 respondents had a family history of
cancer
5. Based on smoking history, 14% were active smokers, 76% were passive smokers, 69.7%
of passive smokers were homeless, 38.2% had been exposed to ≥26 years
6. Based on history of alcohol consumption, as much as 6% actively consume alcohol
7. Based on the level of physical activity, 17% of respondents routinely exercise, 56% of
respondents viewed based on physical activity index classified as less active
8. Based on the history of hormonal was found as much as 48% of first menstrual
respondents once at age ≤12 years, 87% of respondents experienced menstruation
regularly, 61% of respondents pre menopause.
9. Based on the history of reproduction, 45.1% of respondents gave birth first at 21-25 years
old, 51.7% were categorized as multipara (number of children 3-4), 42.7% of respondents
breastfeeded 19-24 months per child
10. Breast cancer is a multifactorial disease both from genetic factors as well as
environmental factors such as hormonal, smoking, alcohol consumption, and lifestyle.
Each individual affected by breast cancer, has different risk factors.
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