EPIDEMIOLOGY OF BENIGN BREAST DISEASES IN FEMALES OF CHILDBEARING AGE GROUP
Sandhya P Iyer#, MA Gore#
#Department of Surgery, LTMGH and Medical College, Sion, Mumbai 400 022.
Very little study has been done in the field of benign breast diseases, especially the incidence and factors associated. This study assesses the incidence of various benign breast lesions in the outpatient department of a hospital.
It compares the age, incidence, clinical signs, and symptoms associated with benign mammary lesions in a random study of females. It analyses and assesses the various factors associated with benign breast diseases. Also, it draws a correlation of clinical diagnosis and histopathological or surgical diagnosis and thus specificity of clinical diagnosis.
Breasts are the most important feature of female anatomy and an integral part of the reproductive system. They are symbols of fertility and woman-hood. They serve very significant roles, especially function of lactation. The breast presents a plethora of benign pathological conditions.
Extensive research has gone into the investigations and treatment of malignant conditions of the breast. The benign conditions, however, are also associated with morbidity and are of great concern to the patient. Benign breast conditions are 4-5 times more common than breast cancer.
This entails a study of benign breast diseases, their incidence, diagnosis and factors associated.
MATERIAL AND METHODS
Study of 500 females in childbearing age group was carried out to assess the incidence of benign breast disease. Women attending the outpatient department for any complaint were surveyed. A specially designed proforma was used for recording the findings of clinical examination and the data was analysed to study the details of benign breast diseases in the group surveyed.
The inclusion and exclusion criteria are as listed below:
Menarche to 50 years was the age group selected for study.
postmenopausal women were excluded.
Females who had not yet achieved menarche were not included in the study.
Patients with carcinoma breast were excluded.
On clinical diagnosis of the particular benign breast disease, patient was further investigated and treated. Wherever clinical diagnosis was in doubt, fine needle aspiration cytology was performed.
Further confirmation of diagnosis was obtained on surgery or on relief of symptoms or on histo-pathological examination. Patients were followed up for a variable duration as demanded by the detected benign breast condition.
In our study, fibroadenoma was found to be the commonest of benign breast disorders.
Table 1 shows the distribution of cases into various disorders and percentage of distribution. There were 21 cases of fibroadenoma, the incidence being 4.2% out of 500 and 35% of the 60 cases. The next common condition is fibroadenosis or fibrocystic disease of breast, the incidence being 3.4% out of 500 patients examined and 28% of the 60 cases. There were 9 patients of breast abscess. Tuberculous mastitis was seen in 5 patents out of 500, the incidence being 1% for 500 patients and 8% of the benign breast conditions. Chronic mastitis was found in 3 patients. There was only 1 case each of cystosarcoma phylloides, lipoma of the breast, duct papilloma, galactocoele and sebaceous cyst of the breast.
TABLE 1 Number of cases and percentage of various disorders Disorder Number of cases % of cases Fibroadenoma 21 35% Fibroadenosis 17 28.33% Breast abscess 9 15% Tuberculous mastitis 5 8.32% Sebaceous cyst 1 1.67% Duct papilloma 1 1.67% Lipoma 1 1.67% Chronic mastitis 3 5% Cystosarcoma phylloides 1 1.67% Galactocoele 1 1.67% Total 60 100%
Table 2 shows the agewise distribution of patients and cases of benign breast neoplasms. Out of 500 females included in the present study, 99 females were below 20 years, 192 females between 20 and 30 years age group, 137 females between 30 and 40 years age group and 72 females were above 40 years of age. Out of these, there were 9
TABLE 2 The age wise distribution of benign breast diseases in 500 Age(years) Total No. Of females examined Number of cases with benign breast disease Percentage of cases with benign breast disease < 20 99 9 9.1% 20-30 192 23 11.97% 30-40 137 21 15.35% > 40 72 7 9.7% Total 500 60 12%
females with age less than 20 years who had benign breast disease, 23 cases in 20-30 years group, 21 cases at 30-40 years and 7 cases above 40 years also had benign breast disease. Thus the age wise distribution of cases in 60 patients with positive evidence of benign breast conditions was 9.1% for females below 20 years and 11.9% for 20-30 years. The maximum number of cases were in the 20-30 years age group i.e. 38% of the patients. The next common age group was 30-40 years with incidence being 35% out of 60. The least numbers of patients were above 40 years - 11.8% of 60 patients with benign breast disease. Also fibroadenoma and fibroadenosis are seen as diseases of younger age group (age < 30 yrs.) and phylloides tumours are seen in older age group. Thus benign breast disorders are common in the 20-40 years age group as compared to breast cancer which is found more often in the older age group after 40 years.
The distribution of clinical symptomatology reveals 3 main symptoms for benign breast diseases. The main symptom patients presented with, was lump in the breast. It was seen in 100% of patients with benign breast disease. The other 2 symptoms patients presented with, were pain (50%) and discharge (15%). Swelling or breast lump was predominant complain in fibroadenoma, fibroadenosis, cystosarcoma phylloides, lipoma and chronic mastitis. Lump associated with pain was seen in fibroadenosis, breast abscess, tuberculous mastitis and chronic mastitis. Pain (30 patients i.e. 50% of patients) was the predominant symptom in breast abscess. Discharge was seen in 9 patients i.e. 15% of patients. Discharge may be of various types - serous, milky or pus. Usually discharge is from the nipple. Nipple discharge was milky in Galactocoele and serous in duct papilloma. Out of the 60 cases in our study, no patient was on oral contraceptive pill.
The quadrant wise distribution of fibroadenoma shows higher incidence of fibroadenoma in the upper quadrant. This is probably due to more breast tissue in the upper quadrant. Further bilateral involvement was seen only in one case of fibroadenoma and 2 cases of fibroadenosis. Recurrence was mainly seen in one case of cystosarcoma phylloides where patient had been operated for similar lump.
Out of 500 patients, 175 were nulliparous and 18 cases of benign breast diseases were detected in this group, most of them being fibroadenoma. 325 multiparous females were examined and 42 cases of benign breast diseases were detected. Lactation was found to have a very strong association with inflammatory breast lesions. 6 out of 9 patients of breast abscess were lactating. The patient with Galactocoele was also lactating.
Correlation between clinical diagnosis and his topathology/surgical confirmation.
Table 3 shows sensitivity of clinical diagnosis.
Fibroadenosis was diagnosed and treated on clinical examination.
Out of 22 cases of fibroadenoma diagnosed clinically, only one case was diagnosed as lipoma on histopathology, sensitivity of clinical diagnosis being 95.45%.
Out of 11 cases of breast abscess, 9 cases were confirmed on surgery and 2 cases were detected to have tuberculous mastitis on histology. Thus sensitivity of clinical diagnosis being 81.82%.
Out of 4 cases clinically diagnosed as tuberculous mastitis, 3 cases were confirmed on histopathology and 1 case was found to have fibrocystic disease on histology, the sensitivity of clinical diagnosis was 75% for tuberculous mastitis.
Previous studies conducted on the spectrum of benign breast conditions shows some variations between Western statistics and the Indian statistics.
Fibroadenoma was most common breast lesion
TABLE 3 Sensitivity of clinical diagnosis of benign breast diseases and in correlation with histopathological/surgical confirmation Disorders Clinical diagnosis Final diagnosis (Histopathological/ Surgical Confirmation) Difference In Final Diagnosis Sensitivity of Clinical Diagnosis Fibroadenoma 22 21 1 95.45% Breast abscess 11 9 2 81.82% Tuberculous mastitis 4 3 1 75% Chronic mastitis 1 1 100% Sebaceous cyst 1 1 100% Cystosarcoma phylloides 1 1 100% Galactocoele 1 1 100% Total 41 37 4 90.24%
in our study as well as reports elsewhere. In the Kings College Hospital Breast Clinic, a study was conducted on breast conditions and 80% of patients with breast symptoms had benign diseases.  A case control study of benign breast diseases was conducted in Greater Boston in 1968-69. Fibroadenoma was commonest and found during second decade, commonly in married nulliparae. None had consistent relationship of risk with parity or with age at first birth. There is, however, no mention of the significance of tuberculosis in this study.  Also analysis of black women showed fibrocystic disease as most frequent disorder in both black and white patients, between 25 and 45 years of age.  Most of the Indian studies done are retrospective studies with consequent problems of emphasis. Only one study by Shukla and Kumar is a prospective study, done in patients with benign breast conditions presenting in Department of Surgery, Varanasi between 1985-87. 90% of the patients in this study were less than 40 years of age. Table 4 shows the analysis of various studies done in India.  Fibroadenosis, Fibroadenoma, tuberculosis and mastalgia are common in these studies. Also most of the studies have been done in women in their 40s than in their 20s as subjected to biopsy to rule out the possibility of malignant disease in the retrospective. 
Most Western studies have shown that oral contraceptive pills with decreased progesterone reduced risk of benign breast disease.  A study in the black population revealed number of relationship between use of oral contraceptives and incidence of benign breast diseases.  Use of oral contraceptives is extremely low in Indian population and the effect, protective or otherwise, cannot be ascertained with certainty. 
Department of Surgery at Tokyo, Japan conducted a study on recurrence of benign breast conditions after surgery and found rate of recurrence for phylloides tumour to be 50%.  Indian reports show a wide variation in incidence of phylloides tumour from 0.63% to 13.8%.  There is only one case of phylliodes tumour seen in our study. The tumour was recurrent and occupied the
TABLE 4 Lesions Shukla and Kumar Retrospective Khanna Retrospective Rangabashyam Retrospective Shukla and Kumar Prospective n = 927 n = 1031 n = 215 n = 272 Fibroadenoma 46.4 40 56.7 37.8 Cystosarcoma Phylloides 0.6 14.2 2.3 10.6 Duct papilloma 0.9 0.7 2.3 2.9 Fibroadenosis 14.3 0 16.2 0 Lobular Hyperplasia 0 0.7 0 0 Sclerosing adenosis 0 4.8 0 3.3 Fibrocystic disease 0 14.3 0 0 Cysts 7.9 0 0 11.3 Fibrosclerosis 7.4 0 0 1.8 Duct Ectasia 7.6 4.4 0 2.5 Chronic Abscess 7.8 11.3 7.9 11 Tuberculosis 5.1 5.7 2.7 4.7 Filariasis 0.1 0 2.3 0.3 Cysticercosis 0.1 0.9 0 0 Fat Necrosis 1.2 0 1.3 1.4 Galactocoele 0 1.2 6.9 0
whole breast. This is low in comparison to other studies which showed higher incidence of phylloides tumour in India. 
The percentage of tuberculous affectation of breast amounts to 8% in our study. This is higher as compared to the incidence of tuberculous mastitis in other Indian studies. This may be due to the high prevalence of tuberculosis in India. The patients in our study presented with chronic breast fistula, abscess or ulcer.
Acute breast abscess was also found in nine patients and six of these patients were lactating. However, no case of gangrene breast is found in our study as compared to the study done by Shukla and Kumar  which reported two cases of breast abscess progressing to gangrene as a result of neglect. This is a positive sign as it indicates higher awareness of patients with respect to conditions of the breast.
There was one case of Galactocoele noted in our study and the patient was lactating. This is in accordance with the retrospective study done by Khanna and Arya who reported all Galactocoele patients to be lactating. One case of lipoma is also seen in our study as compared to three cases in the Khanna and Aryas retrospective analysis.  Majority of infective lesions are seen in child bearing age group in our study as well as the Khanna and Aryas study due to traumatic lactation and are prevalent in lower socio-economic group. 
However, no study has been conducted regarding the correlation between clinical diagnosis and confirmed final diagnosis of histopathology or surgical confirmation. Thus, our study stresses the increased incidence and emergence of tuberculous mastitis as an important condition in the spectrum of benign breast neoplasms and the importance of clinical diagnosis in benign breast conditions. Hence, tuberculous affectation has to be kept in mind while dealing with benign neoplasm.
In our study, 500 females were examined and 60 cases were observed to have benign breast diseases. Most females belonged to younger age groups below 40 years of age. Benign conditions of breast are common and have an incidence of 12%.
Fibroadenoma (21 patients) and fibroadenosis (17 patients) were the commonest lesions detected. Fibroadenoma was observed in younger age group as compared to fibroadenosis.
Parity, oral contraceptive pills and family history were not observed to have any significant effect on the occurrence of benign breast disease.
Lactation was found to be one important factor associated with acute inflammatory lesions.
Tuberculous mastitis was the commonest form of chronic mastitis and the diagnosis was missed earlier in two cases.
Clinical diagnosis of the breast pathology correlated well with the histological diagnosis with sensitivity of 90.24%.
Breast self-examination and education to females is very important in cases of benign breast tumours as well, as they are common source of anxiety and worry. Hence, reassurance is the first step in treating benign breast lesions. As tuberculous mastitis is not a very uncommon disease, high level of suspicions and proper follow up of patients are important.
Hence, in a country like ours, education regarding breast self-examination and proper follow up is highly recommended so that early treatment is sought.