|Year : 2020 | Volume
| Issue : 3 | Page : 115-119
Assessment of breast cancer risk in Libyan women using the gail model
Mouna M ElJilani1, Afaf A Shebani1, Amina M Bishr1, Hamza M Abdul Jalil1, Tarek M Dalyoum1, Halema A Abudalla2, Reema Z Abualroos3, Hamed O Alhodiri4, Hafsa A Alemam1, Eman B Gusbi1, Inas M Alhudiri1
1 Genetic Engineering Department, Biotechnology Research Center, Tripoli, Libya
2 Department of Biology, Aljufra University, Hun, Libya
3 Fezzan Clinic, Sabha, Libya
4 Elgurda Health Center, Sabha, Libya
|Date of Submission||10-Apr-2020|
|Date of Acceptance||06-Aug-2020|
|Date of Web Publication||21-Sep-2020|
Dr. Mouna M ElJilani
Biotechnology Research Center, Alfornaj, Tripoli
Source of Support: None, Conflict of Interest: None
Background/Aim: Breast cancer is the most common cancer in Libyan women. Studies of breast cancer risk assessment in Libyan women are not available, and it is important to detect people at high risk for preventive and screening measures. The aim of this study is to estimate the 5-year and lifetime risk of breast cancer in Libyan women using the Gail model. Subjects and Methods: This cross-sectional study was conducted on 918 Libyan women ≥35 years. The Gail model was used to calculate the 5-year and lifetime risks of developing breast cancer. Risk factors such as age at menarche and first live birth, number of previous breast biopsies, family history, and ethnicity were considered in the model. Results: The mean age of women was 46.9 ± 8.7 years. The mean 5-year and lifetime risks were 1.0 ± 0.6 and 10.7 ± 4.8, respectively. A significant correlation was found between 5-year and lifetime risk and age at menarche, family history, previous breast biopsy, and ethnicity (P < 0.05). Conclusion: The risk estimates obtained from the Gail model could be improved if the risk factors involved are corrected for the Libyan population by conducting cohort studies with long follow-up to calculate the relative risks caused by each factor. In particular, the risk of different ethnic groups should be estimated and a modified model developed for Libyan women.
Keywords: Breast cancer, Gail model, Libyan women, North Africa, risk assessment
|How to cite this article:|
ElJilani MM, Shebani AA, Bishr AM, Abdul Jalil HM, Dalyoum TM, Abudalla HA, Abualroos RZ, Alhodiri HO, Alemam HA, Gusbi EB, Alhudiri IM. Assessment of breast cancer risk in Libyan women using the gail model. Libyan J Med Sci 2020;4:115-9
|How to cite this URL:|
ElJilani MM, Shebani AA, Bishr AM, Abdul Jalil HM, Dalyoum TM, Abudalla HA, Abualroos RZ, Alhodiri HO, Alemam HA, Gusbi EB, Alhudiri IM. Assessment of breast cancer risk in Libyan women using the gail model. Libyan J Med Sci [serial online] 2020 [cited 2020 Oct 22];4:115-9. Available from: https://www.ljmsonline.com/text.asp?2020/4/3/115/295608
| Introduction|| |
According to the World Health Organization, breast cancer is one of the most prevalent diseases worldwide and its rates are increasing in nearly every region around the world; however, they are still higher in more developed countries. Statistics show that it affects over 2.1 million women yearly and also causes the highest number of cancer-related deaths among women. In 2018, 627,000 women died from the disease which means approximately 15% of all cancer deaths among women. Over 50% of women diagnosed with breast cancer in most African countries present late and report to the hospital with advanced Stage III and IV, a primary reason for the poor prognosis.
Libya is one of the North African and Arab Maghreb countries with a population of over six million, according to the 2015 census (Bureau of Statistics and Census Libya). An epidemiological study in 2018 concluded that breast cancer is the most common cancer in females in Western Libya. Another study on cancer incidence, survival, and mortality in Eastern Libya from the Benghazi Cancer Registry for cases diagnosed from 2003 to 2005 also showed similar results. Moreover, delayed diagnosis is reported as a very serious problem in Libya and is associated with complex interactions between many factors (such as fear and shame) and with advanced stages.
To reduce mortality rates, early diagnosis based on awareness of early signs and symptoms and screening are two strategies for early detection of breast cancer. Among several models for breast cancer risk estimation, the Gail model is considered as the most well-known and widely used tool for prediction of the 5-year and lifetime risks of developing breast cancer for women aged between 35 and 85 years.,, The risk factors used are age at first menstrual period, age at first live birth, number of previous breast biopsies, number of first-degree relatives with breast cancer, and race/ethnicity. Gail model of relative risks for various combinations of these factors was developed from case–control data from the Breast Cancer Detection Demonstration Project. The Gail model, to the best of our knowledge, has not been previously performed as a tool for breast cancer risk assessment in North Africa. The aim of this study was to estimate the 5-year and lifetime breast cancer risks among Libyan women and the frequency of women at high risk.
| Subjects and Methods|| |
This cross-sectional study was conducted in the period from January 2019 to April 2019 and included 918 randomly selected healthy Libyan women aged from 35 to 85 years who attended primary health-care centers across Libya. Data were collected from different cities in Libya including Tripoli, Benghazi, Sabha, Gharyan, Ghadames, AlJufra, and Murzug. Information about the study and its purpose was explained and confidentiality guaranteed before a self-administered questionnaire in the Arabic language was completed by the participants. Face-to-face interviews were conducted with a few women who needed assistance. A structured questionnaire was used to collect details of the following risk factors for breast cancer: age, age at first menstrual period, age at first live birth, the number of previous breast biopsies, the presence of atypical hyperplasia in any previous breast biopsy, history of first-degree relatives with breast cancer (mother, sisters, and/or daughters), and ethnicity. Ethnicity was marked as unknown in the Gail model calculator in all cases because of insufficient research on the ethnic groups living in Libya. Five-year and lifetime risks were estimated by the Gail model calculator using the Breast Cancer Risk Assessment Tool of the National Cancer Institute.
The 5-year risk is considered a low risk when the probability of developing breast cancer in the next 5 years is ≤1.7% and high risk when the probability is >1.7%. The lifetime risk is considered low risk when the probability of getting breast cancer <20% and as high risk when the risk is ≥ 20%. Libyan women aged <35 years or >85 years as well as those with a previous history of breast cancer and mentally incapacitated patients were excluded from the study. This study was approved by the Bioethics Committee of Biotechnology Research Center, Tripoli, Libya and conducted in accordance with the Helsinki Declaration.
All statistical analyses were performed using the Statistical Package for the Social Sciences Version 22 for Windows (SPSS Inc. Chicago, Illinois, USA). Descriptive analyses were done to describe the general characteristics of the study population. Chi-squared analyses were used for correlations between different breast cancer risk factors and risk categories. The risk factors were calculated by the Gail model for breast cancer risk which is based on demographic and clinical data of each subject. P < 0.05 was considered statistically significant.
| Results|| |
A total of 918 Libyan females answered the survey with a mean age of 46.9 ± 8.7 years. The majority of women (83%) were below 55 years of age. The age of the first menstrual period for 42% of participants was between 12 and 13 years and 35% of women had no births. Eighty-eight women (9.6%) had one first-degree relative with breast cancer (mother, sisters, or daughters) and 13 women (1.4%) had more than one first-degree relatives. No previous biopsy was taken from most of the participants (93.9%). The majority of women in this study were Arabs (89.7%). [Table 1] displays the distribution of subjects in categories according to the risk factors in the Gail model.
|Table 1: Distribution of subjects in categories defined by the risk factors in the Gail model|
Click here to view
According to the Gail model, the participants in the current study had a mean 5-year risk of 1.0 ± 0.6 and a mean lifetime risk of 10.7 ± 4.8. Sixty-nine women (7.5%) had a high 5-year risk of developing breast cancer, while 28 women (3.1%) had a high lifetime risk. [Table 2] shows the characteristics of women with breast cancer risk using the Gail model for 5-year and lifetime risk. The current study showed a statistically significant correlation between the risk of breast cancer in the following 5 years and age (P = 0.001), age at menarche (P = 0.001), history of first-degree relatives with breast cancer and previous breast biopsy (P = 0.001), age at first live birth (P = 0.046), and ethnicity (P = 0.033). In addition, a significant association was identified between lifetime risk of breast cancer and age at menarche, history of first-degree relatives and previous breast biopsy (P = 0.001), and ethnicity (P = 0.009). Meanwhile, age and age at first live birth did not show a significant association with lifetime risk (P > 0.05).
|Table 2: Predictors of 5.year and lifetime breast cancer risk (confidence interval 95%)|
Click here to view
| Discussion|| |
Breast cancer in Libyan women has been increasing over the years and is the most common cancer affecting women., The cause of breast cancer is probably due to a change in lifestyle and genetic factors. There are recently considerable efforts to start national breast cancer screening programs from Libyan health authorities. There is still uncertainty on the best age for initiation of screening mammography and interval timing. However, women at high risk are strongly advised to undergo screening by annual mammography, regular clinical breast examination, and digital magnetic resonance imaging if she has BRCA gene mutation.
Breast cancer risk assessment in Libyan women has not been evaluated before, and this study is the first to provide national estimates of 5-year and lifetime risk using the Gail model. In addition, we tested the suitability of the model for Libyan women considering the risk factors included in the model. Risk stratification models using multiple risk factors such as family history, reproductive history, hormone replacement therapy use, and breast density are extremely important for screening and prevention of the disease.
The average 5-year risk in this study is 1.0 ± 0.6. This risk proportion is higher than the mean risk in Saudi and Bahraini women but close to the risk of Qatari and Iraqi women. The lifetime risk in Libyan women from this study is 10.7 ± 4.8 which is higher than the average risk of Saudi, Turkish, Bahraini, and English women but consistent with the result of the Qatari study and lower than the risk of Iraqi, Iranian, and American women [Table 3].
Increasing age has been correlated with increased breast cancer risk in many studies. In this study, however, only the 5-year risk was significantly associated with increasing age. Breast cancer incidence in Libyan women apparently affects a younger age group compared with western countries with a mean age at 46 years. This discrepancy in age could be explained by the fact that the Libyan population is generally skewed toward young age. In other words, younger women do not have an increased risk of breast cancer, but the incidence in young women is relatively higher. Age at menarche and first-degree relatives with breast cancer were significant predictors of 5-year and lifetime risk of breast cancer among Libyan women, supporting a study conducted in Saudi Arabia, Qatar, and Turkey.,, However, the Turkish study showed a significant relation between both 5-year and lifetime risk and age at first live birth, the women who had their first live birth at age ≥30 were at higher risk, while this study showed no relation between this variable and breast cancer risk.
Various statistical models are widely used to estimate the breast cancer risk for more than 20 years. The Gail model has been considered to be an available tool for estimating the risk of development of breast cancer using data from regularly screened Caucasian women from the United States participating in the breast cancer screening and detection project. It is also the most frequently used model in chemoprevention trials and clinical studies., In comparison to the Claus model, the Gail model does not account for breast cancer in second degree-relatives as a risk factor in its calculation. However, a comparative study of the Gail and Claus models showed that the Gail model comprises a greater range of risk factors, whereas the Claus model is concentrated primarily on genetic risk factors. In addition, several previous studies based on the Gail model revealed some overestimation of breast cancer risk development.,, On the other hand, the Tyrer–Cuzick estimates 10-year risk and provides information about the potential of a breast cancer susceptibility BRCA1/BRCA2 gene mutations. Likewise, the BRCAPRO model utilizes Bayesian statistics and Mendelian approaches and takes into account family history of bilateral breast cancer and ovarian cancer as risk factors.,
This study was conducted on healthy women in a cross-sectional design which does not permit future knowledge about risk factor changes or estimates the effects of other risk factors such as ethnicity. Therefore, a cohort study with long-term follow-up of healthy women should be conducted. The results of such cohort studies should be added to ethnicity calculations of the Gail model, and developing a modified version of the Gail model including the ethnic groups of Libya as a risk factor is suggested. We also recommend the study of genetic susceptibilities and extensive family history in association with the risk of breast cancer in Libyan women.
| Conclusion|| |
Breast cancer is a major health concern in Libya, and identifying women at high risk is important for preventive and screening measures. The current study showed that the Gail model could be further improved for risk assessment in Libyan women. Therefore, developing a modified model is essential for categorizing women according to risk for the selection of suitable screening modalities and better clinical decision making.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Donkor A, Wiafe S, Yarney J, Opoku Y, Antwi W, Kyei KA. Factors contributing to late presentation of breast cancer in Africa: A systematic literature review. Arch Med 2015;8:1-10.
Elzouki I, Benyasaad T, Altrjoman F, Elmarghani A, Abubaker K, Elzagheid A. Cancer incidence in western region of Libya: Report of the year 2009 from Tripoli pathology-based cancer registry. Libyan J Med Sci 2018;2:12-5.
El Mistiri M, Salati M, Marcheselli L, Attia A, Habil S, Alhomri F, et al
. Cancer incidence, mortality, and survival in Eastern Libya: Updated report from the Benghazi Cancer Registry. Ann Epidemiol 2015;25:564-8.
Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer. BMC Res Notes 2012;5:452.
Gail MH, Brinton LA, Byar DP, Corle DK, Green SB, Schairer C, et al
. Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Cancer Inst 1989;81:1879-86.
Mirghafourvand M, Mohammad-Alizadeh-Charandabi S, Ahmadpour P, Rahi P. Breast cancer risk based on the gail model and its predictors in Iranian women. Asian Pac J Cancer Prev 2016;17:3741-5.
Bener A, Çatan F, El Ayoubi HR, Acar A, Ibrahim WH. Assessing breast cancer risk estimates based on the gail model and its predictors in qatari Women. J Prim Care Community Health 2017;8:180-7.
Bevers TB, Anderson BO, Bonaccio E, Buys S, Daly MB, Dempsey PJ, et al
. Breast cancer screening and diagnosis: Clinical practice guidelines in oncology TM. JNCCN J Natl Compr Cancer Netw 2009;7:1060-96.
Giordano SB, Gradishar W. Breast cancer: Updates and advances in 2016. Curr Opin Obstet Gynecol 2017;29:12-7.
Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, et al
. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57:75-89.
Brentnall AR, Cuzick J, Buist DS, Bowles EJ. Long-term accuracy of breast cancer risk assessment combining classic risk factors and breast density. JAMA Oncol 2018;4:e180174.
Al Otaibi HH. Breast cancer risk assessment using the gail model and it's predictors in saudi women Asian. Pac J Cancer Prev 2017;18:2971-5.
Fikree M, Hamadeh R. Breast Cancer Risk Assessment among Bahraini Women. Bahrain Med Bull 2013;35:1-6.
Ewaid SH, Al-Azzawi LHA. Breast cancer risk assessment by Gail Model in women of Baghdad. Alexandria J Med 2017;53:183-6.
Khaliq W, Jelovac D, Wright SM. Prevalence of chemopreventive agent use among hospitalised women at high risk for breast cancer: A cross-sectional study. BMJ Open 2016;6:e012550.
Eadie L, Enfield L, Taylor P, Michell M, Gibson A. Breast cancer risk scores in a standard screening population. Breast Cancer Manag 2013;2:463-79.
Bener A, Barışık CC, Acar A, Özdenkaya Y. Assessment of the gail model in estimating the risk of breast cancer: Effect of cancer worry and risk in healthy women. Asian Pac J Cancer Prev 2019;20:1765-71.
Khazaee-Pool M, Majlessi F, Nedjat S, Montazeri A, Janani L, Pashaei T. Assessing breast cancer risk among Iranian women using the gail model. Asian Pac J Cancer Prev 2016;17:3759-62.
Corbex M, Harford JB. Perspectives on breast cancer in Arab populations. Lancet Oncol 2013;14:e582.
Gail MH, Costantino JP, Pee D, Bondy M, Newman L, Selvan M, et al
. Projecting individualized absolute invasive breast cancer risk in African American women. J Natl Cancer Inst 2007;99:1782-92.
Costantino JP, Gail MH, Pee D, Anderson S, Redmond CK, Benichou J, et al
. Validation studies for models projecting the risk of invasive and total breast cancer incidence. J Natl Cancer Inst 1999;91:1541-8.
Rosenthal ET, Evans B, Kidd J, Brown K, Gorringe H, van Orman M, et al
. Increased identification of candidates for high-risk breast cancer screening through expanded genetic testing. J Am Coll Radiol 2017;14:561-8.
Braun JACD, Blackford AL, Mazzola E, Acar A, Plichta JK, Griffin M, et al
. Breast cancer risk models: A comprehensive overview of existing models, validation, and clinical applications. Breast Cancer Res Treat 2017;164:263-84.
Glynn RJ, Colditz GA, Tamimi RM, Chen WY, Hankinson SE, Willett WW, et al
. Comparison of questionnaire-based breast cancer prediction models in the nurses' health study. Cancer Epidemiol Biomarkers Prev 2019;28:1187-94.
Wang X, Huang Y, Li L, Dai H, Song F, Chen K. Assessment of performance of the Gail model for predicting breast cancer risk: A systematic review and meta-analysis with trial sequential analysis. Breast Cancer Res 2018;20:18.
Nickson C, Procopio P, Velentzis LS, Carr S, Devereux L, Mann GB, et al
. Prospective validation of the NCI Breast Cancer Risk Assessment Tool (Gail Model) on 40,000 Australian women. Breast Cancer Res 2018;20:155.
Tyrer J, Duffy SW, Cuzick J. A breast cancer prediction model incorporating familial and personal risk factors. Stat Med 2004;23:1111-30.
Berry DA, Iversen ES Jr., Gudbjartsson DF, Hiller EH, Garber JE, Peshkin BN, et al
. BRCAPRO validation, sensitivity of genetic testing of BRCA1/BRCA2, and prevalence of other breast cancer susceptibility genes. J Clin Oncol 2002;20:2701-12.
[Table 1], [Table 2], [Table 3]