INTRODUCTION: The age standardised incidence rate (ASR) of breast cancer in Malaysia which is a high middle- income country is similar to Indonesia, a low middle-income country. (Globocan 2008) It is however unknown whether the presentation of breast cancer differs between these two countries.
OBJECTIVE: We compared the stage, age at presentation, and pathological characteristics of breast cancer between two tertiary hospitals in Indonesia and Malaysia; Dharmais Cancer Centre (DCC), which is the national cancer referral centre in Indonesia, and University Malaya Medical Centre (UMMC), which is an academic hospital with established breast oncology services in Kuala Lumpur. One thousand, one hundred and fourteen consecutive women (477 in UMMC: 637 in DCC) who were newly diagnosed with breast cancer between January and December, 2010 were included. Patient's age, TNM stage at presentation, and pathological characteristics were compared. Estrogen receptor (ER) and progesterone receptor (PR) were considered positive if 10% or greater of invasive cell nuclei were stained while HER2 was considered positive with an immunohistochemistry staining intensity of 3+ . Logistic regression analyses were performed to identify differences.
RESULTS: Median age at diagnosis was 52 years in UMMC and 47 years in DCC, whereby patients in DCC were more likely to be very young at diagnosis (aged < 35 years) compared to their counterparts in UMMC (Odds ratio (OR): 2.09; 95%CI: 1.32-3.31). Approximately one third of patients in UMMC presented with TNM stage III or IV, compared to 63% in DCC. Patients in DCC were three times more likely to present with metastatic breast cancer compared to patients in UMMC (OR: 3.01; 95% CI: 2.02-4.48). The percentage of low grade tumours in DCC was higher than in UMMC (28% vs 11% respectively), and the difference persisted even after multivariate adjustment. Although the frequency of ER and PR positivity appeared to be higher in UMMC (65% and 55% respectively) compared to DCC (48% and 40% respectively), these differences were not statistically significant following adjustment for age, stage, HER2 status and grade. The frequency of HER2 positivity was 45% in DCC compared to 26% in UMMC, and remained significantly higher even after multivariate adjustment (multivariate OR:1.76; 95%CI:1.25-2.47, in DCC compared to UMMC). The proportion of triple negative breast cancer was however similar in the two centres (19% in UMMC vs 21% in DCC).
CONCLUSION: Indonesian women with breast cancer seem to present at a younger age and at later stages compared to Malaysian women. Their tumors were more likely to be of low grade and HER2 positive, even after adjustment for other factors, while hormone receptor positivity proved similar in the two groups. The higher HER2 positivity rate in Indonesian patients warrants further study.
In settings with limited resources, sentinel lymph node biopsy (SNB) is only offered to breast cancer patients with small tumors and a low a priori risk of axillary metastases.