br Introduction br Breast cancer is the most common malignan
Breast cancer is the most common malignancy prevailing among women. Around half and a million new cases of breast cancer are reported yearly, around the globe.1 Its incidence is increasing in developing countries.2 In the US the estimated number of breast cancer patients in 2015 was around 231,840.3 Breast cancer accounts for 29% of all cancers and ranks second in cancer mortality risk among women.3 It is also the most common cancer in India with a relative proportion ranging from 19.3%-27.5%. According to Department of Health and Family Welfare the cancer graph of Punjab, a state of north India, is rising abruptly. The highest number of cancer patients including breast cancer are reported from Malwa region of Punjab (1089 per million per year) in accordance with national average cancer prevalence that is 800 (per million per year).4
Inflammation is the seventh hallmark of cancer or an enabling characteristic of cancer.5 Experimental data suggests that chronic Phosphatase Inhibitor Cocktail II and cancer are linked in a bidirectional manner. Either solid tumors induce inflammatory microenvironment and host immune response or chronic inflammation promotes cancer development including cancer initiation, promotion, and metastasis via pro-inflammatory cytokines and reactive oxygen species.6 Thus understand-ing the relationship between the post diagnosis inflammation and prognosis is the priority in breast cancer research. Different inflammatory biomarkers have been studied in associa-tion with the disease including white blood cells, fibrinogen, interleukin-6, tumor necrosis factor-α, Serum Amyloid A, C-reactive protein (CRP), cancer antigen-15.3, carcinoembryonic antigen. Consistent association of CRP has been seen with disease prognosis in breast cancer patients.7
CRP is a systemic inflammatory marker that plays a role in human innate immunity. It is produced in the liver under the transcriptional control of interleukin-6.8 CRP is produced in re-sponse to inflammation, infection, and tissue damage.9 The circulating amount of CRP increases with progression of the disease.8 CRP levels >10 mg/dl have been reported to be an indicator of acute inflammation. Lower values are found in low-grade chronic inflammation. In post di-agnosis higher levels of CRP are linked with worse survival in different malignancies including breast, cervical, colorectal, and esophageal cancer.6,10 Previous studies have suggested that CRP can be used as a long-term prognostic marker in the breast cancer.11
The present study was taken up with an aim to evaluate the association of CRP levels with breast cancer outcome in patients from Malwa region of Punjab. As per the cancer registry of Guru Gobind Singh Medical College and Hospital, (main referral center in this region) breast cancer is one of the most common type of cancer in this region. In spite of this no empirical studies on breast cancer have been taken up in this area. Moreover, no other study has been carried out in India on this cost effective and easily detectable prognostic marker. Therefore, the aim of the present study was to assess the CRP levels in breast cancer patients in comparison with healthy controls and to determine the relationship between CRP values including mild, moderate, and high levels and poor outcome including recurrence, metastasis, and death. Further
we compared the CRP levels in different types of breast cancer based on histopathology and receptor status to evaluate the association with specific subtypes.
Material and methods
Two hundred and forty-two female breast cancer patients presenting with new breast cancer, evaluated at Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab were included in the study. Patients came from different districts of Malwa region. The study was approved by ethical committee of the study hospital as well as ethical committee of Central University of Punjab. All the patients were examined by a qualified oncologist and breast cancer was di-agnosed by fine needle aspiration cytology, mammography, and histopathology. CRP as an in-flammatory marker has been reported to be associated with many other disorders. Therefore, patients with major cardiac, renal, hepatic, skeletal disorders, and neurologic disorders were excluded from this study. So study mainly includes patients affected with breast cancer. As a control group 242 healthy volunteers belonging to same ethnic group matched for sex and age were recruited from the same demographic area with the help of rural medical o cers. The controls had no history of any inflammatory disease or cancer (nor did their families). Informa-tion on demographic features and risk factors was collected by using a structured questionnaire. The power calculation was carried out for sample size using OpenEpi software. It showed more than 80% power based on normal approximation as well as normal approximation with continu-ity correction (2-sided confidence interval [CI] 95%). Therefore, the sample size included in the study was su cient for the study.