Evaluation of Prevalent Breast Cancer Risk Factors and their Correlation with Demographic Characteristics in Western Sudan

Female breast cancer represents the most prevalent form of cancer, characterized by a substantial disease burden and notable mortality rates. The prevalence of FBC was most pronounced in nations characterized by elevated socioeconomic status, particularly within the European continent. Even though FBC happens less often in countries with a low socio-demographic index, the death rates from it are higher there than in high-income countries. The Eastern Mediterranean Region has recorded the highest age-standardized mortality rate, with the African Region following closely behind. The age-standardized rates of Disability-Adjusted Life Years and Years of Life Lost per 100,000 people were elevated in low-income countries in 2019; on the other hand, the age-standardized rate of Years Lived with Disability (YLD) per 100,000 people was highest in high-income countries [1]. The evolution of screening mammography over the past three decades has significantly diminished breast cancer-related mortality by 20%–30%, facilitating the early detection of small cancerous lesions. Breast screening programs in different countries can be very different. This is because of things like the number of cases, national laws, the strength of the local health infrastructure, and the availability of training opportunities, such as ways to give feedback on performance. Mammography has been the main way to check for breast cancer for many years, but it has thought that between 15% and 35% of cancers are missed during screening because radiologists and other interpreters make mistakes in how they see things and how they make decisions. Additionally, not all countries offer mammography screening, and the rate of new cases of breast cancer has been rising faster in less developed countries than in developed countries over the past few decades [2].

Women can change lifestyle factors that affect their risk of getting breast cancer. These factors are greatly affected by what women know and how they feel, which can make them more or less likely to get the disease. A multitude of risk factors may be at play, and personal lifestyle decisions significantly influence many elements related to the incidence of cancer. According to research, a big chunk of malignant cancers, possibly as much as 70%, are caused by bad habits like diet, lifestyle, or things in the environment [3,4]. A variety of risk factors have been associated with the etiology of breast cancer, encompassing environmental influences, radiation exposure, hormonal factors, cigarette smoking, and alcohol consumption [5]. 

In Sudan, breast cancer among females stands as the most prevalent form of cancer. In Sudan, there existed a diverse range of exposures to various risk factors associated with breast cancer. The main factors found are using birth control, having a family history of breast cancer, having benign breast lesions, being overweight or obese, and being exposed to pesticides [6]. Consequently, this study sought to evaluate the prevalent risk factors for breast cancer and their correlation with demographic characteristics in Western Sudan.

This prospective descriptive study collected data from 201 Sudanese volunteers between 15 December 2024 and 25 January 2025. We randomly selected participants using simple random sampling, regardless of their age, education level, occupation, or other demographic variables. Women were encountered in various public venues, including healthcare facilities and educational institutions. 

We did not establish any explicit inclusion or exclusion criteria. We determined the sample size using survey software with a 95% confidence interval, available at: https://www.surveysystem.com/sscalc.htm. 

We developed and used a targeted questionnaire to gather the necessary data.

We used the Statistical Package for Social Sciences (SPSS) for analysis and to perform the Pearson Chi-square test for statistical significance (P value), We employed a 95% confidence level and confidence intervals. A P value below 0.05 was deemed statistically significant.

All participants were required to provide signed ethical consent during the data collection process. The informed ethical consent form was developed and approved by the ethics committee of Prof Medical Research Consultancy Center, El-Obeid, Sudan.

This study investigated the risk factors for breast cancer in 201 women aged 18 to 40 years, with a mean age of 27 and a standard deviation of 5.8 years. The majority of participants were aged 25-29 years, followed by age ranges 21-24 and ≤20 years, constituting 57/201 (28.4%), 45/201 (22.3%), and 40/201 (20%), respectively. The majority of the participants (179/201, 89%) lived in cities, with the remainder (22/201, 11%) living in the countryside. Of the 201 ladies, 102/201 (50.7%) were single, while 92 (45.8%) were married. According to Table 1 and Figure 1, approximately 137/201 (68%) of the participants had a university education, while 47 (23.4%) had a basic education. The majority of participants were students, followed by housewives, representing 63/201 (31.3%) and 60 (30%), respectively, as indicated in Table 1 and Fig. 1.  

Table 1: Distribution of the study population by demographic characteristics. 

 Figure 1. Describes the research population based on demographic data.

As seen in Table 2 and Figure 2, approximately 15/105 cases (14.2%) have a family history of breast cancer. The majority of cases were between the ages of 21 and 29, accounting for 8 of 15 (53.3%). Menarche occurs at a young age (< 12 years) for approximately 16/105 individuals (15.2%). Approximately 12/16 (75%) of them were now older than 25 years. Approximately 9/88 (10.2%) and 26/88 (29.5%) reported their first entire pregnancy at ages >25 and < 18 years, respectively. Around 122/201 (60.6%) claimed non-breastfeeding, with 67/122 (54.9%) being under the age of 25.

Table 2. Shows the distribution of research subjects according to their history of biological risk factors. 

 Figure 2. Describes the study subjects based on their history of biological risk factors.

Table 3 and Figure 3 described the study individuals' distribution by history of benign breast lesions (HBBL), history of contraceptive pill usage, and use of a weight gain prescription. 9/201 (4.4%) reported having benign breast lesions. 43/201 (21.3%) participants reported having used contraceptive pills (HCP), with the majority being beyond the age of 30 (24/43, 55.8%). Weight gain prescriptions were given to 21/201 (10.4%) individuals, the majority of whom were between the ages of 25 and 29, followed by 21-24 and 30-34, who accounted for 8/21 (38%), 5/21 (23.8%), and 4/21 (19%).
Out of the 9 participants with benign breast lumps, 4/9 (44.4%) used contraceptive pills. The risk of benign breast lumps among those using contraceptive pills, the relative risk (RR), and the 95% confidence interval (95% CI): RR (95% CI) = 2.177 (0.915-5.178), P value = 0.056.

Table 3. Shows the distribution of research individuals based on their history of benign breast conditions, contraceptive pill use, and use of weight gain prescriptions. 

Figure 3. Depicts the study individuals' histories of benign breast conditions, contraceptive pill use, and weight gain. Prescription

Table 4 and Figure 4 summarize the study population's distribution by chest radiation exposure, living near an industrial area (LNIA), cigarette smoking, and alcohol consumption. Chest radiation exposure occurred in 24/201 (11.9%) of the participants. Approximately 22/104 (21.1%) indicated they were living near an industrial area. Only 4 out of 201 (1.9%) have admitted to smoking. Alcohol consumption was reported by 3/201 (1.4%).

Table 4. Shows the distribution of the study population according to chest radiation exposure, living near an industrial area, cigarette smoking, and alcohol consumption.

Figure 4. Description of the study population based on chest radiation exposure, proximity to industrial areas, cigarette smoking, and alcohol consumption.

This study aims to clarify the common risk factors linked to breast cancer in western Sudan. This study assesses the complex landscape of breast cancer risks, detailing the various risk factors associated with its occurrence and examining advancements in diagnostic methods. An extensive review of the literature has identified several risk factors, including genetic predispositions like BRCA mutations, hormonal influences, lifestyle factors, and reproductive patterns. Age, family history, and environmental factors contribute to the complex etiology of breast cancer [7]. 

About 14.3% of participants in this study have a family history of breast cancer. Research indicates that the average familial relative risk for first-degree relatives of women diagnosed with breast cancer is roughly twofold [8]. The development of breast cancer involves multiple factors, some of which can be modified. Currently, the risk associated with family history and hereditary pathogenic variants in an individual's genetic code represents a significant fixed variable [9]. Family history of breast cancer and mammographic breast density are distinct risk factors for breast cancer [10].

In the current study, early age at menarche was observed in 15.2% of the participants. Previous studies have reported a relationship between early age at menarche and certain subtypes of breast cancer [11]. Recent evidence suggests that certain altered methylation patterns observed in breast tumors may also be present in the breast tissue of healthy women, correlating with breast cancer risk factors. The progesterone receptor (PR) isoform α is a key regulator of breast hormone responsiveness, and its hypermethylation significantly contributes to the initiation and progression of breast tumors [12]. The age at menarche is a recognized risk factor for breast cancer; identifying its external determinants may provide insights into the origins of the disease. 

Advanced age at In 8.6% of the participants, the first full pregnancy was reported. Delayed first full-term pregnancy is associated with a slight elevation in breast cancer risk [13]. 

Fortunately, over 75% of the participants are familiar with breastfeeding. Research indicates that breastfeeding and its duration are inversely related to the risk of breast cancer. This emphasizes the significance of endocrine processes initiated by suckling stimulation, the progressive onset of lactational amenorrhea, postponed weaning, chromosomal repair mechanisms, and immunological occurrences during the lactation cycle. The insights offer a potential explanation for the protective effects of breastfeeding against breast carcinomas [14].
Approximately 41% of participants reported the use of hormonal contraceptive pills. Numerous studies have examined the potential association between the use of hormonal pills and the incidence and development of breast cancer among the recognized risk factors for the disease. Data regarding the relationship between oral contraceptive use and breast cancer incidence remain contentious and inconclusive. The significance of breast cancer in public health, coupled with the widespread use of hormonal contraceptive pills, renders the relationship between oral contraceptive use and breast cancer risk pertinent from both clinical and social perspectives [15].

In the current study, 20% of the subjects utilized weight gain prescriptions. The limited data on the relationship between weight gain prescriptions and breast cancer risk indicates a need for further investigation.
Benign breast lesions were reported in 8.6% of the study participants. Female patients with solid breast lesions exhibit a significant predisposition to breast cancer, highlighting the importance of effective screening for high-risk individuals in the early detection of the disease [16]. 

In the current study, approximately 23% were subjected to chest radiation exposure. Ionizing radiation exposure elevates lifetime cancer risk in a dose-proportional manner, as per the linear no-threshold model utilized for radioprotection. These exposures offer a distinct opportunity to enhance our understanding of the association between ionizing radiation exposure and cancer risk [17]. Diagnostic ionizing radiation poses a risk for breast cancer. The risk of breast cancer escalates with higher doses to the chest and diminishes with advancing age at the time of exposure, potentially influenced by familial or genetic factors. Chest X-ray exposure, whether ever or never, doubles the risk of breast cancer, independent of the age at first exposure, and increases the risk by up to fivefold when three or more rare variants in a DNA repair gene are present [18]. 

Approximately 21% of the study participants are exposed to industrial pollution. Industrial facilities emit chemicals that are known or suspected to be mammary carcinogens and endocrine disruptors. The association between elevated industrial benzene emissions and an increased risk of breast cancer necessitates further investigation, especially among participants with varied sociodemographic backgrounds residing in regions with a higher concentration of industrial facilities [19]. 

Cigarette smoking and alcohol consumption are perceived as social stigmas among females; however, only a limited number of participants have admitted to these behaviors. The relative risk of breast cancer increased by 7.1% (95% CI 5.5–8.7%; P < 0.00001) for each additional 10 g per day of alcohol intake, corresponding to each extra unit or drink consumed daily. The increase was consistent across both ever-smokers and never-smokers, recorded at 7.1% per 10 g per day (P < 0.00001 for each group) [20]. 

The current study offers valuable insights into breast cancer risk in Sudan; however, it is limited by a small sample size. 

In conclusion, most Sudanese women are exposed to a combination of breast cancer risk factors. More research is needed to determine the significance of these factors in contributing to early breast cancer start.

The authors express gratitude to the participants for their cooperation in providing time and information.

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