SURVEILLANCE OF BLOOD CHEMISTRY IN BREAST CANCER PATIENTS BELONGING TO PUNJAB, PAKISTAN

: Cancer is known to be second largest killer worldwide. In various types of cancer, the incidence rate of breast cancer has increased steadily in women. Any abnormality especially cancer has a direct impact on all the blood parameters so it is crucial to assess the variation in haematological and biochemical parameters. The aim of present study is to analysis the association and variation in haematological parameters among breast cancer patients. A cross-sectional study was accomplished in line with the research regulations, ssociodemographic survey was done to collect the covariates. The blood samples were collected from 16 districts of Punjab, Pakistan. Population selected for this study included 40 breast cancer patient and the written consent was also obtained from all the individuals. After collection the samples were transported to Department of Pathology, Mayo hospital, Lahore for the laboratory analysis. The study revealed that majority of the subjects were of 48-57 years old (N=12(30%) with weight ranging from 64 kg to 74 kg (N=14(35%) and height from 5.01 ft to 5.50 ft (N=23 (57.5%). All the sociodemographic, clinical, biochemical and haematological characteristics were analyzed by ANOVA test with P value 0.05 and the test revealed that all the parameters are statistically significant except duration of marriage P = 0.085 and blood urea P = 0.099. In conclusion, study reveals that biochemical parameters are an important diagnostic tool in disease monitoring. Moreover, awareness campaign regarding breast cancer should be carried out and more research should be done to observe the pattern of other haematological parameters.


INTRODUCTION
Cancer is one of the diseases in which uncontrolled abnormal growth of cells occur, which further invade the tissues (Peate, 2018;Ali et al., 2014).The cancer cells in the breast tissues which are in the form of lobules and ducts is known to be breast cancer (Das et al., 2021).In men it is very rare but in women it is common and considered to be second largest killer globally among the ages of 20 and 50 years (Khan et al., 2017) and the most prone age group is between 40 and 44 years (Seema 2015).Annually, more than 315,000 deaths in women are caused by breast cancer, having significant progress during the treatment and diagnose (Schneider et al., 2014;Osaro et al., 2018;American Cancer Society, 2019).Over the past 40 years, the incidence rate of breast cancer has increased steadily (Jemal 2003) all over the world but majority of rise is seen in the developing countries (Globocan 2008).Currently, 1 in 4 women is diagnosed with breast cancer globally (Bray et al., 2018) and is said to be commonest cancer in rural and urban females (Gaurav et al., 2008 andNational Cancer Registry Program 2011).Among the Asian population, women of Pakistan have more threat of having breast cancer and the incidence rate is about 2.5 times greater than Iran and India (Asif et al., 2014;Khan et al., 2017).
Furthermore, Pakistan has the highest incidence rate of breast cancer in Asia continent except the west bank of Palestine.Even though, the incidence rate of breast cancer is still less than the western countries (Fitzmaurice et al., 2017).Over the period of time, incidence of breast cancer has increased in Pakistan and it is observed that 1 in 9 women in Pakistan get diagnosed with carcinoma breast (Sohail et al., 2007;Zaheer et al., 2019).
Any abnormality especially cancer has a direct impact on all the blood parameters so it is crucial to assess the variation in haematological and biochemical parameters.These parameters provide information regarding types and count of blood cells specifically red blood cells, platelets and white blood cells.In the treatment of breast cancer, Complete blood count (CBC) is considered to be prerequisite investigation and is helpful for the diagnosis of various diseases (Liqaa et al., 2014;Akinbami et al., 2013).Physicians found CBC useful to check any symptoms in patients regarding fatigue and bruising (Ali et al., 2014).Blood chemistry panel basically determines the proper functioning and healthiness of various organs during treatment (Chauhan et al., 2016).The abnormal blood profile also implies the spread of carcinoma breast to the kidney, bone or liver.There are only few studies which have associated the liver and kidney function tests (LFTs and KFTs) with the breast cancer (Wyld et al., 2003 andBrown et al., 2012).Sodium, calcium and potassium are the electrolyte that regulates the physiological functions.Electrolyte concentration should be within limits, excess or insufficiency can be dangerous and in some individuals fatal (Tietzet al., 2008).Serum electrolyte is a test to check the levels of these ions in the human body and its disorder is commonly encountered with cancer (Rosner & Dalkin, 2014: Bowman, 2017).
One of the leading health challenges is obesity and it is related to increase in risk of cancer (Lega and Lipscombe, 2020).Approximately 20 % of all tumor types are attributed to obesity and causes 20% death in women due to cancer and 14 % among men (Zhang et al., 2016;Goodwin & Chlebowski, 2016).Almost 6-19% of all cancer patients having chemotherapy are obsessed (Grueso et al., 2019) the relationship between obesity and risk of developing cancer is casual (Renehan et al., 2015).It has been reported in previous studies that obesity such as the body mass index (BMI) of ≥30.0 kg/m 2 affects negatively on cancer progression, survival and mortality (Gomez et al., 2021, Goodwin & Chlebowski, 2016;Renehan et al., 2015;Wolk et al., 2001).BMI can also be correlated with a difference in the detection of tumor and cancer stage (Khan et al., 2017).BMI is often used as a screening tool to decide if your weight might be putting you at risk for health problems such as heart disease, diabetes, and cancer.The aim of present study is to analysis the association and variation in hematological parameters among breast cancer patients.The clinical assessment included complete blood profile (CBC), liver functioning test (LFT), kidney functioning test (KFT) and serum electrolyte.Findings of the current study will potentially enhance the better management and follow up of breast cancer patients.

MATERIAL AND METHODS
A cross-sectional study was accomplished in line with the research regulations, as well as the approval of the Bioethical Committee of University of the Punjab, Lahore, Pakistan.Furthermore, ethical approval from King Edward Medical University, Lahore was also taken to precede the study.In this study some biochemical and hematological parameters of breast cancer female patients were observed.The samples were collected from 16 districts of Punjab, Pakistan (Figure 1).Population selected for this study included 40 breast cancer patient and the written consent was also obtained from all the individuals.These patients were observed between March 2020 and July 2021.It took a lot of time to do sampling because of the pandemic (COVID-19) condition.The results were demonstrated as means ± standard deviation, range, percentage and ANOVA with p<0.05 that denotes the significant difference between the groups.

RESULTS AND DISCUSSIONS
The current study shows the haematological and biochemical parameters among the breast cancer patients of Punjab, Pakistan.These parameters play a vital role in the diagnosis and treatment of various types of diseases.Any type of disease such as cancer directly affect the biochemical and haematological constituent of blood.The population observed in this study was histologically confirmed patients.A total of 40 female breast cancer patients with age range of 27-67 years were enrolled for the research.Table 1 shows socio-demographic characteristics of breast cancer patients and reveals that majority of the subjects were of 48-57 years old (N=12(30%) with weight ranging from 64 kg to 74 kg (N=14(35%) and height from 5.01 ft to 5.50 ft (N=23 (57.5%).American Cancer Society (2011) reported that mostly breast cancer develops in patients above 50 years.In another study it was reported that increase in age also increase the chance of breast cancer to occur in women, 50% of women above 60 years had breast cancer (Binder-Foucard et al., 2013;Ji et al., 2020).BMI was also calculated and most of the patients fall in the criteria of overweight, 18(45%).In a previous study it was revealed that with the increase of 1kg/m 2 BMI of women, 3% incident rate of breast cancer increases ( Van den Brandt et al., 2000).Cmrecak et al., (2020) stated that the quality of life is affected by obesity and also increases the risk of cancer-related mortality and recurrence.Hopper et al. (2018) reported significant correlation between increase in number of breast cancer patients and BMI, which means that women whose BMI is higher or categorized as obese can be at high risk of breast cancer and these results also align with the results predicted by Elkum et al. (2014).The distribution of the breast cancer patients based on locality shows that most of the subjects belong to the urban 27 (67.5%)as well as rural 13 (32.5%)respectively.It can be concluded from this study that cancer basically occurs more in the urban areas than rural areas, similar trend was found in Fei et al., 2015.In another study it is also reported that incidence rates of combined cancers were usually higher in population living in urban areas (Zahnd et al., 2018).The results declared that the breast cancer is more common in the married women 39 (97.5%) as compared to the unmarried 1 (2.5%).This study is similar to Khan et al. (2017), in which it is reported that 91.66% married women had breast cancer while 8.33% unmarried had breast cancer.Duration of marriage was also taken into consideration and it was seen that the patients having duration range between 22-28years (N= 13(32.5%)were more prone to cancer.
The distribution according to occupation indicated that 1 (2.5%) were maid, 2 (5%) were educationist while the remaining 37 (92.5%) were full time housewives.The educational status of the subjects revealed that 1(2.5%) had master degree, 1(2.5%) had bachelor degree, 3 (7.5%)had intermediate, 7 (17.5%)had matric, 8 (20%) had primary and 20 (50%) had no formal education.The present study literacy rate was found to be similar as Khan et al., (2017) that most of the patients were illiterate.The maximum number of children of the patients observed were 9 (N=1(2.5%)whereas most of the patient had 4 (N=9 22.5%) children and there were 3 patients who had none.Same trend was observed in the breast feeding behaviour and frequency.
It is revealed in a previous study that more the number of children less will be the risk of breast cancer to occur.It is also reported that women who give birth to five or more children have half the risk of breast cancer than the women who have not given any birth (Lambe et al., 1996;Babiker et al., 2020).It can be stated because of some evidence that breastfeeding the child for at least a year decreases the risk of both hormones receptornegative and hormone receptor-positive breast cancer (Ma et al., 2006;Beral et al., 2002).In another study it was concluded that to prevent cancer breast feeding is useful but in some studies this statement was denied by reporting that lactation does not play any role in reducing breast cancer risk (Lipworth et al., 2000).
Most of the patients 29 (72.5%) were using Sui Northern Gas for cooking food, other cooking system were LPG 2 (5%), wood burning 5 (12.5%) and the combination of wood burning with SNG 4(10%).Indoor wood burning stove or fireplace in the residence was linked with a higher risk of breast cancer, this risk increases with increase in average frequency used.An elevated risk was observed in the female burning wood and natural gas but no association was found for burning artificial biomass (White et al., 2017).As well as family history of breast cancer is concerned, only one patient had a history of father having breast cancer.In the current study, family history did not play a protective role for the study of breast cancer, since a smaller number of family history cases were considered.Family history a sociodemographical parameter plays a significant role (Collaborative Group, 2001;Elkum et al., 2014) for the occurrence of breast cancer and reported as a risk factor in the previous studies (Braithwaite et al., 2018).
In case of dairy products, 36 (90%) had an intake of milk, yogurt and butter while the rest 4 (10%) had an intake of milk and yogurt.It is said that the incidence rate of breast cancer is influenced by various factors such as exogenous diet, hormone intake and alcohol.Chen et al. (2019) deduced that the available epidemiologic evidence and milk models used in the study do not support a strong correlation among breast cancer risk and dairy products, however, there are complex components in diet including milk, cheese consisting of pesticides which are carcinogenic in nature and have potential to cause cancer.In a previous study it was reported that high consumption of non-fermented milk for long time was associated with increase incident of breast cancer, and this incident rate is specific for women with BMI less than 25kg/m 2 while no significant relationship was observed in between milk consumption and rate of breast cancer to occur (Kaluza et al., 2021), whereas consumption of fermented milk reduces the chance of breast cancer.Moreover, another study contradicted with this study and revealed that milk intake was positively related to risk while the cheese products were negatively relation with the development of breast cancer (Maliou et al., 2018).In another research it was concluded that consumption of non-fermented and fermented milk does not play any significant beneficial or adverse effects in the diet from a perspective of cancer risk (Nilsson et al., 2020).In the current study, all the patients were eating carbohydrates, lipids, protein and smoked barbecue.Diet of an individual is considered to be one of the major modifiable exposure among environmental risk factors of breast cancer (Lammert et al., 2018).Furthermore, various epidemiological studies have published conflicting results related to the association among breast cancer risk and food in-take (Petimar et al., 2019;Baglietto et al., 2011).Moreover, various studies have traditionally reported the effects of nutrients and foods on cancer risk (Miller et al., 2013;Catsburg et al., 2015).This study also reported that 36 (90%) were not using any kind of cosmetics, 2 (5%) were using occasionally and similar for the frequent users.In a study it is revealed that use of hair color, nail enamel, oxidant, eye shades, mascara, deodorant and cream powder were not associated with the development of breast cancer (Dehdhan et al., 2018).Current research also found that 3 (7.5%) of patients had knowledge about breast cancer, 8 (20%) had very little knowledge and 29 (72.5%) had none.Similar results were also noted by Naqvi et al., (2018) that their knowledge related to breast cancer was dearth among the patients.
This study also reported that 36 (90%) were not using any kind of cosmetics, 2 (5%) were using occasionally and similar for the frequent users.In a study it is revealed that use of hair color, nail enamel, oxidant, eye shades, mascara, deodorant and cream powder were not associated with the development of breast cancer (Dehdhan et al., 2018).Current research also found that 3 (7.5%) of patients had knowledge about breast cancer, 8 (20%) had very little knowledge and 29 (72.5%) had none.Similar results were also noted by Naqvi et al., (2018) that their knowledge related to breast cancer was dearth among the patients.
All the sociodemographic characteristics were analysed by ANOVA test with P value 0.05 and the test revealed that all the parameters are statistically significant except duration of marriage p= 0.085 as shown in table 1.In table 2 clinical characteristics of the breast cancer patients are shown and it reveals that of the 40 patients, 32 patients (80%) had no other disease except cancer but rest were having different diseases such as asthma, diabetes, hepatitis C, tonsils, appendix and uterus fibres, heart and liver problems.
Frequency of conception followed the same trend as discussed above for the number of children.More than half of the patients (23) were having lump in the right breast and rest 17 (42.5%)were having lump in left breast.32 (80%) of the patients was not experiencing any kind of secretions from the breast, 4 (10%) had (57.5%) yellow secretions and similar result was observed for white secretions.All the subjects' tumor type was malignant and all of them were experiencing metabolic syndrome and hormonal imbalance because of having chemotherapy.23(57.5%) had grade II cancer, 16 (40%) had grade III and only 1 (2.5%) had grade I. Almost all the patients 39 (97.5%) were having chemotherapy for the treatment of breast cancer except the 1(2.5%) was on oral medication.About 31 (77.5%) of the patients were having no precautionary and remedial measures but 9 (22.5%) were avoiding fats in their eating habits.According to anova all the clinical characteristics were statistically significant at P value 0.05.Breast cancer is known to be leading cause of death all around the globe but till date very little knowledge regarding the biological markers is there which help to diagnose the disease.Haematological and biological parameters are important parameters used in diagnosis of various diseases, above them one is breast cancer.In table 3, biochemical and haematological parameters were discussed and after statistically analysis it is deduced that all the parameters showed significant results except blood urea (0.099) subjecting to anova with P value 0.05.Of the 40 patients included in the study, 42.5% were having less hemoglobin as compared to the clinical range, 55% were within the range and 2.5% were above the range.
Red blood cells (RBC) test was also done and it was noted that 55% were within the clinical range, 15% patients were having less than the range and 30% were having more that clinical range.A total of 55% of the cases had HCT within the permissible limit, while 45% had less than the permissible limit.Only 25% of the patients had MCV less than the permissible limit but 75% were within the limit.In the case of MCH 40% subjects were within range but 57.5% were below range and only 2.5% were above the range.17.5% patients had MCHC less than the limit while majority of patients (75%) had MCHC with the limit but 7.5% had MCHC greater than 30%.Almost all the individuals (92.5%) had TLC within limit except 7.5% individuals whom level was exceeding the limit.The platelets count of 72.5% effected women was within range but 22.5% range was acceding from the normal and only 5% were below the range.This study results showed that lymphocytes were almost within the limits of 75% subject population but 10% were above the permissible limit and 15% were below the limits.Neutrophils were also recorded, 90% patients were within the range and 7.5% were greater than the range and 2.5% were less than the range.The majority of the individuals (62.5%) had monocytes above the clinical range furthermore 37.5% were within the clinical range.Most of the patients (77.5%) had eosinophil within the clinical range but 22.5% were above the range.
In case of basophils, almost all the patients (90%) were within the prescribed range but 10% were having basophils more than the prescribed range.In case of total bilirubin all the patients were within the clinical range.Alkaline phosphatase, a biochemical parameter is a potential marker for the early detection of cancer which helps in diagnose of people in developing countries.65% of the patients had alkaline phosphatase level above the permissible limit and 35% had within the limit.SGPT (ALT) of 72.5% were within the clinical range and 27.5% were above the range.Most of the subjects (62.5%) were within limit, in case of SGOT (AST) but 37.5% were greater than the limit.
The blood urea was found to be within limit in 95% of the patients, 2.5% were above and 2.5% were below the limit.Most of the patients (95%) in case of S/Creatinine were within the limits and 5% were below the limits.Present study revealed that 67.5% had sodium level within limit, 25% had below limit and 7.5% had above the limit.Potassium level in 92.5% patients was within limit, while potassium level in 5% patients was less and in 2.5% was high.Majority of the patients (85%) were having chloride level with in clinical range but 7.5% were having high and 7.5% were having low chloride level.Similar results of haematological and biological Parameters were found in Dejene et al., (2020).Both of these parameters are important for the treatment, as the chemotherapy treatments proceed fluctuation in these parameters occurs which can create more uncertainties.The fluctuations in these parameters are may be due to elevated levels of pro-inflammatory cytokines (Ali et al., 2014).

Conclusion:
This study concluded that most of the patients were 48-57 years old and illiterate.It was also found that breast cancer is more dominant in married women.Regarding hematologic profile, the mean hemoglobin, red blood cell count, packed cell volume, mean corpuscular volume; mean corpuscular hemoglobin concentration values were significantly lower among some cases.On the other hand, some hematological parameters like platelet count, neutrophil count, are significantly higher.The incidence rate of breast cancer is 2.5 times higher in Pakistani women than the neighboring countries.An increase in the number of incident cases of cancer has implications for understanding the health-care needs of growing population and the subsequent demands on health-care system.

Figure. 1 .
Figure.1.A map showing the locations of areas from where cancer patients were sampled.