The study shows that Kurdish women of Sulaimaniyah have a relatively low incidence of breast cancer, but that the cancers are diagnosed at advanced stages and at an average age that is 8 to 12 years younger than women in the US. It is further shown that, at equivalent ages, the breast cancers of both Kurdish and Arabic women have HR profiles similar to that of US white women.
The young average age of breast cancer patients in the Middle-East is not the result of an increase in breast cancer in young people but because of the relatively low incidence in older women [20–22]. Egypt is thought to have the highest rate of breast cancer in the Middle-East with an age standardized incidence of 53.9/100,000 . For Kurdish women, the age standardized incidence is 40.5/100,000 with both Egyptian and Kurdish estimates being less than half the rate of 116.0/100,000 seen in the US white women [20, 21]. For Egyptian and Kurdish women, the age specific incidences for patients < 50 are similar or somewhat less than in the US and peak at 50–59 years of age [20, 21]. These patterns contrasts markedly with the West where breast cancer steadily increases in postmenopausal women and at age 70 doubles the rates seen at 50–54 years old [9, 21].
The most comprehensive studies on breast cancer HR and HER2 status in the Middle-East come from Egypt, Saudi Arabia and Jordan [22–27]. The reports emphasize the young age at diagnosis with most patients being between 40–50 years old. Outside of Egypt, the proportion of ER + cases ranges from a low of 19.9% in Saudi Arabia to 52.8% in Jordan [23, 24].
An analysis of ER testing at the Gharbiah, Egypt Cancer Registry for the years 2001–2006  identified 3673 breast cancer patients having a median age of 50.1 with urban women at 51.8 years being slightly older than those from rural areas at 49.2 years. It was notable that a majority of the patients (62.9%) had an unknown ER status. For rural women, the ratio of ER + to ER- tumors showed only a slight excess of ER + cases, but the urban ER + ratio was 68.9% and very similar to US white women and our Kurdish and Arabic patients. These findings have been supported by a more recent Egyptian study by Salhia et al. and suggest that for urban Egyptian women, and by inference patients treated in Sulaimaniyah, the predominant mode of tumor development is related to estrogenic risk factors and that most tumors will be tamoxifen responsive.
The relatively high ER + rates do not mean that there is a correspondingly reduced burden of morbidity and mortality for Kurdish and Arabic breast cancer patients. In Western studies, the tumors of young patients tend to be of higher histologic grade and to have higher growth fractions than the tumors of older patients with these factors being independent of HR expression [8, 29, 30]. Among Sulaimaniyah patients, 57.8% of ER + tumors were found in patients < 50 years old and 12.8% were ER+/HER2+. The former, on the basis of patient age, are potentially aggressive tumors and the latter, on the basis of ER and HER2 co-expression, may be tamoxifen resistant [12, 16].
The proportion of HER2+ tumors among Kurds and Arabs at 20.4% to 24.8% reflects the prevalence of high histologic grade cancers. The 21.9% of grade III tumors that were ER-/HER2+ and the 13.8% that were ER+/HER2+ are rates comparable to those seen in high grade tumors in the US and Europe [7, 8, 11, 30]. Although, the proportions of HER2+ tumors among Kurds were higher than for US whites, the incidence of HER2+ tumors, was lower than for either US whites or African Americans.
It is the marked increase in ER+/PR+/HER2- tumors among older women that characterizes US and European populations . For Sulaimaniyah Kurds, ER+/PR+/HER2- tumors are the most common triple subtype and have an incidence of 16.4/100,000 under 50 that increases to 45.5/100,000 among patients ≥ 50 years old. This contrasts with the much higher rate of 226.1/100,000 among post-menopausal US whites .
A Finnish study showed that over a 22 year period when the incidence of ER + tumors doubled from 44.1 to 82.3/100,000, the proportion of HER2+ tumors declined from 21.6% to 13.6% . During this time, the incidence of HER2+ tumors remained stable at 12 to 13/100,000. The higher proportion but relatively low incidence of HER2+ tumors in Kurdish women appears to correspond to the Finnish data and does not indicate an increased risk of developing HER2+ breast cancers in younger women but rather a low risk of developing favorable ER+/HER2- tumors after the menopause.
Triple negative tumors that do not fall into a defined hormonal or HER2 treatment category were found in 11% of Sulaimaniyah residents and were the second most common triple subtype. This proportional rate is not excessive, and the estimated incidences of triple negative tumors for both younger and older Kurdish women were somewhat lower than US whites and considerably lower than the very high incidence among African Americans .
The general similarity of tumor characteristics to those of US white women suggests that breast cancer in the Middle-East resembles the Western disease and that the principles of treatment in Western medical practice may produce results comparable to the US. Improved results may be difficult to achieve in the near term. A very large proportion of Gharbiah and Sulaimaniyah patients had untested tumors and were not being provided the benefit of therapy relevant to HR or HER2 status [22, 32].
In Sulaimaniyah, the failure to test was the choice of the physicians managing the patients. The Sulaimaniyah Governate supports pharmaceutical services that provide nearly all currently recommended generic drugs for breast cancer management including trastuzumab. Nevertheless, many breast cancer patients continue to be treated with surgery alone until there are recurrences or metastases. The Breast Health Global Initiative defines testing for ER status as a “basic level” of pathology evaluation for breast cancer in low and middle income countries [32, 33]. The lack of studies for HR and HER2 in nearly 50% of Sulaimaniyah patients points to deficiencies in regional practice standards that appear to be common in many lower income countries but that should be remediable with suitably directed educational programs.