PREVALENCE OF

RISK FACTORS FOR

BREAST CANCER
 GROUP MEMBERS
DEVIKA SINDU
DIVYA V. C
ELISA T. S. THOMAS
BINTHAF P. P
INTRODUCTION
 BREAST
CANCER IS THE COMMONEST
MALIGNANCY IN THE WORLD AMONG
WOMEN, AND COMPRISES 18% OF ALL
FEMALE CANCERS.

 DESPITEGOOD HEALTH INDICATORS,

BREAST CANCER IS A PUBLIC HEALTH
PROBLEM IN KERALA.
 ACCORING TO THE ESTIMATES FOR THE
YEAR 2014, THIRUVANANTHAPURAM
RECORDED A CRUDE INCIDENCE RATE
OF 40 PER 1,00,000.

 BREAST CANCER CONSTITUTES 28-30%

OF ALL CANCERS AT RCC.

 THEINCIDENCE OF BREAST CANCER IS

SEEN TO HAVE INCREASED OVER THE
PAST THREE DECADES.
 GOING BY RCC THIRUVANANTHAPURAM
TREATMENT RECORDS ABOUT 50% OF
CANCERS ARE OCCURRING IN WOMEN
<50 YEARS OF AGE.

 IDENTIFICATIONOF THE RISK FACTORS

CAN HELP REDUCE THE MORBIDITY AND
MORTALITY LEVELS DUE TO THIS
PATHOLOGY BY FACILITATING
SCREENING AND MITIGATION OF
MODIFIABLE RISK FACTORS.
IN SCIENTIFIC TERMS THERE ARE
NO SPECIFIC STRATEGIES THAT
PERMIT PRIMARY BREAST
CANCER PREVENTION,
ALTHOUGH ITS INCIDENCE
LEVELS CAN BE REDUCED
THROUGH PROMOTION OF
CANCER AWARENESS AND
EMPHASIS ON DECREASING THE
MODIFIABLE RISK FACTORS.
 OBJECTIVE
1. TO IDENTIFY THE FREQUENCY OF VARIOUS
RISK FACTORS FOR BREAST CANCER, IN THE
FEMALE STAFF, BY-STANDERS AND
PATIENTS, ABOVE 30 YEARS OF AGE, IN
SGMC, VENJARAMOOD.

2. TO FIND OUT THE PREVALENCE OF BREAST

SELF-EXAMINATION AMONG THESE
FEMALES.
REVIEW OF LITERATURE
 BREASTCANCER IS CANCER THAT
DEVELOPS FROM BREAST TISSUE –
CELLS LINING THE DUCTS AND
LOBULES.

 SIGNS– LUMP IN THE BREAST, A

CHANGE IN BREAST SHAPE,
DIMPLING OF SKIN, FLUID FROM
THE NIPPLE, OR A RED SCALY PATCH
OF SKIN.
BREAST CANCER SCREENING
 THE BASIC TECHNIQUES FOR EARLY
DETECTION OF BREAST CANCER ARE:

a) BREAST SELF-EXAMINATION BY THE

PATIENT IS A USEFUL ADJUVANT TO EARLY
CASE DETECTION AND A FEASIBLE APPROACH
TO WIDE POPULATION COVERAGE.

b) PALPATION BY A PHYSICIAN

c) THERMOGRAPHY HAS THE ADVANTAGE THAT

THE PATIENT IS NOT EXPOSED TO RADIATION.
IT IS, HOWEVER, NOT SENSITIVE.
d) MAMMOGRAPHY IS MOST SENSITIVE AND
SPECIFIC IN DETECTING CARCINOMAS EVEN
BEFORE THEY BECOME PALPABLE. IT HOWEVER
CARRIES THE RISK OF RADIATION EXPOSURE
WHEN USED ROUTINELY AND IS THEREFORE
NOT RECOMMENDED FOR WOMEN UNDER 35
YEARS OF AGE UNLESS THEY ARE SYMPTOMATIC
OR HAVE A FAMILY HISTORY OF EARLY ONSET OF
BREAST CANCER. ITS REQUIREMENT OF
TECHNICAL EQUIPMENT AND RADIOLOGISTS
LIMITS ITS MORE WIDESPREAD USE FOR MASS
SCREENING PURPOSES.

 METASTASES OCCUR THROUGH LYMPHATIC

AND HEMATOGENOUS CHANNELS TO LYMPH
NODES, LUNGS, BONES, LIVER, ADRENALS ETC.
 PROGNOSISDEPENDS ON
VARIOUS FACTORS INCLUDING
TUMOR INVASION, SIZE, LYMPH
NODE INVOLVEMENT, DISTANT
METASTASES, HISTOLOGIC TYPE
AND GRADE, AND PRESENCE OF
HORMONE RECEPTORS.

 ESTROGEN RECEPTOR(ER)-
POSITIVE AND ER- NEGATIVE
CARCINOMAS SHOW STRIKING
DIFFERENCES WITH REGARD TO
PATIENT CHARACTERISTICS,
PATHOLOGICAL FEATURES,
TREATMENT RESPONSE AND
OUTCOME.
 ESTABLISHED AND
PROBABLE RISK
FACTORS
(Reference: Robbins Basic Pathology,
9th Edition)
ESTABLISHED RISK FACTORS RELATIVE RISK

INCREASES AFTER
AGE
AGE 30

FAMILY HISTORY:

- FIRST DEGREE RELATIVE WITH BREAST 1.2-3.0

CANCER
- PREMENOPAUSAL 3.1
- PREMENOPAUSAL AND BILATERAL 8.5-9.0
- POSTMENOPAUSAL 1.5
- POSTMENOPAUSAL BILATERAL 4.0-5.4
ESTABLISHED RISK FACTORS RELATIVE RISK
MENSTRUAL HISTORY:
- AGE AT MENARCHE < 12 YEARS 1.3

- AGE AT MENOPAUSE > 55 YEARS 1.5- 2

PREGNANCY:
- FIRST LIVE BIRTH AFTER 35 YEARS 2-3

- NULLIPAROUS 3

- LOBULAR CARCINOMA IN SITU 6.9- 12

- OTHER BENIGN BREAST DISEASES >2

 OTHER RISK FACTORS RELATIVE RISK
EXOGENOUS HORMONES:
- HORMONE REPLACEMENT 1.4
THERAPY
- ORAL CONTRACEPTIVE PILLS 1.2
OBESITY:
- PRE-MENOPAUSAL 0.7
- POST-MENOPAUSAL 2

DIET:
- HIGH FAT, MEAT BASED DIET
- POOR INTAKE OF PLANT FOOD 1.5-2
AND DIETARY FIBRES
 OTHER RISK FACTORS

• RADIATION EXPOSURE:
ROUTINE MAMMOGRAPHY SCANS ON YOUNG
WOMEN (<35 YEARS)

• PRIOR BREAST BIOPSY

• LACK OF PHYSICAL EXERCISE

• SMOKING

• ALCOHOL INTAKE
 MATERIALS AND
METHODS
• STUDY DESIGN: HOSPITAL-BASED
CROSS-SECTIONAL STUDY
• STUDY SETTING: SGMC&RF,
VENJARAMOOD
• STUDY PERIOD:20TH OCTOBER 2015
– 17TH NOVEMBER 2015
• STUDY POPULATION: WOMEN,
ABOVE 30 YEARS OF AGE
 MATERIALS AND
METHODS
• SAMPLE SIZE: 200
• SAMPLING TECHNIQUE:
CONVENIENT SAMPLING
• STUDY TOOLS: STRUCTURED
QUESTIONNAIRE
• STUDY TECHNIQUE: SELF-
ADMINISTERED MCQs
 MATERIALS AND
METHODS
STUDY VARIABLES:
AGE (30-80 YEARS)
EDUCATION STATUS
EARLY MENARCHE
LATE MENOPAUSE
POST-MENOPAUSAL WEIGHT GAIN
HORMONE REPLACEMENT THERAPY
NULLIPARITY
FIRST LIVE BIRTH AFTER THE AGE OF 30 YEARS
 STUDY VARIABLES
FAMILY HISTORY OF BREAST CANCER
ROUTINE MAMMOGRAPHY SCANS
PROLONGED USE OF OCPs
SMOKING AND ALCOHOL INTAKE
HIGH FAT DIET
DECREASED INTAKE OF FRUITS AND VEGETABLES
LACK OF PHYSICAL EXERCISE
 DATA COLLECTION

 DATA WERE COLLECTED THROUGH SELF

ADMINISTERED MULTIPLE CHOICE
QUESTIONS, WITH THE HELP OF A
STRUCTURED QUESTIONNAIRE
CONTAINING QUESTIONS RELATED TO
THE RISK FACTORS OF BREAST CANCER,
FROM FEMALE STAFF, PATIENTS AND BY-
STANDERS, IN SGMC, VENJARAMOOD.
 ETHICAL CONSIDERATION

 INFORMED VERBAL CONSENT WAS

OBTAINED FROM THE STUDY PARTICIPANTS.
 DATA ANALYSIS

 DATA ANALYSIS WAS CARRIED OUT

USING SPSS Vs. 16.0
 QUALITATIVE VARIABLES ARE
EXPRESSED AS PERCENTAGE.
TABLES AND
GRAPHS
 TABLE NO:1-DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO AGE (n=200)

AGE FREQUENCY PERCENTAGE

30-49 150 75%

50-69 48 24%

> 69 2 1%

TOTAL 200 100%

FIG. NO: 1- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO AGE
(n=200)
1%
24% 30-49
50-69
>69

75%
 TABLE NO:2- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO THEIR
EDUCATION STATUS (n=200)
EDUCATION FREQUENCY PERCENTAGE

ILLITERATE 2 1%

MIDDLE SCHOOL 32 16%

HIGH SCHOOL/
POST HIGH SCHOOL 98 49%
DIPLOMA
GRADUATE 54 27%

PG/PROFESSIONAL 14 7%

TOTAL 200 100%

FIG. NO: 2- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO THEIR
EDUCATION STATUS (n=200)

7% 1% UNEDUCATED
16%
MIDDLE SCHOOL
27%
HIGH SCHOOL/ POST HIGH
SCHOOL DIPLOMA
GRADUATE
49%
PG/PROFESSION
TABLE NO:3- BREAST CANCER AWARENESS
AMONG STUDY PARTICIPANTS (n=200)
AWARENESS FREQUENCY PERCENTAGE
NOT AWARE 6 3%
AWARE 194 97%
TOTAL 200 100%
SOURCE OF INFORMATION FREQUENCY PERCENTAGE
NIL 6 3%
BOOKS, MAGAZINES 65 32.5%
SOCIAL MEDIA (TV, RADIO) 103 51.5%
FRIENDS 12 6%
OTHERS 14 7%
TOTAL 200 100%
 FIG. NO: 3- AGE AT MENARCHE
AMONG STUDY PARTICIPANTS (n=200)

5% 17%

<12 YEARS
12-17 YEARS
>17 YEARS

78%
 FIG. NO: 4- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO
ATTAINMENT OF MENOPAUSE (n=200)

NO
78% YES

22%
 FIG NO. 5-DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO POST-
MENOPAUSAL WEIGHT GAIN (n=44)

9.1%2.3%
NIL
<5 kg
22.7% 50% 5-10 kg
10-20 kg
>20 kg

15.9%
TABLE NO:4- DISTRIBUTION OF STUDY PARTICIPANTS ACCORDING TO THE
NUMBER OF PREGNANCIES AND THEIR AGE AT FIRST TERM PREGNANCY
(n=200)
NO. OF PREGNANCIES FREQUENCY PERCENTAGE
NIL 10 5%
1-2 146 73%
3-4 38 19%
>4 6 3%
TOTAL 200 100%
AGE AT FIRST TERM
FREQUENCY PERCENTAGE
PREGNANCY
NIL 10 5%
<18 24 12%
18-25 139 69.5%
26-30 21 10.5%
31-35 5 2.5%
>35 1 0.5%
TOTAL 200 100
 TABLE NO:5- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO THEIR
FAMILY HISTORY (n=200)
FAMILY HISTORY FREQUENCY PERCENTAGE

NO FAMILY HISTORY 158 79%

MOTHER 6 3%

SISTER 8 4%
OTHER FEMALE
28 14%
RELATIVES
TOTAL 200 100%
 FIG. NO:6- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO BREAST
SELF EXAMINATION (n=200)

38.5%
44.5% NO
EVERY 3 MONTHS
MONTHLY

17%
 TABLE NO: 6- DISTRIBUTION ACCORDING
TO THE FREQUENCY OF MAMMOGRAPHY
AMONG THE STUDY PARTICIPANTS (n=200)
FREQUENCY OF
FREQUENCY PERCENTAGE
MAMMOGRAPHY

NOT DONE 187 93.5%

YEARLY 5 2.5%

EVERY 2 YEARS 3 1.5%

EVERY 5 YEARS 5 2.5%

TOTAL 200 100%

 TABLE NO: 7- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO HORMONE
REPLACEMENT THERAPY AND OCP USE
(n=200)
FREQUENCY PERCENTAGE

HORMONE NO 199 99.5%

REPLACEMENT THERAPY
YES 1 0.5%

FREQUENCY PERCENTAGE

USE OF ORAL NO 187 93.5%

CONTRACEPTIVE PILLS
YES 13 6.5%
FIG. NO:7- DISTRIBUTION ACCORDING
TO THE DURATION OF OCP USE
AMONG STUDY PARTICIPANTS (n=13)

69.2%

1-2 YEARS
30.8% 3-4 YEARS
TABLE NO:8- DISTRIBUTION ACCORDING
TO THE PREVALENCE OF SMOKING AND
ALCOHOL INTAKE AMONG STUDY
PARTICIPANTS (n=200)
SMOKING AND
FREQUENCY PERCENTAGE
ALCOHOL INTAKE
NO 200 100%

SMOKING 0 0%

ALCOHOL INTAKE 0 0%

TOTAL 200 100

FIG. NO: 8- DISTRIBUTION OF STUDY
PARTICIPANTS BASED ON INTAKE OF
FRUITS AND VEGETABLES (n=200)
12.5% 5%
EVERY MEAL
DAILY
21.5% WEEKLY
SOMETIMES

61%
 FIG. NO: 9- DISTRIBUTION OF STUDY
PARTICIPANTS ACCORDING TO INTAKE
OF HIGH FAT DIET (n=200)

15%
NO
>3 TIMES A WEEK
SOMETIMES
69% 16%
FIG. NO: 10- DISTRIBUTION BASED ON
THE EXERCISE HABITS AMONG STUDY
PARTICIPANTS (n=200)

35% 36% NO
YES
SOMETIMES

29%
 SUMMARY
 BREAST CANCER HAS EMERGED AS A MAJOR
NON-COMMUNICABLE DISEASE AND A
PUBLIC HEALTH PROBLEM IN THE STATE.

 THIS STUDY AIMS TO ASSESS THE

PREVALENCE OF RISK FACTORS IN THE
GENERAL FEMALE POPULATION ABOVE 30
YEARS OF AGE IN SGMC,VENJARAMOOD.

 THE PROFILE OF THE STUDY POPULATION

COMPRISED 200 WOMEN BETWEEN 30-80
YEARS OF AGE. 75% BELONGED TO THE AGE
GROUP OF 30-49 YEARS.
 IN THE STUDY GROUP, 194 (97%) WOMEN
HAVE HEARD OF BREAST CANCER.

 103 (51.5%) RECEIVED THE INFORMATION

THROUGH SOCIAL MEDIA ( TV, RADIO).

 ONLY 14 (7% ) WOMEN CAME TO KNOW

ABOUT BREAST CANCER FROM CAMPS
AND COMMUNITY OUTREACH
PROGRAMMES.
 34 (17%) WOMEN HAD EARLY MENARCHE
(<12 YEARS)

 AMONG THE STUDY PARTICIPANTS, 10

(5%) WERE NULLIPAROUS.

 6 (3%) WOMEN HAD THEIR FIRST LIVE

BIRTH AFTER THE AGE OF 30 YEARS.
 IN THE STUDY GROUP, 44 (22%) WOMEN
HAD ATTAINED MENOPAUSE, AND 5 (2.5%)
HAD POST MENOPAUSAL WEIGHT GAIN OF
MORE THAN 10 kg.

 ONLY 1(0.5%) WOMAN (56 YEAR OLD, POST-

MENOPAUSAL), HAS UNDERGONE
HORMONE REPLACEMNT THERAPY.

 OUT OF THE 13 (6.5%) WOMEN WHO HAVE

USED ORAL CONTRACEPTIVE PILLS, 4 (2%)
HAVE USED IT FOR 3-4 YEARS.
 AS FOR THE FAMILY HISTORY OF BREAST
CANCER, 14 (7% WOMEN) REPORTED
HAVING A FIRST DEGREE RELATIVE
(MOTHER OR SISTER) WITH BREAST
CANCER.

 89 (44.5%) WOMEN DO NOT CONDUCT

BREAST SELF EXAMINATION.

 IN THE STUDY GROUP, 5 (2.5%) WOMEN

CONDUCTED YEARLY MAMMOGRAPHY
SCAN.
 NONE OF THE STUDY PARTICIPANTS
HAVE SMOKED OR CONSUMED
ALCOHOL.

 OF ALL THE STUDY PARTICIPANTS, 68

(34%) OF THEM CONSUME FRUITS AND
VEGETABLES ONLY ONCE IN A WHILE.
 AMONG THE STUDY PARTICIPANTS, 32
(16%) WOMEN HAVE HIGH FAT DIET
MORE THAN THREE TIMES A WEEK.

 IT IS NOTED THAT 36% (72) WOMEN DO

NOT DO REGULAR PHYSICAL EXERCISES.
 IN A STUDY CONDUCTED IN ARPOOKARA
PANCHAYAT OF KOTTAYAM, OF THE 100
PARTICIPANTS, 70 % PARTICIPANTS BELONGD TO
THE AGE GROUP OF 32-55 YEARS.
 IN THE SAME STUDY, 3% WOMEN HAD THEIR FIRST
LIVE BIRTH AFTER 30 YEARS, AS IN OUR STUDY.
 THIS STUDY ALSO NOTED A LOW PREVALENCE
OF SELF EXAMINATION OF THE BREAST. THEY
SUGGESTED IMPLEMENTATION OF PUBLIC
PRIVATE PARTNERSHIPS IN SPREADING
AWARENESS ABOUT MODIFIABLE RISK FACTORS,
SCREENING AND BREAST SELF-EXAMINATION.
 AN UNMATCHED CASE-CONTROL STUDY
WAS CONDUCTED AMONG 660 NEWLY
DETECTED BREAST CANCER PATIENTS
ADMITTED FOR SURGERY IN RCC,
TRIVANDRUM AND 920 CONTROLS
FROM THE HOSPITAL AND COMMUNITY
IN TRIVANDRUM, BY PAUL AUGUSTINE,
JEESHA C. HARAN, ET AL, AND WAS
PUBLISHED IN THE ACADEMIC MEDICAL
JOURNAL OF INDIA VOL.2 ISSUE 1,
 ACCORDING TO THIS STUDY, MOST
STUDY PARTICIPANTS BELONGED TO THE
AGE GROUP OF 30-49 YEARS, SIMILAR
TO OUR STUDY.
 10% PARTICIPANTS HAD EARLY MENARCHE
COMPARED TO 17% IN OUR STUDY. 49.2%
STUDY PARTICIPANTS WERE POST-
MENOPAUSAL COMPARED TO 22% IN OUR
STUDY. 33% WOMEN WERE NULLIPAROUS
(COMPARED TO 5% IN OUR STUDY)
 THE STUDY ALSO NOTED THAT 5%
PARTICIPANTS HAD A FIRST DEGREE RELATIVE
WITH BREAST CANCER WHILE 2% REPORTED
THE USE OF ORAL CONTRACEPTIVE PILLS,
WHICH ARE SIMILAR TO THE FINDINGS IN
OUR STUDY.
 THIS STUDY TRIED TO DETERMINE THE
STRENGTH OF ASSOCIATION OF KNOWN
RISK FACTORS OF BREAST CANCER AMONG
WOMEN IN KERALA.
 THESTUDY CONCLUDES THAT AGE
AND PARITY PLAY A MAJOR ROLE IN
THE OCCURRENCE OF BREAST
CANCER IN KERALA. IT ALSO
SUGGESTED THAT PAST HISTORY OF
BREAST SYMPTOMS REQUIRING
BIOPSY IS ASSOCIATED WITH AN
INCREASED RISK OF BREAST CANCER.
A STUDY CONDUCTED IN PAKISTAN
BY HAFIZ MUHAMMED ASIF ET AL
(ASIAN PACIFIC JOURNAL OF
CANCER PREVENTION VOL.15,
2014), TO DETERMINE PREVALENCE
OF RISK FACTORS AMONG WOMEN
IN PAKISTAN, ALSO NOTED SIMILAR
FINDINGS AS OUR STUDY, ALONG
WITH AN INCREASED GENETIC
PREDISPOSITION IN THEIR
POPULATION.
 IN THIS RESEARCH IT WAS NOTED THAT
THERE IS AN INCREASING FREQUENCY
OF RISK FACTORS, WHICH MIGHT HELP
EXPLAIN THE INCREASING INCIDENCE
OF BREAST CANCER.

 A LOW PREVALENCE OF BREAST SELF

EXAMINATION WAS ALSO OBSERVED.
 THE STUDY OF RISK FACTORS
CAN PERMIT THE
IDENTIFICATION OF
MODIFIABLE RISK FACTORS,
HIGHLIGHTING WOMEN’S
LIFESTYLE, THAT INCREASE THE
INCIDENCE OF BREAST CANCER
CASES.
 A HEALTHY LIFESTYLE TOGETHER
WITH THE OFFERING OF
SECONDARY BREAST CANCER
PREVENTION, WOULD AVOID
MANY DISEASES AND DEATHS DUE
TO LATE DIAGNOSIS OF BREAST
CANCER.
 STUDIES ABOUT RISK FACTORS CAN
ALSO HELP RESEARCHERS
MONITOR THE IMMINENT
VARIATIONS IN CANCER
INCIDENCE IN THE STATE AND
THEREBY HELP THE STATE
GOVERNMENT TO TAKE MEASURES
FOR EFFECTIVE SCREENING AND
TO PROPAGATE AWARENESS ABOUT
THIS MALIGNANCY.
 THE GOVERNMENT SHOULD
INTRODUCE PROGRAMMES THAT WILL
ENABLE MONITORING OF BREAST
CANCER CASES AS WELL AS DETERMINE
THE PREVALENCE OF RISK FACTORS IN
THE STATE.
 THERE IS A NEED FOR ESTABLISHING
EFFECTIVE SCREENING PROGRAMMES
AT THE NATIONAL LEVEL FOR EARLY
DETECTION OF CASES.

 FEMALE AWARENESS ABOUT BREAST

SELF EXAMINATION SHOULD ALSO BE
INCREASED.
 THE POLICY MAKERS CAN CONSIDER
ENCOURAGING COMMUNITY
PARTICIPATION BY INVOLVING THE
NON-GOVERNMENTAL
ORGANIZATIONS AND WOMEN SELF
HELP GROUPS IN SPREADING
AWARENESS ABOUT BREAST CANCER
SCREENING.
 REFERENCES
1. Robbins Basic Pathology, (Kumar, Abbas, Aster),
9th Edition
2. Park’s Textbook of Preventive and Social
Medicine, K.Park, 23rd Edition
3. Hafiz Muhammed Asif et al, Prevalence, Risk
Factors and Disease Knowledge of Breast Cancer in
Pakistan, Asian Pacific Journal of Cancer Prevention,
Volume 15, 2014
 REFERENCES
4. Paul Augustine, Regi Jose, Jeesha C. Haran et
al, Risk Factors of Breast Cancer in Kerala, India-
A Case Control Study, Academic Medical Journal
of India, Volume 2, Issue 1

5. Jennifer. H. Gladius et al, A Population Based

Case Control Study on Breast Cancer and the
Associated Risk Factors in a Rural setting in
Kerala, Southern India; Journal of Clinical and
Diagnostic Research: JCDR 2013
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6. Mizota Y et al, Prevalence of breast cancer risk
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7. Winter et al, Prevalence of risk factors for

breast cancer in German airline cabin crew: a
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 REFERENCES
1. www.thehindu.com – Article: Capital records
highest crude incidence rate in the country
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THANK YOU