Breast Anthropometry—Results of a Prospective Study Among Indian Breast Cancer Patients

Abstract

Breast anthropometry plays an important role in surgical decision-making in the era of breast conservation therapy, oncoplasty and reconstruction. Majority of the currently available breast anthropometry data is from Western countries, and there is a need to evaluate anthropometric data among Indian women to tailor our surgical decision-making and achieve optimum surgical results. Two hundred and thirty-one breast cancer patients were included in this prospective study, and different anthropometric parameters were evaluated to assess and describe the nipple-areola complex, breast shape, size, volume and ptosis. Breast volume was calculated using formula developed by Qiao et al. Outcomes were compared with data available from different countries. Mean breast volume among Indian women was 515 ml. Nearly, 81% of patients had ptosis and up to 40% had grade 3 ptosis. Breast volume among Indian patients can be grouped into three categories based on quartiles (category I—≤ 220 ml, category II—> 220 to ≤ 730 ml, category III—> 730 ml). Overall breast anthropometry data among Indian women was different from the data reported from western studies. Breast anthropometry plays an important role in the surgical decision-making, and results of the study indicate that the anthropometry of Indian women is different from western counterparts.

Electronic supplementary material

The online version of this article (10.1007/s13193-019-01031-3) contains supplementary material, which is available to authorized users.

Introduction

Breast cancer is the leading cancer among women globally, and it has replaced cervical cancer as the leading cancer in India [1]. Surgery plays an important role in the management of breast cancer. The surgical approach for breast cancer has shown a paradigm shift globally from predominantly a mastectomy-based approach to an approach based on breast conservation, oncoplasty and reconstruction.

Breast anthropometry including size, shape, ptosis, and nipple areola complex (NAC) anatomy plays an important role in surgical decision-making especially in fields related to breast conservation, oncoplasty, reconstruction and implant selection. Current breast anthropometry-based surgical guidelines are predominantly based on data from Western countries, and the same guidelines are being followed by surgeons from developing countries. It is a well-known fact that racial, ethnic and socioeconomic factors influence human anthropometry [2, 3]. Various techniques of estimating breast anthropometry were described in literature, and there is no consensus on the ideal method. Ideal technique should be simple, cheap and reproducible.

There is a need to study anthropometric data of breast cancer patients from different regions of the world to evolve individualized surgical decision-making guidelines. This study was conducted to evaluate the breast anthropometric data among Indian breast cancer patients, and an attempt was made to compare the data with published breast anthropometric data from different countries.

Materials and Methods

This is a prospective, observational study conducted between January 2016 and July 2018. Subjects were recruited prospectively from inpatients admitted for breast cancer surgery. An institutional ethics committee clearance was obtained, and an informed consent was taken from all the study subjects.

A total of 231 consenting inpatients with operable breast cancer above 18 years of age were included. Patients with male breast cancer, bilateral carcinoma breast, pregnant and lactating women, patients with prior history of breast surgery and chest or spinal deformities were excluded.

A custom-made pro forma for the study was designed for documentation of patient's clinical details and anthropometric data (Annexure -1). General information of the patient including identification data, diagnosis, laterality and stage of breast cancer and parity were recorded in a standard format.

Anthropometric data was collected by direct measurement of parameters as described by Hall et al., Qiao et al., and Dilek et al. with some modifications [4, 5]. This included basic anthropometry measurements like height, weight and body mass index (BMI), shoulder width, upper chest, middle chest and lower chest width, waist and hip width and upper arm length. Relevant breast anthropometric data was obtained as indicated in Table 1. All the breast measurements were calculated in erect posture with hands by the side.

Table 1.

Anthropometric data recorded in the study

General anthropometry	1. Shoulder width 2. Upper chest width 3. Middle chest width 4. Lower chest width 5. Waist width 6. Hip width 7. Upper arm length
Breast volume	Calculated by formula given by Qiao et al.
Breast shape	Martin Saller classification was used
Ptosis	Renaults classification
NAC	1. Nipple diameter 2. Nipple projection 3. Areolar diameter
Nipple triangulation	1. Clavicle nipple length 2. Sternal notch nipple length 3. Sternal nipple length
Breast density	Mammographic breast density using ACR grades I, II, III and IV

Breast volume (MV) was calculated using the formula described by Qiao et al. [4].

MV = 1/3 × 3.14 × MP² × (MR + LR + IR − MP)

(MR is medial mammary radius—nipple to medial terminal crest, LR is lateral mammary radius—nipple to lateral terminal crest, IR is Inferior radius—nipple inframammary fold length, and MP is mammary projection).

Breast ptosis was evaluated using Renault’s classification of ptosis while breast density was measured radiologically using ACR gradings from I to IV. Martin Saller classification was used to categorize breast shape.

Each of the collected quantitative measurements was described using mean, median, mode, quartiles, standard deviation or standard error and range values. The quartile distribution of breast volume and NAC parameters was used to attempt a group categorization of these variables.

Results

A total of 231 subjects were enrolled in the study. Majority of the study population belonged to age group of 40 to 60 years (56.7%) and predominant clinical stage of breast cancer was stage II (n = 109).

General Anthropometry

The study population had a mean BMI of 25.30 kg/m². Mean shoulder, upper chest, middle chest and lower chest widths were 36.83 cm, 14.77 cm, 19.21 cm and 16.72 cm, respectively, while mean waist and hip widths were 90.67 and 97.69 cm, respectively. Mean upper arm length was 31.83 cm.

Breast Anthropometry

The values of medial mammary radius, lateral mammary radius, nipple inframammary fold length, mammary projection, breast volume and nipple areolar complex measurements (NAC) along with mean, median, standard deviation, standard error and ranges are given in Table 2.

Table 2.

Medial mammary radius, lateral mammary radius, nipple inframammary fold length, breast volume and NAC measurements of the study population

	Mean	Median	Standard deviation	Standard error	Range
MR(in cm)	8.12	8	2.38	0.16	4–16
LR(in cm)	7.29	7	1.93	0.13	4–15
IR(in cm)	7.36	7	2.01	0.13	3.5–14.5
MP(in cm)	4.90	4.5	1.68	0.11	2–11
Breast volume (in ml)	515.08	388.19	411.73	27.08	60.09–2279.64
Nipple diameter (in cm)	0.90	1	0.23	0.015	0.2–2
Areola diameter (in cm)	4.47	4.5	1.20	0.08	0.5–8
Nipple projection (in cm)	0.72	0.7	0.31	0.02	0.2–2.5

Mean clavicle-nipple length, sternal notch-nipple length and sternum-nipple length of the study population were 24.07 cm, 23.99 cm and 10.60 cm, respectively.

Shape and Ptosis

Most of the patients had grade 3 ptosis of the breast (n = 91), and bowl-shaped breasts were the most common shape encountered (n = 189). The distribution of grade of ptosis according to age and parity is given in Fig. 1.

Fig. 1.

Distribution of grades of ptosis according to age and paritye

Size of Breast

Most common cup sizes were D and C (n = 62 and 58, respectively).

Breast Volumetry

The mean breast volume according to age, parity, BMI and cup size is depicted in Fig. 2.

Fig. 2.

Mean breast volume variation with age, parity, BMI and cup size

NAC Data

Out of the 231 patients in the study population, 136, 71 and 24 patients had brown, black and pink nipples, respectively. The different NAC dimensions that were recorded are given in Table 2.

Breast Density

Among 231 study participants, 186 patients underwent mammogram and most common mammographic breast density was of ACR category II (n = 92) followed by ACR III, I and IV with 45, 40 and 9 patients, respectively.

Classification of Indian Breast Based on Anthropometry

Categorization of Indian breast was done using quartiles for breast volume, nipple diameter and projection and grouped into category I (small), category II (medium) and category III (large)—Table 3.

Table 3.

Categorization of breast volume and NAC in Indian patients

	I	II	III
Breast volume category	≤ 220 ml	> 220 to ≤ 730 ml	> 730 ml
Nipple diameter category	≤ 0.7 cm	> 0.7 to ≤ 1 cm	> 1 cm
Nipple projection category	≤ 0.5 cm	> 0.5 to ≤ 1 cm	> 1 cm
Areola diameter category	≤ 4 cm	> 4 to ≤ 5 cm	> 5 cm

The classification is based on quartile distribution of data. Categories I and III each have 25% of the study population with majority (50%) belonging to category II. Hence, based on study outcome data, it can be said that majority of the study population has a breast volume between 220 and 730 ml, nipple diameter 0.7 to 1 cm, nipple projection 0.5 to 1 cm, areola diameter 4 to 5 cm and with bowl-shaped breasts and grade 3 ptosis.

Discussion

The rising breast cancer trend globally has been associated with a shift in surgical trend towards more breast conservation procedures, oncoplasty and reconstruction. Breast anthropometry plays a critical role in overall modern breast surgical decision-making and can influence surgical decisions and outcomes [6–11]. Global breast anthropometry data is skewed due to paucity of literature from Asian and developing countries. There is a need for assessment of breast anthropometry among women from low- and middle-income countries.

Basic breast anthropometric data includes size, volume, shape, dimensions of NAC, mammographic breast density, the position of nipple with respect to bony prominences and degree of ptosis [12, 13]. Various techniques were described to measure breast volume and can be classified in to natural shape methods, stereological methods, geometric methods and mathematical modelling methods [12, 14–20]. The most affordable techniques for developing countries are geometric methods. They can be done with simple instruments like measuring tapes, rulers and callipers. These methods approximate the shape of breast to a cone or sphere and use mathematical formulae to calculate breast volume. In comparison, other methods require special or expensive instruments and geometric methods are also less cumbersome than the traditional water displacement method.

Mean BMI of Indian woman is 22 kg/m² being two points lower compared with European data and much lesser compared with the BMI data of women from the UK, USA and Middle Eastern countries [21].The comparative data is shown in Fig. 3. The present study revealed a trend towards increasing breast volume with corresponding increase of BMI (Fig. 2).

Fig. 3.

Mean BMI of women in different countries

Few studies reported breast anthropometry using geometric methods [4, 5]. Qiao et al. studied 125 Chinese women between the ages of 18 to 26 years, while Dilek et al. studied 385 Turkish female students of the same age group with a BMI between 20 and 26 kg/m². Dilek et al. also noted that there was a significant difference in breast volume of the right and left sides, with the right side being larger [4, 5]. Such evaluation could not be done in the present study due to the presence of tumour in the contralateral breast. Westreich et al. measured breast volume in 50 women with aesthetically perfect breasts using the Grossman Roudner device while Oteify used a different formula using the breast circumference in 52 nursing students who had no breast pathology [22, 23]. Dierdre et al. used the water displacement technique which is accurate but cumbersome [24]. In a large population-based study, Anderson et al. used a multitude of sources to acquire data in women between 28 and 30 years of age. They used mostly information from the clothing industry and cosmetic surgery providers for 342,000 individual breast measurements [25]. They also used 3D scanning to calculate breast volume in 11,682 patients. Data on cup sizes across nations in this age group was also acquired in this study. Most common cup size in the UK, Netherlands and Iceland was D cup [25]. Women from Canada and the USA were noted to have predominantly E and F cups while women from African and Asian countries were found to have a mean. Many unpublished surveys done by newsgroups, textile manufacturers and others mention that the average Indian bra cup size is B and A. According to the present study, C and D are the most common cup sizes among Indian women and this may be due to the sample size belonging to 4-0 to 50-year age group.

The comparison of breast volume of the study population with data from other global literature has been summarized in Fig. 4. The comparison of various aspects of NAC measurements of the study population and global literature has been summarized in Table 4. The ptotic nature of Indian breasts is evident in the differences in the clavicle-nipple and the sternal-notch nipple length with other studies. There have been few population-based studies performed with uniform methodology evaluating breast shapes and ptosis.

Fig. 4.

Breast volume comparison with other studies

Table 4.

Comparison of the NAC among global literature (measurements in cm)

Parameter	Present study	Qiao et al. [4] (Chinese)	Dilek et al. [5](Turkish)	Westreich et al. [22]	Liu et al. [26] (United States)
Areola diameter	4.47	3.3	3.6	3.49, 3.69	4
Areola colour	Brown	-	-	-	-
Nipple diameter	0.90	-	2.5	-	-
Nipple projection	0.72	0.466	0.4	-	-
Clavicle nipple length	24.07	19.26	19.5	18.8	22
Sternal notch nipple length	23.99	19.05	19.6	-	21.5
Sternal nipple length	10.6	10.02	9.95	9.66	10.5

Eighty-one percent of the study population had ptotic breasts (n = 188), and grade 3 was the most common degree of ptosis (n = 91, 40%) in the study population. A comparison of the grades according to parity and age revealed that grade 3 ptosis was the most common degree of ptosis irrespective of parity status or age group (Fig. 1). In contrast, Huang et al. reported a ptosis of 22.8% in the Chinese population evaluated for breast cancer and benign breast diseases [27]. This high incidence of ptosis is an important dimension of breast anthropometry among Indian population which can influence surgical decisions and outcomes. It can also influence decisions regarding implant reconstruction as well as the need for contralateral symmetrisation surgeries. The most common breast shape encountered was bowl-shaped (n = 181) followed by the dependent shape (n = 33) according to Martin Saller classification.

Since breast volume can be affected by age, BMI and parity, we tried to correlate breast volume with age, body mass index and parity (Fig. 2). Average breast volumes in age groups less than 40 years old was 499.15 ml, between 40 and 60 years old was 515.89 ml and in women older than 60 years was 544.21 ml.

Mean breast volume was calculated in each BMI category and was found to be 234.31 ml in underweight, 430.32 ml in normal, 549.59 ml in overweight, 706.70 ml in grade I obese and 1051.80 ml in grade II obese individuals. Mean breast volumes in nulliparous, uniparous and multiparous women were also different as expected ranging from 432.73, 735.80 to 492.63 ml, respectively. The limitations of the study include a modest sample size and being a single-center hospital-based study, the inherent bias of population selection from a specific cohort of people.

Overall, the current study is one of the most comprehensive studies attempting to evaluate breast anthropometry among Indian women and the outcomes revealed deviations and variations of breast anthropometry in comparison with western population. The outcomes of the study emphasize the need for large-scale anthropometric studies in India which can influence surgical decisions and outcomes.

Conclusion

Breast anthropometry is an important parameter to be considered in modern surgical decision-making. There is a lack of breast anthropometry data from low- to middle-income countries like India which are likely to witness significant increase in breast cancer burden. The results of the current study indicate that breast anthropometry data of Indian women is different from western population and it can be influenced by age, BMI and parity. There is a need to initiate large studies to evaluate breast anthropometry including diverse population groups in India.

Compliance with Ethical Standards

Conflicting Interest

The authors declare that they have no conflict of interest.