According to WHO mortality database, cancer is the fourth ranked cause of death in the Eastern Mediterranean Region (EMR), after cardiovascular diseases, infectious/parasitic diseases and injuries [8]. In this current study, breast cancer was diagnosed in 28% of patients presenting with apparent breast lumps, and more than half of the patients (203/357, 56.9%) were 50 years or younger. A study by Alwan NAS [2] in Iraq demonstrated that breast cancer was diagnosed in 14.3% of patients presenting with apparent breast lumps, and one third of the patients had been diagnosed in their forties, where the peak frequency occurred, but an obvious decline was displayed after the age of 60 years.

The continuing trend for this disease to affect younger generations has been comprehensively illustrated in the Iraqi Cancer Registry [8]. WHO estimates revealed that approximately half of the cancers in the EMR occur before the age of 55 and that the age standardized incidence rates of all cancers in this region is expected to double as risk factor exposure increases [9]. Hacihasanoglu & Gozum, also reported the mean age of patients with breast cancer to be one decade lower in Turkey, compared to western countries [10]. Comparable to our study, Hashemian H et al 2016 showed in their study the highest incidence rate of breast cancer was observed in patients aged 40-49 years [11]. Similar observations were also reported by Suresh p [12] from North India, Kokiwar P [12] from South India and Acharya SC [13] from Nepal.  Our findings was similar to studies from other African Centre were the mean age is 48 years and approximately two-thirds are premenopausal [14,15]. The increase in the incidence of breast cancer is most likely due to the adoption of a more “Westernized” lifestyle, like physical activity, adverse changes in diet, and fertility (Shin et al., 2010, Youden et al., 2014, Park et al., 2008, Porter, 2008). This effect has been greatest among younger women living in urban areas of lower and middle-income countries (Green and Raina, 2008).

This finding differs from that demonstrated in studies from Western and developed countries. In this regard, American Cancer Society (ACS) has suggested age to be the second leading risk factor for breast cancer following gender [16]. It is possible that the higher median age at diagnosis among women in Western countries could be partly explained by the population-based mammography breast-screening program that is widely available in these countries, which mainly targets women aged 50 years and over (Youlden et al., 2012) [17] which is not at all available in India neither in Erbil province. Another factor for the difference in age of onset of female breast cancer between Asian countries and Western countries can be attributed to differences in life expectancy, with a greater proportion of the population in the younger age groups for females in developing countries (United Nations, 2010).

The present study showed that family history of breast cancer was reported in 83 patients (23.2%); 57 of these (68.7%) had an affected first-degree relative. The study by Alwan N 2010 in Iraq documented that family history was positive in 16.2% of 721 females ². Having a positive family history of breast cancer is a well-known risk factor for the disease. Women having one first degree relative with breast cancer have nearly two-fold increased risk of developing breast cancer [18]. Nevertheless, this result was not in congruence with the studies by Khameghian et al. (frequency: 2%) [19], and Gao (frequency: 3.7%) [20]. The prevalence of positive family history of breast cancer might vary based on the race/ethnicity of the patients, which could be the reason for this inconsistency in results. The relatively high incidence of positive family history noted in this study could be related to the customary consanguineous marriages, which is common in this region.

The findings from this study indicates an urgent cooperation between department of health, education and Early detection breast Centre to develop breast screening program in Erbil province and ideally include patients 40 years’ old, together with targeted education would help in early diagnosis and potentially reduce the current high incidence of stage III and IV breast cancer.