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Ngwa W, Addai BW, Adewole I, Ainsworth V, Alaro J, Alatise OI, Ali Z, Anderson BO, Anorlu R, Avery S, Barango P, Bih N, Booth CM, Brawley OW, Dangou JM, Denny L, Dent J, Elmore SNC, Elzawawy A, Gashumba D, Geel J, Graef K, Gupta S, Gueye SM, Hammad N, Hessissen L, Ilbawi AM, Kambugu J, Kozlakidis Z, Manga S, Maree L, Mohammed SI, Msadabwe S, Mutebi M, Nakaganda A, Ndlovu N, Ndoh K, Ndumbalo J, Ngoma M, Ngoma T, Ntizimira C, Rebbeck TR, Renner L, Romanoff A, Rubagumya F, Sayed S, Sud S, Simonds H, Sullivan R, Swanson W, Vanderpuye V, Wiafe B, Kerr D. Cancer in sub-Saharan Africa: a Lancet Oncology Commission. Lancet Oncol 2022; 23:e251-e312. [PMID: 35550267 PMCID: PMC9393090 DOI: 10.1016/s1470-2045(21)00720-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 01/13/2023]
Abstract
In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.
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Affiliation(s)
- Wilfred Ngwa
- Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA; Sidney Kimmel Comprehensive Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Information and Sciences, ICT University, Yaoundé, Cameroon.
| | - Beatrice W Addai
- Breast Care International, Peace and Love Hospital, Kumasi, Ghana
| | - Isaac Adewole
- College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Victoria Ainsworth
- Department of Physics and Applied Physics, University of Massachusetts Lowell, Lowell, MA, USA
| | - James Alaro
- National Cancer Institute, National Institute of Health, Bethesda, MD, USA
| | | | - Zipporah Ali
- Kenya Hospices and Palliative Care Association, Nairobi, Kenya
| | - Benjamin O Anderson
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Non-communicable Diseases, WHO, Geneva, Switzerland
| | - Rose Anorlu
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Stephen Avery
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Prebo Barango
- WHO, Regional Office for Africa, Brazzaville, Republic of the Congo
| | - Noella Bih
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - Otis W Brawley
- Sidney Kimmel Comprehensive Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Lynette Denny
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa; South African Medical Research Council, Gynaecological Cancer Research Centre, Tygerberg, South Africa
| | | | - Shekinah N C Elmore
- Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Ahmed Elzawawy
- Department of Clinical Oncology, Suez Canal University, Ismailia, Egypt
| | | | - Jennifer Geel
- Division of Paediatric Haematology and Oncology, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Katy Graef
- BIO Ventures for Global Health, Seattle, WA, USA
| | - Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Nazik Hammad
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Laila Hessissen
- Pediatric Oncology Department, Pediatric Teaching Hospital, Rabat, Morocco
| | - Andre M Ilbawi
- Department of Non-communicable Diseases, WHO, Geneva, Switzerland
| | - Joyce Kambugu
- Department of Pediatrics, Uganda Cancer Institute, Kampala, Uganda
| | - Zisis Kozlakidis
- Laboratory Services and Biobank Group, International Agency for Research on Cancer, WHO, Lyon, France
| | - Simon Manga
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | - Lize Maree
- Department of Nursing Education, University of the Witwatersrand, Johannesburg, South Africa
| | - Sulma I Mohammed
- Department of Comparative Pathobiology, Center for Cancer Research, Purdue University, West Lafayette, IN, USA
| | - Susan Msadabwe
- Department of Radiation Therapy, Cancer Diseases Hospital, Lusaka, Zambia
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya
| | | | - Ntokozo Ndlovu
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Kingsley Ndoh
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Twalib Ngoma
- Department of Clinical Oncology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Timothy R Rebbeck
- Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Lorna Renner
- Department of Paediatrics, University of Ghana School of Medicine and Dentistry, Accra, Ghana
| | - Anya Romanoff
- Department of Health System Design and Global Health, Icahn School of Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Fidel Rubagumya
- Department of Oncology, Rwanda Military Hospital, Kigali, Rwanda; University of Global Health Equity, Kigali, Rwanda
| | - Shahin Sayed
- Department of Pathology, Aga Khan University Hospital, Nairobi, Kenya
| | - Shivani Sud
- Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Hannah Simonds
- Division of Radiation Oncology, Tygerberg Hospital and University of Stellenbosch, Stellenbosch, South Africa
| | | | - William Swanson
- Department of Physics and Applied Physics, Dana-Farber Cancer Institute, University of Massachusetts Lowell, Lowell, MA, USA
| | - Verna Vanderpuye
- National Centre for Radiotherapy, Oncology, and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | | | - David Kerr
- Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
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Joshi S, Noronha J, Hawaldar R, Kundgulwar G, Vanmali V, Parmar V, Nair N, Shet T, Badwe R. Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India. J Glob Oncol 2020; 5:1-8. [PMID: 30811304 PMCID: PMC6426546 DOI: 10.1200/jgo.18.00165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A complete axillary lymph node (ALN) dissection is therapeutic in node-positive breast cancer. Presently, there is no international consensus regarding anatomic levels to be addressed in complete axillary dissection. We assessed the burden of disease in level III axilla. MATERIALS AND METHODS A prospectively maintained database was assessed for 1,591 consecutive patients with nonmetastatic breast cancer registered at Tata Memorial Center, Mumbai, between January 2009 and December 2014. RESULTS A median of four (zero to 20) level III ALNs were dissected and a median of two (one to 17) nodes were positive. A total of 27.3% (434 of 1,591) patients had level III ALN metastasis, and 4.7% of patients had positive interpectoral nodes. Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. A total of 9.4% of patients had level III involvement when one to three ALNs were positive in level I and II ( P < .001). Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. On logistic regression analysis, four or more positive ALNs in level I or II ( P < .001), inner/central quadrant tumor location ( P = .013), and perinodal extension ( P < .001) were associated with level III ALN involvement. At a median follow-up of 36 months, the disease-free survival was significantly worse for level III ALN metastases on univariate analysis ( P < .001). On multivariate Cox regression analysis, histologic grade ( P = .006), four or more positive ALNs ( P < .001), hormone receptor status ( P < .001), and tumor size ( P = .037) were independent prognostic factors for disease-free survival. CONCLUSION The axillary nodal burden is high in patients with breast cancer in developing countries like India. One of two women with four or more positive level I and II ALNs may have residual disease in level III if it is not cleared during surgery. Intraoperative interpectoral space clearance should be considered in the presence of either palpable interpectoral lymph nodes or multiple positive ALNs.
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Affiliation(s)
- Shalaka Joshi
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Jarin Noronha
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | | | | | | | - Vani Parmar
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Nita Nair
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Tanuja Shet
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
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Sentinel Lymph Node Biopsy After Initial Lumpectomy (SNAIL Study)-a Prospective Validation Study. Indian J Surg Oncol 2019; 10:350-356. [PMID: 31168261 DOI: 10.1007/s13193-018-0861-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022] Open
Abstract
Tertiary oncology center clinicians are commonly faced with the problem of managing patients with a diagnosis of breast cancer made after lumpectomy in the Primary Health Care (PHC) setting. There are no studies or guidelines that address the further surgical management in this group of patients regarding sentinel lymph node biopsy (SLNB) and need for breast post-operative cavity excision. Prospective observational study was planned to evaluate the feasibility of SLNB and defining the need for definitive breast surgery in patients diagnosed with breast cancer after lumpectomy in PHC. The study was carried out from January 2015 to August 2017 in Tata Medical Center, India, approved by institutional review board (EC/TMC/36/14). Seventy patients who underwent lumpectomy with a definitive histological analysis of breast cancer were included in this study. Each patient had definitive breast surgery and SLNB using subareoral blue dye injection followed by validation axillary dissection. The identification rate (IR) for SLNB was 92% (64/70). The median number of SLNs removed was 2 (IQR 1, 3). There were 2 patients with false negative results resulting in false negative rate (FNR) of 11%. Overall, SLNB procedure has the sensitivity of 89%, NPV of 96%, and accuracy was 97%. Peri-areoral incision of initial surgery was associated with low IR (84%) and high FNR (33%). Final histopathology showed residual invasive cancer in 43% and ductal carcinoma in situ in 14% of patients. Among 21 patients where initial lumpectomy histopathology margin was free of cancer, residual malignancy was found in 57% of patients. Prior excision of lumps for breast cancer does not affect the accuracy of SLNB. Peri-areoral scar may be associated with high FNR and low IR, although further studies are needed to validate this statement. Definitive breast surgery is required for all patients, irrespective of initial lumpectomy histopathological margin status.
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Rangarajan B, Shet T, Wadasadawala T, Nair NS, Sairam RM, Hingmire SS, Bajpai J. Breast cancer: An overview of published Indian data. South Asian J Cancer 2016; 5:86-92. [PMID: 27606288 PMCID: PMC4991144 DOI: 10.4103/2278-330x.187561] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Incidence of breast cancer has been steadily increasing in the last two decades, more so in urban areas of the sub-continent. Cancer ceters across the country have large numbers of patients being treated with multiple publications in this field. Inspite of paucity of prospective data and randomised clinical trials from India, there are large number of retrospective publications on various aspects of the disease including pathology, radiology, surgery, chemotherapy, radiation, palliative care and alternatitive treatment modalities. These published data provide an insight into the trends of breast cancer in the country and this comprehensive data review of Indian data will provide a basis for designing trials relevant to our population and planning health care.
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Affiliation(s)
- Bharath Rangarajan
- Department of Medical Oncology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Tanuja Shet
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharastra, India
| | | | - Nita S Nair
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharastra, India
| | - R Madhu Sairam
- Department of Radiotherapy, Kovai Medical Center and Hospital, Coimbatore, India
| | - Sachin S Hingmire
- Department of Medical Oncology, Deenanath Mangeshkar Hospital, Pune, India
| | - Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharastra, India
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Sullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, Balch C, Brennan MF, Dare A, D'Cruz A, Eggermont AMM, Fleming K, Gueye SM, Hagander L, Herrera CA, Holmer H, Ilbawi AM, Jarnheimer A, Ji JF, Kingham TP, Liberman J, Leather AJM, Meara JG, Mukhopadhyay S, Murthy SS, Omar S, Parham GP, Pramesh CS, Riviello R, Rodin D, Santini L, Shrikhande SV, Shrime M, Thomas R, Tsunoda AT, van de Velde C, Veronesi U, Vijaykumar DK, Watters D, Wang S, Wu YL, Zeiton M, Purushotham A. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2016; 16:1193-224. [PMID: 26427363 DOI: 10.1016/s1470-2045(15)00223-5] [Citation(s) in RCA: 403] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 08/07/2015] [Accepted: 08/07/2015] [Indexed: 12/20/2022]
Abstract
Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.
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Affiliation(s)
- Richard Sullivan
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK.
| | | | - Benjamin O Anderson
- University of Washington School of Medicine, Seattle, WA, USA; Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Ajay Aggarwal
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK; London School of Hygiene & Tropical Medicine, London, UK
| | - Charles Balch
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Anna Dare
- Centre for Global Health Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anil D'Cruz
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | | | - Kenneth Fleming
- Green Templeton College, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Trust, Oxford, UK
| | - Serigne Magueye Gueye
- University Cheikh Anta Diop, Dakar, Senegal; Grand Yoff General Hospital, Dakar, Senegal
| | - Lars Hagander
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - Cristian A Herrera
- Cabinet of the Minister, Ministry of Health, Santiago, Chile; Department of Public Health, School of Medicine, Pontificia Universidad Católica, Santiago, Chile
| | - Hampus Holmer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - André M Ilbawi
- University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Union for International Cancer Control, Geneva, Switzerland
| | - Anton Jarnheimer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jia-Fu Ji
- Peking University Cancer Hospital and Institute, Beijing, China; Chinese Anti-Cancer Association, Tianjin, China
| | | | | | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - John G Meara
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shilpa S Murthy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA; Department of General Surgery, Indiana University, Bloomington, IN, USA
| | | | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; University of Zambia, Lusaka, Zambia
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Luiz Santini
- INCA (Brazilian National Cancer Institute), Rio de Janeiro, Brazil
| | | | - Mark Shrime
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Thomas
- Department of Health & Human Services, Melbourne, VIC, Australia
| | - Audrey T Tsunoda
- Gyne-Oncology Department, Barretos Cancer Hospital, Barretos, Brazil
| | - Cornelis van de Velde
- Department of Surgical Oncology, Endocrine and Gastrointestinal Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - David Watters
- Deakin University, Geelong, VIC, Australia; Barwon Health, Geelong, VIC, Australia
| | - Shan Wang
- Peking University People's Hospital, Beijing, China; Chinese College of Surgeons, Beijing, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital, Guangzhou, China; Guangdong Academy of Medical Sciences, Guangzhou, China; Chinese Society of Clinical Oncology, Beijing, China
| | - Moez Zeiton
- Sadeq Institute, Tripoli, Libya; Trauma and Orthopaedic Rotation, North-West Deanery, Manchester, UK
| | - Arnie Purushotham
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
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7
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Anderson BO, Ilbawi AM, El Saghir NS. Breast cancer in low and middle income countries (LMICs): a shifting tide in global health. Breast J 2014; 21:111-8. [PMID: 25444441 DOI: 10.1111/tbj.12357] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Cancer control planning has become a core aspect of global health, as rising rates of noncommunicable diseases in low-resource settings have fittingly propelled it into the spotlight. Comprehensive strategies for cancer control are needed to effectively manage the disease burden. As the most common cancer among women and the most likely reason a woman will die from cancer globally, breast cancer management is a necessary aspect of any comprehensive cancer control plan. Major improvements in breast cancer outcomes in high-income countries have not yet been mirrored in low-resource settings, making it a targeted priority for global health planning. Resource-stratified guidelines provide a framework and vehicle for designing programs to promote early detection, diagnosis, and treatment using existing infrastructure and renewable resources. Strategies for evaluating the current state and projecting future burden is a central aspect of developing national strategies for improving breast cancer outcomes at the national and international levels.
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Affiliation(s)
- Benjamin O Anderson
- Breast Health Global Initiative, Fred Hutchinson Cancer Research Center, Departments of Surgery and Global Health-Medicine, University of Washington, Seattle, Washington
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Kantelhardt EJ, Zerche P, Mathewos A, Trocchi P, Addissie A, Aynalem A, Wondemagegnehu T, Ersumo T, Reeler A, Yonas B, Tinsae M, Gemechu T, Jemal A, Thomssen C, Stang A, Bogale S. Breast cancer survival in Ethiopia: a cohort study of 1,070 women. Int J Cancer 2014; 135:702-9. [PMID: 24375396 DOI: 10.1002/ijc.28691] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 12/11/2013] [Indexed: 11/07/2022]
Abstract
There is little information on breast cancer (BC) survival in Ethiopia and other parts of sub-Saharan Africa. Our study estimated cumulative probabilities of distant metastasis-free survival (MFS) in patients at Addis Ababa (AA) University Radiotherapy Center, the only public oncologic institution in Ethiopia. We analyzed 1,070 females with BC stage 1-3 seen in 2005-2010. Patients underwent regular follow-up; estrogen receptor-positive and -unknown patients received free endocrine treatment (an independent project funded by AstraZeneca Ltd. and facilitated by the Axios Foundation). The primary endpoint was distant metastasis. Sensitivity analysis (worst-case scenario) assumed that patients with incomplete follow-up had events 3 months after the last appointment. The median age was 43.0 (20-88) years. The median tumor size was 4.96 cm [standard deviation (SD) 2.81 cm; n = 709 information available]. Stages 1, 2 and 3 represented 4, 25 and 71%, respectively (n = 644). Ductal carcinoma predominated (79.2%, n = 1,070) as well as grade 2 tumors (57%, n = 509). Median follow-up was 23.1 (0-65.6) months, during which 285 women developed metastases. MFS after 2 years was 74% (69-79%), declining to 59% (53-64%) in the worst-case scenario. Patients with early stage (1-2) showed better MFS than patients with stage 3 (85 and 66%, respectively). The 5-year MFS was 72% for stages 1 and 2 and 33% for stage 3. We present a first overview on MFS in a large cohort of female BC patients (1,070 patients) from sub-Saharan Africa. Young age and advanced stage were associated with poor outcome.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/therapy
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/therapy
- Cohort Studies
- Combined Modality Therapy
- Ethiopia/epidemiology
- Female
- Follow-Up Studies
- Humans
- Middle Aged
- Neoplasm Grading
- Neoplasm Metastasis
- Neoplasm Staging
- Prognosis
- Survival Rate
- Young Adult
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Affiliation(s)
- E J Kantelhardt
- Department of Gynaecology, Martin Luther University, Halle an der Saale, Germany; Institute of Clinical Epidemiology, Martin Luther University, Halle an der Saale, Germany
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Yip CH, Taib NA. Challenges in the management of breast cancer in low- and middle-income countries. Future Oncol 2013; 8:1575-83. [PMID: 23231519 DOI: 10.2217/fon.12.141] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The incidence of breast cancer is rising in low- and middle-income countries (LMICs) due to 'westernization' of risk factors for developing breast cancer. However, survival remains low because of barriers in early detection and optimal access to treatment, which are the two main determinants of breast cancer outcome. A multidisciplinary approach to treatment gives the best results. An accurate diagnosis is dependent on a reliable pathology service, which will provide an adequate pathology report with prognostic and predictor information to allow optimal oncological treatment. Stratification of clinical practice guidelines based on resource level will ensure that women will have access to treatment even in a low-resource setting. Advocacy and civil society play a role in galvanizing the political will required to meet the challenge of providing opportunities for breast cancer control in LMICs. Collaboration between high-income countries and LMICs could be a strategy in facing these challenges.
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Affiliation(s)
- Cheng-Har Yip
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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10
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El Saghir NS, Adebamowo CA, Anderson BO, Carlson RW, Bird PA, Corbex M, Badwe RA, Bushnaq MA, Eniu A, Gralow JR, Harness JK, Masetti R, Perry F, Samiei M, Thomas DB, Wiafe-Addai B, Cazap E. Breast cancer management in low resource countries (LRCs): consensus statement from the Breast Health Global Initiative. Breast 2011; 20 Suppl 2:S3-11. [PMID: 21392996 DOI: 10.1016/j.breast.2011.02.006] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 01/18/2011] [Accepted: 01/20/2011] [Indexed: 01/10/2023] Open
Abstract
The Breast Health Global Initiative (BHGI) brought together international breast cancer experts to discuss breast cancer in low resource countries (LRCs) and identify common concerns reviewed in this consensus statement. There continues to be a lack of public and health care professionals' awareness of the importance of early detection of breast cancer. Mastectomy continues to be the most common treatment for breast cancer; and a lack of surgeons and anesthesia services was identified as a contributing factor in delayed surgical therapy in LRCs. Where available, radiation therapy is still more likely to be used for palliation rather than for curative treatment. Tumor receptor status is often suboptimally performed due to lack of advanced pathology services and variable quality control of tissue handling and processing. Regional pathology services can be a cost-effective approach and can serve as reference, training and research centers. Limited availability of medical oncologists in LRCs often results in non-specialist providing chemotherapeutic services, which requires additional supervision and training. Palliative care is an emerging field in LRCs that requires investment in training and infrastructure development. A commitment and investment in the development of breast cancer care services by LRC governments and health authorities remains a critical need in LRCs.
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Affiliation(s)
- Nagi S El Saghir
- Breast Cancer Center of Excellence, NK Basile Cancer Institute, American University of Beirut, Beirut, Lebanon
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Aziz Z, Iqbal J, Akram M, Anderson BO. Worsened oncologic outcomes for women of lower socio-economic status (SES) treated for locally advanced breast cancer (LABC) in Pakistan. Breast 2010; 19:38-43. [DOI: 10.1016/j.breast.2009.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 10/08/2009] [Indexed: 01/22/2023] Open
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Anderson BO, Jakesz R, El Saghir NS, Yip CH, Khaled HM, Otero IV, Adebamowo CA, Badwe RA, Harford JB. Breast cancer issues in developing countries: an overview of the Breast Health Global Initiative. World J Surg 2009; 12:387-98. [PMID: 18283512 DOI: 10.1016/s1470-2045(11)70031-6] [Citation(s) in RCA: 210] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Of the 411,000 breast cancer deaths around the world in 2002, 221,000 (54%) occurred in low- and middle-income countries (LMCs). Guidelines for breast health care (early detection, diagnosis, and treatment) that were developed in high-resource countries cannot be directly applied in LMCs, because these guidelines do not consider real world resource constraints, nor do they prioritize which resources are most critically needed in specific countries for care to be most effectively provided. METHODS Established in 2002, the Breast Health Global Initiative (BHGI) created an international health alliance to develop evidence-based guidelines for LMCs to improve breast health outcomes. The BHGI held two Global Summits in October 2002 (Seattle) and January 2005 (Bethesda) and using an expert consensus, evidence-based approach developed resource-sensitive guidelines that define comprehensive pathways for step-by-step quality improvement in health care delivery. RESULTS The BHGI guidelines, now published in English and Spanish, stratify resources into four levels (basic, limited, enhanced, and maximal), making the guidelines simultaneously applicable to countries of differing economic capacities. The BHGI guidelines provide a hub for linkage among clinicians and alliance among governmental agencies and advocacy groups to translate guidelines into policy and practice. CONCLUSIONS The breast cancer problem in LMCs can be improved through practical interventions that are realistic and cost-effective. Early breast cancer detection and comprehensive cancer treatment play synergistic roles in facilitating improved breast cancer outcomes. The most fundamental interventions in early detection, diagnosis, surgery, radiation therapy, and drug therapy can be integrated and organized within existing health care schemes in LMCs. Future research will study what implementation strategies can most effectively guide health care system reorganization to assist countries that are motivated to improve breast cancer outcome in their populations.
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Affiliation(s)
- Benjamin O Anderson
- Breast Health Global Initiative, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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Anderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A, Carlson RW, Azavedo E, Harford J. Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer 2009; 113:2221-43. [PMID: 18816619 DOI: 10.1002/cncr.23844] [Citation(s) in RCA: 306] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Breast cancer outcomes in low- and middle-income countries (LMCs) correlate with the degree to which 1) cancers are detected at early stages, 2) newly detected cancers can be diagnosed correctly, and 3) appropriately selected multimodality treatment can be provided properly in a timely fashion. The Breast Health Global Initiative (BHGI) invited international experts to review and revise previously developed BHGI resource-stratified guideline tables for early detection, diagnosis, treatment, and healthcare systems. Focus groups addressed specific issues in breast pathology, radiation therapy, and management of locally advanced disease. Process metrics were developed based on the priorities established in the guideline stratification. The groups indicated that cancer prevention through health behavior modification could influence breast cancer incidence in LMCs. Diagnosing breast cancer at earlier stages will reduce breast cancer mortality. Programs to promote breast self-awareness and clinical breast examination and resource-adapted mammographic screening are important early detection steps. Breast imaging, initially with ultrasound and, at higher resource levels with diagnostic mammography, improves preoperative diagnostic assessment and permits image-guided needle sampling. Multimodality therapy includes surgery, radiation, and systemic therapies. Government intervention is needed to address drug-delivery problems relating to high cost and poor access. Guideline dissemination and implementation research plays a crucial role in improving care. Adaptation of technology is needed in LMCs, especially for breast imaging, pathology, radiation therapy, and systemic treatment. Curricula for education and training in LMCs should be developed, applied, and studied in LMC-based learning laboratories to aid information transfer of evidence-based BHGI guidelines.
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Affiliation(s)
- Benjamin O Anderson
- Department of Surgery, University of Washington, Seattle, Washington 98195, USA.
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