Breast Cancer in Low- and Middle-Income Countries: Why We Need Pathology Capability to Solve This Challenge

Bridging frontiers: The role of a Global Breast Research Working Group

Breast cancer remains a significant cause of death for women globally, despite advancements in detection and treatment, low- and middle-income countries face unique obstacles. Role of Research Working Group (RWG) can expedite research progress by fostering collaboration between scientists, clinicians, and stakeholders. Benefits of a Global RWG include pooling resources and expertise to develop new research ideas, addressing disparities, and building local research capacity, with the potential to improve breast cancer research and outcomes.

Ippia Alba Essential Oil: A Promising Complementary Therapy for Breast Cancer

Breast cancer remains a pressing global health issue, spurring exploration into innovative therapies. This review focuses on Lippia alba (Mill.) essential oil's potential as a complementary breast cancer treatment. With growing interest in natural approaches, Lippia alba shows promise in breast cancer management. The review will explore Lippia alba's multifaceted role in treatment, highlighting its anticancer effects on breast cancer cells, potential synergy with conventional treatments, safety profiles, and existing clinical evidence. It will also address knowledge gaps, stressing the need for further research to unlock Lippia alba's full therapeutic potential in breast cancer therapy. In a field craving novel therapies, this review offers a timely analysis. Despite the lack of existing reviews on this topic, Lippia alba's significance cannot be understated. As research progresses, this article will be a valuable resource for researchers and healthcare practitioners seeking to augment breast cancer management through complementary therapies.

Designing a Collaborative Breast Radiology Training Program to Tackle Tanzania's Breast Cancer Crisis

Breast cancer incidence and mortality continue to increase in Africa. In Tanzania, breast cancer is the second leading cause of cancer death for women, and breast cancer incidence and mortality are projected to increase by 80% by 2030. Education gaps among health care workers, delayed presentation, limited screening, and low health literacy all pose significant challenges to providing optimal breast cancer care. Considering these factors, it is imperative to train expert breast radiologists. We present a collaborative breast radiology training program in Tanzania aimed at building local capacity to address national breast cancer challenges. Although cancer control in Africa faces many challenges, developing customized training programs for breast radiology, in conjunction with national cancer programs, may represent a key strategy for addressing breast cancer.

Autologous breast reconstruction in low- and middle-income countries (LMICs): a systematic review of current practices and challenges

INTRODUCTION

Efforts to improve global healthcare persist, yet LMICs face challenges accessing surgical care, especially breast reconstruction amidst rising breast cancer cases. This review evaluates the present state and challenges of autologous breast reconstruction in low- and middle-income countries (LMICs).

EVIDENCE ACQUISITION

Utilizing the PRISMA guidelines and the Cochrane Collaboration's standards, databases such as EMBASE, MEDLINE, Cochrane, PubMed, and Google Scholar were examined for studies on breast reconstruction in LMICs (based on the World Bank's 2022-2023 definitions) up to August 2022. Articles and case reports focusing on autologous reconstruction following breast cancer surgery in these regions were incorporated.

EVIDENCE SYNTHESIS

From an initial 288 articles, 19 met the criteria after thorough assessment. These articles documented 4899 patient cases from LMICs, with the breakdown being: 11 on LD flaps, nine on TRAM flaps, eight on DIEP flaps, two on TDAP flaps, and one on TMG flap. Flap necrosis emerged as the prevalent complication in four studies.

CONCLUSIONS

While autologous breast reconstruction presents superior aesthetic benefits without notable long-term economic setbacks, its adoption in LMICs is limited. This is partly due to the domination of implant-based methods among patients and surgeons, selected due to convenience. The scarcity of concrete evidence and standardized metrics in LMICs clouds the understanding of this procedure. Despite its advantages, awareness is low, necessitating more training and awareness campaigns. Uniform reporting, quality data, and financial analysis can provide a comprehensive LMIC understanding, aiding future research.

A Qualitative Study on Psychosocial Challenges of Patients With Cancer in Ethiopia Using the Social-Ecological Model

Cancer diagnosis and treatment can be physically arduous, disrupting patients' social and work lives. Understanding the extent of these problems is key to addressing patients' needs, but specific psychosocial challenges have not yet been well studied in resource-limited settings. A qualitative study was conducted in the capital and two regions of Ethiopia with the aim of exploring psychosocial challenges among cancer patients. A total of 14 in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were done with cancer patients, health professionals, community representatives, and religious leaders. Four separate interview guides were used to facilitate the interviews and discussions. All transcribed documents, field notes, and reflexive memos were entered into NVivo 12 software, and deductive thematic analysis using the social-ecological model was applied to summarize the main findings. At an individual level, emotional distress, suicidal risk, denial, and refusal of treatment were identified immediately after diagnosis while hopelessness, feeling depressed, and fear of death were commonly reported psychosocial challenges during the course of treatment. Involvement of family members in major treatment decisions was recognized at an interpersonal level. Our result also revealed that cancer patients had strong social support from family members and close friends. In the community, traditional medicine and religious rituals were considered an alternative treatment for cancer. The findings indicate that counselling and psychoeducation are crucial for cancer patients, family members, and close friends. Awareness creation programmes should be delivered through collaboration with religious leaders and traditional healers.

"How can a woman live without having a breast?": challenges related to mastectomy in Ethiopia

BACKGROUND

Although mastectomy is the standard treatment modality for breast cancer patients in Ethiopia, our previous study revealed that one in five patients do not receive the recommended procedure, half due to patient refusal or lack of returning to the hospital. Therefore, this study aimed to explore reasons for refusing mastectomy and identify challenges among breast cancer patients in Ethiopia.

METHODS

An explorative qualitative study was conducted in four hospitals located in the towns of Woliso, Butajira, Hossana, and Assela. A total of 14 in-depth interviews (IDIs) and eight focus group discussions (FGDs) were held with breast cancer patients, patient relatives, and health professionals. Four semi-structured interview guides were used to facilitate the IDIs and FDGs. All recorded IDIs and FGDs were transcribed and translated verbatim and entered in NVivo 12 software. Emerging ideas were categorised and explained using an inductive content analysis approach.

RESULTS

Our participants reported that particularly elderly and very young women refuse to have mastectomy. The main reasons identified in this study were summarised into six themes: (i) fear of the surgical procedure, (ii) religious beliefs and practice, (iii) utilisation of traditional treatments, (iv) in relation to having a baby and breastfeeding their children (young patients often request to remove only the lump, leaving their breast tissue intact), (v) lack of awareness about the disease, and (vi) sociocultural factors and advice from the community that influence women, since breasts are considered an attribute of femininity, beauty, and motherhood. In addition, knowing someone who died after mastectomy emerged as a main reason for not having breast cancer surgery.

CONCLUSIONS

High refusal rate for mastectomy has direct implication on increased breast cancer mortality. Hence, expansion of radiotherapy service is instrumental to initiate breast-conserving surgery as an alternative surgical procedure, especially for young women with early-stage breast cancer. Involving religious leaders, traditional healers, and breast cancer survivors could be an effective strategy to persuade newly diagnosed breast cancer patients. Addressing individual patient psychosocial needs and preferences may substantially improve retention of breast cancer patients in the health system.

Building pathology capacity in sub-Saharan Africa to improve breast cancer diagnosis and treatment: training laboratory technicians in high-quality manual immunohistochemistry

BACKGROUND

To address the need for a skilled workforce in breast cancer (BC) pathology in sub-Saharan Africa (SSA), we implemented an education program to train laboratory technicians in manual immunohistochemistry (IHC).

METHODS

A quality improvement education project was developed. Interactive webinars were held every six months with didactics and presentations from African experts with experience in IHC. We conducted knowledge assessments and surveys on current practice, equipment, and human resources. A digital mentorship platform (DMP) was created for discussions, sharing SOPs, and networking. For one year (2022-2023), we followed developments in pathology capacity, practice changes, and educational needs. A paired t-test was used to calculate the significance of changes in knowledge immediately after the webinar and comfort level with topics 35 days after the webinar.

RESULTS

Two hundred and sixty six participants from 10 SSA countries attended the first webinar, a series of six lectures on IHC theory, methods, and practice. Ninety-five participants from nine SSA countries provided a baseline assessment of pathology capacity and feedback. Mean knowledge increased by 17.4% immediately after the webinar (from 41.8% pre-webinar to 59.2% post, p =  < 0.0001). Self-reported comfort level in topics 35 days after the webinar increased by 11.3%, but this was not statistically significant (mean 3.36 pre- to 3.74 post, p = 0.1). Over six months, recordings were accessed 412 times. After six months, the second webinar had 93 participants from eight SSA countries. Membership in the DMP increased from 64 to 172; recordings were viewed 412 times in six months; and 113 participants from nine SSA countries completed surveys. Among 74 respondents who perform IHC, 43.5% reported moderate or significant positive practice changes such as improved antigen retrieval techniques and optimization of preanalytical variables. Over half (52.7%, n = 39) reported the quality of slides had moderately or significantly improved. After one year, a third webinar had 98 participants from eight SSA countries. Thirty-eight completed surveys, DMP membership increased to 199, and 1 reported launching IHC in a lab in Nigeria.

CONCLUSIONS

Our program 1) reached hundreds of participants and provided a baseline assessment of pathology capacity across nine SSA countries; 2) created a novel mechanism to build pathology capacity and assess progress with this cohort; and 3) improved practices and the preparation of slides for over half performing manual IHC. After one year, interest was sustained. Tracking impact on diagnosis and treatment of BC in the region is needed long-term.

Contraceptive use with breast cancer incidence in Indonesia

INTRODUCTION

Breast cancer is the most common cancer in women worldwide and is a significant threat to public health. This study aims to conduct a systematic review of the relationship between hormonal contraceptive use and breast cancer incidence.

METHODS

The search was conducted using Google Scholar, Proquest, Pubmed and one Indonesian database, Garuda, using English and Indonesian keywords. The inclusion criteria in this study were the publication year of the last five years, namely 2019-2023, English and Indonesian language, case-control observational research, using the Indonesian population, and full-text access.

RESULTS

A total of 165 studies were obtained from the Google Scholar database, including 104 studies. The overall multivariate analysis revealed that there was a statistically significant association of hormonal contraception with the incidence of breast cancer with OR values in the range of 2-6.

CONCLUSIONS

The findings of this systematic study suggest that the use of hormones can contribute to hormonal imbalances that further increase breast cell proliferation and disrupt gene expression, resulting in uncontrolled cell development/cancer. In addition, the findings recommend increasing the number of studies on this topic to obtain more adequate and possibly more diverse information.

Prognostic significance and expression pattern of glucose related genes in breast cancer: A comprehensive computational biology approach

Breast cancer (BC) is the most common type of malignancy globally and the main reason why women die from tumours. The Warburg effect, a characteristic of tumor, describes how most solid tumour cells acclimatize to their diverse surroundings by relying heavily on aerobic glycolysis for production of energy. In addition to producing key metabolic intermediates that are crucial for the production of macromolecules, which enable cancer cell division, invasiveness, and drug resistance, the transformed energy metabolism also supplies tumor cells with ATP for cellular energy. Here, we evaluated the expression profile, prognostic significance, and clinical relevance of glucose-related genes in BC using a bioinformatic approach. To clarify the significance of glucose-related genes in the development of breast tumours, we also performed a functional enrichment investigation of deregulated genes using the STRING and KEGG portal. The study depicted that of the 61 genes examined, 8 genes had a fold change Collapse

Key Words

• Bioinformatics
• Breast cancer
• Deregulation
• Glucose metabolism
• Prognosis
• Survival analysis
• Warburg effect

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MESH Headings Collapse

Grants Collapse

Affiliation(s)

Bader Alshehri Department of Medical Laboratory Sciences, College of Applied Medical Sciences, Majmaah University, Almajmaah 11952, Saudi Arabia

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Routine Use of a Standardized Mastectomy Diagram by Surgeons Improves Accuracy and Timeliness of the Final Pathological Report

BACKGROUND

Accurate and timely assessment of pathology specimens is critical for patient care and oncologic management. This study aimed to determine whether a standardized mastectomy diagram would facilitate communication among surgeons and pathologists and improve pathologic processing.

METHODS

A prospective quality improvement study was conducted over a continuous 12-month period. During the first 6 months, usual pathologic processing of mastectomy specimens was performed per standard department protocol. In the second 6 months, a standardized mastectomy diagram was completed at the time of surgery, noting the location and preoperative pathologic diagnosis of all benign and malignant lesions. An analysis of covariance was used to compare the number of breast lesions identified and the number of days between specimen receipt and the date of the final pathology report between each group.

RESULTS

Time from specimen receipt to final pathologic report decreased from a mean (± SE) of 8.3 ± 0.7 days in the usual processing group to 6.1 ± 0.6 days with the use of the standardized mastectomy diagram, for a between-group difference of 2.1 days (95% confidence interval [CI] 0.3-4.0; p = 0.02). The number of lesions identified increased from 1.8 ± 0.2 to 2.6 ± 0.2, for a between-group difference of 0.8 (95% CI 0.1-1.5; p = 0.02).

CONCLUSION

A standardized mastectomy diagram completed at the time of surgery improves the quality of pathologic processing. The diagram, which serves as a mastectomy lesion map, assists lesion localization, enhances accuracy, and reduces time to final pathology report.

Tailoring Potential Natural Compounds for the Treatment of Luminal Breast Cancer

Breast cancer (BC) is the most diagnosed cancer worldwide, mainly affecting the epithelial cells from the mammary glands. When it expresses the estrogen receptor (ER), the tumor is called luminal BC, which is eligible for endocrine therapy with hormone signaling blockade. Hormone therapy is essential for the survival of patients, but therapeutic resistance has been shown to be worrying, significantly compromising the prognosis. In this context, the need to explore new compounds emerges, especially compounds of plant origin, since they are biologically active and particularly promising. Natural products are being continuously screened for treating cancer due to their chemical diversity, reduced toxicity, lower side effects, and low price. This review summarizes natural compounds for the treatment of luminal BC, emphasizing the activities of these compounds in ER-positive cells. Moreover, their potential as an alternative to endocrine resistance is explored, opening new opportunities for the design of optimized therapies.

Geospatial availability of breast cancer treatment modalities and hypothetical access improvement in Ghana: A nationwide survey

Breast cancer in Ghana is a growing public health problem with increasing incidence and poor outcomes. Lack of access to comprehensive treatment in Ghana may be a contributing factor to its high mortality. The purpose of this study was to evaluate the availability of treatments nationwide and systematically identify high yield areas for targeted expansion. We conducted a cross-sectional, nationwide hospital-based survey from November 2020-October 2021. Surveys were conducted in person with trained research assistants and described hospital availability of all breast cancer treatments and personnel. All individual treatment services were reported, and hospitals were further stratified into levels of multi-modal treatment modeled after the National Comprehensive Cancer Network (NCCN) Framework treatment recommendations for low-resource settings. Level 3 included Tamoxifen and surgery (mastectomy with axillary lymph node sampling); Level 2 included Level 3 plus radiation, aromatase inhibitors, lumpectomy, and sentinel lymph node biopsy; Level 1 included Level 2 plus Her2 therapy and breast reconstruction. Hospitals were identified that could expand to these service levels based on existing services, location and personnel. The distance of the total population from treatment services before and after hypothetical expansion was determined with a geospatial analysis. Of the 328 participating hospitals (95% response rate), 9 hospitals had Level 3 care, 0 had Level 2, and 2 had Level 1. Twelve hospitals could expand to Level 3, 1 could expand to Level 2, and 1 could expand to Level 1. With expansion, the population percentage within 75km of Level 1, 2 and 3 care would increase from 42% to 50%, 0 to 6% and 44% to 67%, respectively. Multi-modal breast cancer treatment is available in Ghana, but it is not accessible to most of the population. Leveraging the knowledge of current resources and population proximity provides an opportunity to identify high-yield areas for targeted expansion.

Sociodemographic disparities associated with advanced stages and distant metastatic breast cancers at diagnosis in Indonesia: a cross-sectional study

Background

The global health burden of breast cancer is increasing with 5-year survival rates being much shorter in low-income and middle-income countries. Sociodemographic and clinical disparities in early cancer detection affect long-term outcome.

Methods

The authors compared social, demographic, and pathological characteristics associated with metastatic and late stages of breast cancer diagnosis using data collected from a special registry developed by Perhimpunan Bedah Onkologi Indonesia (PERABOI) in 2015.

Results

Of 4959 patients recruited in this study, 995 women (20.1%) were diagnosed with metastatic breast cancer. Lower education status and living in rural areas were significantly associated with Stage IV at diagnosis [odds ratio (OR)=1.256, 95% CI=1.093-1.445, P=0.001; and OR=1.197, 95% CI=1.042-1.377, P=0.012; respectively). Main complaints other than lump (ulceration, breast pain, and discharge) and occupation as a housewife were also associated with the presentation of metastatic diseases (OR=2.598, 95% CI=2.538-3.448, P<0.001 and OR=1.264, 95% CI=1.056-1.567, P=0.030, respectively). Having lower education and living outside Java and Bali islands were associated with the diagnosis of late-stage breast cancers (OR=1.908, 95% CI=1.629-2.232, P<0.001 and OR=3.039, 95% CI=2.238-4.126, P<0.001; respectively). A higher proportion of breast cancer patients were relatively younger with bigger tumour size, positive axillary nodal involvement, and more frequent Human epidermal growth factor receptor 2 overexpression.

Conclusion

The authors identified sociodemographic disparities in the metastatic and late-stage diagnosis of breast cancers among Indonesian women. The subsequent action is required to reduce disparities faced by women with lower social and educational levels for early diagnosis and better healthcare access.

Projection of morbidity and mortality due to breast cancer between 2020 and 2050 across 42 low- and middle-income countries

Objective

Aim of the study is to predict trends in morbidity and mortality due to breast cancer in 42 LMICs between 2020 and 2050.

Design

and Setting: National level cross-sectional breast cancer related data between 1990 and 2019 were used. Recurrent Neural Network, Long-Short-Term Memory (RNN-LSTM) model was employed to forecast the trend in breast cancer burden.

Main outcomes and measures

Age standardized breast cancer incidence, mortality, and disability adjusted life years (DALYs) rates.

Results

By 2050, the age standardized breast cancer incidence rate is expected to increase in 38 LMICs with highest incidence rate in Namibia; 127.0 (78.0-176.0) followed by Nigeria 71.1 (53.9-88.3) and Papua New Guinea 70.6 (88.7-74.6). Similarly, the age standardized breast cancer mortality and DALYs rates in 2050 are expected to increase in 33 and 35 LMICs respectively. The highest mortality and DALYs rates in 2050 are expected to be 64.7 (42.6-86.7) in Namibia and 1543.6 (1463.1-1624.1) in Pakistan. The estimated annual percentage change (EAPC) is expected to increase uniformly in all the countries during the same period. Due to considerable variation in exposure risk, such as high plasma glucose level, high body mass index (BMI) and socio-demographic index (SDI), high regional disparity in burden of breast cancer is expected among the countries.

Conclusion

and Relevance: Breast cancer burden is expected to increase in most of the LMICs with high regional disparity by 2050. Our study's finding focuses on LMICs with high breast cancer burden that require tailored strategies and effective action plans to ensure prevention from catastrophic consequences in the future. Minimizing the exposure to behavioral and metabolic risk factors such as high plasma glucose, high BMI, along with tackling the issue of low fertility rate would be important in managing breast cancer burden in LMICs.

In vitro models of breast cancer bone metastasis: analyzing drug resistance through the lens of the microenvironment

Even though breast cancers usually have a good outcome compared to other tumors, the cancer can progress and create metastases in different parts of the organism, the bone being a predilection locus. These metastases are usually the cause of death, as they are mostly resistant to treatments. This resistance can be caused by intrinsic properties of the tumor, such as its heterogeneity, but it can also be due to the protective role of the microenvironment. By activating signaling pathways protecting cancer cells when exposed to chemotherapy, contributing to their ability to reach dormancy, or even reducing the amount of drug able to reach the metastases, among other mechanisms, the specificities of the bone tissue are being investigated as important players of drug resistance. To this date, most mechanisms of this resistance are yet to be discovered, and many researchers are implementing in vitro models to study the interaction between the tumor cells and their microenvironment. Here, we will review what is known about breast cancer drug resistance in bone metastasis due to the microenvironment and we will use those observations to highlight which features in vitro models should include to properly recapitulate these biological aspects in vitro. We will also detail which elements advanced in vitro models should implement in order to better recapitulate in vivo physiopathology and drug resistance.

Between life & death: Political economy of breast cancer care for refugee populations in Lebanon

Refugees and displaced groups have been shown to face increased risk of developing advanced cancer stages. This has been shown to be evident in Lebanon, whereby refugees are detected at later stages when compared to the Lebanese population. Lebanon is one of the biggest host (per capita) of refugees worldwide, and suffers from difficult political situation, compounded by an economic crisis, the COVID-19 pandemic and a blast which hit the capital Beirut in 2020. The main determinants of poor health outcomes among migrant populations in Lebanon include a fragmented and inequitable healthcare system and legal constraints to healthcare accessibility. The health care system is largely privatised with multiple health systems operating simultaneously for different nationalities. The current multi-crisis situation has exacerbated the fragility of the health system and its ability to cope with increasing needs. On the other hand, legal constraints for refugees to obtain residency in Lebanon has also contributed to insufficient access to health care and poor health outcomes among this population. Health system reforms, improved emergency preparedness and response measures, and an ease on legal and political restrictions for the refugee populations in Lebanon are considered key policy recommendations to ensure refugees right to health in Lebanon.

Knowledge regarding breast cancer among Congolese women in Kinshasa, Democratic Republic of the Congo

INTRODUCTION

Breast cancer is the most frequent type of cancer in women and is characterized by late clinical signs in developing countries, including the Democratic Republic of the Congo. One of the main reasons of death from breast cancer is lack of awareness and screening, which has led to late diagnosis (at an advanced stage). This study aims to measure women's knowledge regarding breast cancer in Kinshasa, in the Democratic Republic of the Congo.

MATERIALS AND METHODS

A cross-sectional study of 489 women aged 20-65 years was conducted. Data was collected using a predesigned, tested, self-administered questionnaire. The questionnaire included specific sections to test the participants' knowledge related to breast cancer and its screening, and practices related to breast self-examination (BSE). Bivariate and multivariate analyzes were used.

RESULTS

Our results indicated that 22.09% of the participants had good breast cancer knowledge and 77.91% had poor breast cancer knowledge. Overall, 322 (65.85%) participants recognized that BSE is a valuable method for early screening of BSE. In total, 136 (27.81%) respondents had learned to do the BSE and 216 (44.17%) had reported doing it. Two hundred and ninety-two (59.71%) respondents mentioned that any woman was at risk for breast cancer and 357 (71.78%) mentioned that it was possible to prevent breast cancer. Determinants of an adequate level of knowledge were higher/university educational level (adjusted odds ratio = 2.70; 95% confidence interval: 1.27-5.73; p = .010) and having previously been screened for breast cancer (adjusted odds ratio = 2.31; 95% confidence interval: 1.40-3.83; p = .001).

CONCLUSION

The majority (77.91%) of women have demonstrated poor knowledge of signs/symptoms, risk factors, and screening methods of breast cancer. Additional efforts should be made through women's healthcare workers to raise knowledge of breast cancer screening.

Discriminatory Ability and Clinical Utility of the AJCC7 and AJCC8 Staging Systems for Breast Cancer in a Middle-Income Setting

(1) Background: Differences in access to biomarker testing and cancer treatment in resource-limited settings may affect the clinical utility of the AJCC8 staging system compared to the anatomical AJCC7 system. (2) Methods: A total of 4151 Malaysian women who were newly diagnosed with breast cancer from 2010 to 2020 were followed-up until December 2021. All patients were staged using the AJCC7 and AJCC8 systems. Overall survival (OS) and relative survival (RS) were determined. Concordance-index was used to compare the discriminatory ability between the two systems. (3) Results: Migration from the AJCC7 to AJCC8 staging system resulted in the downstaging of 1494 (36.0%) patients and the upstaging of 289 (7.0%) patients. Approximately 5% of patients could not be staged using the AJCC8 classification. Five-year OS varied between 97% (Stage IA) and 66% (Stage IIIC) for AJCC7, and 96% (Stage IA) and 60% (Stage IIIC) for AJCC8. Concordance-indexes for predicting OS using the AJCC7 and AJCC8 models were 0.720 (0.694-0.747) and 0.745 (0.716-0.774), and for predicting RS they were 0.692 (0.658-0.728) and 0.710 (0.674-0.748), respectively. (4) Conclusions: Given the comparable discriminatory ability between the two staging systems in predicting the stage-specific survival of women with breast cancer in the current study, the continued use of the AJCC7 staging system in resource-limited settings seems pragmatic and justifiable.

Breast cancer molecular diagnostics in Rwanda: a cost-minimization study of immunohistochemistry versus a novel GeneXpert® mRNA expression assay

Objective

To compare the financial and time cost of breast cancer biomarker analysis by immunohistochemistry with that by the Xpert^® STRAT4 assay.

Methods

We estimated costs (personnel, location, consumables and indirect) and time involved in breast cancer diagnosis at the Butaro Cancer Centre of Excellence, Rwanda, using time-driven activity-based costing. We performed a cost-minimization analysis to compare the cost of biomarker analysis for estrogen receptor, progesterone receptor and human epidermal growth factor receptor-2 status with immunohistochemistry versus STRAT4. We performed sensitivity analyses by altering laboratory-specific parameters for the two methods.

Findings

We estimated that breast cancer diagnosis in Rwanda costs 138.29 United States dollars (US$) per patient when conducting biomarker analysis by immunohistochemistry. At a realistic immunohistochemistry antibody utilization efficiency of 70%, biomarker analysis comprises 48.7% (US$ 67.33) of diagnostic costs and takes 33 min. We determined that biomarker analysis with STRAT4 yields a reduction in diagnosis cost of US$ 7.33 (10.9%; 7.33/67.33), and in pathologist and technician time of 20 min (60.6%; 20/33), per patient. Our sensitivity analysis revealed that no cost savings would be made in laboratories with antibody utilization efficiencies over 90%, or where only estrogen and/or progesterone receptor status are assessed; however, such operational efficiencies are unlikely, and more laboratories are pursuing human epidermal growth factor receptor-2 analysis as targeted therapies become increasingly available.

Conclusion

Breast cancer biomarker analysis with STRAT4 has the potential to reduce the required human and capital resources in sub-Saharan African laboratories, leading to improved treatment selection and better clinical outcomes.

NOHA: A Promising Biomarker for Determining Estrogen Receptor Status Among Patients With Breast Cancer in Resource-Constrained Settings

PURPOSE

Challenges to breast cancer control in low-and middle-income countries exist because of constrained access to care, including pathology services. Immunohistochemistry (IHC)-based estrogen receptor (ER) analysis is limited-nonexistent because of few and inadequately staffed and equipped pathology laboratories. We have identified N^w-hydroxy-L-Arginine (NOHA) as a blood-based biomarker to distinguish ER status in US patients with breast cancer. Here, we examine NOHA's clinical utility as an ER IHC alternative in Tanzanian patients.

MATERIALS AND METHODS

Following informed consent, 70 newly diagnosed, known or suspected patients with breast cancer were enrolled at Kilimanjaro Christian Medical Center; basic, deidentified clinical and sociodemographic data were collected. For each, a needle prick amount of blood was collected on a Noviplex plasma card and stored at -80°C. Plasma cards and unstained tumor pathology slides were shipped regularly to US laboratories for NOHA, histologic and IHC analysis. NOHA and IHC assay operators were blinded to each other's result and patient clinical status. Paired NOHA and IHC results were compared.

RESULTS

Slides from 43 participants were available for pathological analysis in the United States. Of those with confirmed malignancy (n = 39), 44%, 51%, 5% were ER-positive, ER-negative, and ER inconclusive, respectively. NOHA levels were available among 33 of 43 of those with pathological data and showed distinct threshold levels correlating 100% to tumor ER IHC and disease categorization where a level below 4 nM, from 4 to 8 nM, and above 8 nM signified ER-negative, ER-positive, and no cancer, respectively.

CONCLUSION

The results are consistent with findings from US patients and suggest NOHA's clinical utility as an accessible IHC replacement in determining ER status among low-and middle-income country patients with breast cancer, promising to extend access to cost-efficient, available hormonal agents and improve outcomes.

Breast Cancer in Asia: Incidence, Mortality, Early Detection, Mammography Programs, and Risk-Based Screening Initiatives

Simple Summary

Nearly all breast cancer patients survive for more than five years when the tumor is found early and in the localized stage. Regular clinical breast examinations, mammograms, and monthly self-exams of the breasts all contribute to early detection. However, late-stage breast cancers are common in many Asian countries. Low-income countries suffer from a lack of resources for breast cancer screening. High-income countries, on the other hand, are not benefiting fully from national breast screening programs due to an underutilization of the preventive healthcare services available. Existing reviews on Asian breast cancers are heavily focused on risk factors. The question of whether we should adopt or adapt the knowledge generated from non-Asian breast cancers would benefit from an extension into screening guidelines. In addition, several Asian countries are piloting studies that move away from the age-based screening paradigm.

Abstract

Close to half (45.4%) of the 2.3 million breast cancers (BC) diagnosed in 2020 were from Asia. While the burden of breast cancer has been examined at the level of broad geographic regions, literature on more in-depth coverage of the individual countries and subregions of the Asian continent is lacking. This narrative review examines the breast cancer burden in 47 Asian countries. Breast cancer screening guidelines and risk-based screening initiatives are discussed.

Burden of Cancer and Utilization of Local Surgical Treatment Services in Rural Hospitals of Ethiopia: A Retrospective Assessment from 2014 to 2019

BACKGROUND

Global cancer estimations for Ethiopia announced 77 352 new cases in 2020 based on the only population-based registry in Addis Ababa. This study characterizes cancer patients in rural Ethiopia at 8 primary and secondary hospitals between 2014 and 2019.

PATIENTS AND METHODS

All clinically or pathologically confirmed cancer cases that were diagnosed between 1 May 2014 and 29 April 2019 were included. A structured data extraction tool was used to retrospectively review patients' charts and descriptive analysis was done.

RESULTS

A total of 1298 cancer cases were identified, of which three-fourths were females with a median age of 42 years. Breast (38%) and cervical (29%) cancers were the most common among females, while prostate (19%) and oesophageal cancers (16%) were the most common among males. Only 39% of tumors were pathologically confirmed. Nearly two-thirds of the cases were diagnosed at an advanced stage. Surgery was the only accessible treatment option for more than half of the cancer patients, and systemic treatment (except endocrine) was rarely available. One in 5 patients did not receive the recommended surgical procedure, half due to patient refusal or lack of the patient returning to the hospital.

CONCLUSION

The pattern of cancer diagnoses in rural hospitals shows an exceptionally high burden in women in their middle-ages due to breast and cervical cancers. Advanced stage presentation, lack of pathology services, and unavailability of most systemic treatment options were common. The surgery was offered to nearly 60% of the patients, showing the significant efforts of health workers to reduce sufferings.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

Simple Summary

For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care.

Abstract

Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.

A comparison of Chinese multicenter breast cancer database and SEER database

There are different characteristics of BC in developing countries and developed countries. We intended to study the factors which influence the survival and prognosis of BC between southern China and the United States. (a) To study the two groups BC patients in southern China from 2001 to 2016 and SEER database from 1975 to 2016. (b) To register, collect and analyze the clinicopathological features and treatment information. Our study found that there are significant differences in tumor size, positive lymph node status and KI-67 between southern China and SEER cohort (P < 0.000). The positive lymph node status may be one of the causes of difference of morbidity and mortality of BC patients in China. Furthermore, the differences in treatment methods may also account for the differences between China and seer databases.

Treatment guideline concordance, initiation, and abandonment in patients with non-metastatic breast cancer from the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort in sub-Saharan Africa: a prospective cohort study

BACKGROUND

Comprehensive breast cancer management is essential to achieve high breast cancer survival; however, detailed reports of the treatment regimens received by patients are scarce in sub-Saharan Africa where survival is low. We aimed to examine treatment initiation, guideline concordance, and abandonment in patients with non-metastatic breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort.

METHODS

The ABC-DO prospective cohort study recruited women (aged ≥18 years) with newly diagnosed invasive breast cancer in eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, Uganda, South Africa, and Zambia). We analysed treatments received by women who were classified as non-metastatic (M0) at the initial presentation. Data on surgery, radiotherapy, and systemic therapies were obtained from medical records and a self-reported follow-up questionnaire at 6 months after the diagnosis, follow-up calls every 3 months, and a baseline questionnaire. Initiation, completion, and abandonment of treatment modalities and combined therapy regimens were examined overall, by country-specific groups, and by clinical factors relevant for guideline-based treatment.

FINDINGS

Of 2313 women recruited into the ABC-DO study between Sept 10, 2014, and Dec 31, 2017, 2226 had histologically or clinically confirmed breast cancer. Of these 2226 women, 510 were excluded from the present analysis because 378 had metastatic disease, 37 were prevalent cases (defined as those previously diagnosed with breast cancer >2 years before baseline), 82 had unknown TNM stage, and 13 were White or Asian women in South Africa (number was too small for analysis). After a median follow-up of 5·2 years (IQR 4·6-5·9), 1163 (68%) of 1716 women underwent breast cancer surgery. Surgery and systemic therapy (ie, multimodality treatment) with radiotherapy was initiated in 370 (36%) of 1028 women with localised tumours versus 156 (23%) of 688 women with locally advanced tumours, whereas multimodality treatment without radiotherapy was initiated in 386 (38%) versus 167 (24%) women, respectively. Of 1530 patients requiring chemotherapy (which excludes 105 who died within 6 months after baseline), 1013 (66%) initiated treatment of neoadjuvant chemotherapy or surgery within 3 months after baseline, which was adequately completed by 359 (35%) of 1013 women, marginally completed by 284 (28%), abandoned by 200 (20%), and unknown in 151 (15%). 19 (2%) women died within 6 months after chemotherapy initiation. Of 1375 women in whom endocrine therapy was indicated, this treatment was initiated in 920, and lasted at least 3 years in 367 (40%) women. Treatment disparities between country-specific groups were substantial for all therapy regimens.

INTERPRETATION

A high proportion of patients with non-metastatic breast cancer did not initiate, did not fully complete, or abandoned treatment with surgery, systemic therapy, radiotherapy, or an appropriate combination of these, highlighting the need for improved treatment access and completion in sub-Saharan Africa to potentially prevent premature breast cancer deaths.

FUNDING

National Institutes of Health (National Cancer Institute), Susan G Komen, and the International Agency for Research on Cancer.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

OBJECTIVES

To systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries (LMICs).

DESIGN

A systematic review of published evidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses.

DATA SOURCES

A comprehensive search of published literature was conducted. In addition, relevant grey literature sources and bibliographical references of included studies were searched for potentially eligible evidence.

STUDY SELECTION

Studies published between January 2010 and November 2020 were eligible for inclusion. To be eligible, studies had to report on interventions/strategies targeted at women, the general public or healthcare workers, aimed at improving the timely diagnosis of breast and/or cervical cancers in LMIC settings.

DATA EXTRACTION AND SYNTHESIS

Literature search, screening, study selection, data extraction and quality appraisal were conducted by two independent reviewers. Evidence was synthesised and reported using a global taxonomy framework for early cancer diagnosis.

RESULTS

From the total of 10 593 records identified, 21 studies conducted across 20 LMICs were included in this review. Most of the included studies (16/21) focused primarily on interventions addressing breast cancers; two focused on cervical cancer while the rest examined multiple cancer types. Reported interventions targeted healthcare workers (12); women and adolescent girls (7) and both women and healthcare workers (3). Eight studies reported on interventions addressing access delays; seven focused on interventions addressing diagnostic delays; two reported on interventions targeted at addressing both access and diagnostic delays, and four studies assessed interventions addressing access, diagnostic and treatment delays. While most interventions were demonstrated to be feasible and effective, many of the reported outcome measures are of limited clinical relevance to diagnostic timeliness.

CONCLUSIONS

Though limited, evidence suggests that interventions aimed at addressing barriers to timely diagnosis of breast and cervical cancer are feasible in resource-limited contexts. Future interventions need to address clinically relevant measures to better assess efficacy of interventions.

PROSPERO REGISTRATION NUMBER

CRD42020177232.

Precision Medicine in Low- and Middle-Income Countries

Most cancer cases occur in low- and middle-income countries (LMICs). The sophisticated technical and human infrastructure needed for optimal diagnosis, treatment, and monitoring of cancers is difficult enough in affluent countries; it is especially challenging in LMICs. In Western, educated, industrial, rich, democratic countries, there is a growing emphasis on and success with precision medicine, whereby targeted therapy is directed at cancers based on the specific genetic lesions in the cancer. Can such precision approaches be delivered in LMICs? We offer some examples of novel partnerships and creative solutions that suggest that precision medicine may be possible in LMICs given heavy doses of will, creativity, and persistence and a little luck.

Provider Barriers and Facilitators of Breast Cancer Guideline-Concordant Therapy Delivery in Botswana: A Consolidated Framework for Implementation Research Analysis

Introduction

Systemic treatment for breast cancer in sub‐Saharan Africa (SSA) is cost effective. However, there are limited real‐world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline‐concordant care at Princess Marina Hospital (PMH) in Botswana.

Materials and Methods

The Consolidated Framework for Implementation Research was used to conduct one‐on‐one semistructured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size was determined by thematic saturation. Transcribed interviews were double‐coded and analyzed in NVivo using an integrated analysis approach.

Results

Forty‐one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government‐funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention, lack of relative priority compared with HIV/AIDS, suboptimal interdepartmental communication, and lack of a clearly defined national cancer control policy. Community‐level barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy‐in, expansion of multidisciplinary tumor boards, leveraging nongovernmental and academic partnerships, and setting up monitoring, evaluation, and feedback processes.

Discussion

The study identified complex, multilevel factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes.

Implications for Practice

To address the increasing cancer burden in low‐ and middle‐income countries, resource‐stratified guidelines have been developed by multiple international organizations to promote high‐quality guideline‐concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they are intended to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource‐stratified guidelines in sub‐Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country‐level and facility‐level resources, cancer care accessibility, and community‐level barriers and facilitators.

To address an increasing mortality burden, resource‐stratified guidelines have been developed to ensure that breast cancer care is matched to specific resources in low‐ and middle‐income countries. This article identifies facilitators and barriers to the use of breast cancer guidelines by oncology providers at Princess Marina Hospital in Botswana using the Consolidated Framework for Implementation Research (CFIR).

Practical considerations for expediting breast cancer treatment in Brazil

Patients in Brazil continue to present with late-stage breast cancer. Notwithstanding these figures, policies and programs to overcome this long-lasting scenario have had limited results. We enlist the main barriers for advancing breast cancer diagnosis in Brazil, based on the available evidence, and we propose feasible strategies that may serve as a platform to address this major public health challenge.

Cellphone enabled point-of-care assessment of breast tumor cytology and molecular HER2 expression from fine-needle aspirates

Management of breast cancer in limited-resource settings is hindered by a lack of low-cost, logistically sustainable approaches toward molecular and cellular diagnostic pathology services that are needed to guide therapy. To address these limitations, we have developed a multimodal cellphone-based platform—the EpiView-D4—that can evaluate both cellular morphology and molecular expression of clinically relevant biomarkers directly from fine-needle aspiration (FNA) of breast tissue specimens within 1 h. The EpiView-D4 is comprised of two components: (1) an immunodiagnostic chip built upon a “non-fouling” polymer brush-coating (the “D4”) which quantifies expression of protein biomarkers directly from crude cell lysates, and (2) a custom cellphone-based optical microscope (“EpiView”) designed for imaging cytology preparations and D4 assay readout. As a proof-of-concept, we used the EpiView-D4 for assessment of human epidermal growth factor receptor-2 (HER2) expression and validated the performance using cancer cell lines, animal models, and human tissue specimens. We found that FNA cytology specimens (prepared in less than 5 min with rapid staining kits) imaged by the EpiView-D4 were adequate for assessment of lesional cellularity and tumor content. We also found our device could reliably distinguish between HER2 expression levels across multiple different cell lines and animal xenografts. In a pilot study with human tissue (n = 19), we were able to accurately categorize HER2-negative and HER2-positve tumors from FNA specimens. Taken together, the EpiView-D4 offers a promising alternative to invasive—and often unavailable—pathology services and may enable the democratization of effective breast cancer management in limited-resource settings.

Prediction of the number of metastatic axillary lymph nodes in breast cancer by radiomic signature based on dynamic contrast-enhanced MRI

BACKGROUND

The number of metastatic axillary lymph nodes (ALNs) play a crucial role in the staging, prognosis and therapy of patients with breast cancer.

PURPOSE

To predict the number of metastatic ALNs in breast cancer via radiomics.

MATERIAL AND METHODS

We enrolled 197 patients with breast cancer who underwent dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). A total of 3386 radiomic features were extracted from the early- and delayed-phase subtraction images. To classify the number of metastatic ALNs, logistic regression was used to develop a radiomic signature and nomogram.

RESULTS

The radiomic signature were constructed to distinguish the N₀ group from the N₊ (metastatic ALNs ≥ 1) group, which yielded area under the curve (AUC) values of 0.82 and 0.81 in the training and test group, respectively. Based on the radiomic signature and BI-RADS category, a nomogram was further developed and showed excellent predictive performance with AUC values of 0.85 and 0.89 in the training and test groups, respectively. Another radiomic signature was constructed to distinguish the N₁ (1-3 ALNs) group from the N_2-3 (≥4 metastatic ALNs) group and showed encouraging performance with AUC values of 0.94 and 0.84 in training and test group, respectively.

CONCLUSIONS

We developed a nomogram and a radiomic signature that can be used to predict ALN metastasis and distinguish the N₁ from the N_2-3 group. Both nomogram and radiomic signature may be potential tools to assist clinicians in assessing ALN metastasis in patients with breast cancer.

Evaluation of diagnostic ultrasound use in a breast cancer detection strategy in Northern Peru

To evaluate the diagnostic impact of point-of-care breast ultrasound by trained primary care physicians (PCPs) as part of a breast cancer detection program using clinical breast exam in an underserved region of Peru. Medical records and breast ultrasound images of symptomatic women presenting to the Breast Cancer Detection Model (BCDM) in Trujillo, Peru were collected from 2017–2018. Performance was measured against final outcomes derived from regional cancer center medical records, fine needle aspiration results, patient follow-up (sensitivity, specificity, positive, and negative predictive values), and by percent agreement with the retrospective, blinded interpretation of images by a fellowship-trained breast radiologist, and a Peruvian breast surgeon. The diagnostic impact of ultrasound, compared to clinical breast exam (CBE), was calculated for actual practice and for potential impact of two alternative reporting systems. Of the 171 women presenting for breast ultrasound, 23 had breast cancer (13.5%). Breast ultrasound used as a triage test (current practice) detected all cancer cases (including four cancers missed on confirmatory CBE). PCPs showed strong agreement with radiologist and surgeon readings regarding the final management of masses (85.4% and 80.4%, respectively). While the triage system yielded a similar number of biopsies as CBE alone, using the condensed and full BI-RADS systems would have reduced biopsies by 60% while identifying 87% of cancers immediately and deferring 13% to six-month follow-up. Point-of-care ultrasound performed by trained PCPs improves diagnostic accuracy for managing symptomatic women over CBE alone and enhances access. Greater use of BI-RADS to guide management would reduce the diagnostic burden substantially.

Metabolic comorbidities and the association with risks of recurrent metastatic disease in breast cancer survivors

BACKGROUND

Obesity and other metabolic comorbidities affect over 10% of patients with breast cancer and are closely related with adverse outcomes. Although metabolic comorbidities among breast cancer patients in low- and middle-income countries are suggested to be lower, only a few studies are currently available. Effective management of metabolic comorbidities in cancer patients has been associated with better outcomes.

METHODS

Non-metastatic breast cancer patients (N = 1081) treated in our department (2014-2018) were monitored for the presence of high Body Mass Index (BMI), diabetes or glucose intolerance, dyslipidemia, and hypertension and the development of recurrent metastatic diseases during a median follow-up of 3.9 years.

RESULTS

Glucose intolerance, hypertension, dyslipidemia, and BMI ≥ 27.7 kg/m² considered at risk for metabolic comorbidities were found in 26.5, 42.6, 27.7, and 23.3% of breast cancer patients, respectively. Diabetes or glucose intolerance and having both glucose intolerance and dyslipidemia were associated with the risk of recurrent metastatic disease (OR = 1.442, 95%CI = 1.071-1.943, p = 0.016 and OR = 1.495, 95%CI = 1.090-2.049, p = 0.010; respectively). Having three or more metabolic comorbidities was significantly associated with the risk of recurrent metastatic disease (OR = 1.647, 95%CI = 1.139-2.382, p = 0.008) compared to patients without any comorbidity. The metabolic comorbidities were distributed unevenly among breast cancer subtypes. A significant association with recurrent metastatic disease was found in the Luminal B-like subtype. In post-menopausal patients, having more than three comorbidities was associated with a higher risk of recurrent metastatic disease compared to those without any comorbidity (OR = 2.000, 95%CI = 1.035-3.067, p = 0.001). The risks of having three or more metabolic comorbidities were significantly higher in breast cancer survivors who were obese, lived in an urban area, and received hormonal therapy of aromatase inhibitors.

CONCLUSION

Metabolic comorbidities were frequently found in breast cancer patients and were associated with higher risks to develop recurrent metastatic disease, particularly in post-menopausal women. Subsequent larger studies are needed to better understand the association of metabolic comorbidities with patients' quality of life and prognosis, and to explore the potential combination of clinical intervention and lifestyle modification in breast cancer survivors to treat as well as reduce their impact.

Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018

Background

Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub‐Saharan Africa (SSA) with radiotherapy access.

Methods

A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non‐adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease.

Results

In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43–61). Receptor status was missing for 71% (248). 199 (57%) had non‐metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post‐mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study‐defined non‐adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non‐adherence (aOR: 0.18, 95% CI: 0.09, 0.36).

Conclusions

Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient‐level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.

Recommendations for streamlining precision medicine in breast cancer care in Latin America

Background

The incidence of breast cancer (BC) in LMICs has increased by more than 20% within the last decade. In areas such as Latin America (LA), addressing BC at national levels evoke discussions surrounding fragmented care, limited resources, and regulatory barriers. Precision Medicine (PM), specifically companion diagnostics (CDx), links disease diagnosis and treatment for better patient outcomes. Thus, its application may aid in overcoming these barriers.

Recent findings

A panel of LA experts in fields related to BC and PM were provided with a series of relevant questions to address prior to a multi‐day conference. Within this conference, each narrative was edited by the entire group, through numerous rounds of discussion until a consensus was achieved. The panel proposes specific, realistic recommendations for implementing CDx in BC in LA and other LMIC regions. In these recommendations, the authors strived to address all barriers to the widespread use and access mentioned previously within this manuscript.

Conclusion

This manuscript provides a review of the current state of CDx for BC in LA. Of most importance, the panel proposes practical and actionable recommendations for the implementation of CDx throughout the Region in order to identify the right patient at the right time for the right treatment.

Knowledge of breast cancer among medical students in Syrian Private University, Syria: a cross-sectional study

BACKGROUND

Breast cancer is the most common cancer among women and the second leading cause of cancer death globally. Since early diagnosis is crucial to reducing mortality, high levels of knowledge regarding general information, risk factors, and symptoms are required among healthcare professionals to deliver breast cancer care. This study aimed to determine Syrian medical students' knowledge about breast cancer in the fields of general knowledge, common clinical features, and risk factors.

METHODS

This cross-sectional study was conducted at the Syrian Private University in October 2019 (Breast Cancer Awareness Month), Damascus, during the Syrian war crisis. Data were collected through self-administered surveys and analyzed using the Statistical Package for Social Sciences version 25.0 (SPSS Inc., United States). The chi-square test was applied to assess the relationship between the level of knowledge and gender. One way analysis of variance was performed to assess the overall differences in mean knowledge score by study year, GPA, mother's education, and source of information. Unpaired Student's T-test was used to analyze the differences in mean knowledge scores (continuous variable) based on smoking status and alcohol consumption.

RESULTS

Of 320 students, 301 completed the questionnaire (response rate = 94.0%), of which 179(59.5%) were males. The study revealed above-average knowledge scores (total mean = 68.4%) regarding breast cancer, general information (71.9%), common clinical features (71.6%), and risk factors (71.6%). Clinical students (4th, 5th, and 6th years) scored higher compared with pre-clinical students (1st, 2nd, and 3rd years).

CONCLUSION

This study showed above-average knowledge scores regarding breast cancer. More efforts to correct misinformation, through reassessing the university curriculum and promoting awareness about breast cancer are required.

Expression of E26 transformation specific-1 (ETS-1) in tumour-infiltrating lymphocytes (TILs) is adverse prognostic factor in invasive breast cancer

AIM OF THE STUDY

The microenvironment depicts the relationship between tumour cells and immune response, and every insight into stromal lymphocytes could contribute to explain their role and activity. E26 transformation specific-1 (ETS-1) is a transcription factor that is active in cell proliferation. We analysed its immunohistochemical expression in tumour infiltrating lymphocytes (TILs) in invasive breast cancer and correlated its immunohistochemical score (IHS) to traditional predictive and prognostic factors and survival.

MATERIALS AND METHODS

The sample contains data of 121 patients with invasive breast cancer, not otherwise specified (NOS) who underwent mammectomy and lymphadenectomy in 2002 at the Clinical Hospital Centre Zagreb, Croatia. Paraffin blocks of the tumour tissue were collected from the pathological archive. Three representative areas of every patient were chosen and multiple tissue samples were made. Immunohistochemical staining with rabbit anti-ETS-1 (Novocastra, UK) and the ABC method was performed on a DAKO Autostainer. The expression of ETS-1 in stromal TILs was analysed on an Olympus 41 microscope. The IHS score was calculated and correlated with clinical and pathological parameters, as well as disease-free survival (DFS) and overall survival (OS).

RESULTS

In almost all patients (95%), some expression of ETS-1 in TILs was found. A moderate/high score of ETS-1 correlated with larger tumour size and higher histological grade, high proliferation index and low progesterone receptors (PgR). The patients with moderate/high ETS-1 expression in TILs had shorter DFS than patients with weak/negative ETS-1 expression.

CONCLUSION

In invasive breast cancer NOS, expression of ETS-1 in TILs is an adverse prognostic factor.

Health Iniquity, Unhealthy Behavior, and Coverage of Mammography in Brazil

OBJECTIVE

To investigate the prevalence of mammography screening and the association among socio-demographic, behavior factors and non-adherence to mammography screening among women between 50 and 69 years old, using data from Vigitel 2016.

METHOD

Cross-sectional, population-based study with data from Vigitel including 12,740 women in the 50-69 age group. The variables were analyzed using logistic regression.

RESULTS

Among the women studied, 21.8% had not had a mammography in the past 2 years. The characteristics associated with non-adherence to the test were having less than 12 years of education (p<0.001), having no partner (p=0.001), being underweight (p=0.002), having a negative self-perceived health status (p<0.001) and having at least one negative health behavior (p<0.001).

CONCLUSION

There is a subgroup of women with markers of social vulnerability, which reflect the inequality in mammography screening.

Implementation of breast cancer continuum of care in low- and middle-income countries during the COVID-19 pandemic

Breast cancer is the most common malignancy among women worldwide. The current COVID-19 pandemic represents an unprecedented challenge leading to care disruption, which is more severe in low- and middle-income countries (LMIC) due to existing economic obstacles. This review presents the global perspective and preparedness plans for breast cancer continuum of care amid the COVID-19 outbreak and discusses challenges faced by LMIC in implementing these strategies. Prioritization and triage of breast cancer patients in a multidisciplinary team setting are of paramount importance. Deescalation of systemic and radiation therapy can be utilized safely in selected clinical scenarios. The presence of a framework and resource-adapted recommendations exploiting available evidence-based data with judicious personalized use of current resources is essential for breast cancer care in LMIC during the COVID-19 pandemic.

ESR1 gene variants, haplotypes and diplotypes may influence the risk of breast cancer and mammographic density

Breast cancer as the most common cancer worldwide is influenced by genetic and physiological factors. Based on some evidence indicating the role of estrogen receptor 1 gene (ESR1) in breast cancer development, in this study, the association of three common variations in ESR1 gene with breast cancer and density in an Iranian population was evaluated. In a case-control study, 400 blood samples were collected for DNA extraction and genotyping. Breast density was assessed using mammography. ESR1 rs6915267 (G/A), rs2077647 (C/T) and rs1801132 (C/G) were genotyped using ARMS-PCR method. PHASE program was used to estimate the haplotypes frequencies. Our data analysis showed rs6915267 GA genotype in the heterozygous (GA) as well as co-dominant models was associated with lower mammographic density. None of the three variations were associated with the breast cancer risk. Haplotype analysis indicated G-T-C haplotype of rs6915267, rs2077647 and rs1801132 [OR = 0.54, 95% CI (0.31-0.92), p = 0.025] and G-T/G-T diplotype of rs6915267-rs2077647 [OR = 0.38, 95% CI (0.17-0.86), p = 0.019] were associated with a decreased risk of breast cancer. ESR1 may affect density of the breast and its haplotypes may modulate breast cancer risk.

A Global Perspective on Screening

Breast cancer is emerging as a major global public health problem. Incidence and mortality continues to rise in low- and middle-income countries (LMICs). A significant and growing disparity exists between high-income countries and LMICs in the availability of screening services and associated preventable mortality. However, population imaging-based screening programs are not appropriate for all settings. Planners should perform a thorough assessment of the target setting prior to implementing any breast cancer detection program, as appropriate guidelines vary according to the resources available. Financial, social, and cultural barriers to breast cancer care need to be addressed to sustainably improve the morbidity and mortality of the populations and make efficient use of available services. Creative approaches, such as mobile and portable imaging and bundling of services, can facilitate the installation of early breast cancer detection programs in LMICs. While image-based screening programs are not initially resource-appropriate in many LMICs, planners can work towards this goal as part of their comprehensive breast cancer detection strategy.

Patient Characteristics and Outcomes of Nonmetastatic Breast Cancer in Haiti: Results from a Retrospective Cohort

BACKGROUND

There are few studies on breast cancer outcomes in the Caribbean region. This study identified a retrospective cohort of female patients with nonmetastatic breast cancer in Haiti and conducted survival analyses to identify prognostic factors that may affect patient outcomes.

METHODS

The cohort included 341 patients presenting between June 2012 and December 2016. The primary endpoint was event-free survival (EFS), defined as time to disease progression, recurrence, or death. Descriptive summaries of patient characteristics and treatments were reported. Survival curves were plotted using Kaplan-Meier estimation. Multivariate survival analyses were performed using Cox proportional hazards regression.

RESULTS

Median age at diagnosis was 49 years, with 64.2% being premenopausal. Most patients (55.1%) were staged as locally advanced. One hundred and sixty patients received neoadjuvant therapy: 33.3% of patients with early stage disease and 61.2% of those with locally advanced stage disease. Curative-intent surgery was performed in 278 (81.5%) patients, and 225 patients received adjuvant therapy. Adjuvant endocrine therapy was used in 82.0% of patients with estrogen receptor-positive disease. During the follow-up period, 28 patients died, 77 had disease recurrence, and 10 had progressive disease. EFS rates at 2 years and 3 years were 80.9% and 63.4%, respectively. After controlling for multiple confounders, the locally advanced stage group had a statistically significant adjusted hazard ratio for EFS of 3.27 compared with early stage.

CONCLUSION

Patients with nonmetastatic breast cancer in Haiti have more advanced disease, poorer prognostic factors, and worse outcomes compared with patients in high-income countries. Despite several limitations, curative treatment is possible in Haiti.

IMPLICATIONS FOR PRACTICE

Patients with breast cancer in Haiti have poor outcomes. Prior studies show that most Haitian patients are diagnosed at later stages. However, there are no rigorous studies describing how late-stage diagnosis and other prognostic factors affect outcomes in this population. This study presents a detailed analysis of survival outcomes and assessment of prognostic factors in patients with nonmetastatic breast cancer treated in Haiti. In addition to late-stage diagnosis, other unfavorable prognostic factors identified were young age and estrogen receptor-negative disease. The study also highlights that the availability of basic breast cancer treatment in Haiti can lead to promising early patient outcomes.

National Policies to Prevent and Manage Cervical Cancer in East African Countries: A Policy Mapping Analysis

Policy mapping is used to provide evidence on effective interventions and highlight the necessary refinements of health policies. The goal of this work is to carry out legal mapping to identify and assess health policies for the prevention and management of cervical cancer in East African countries. Cervical cancer, as a largely preventable disease, is the cause of most cancer deaths among women in East African countries. Legal documents were searched uniformly from government websites, national cancer institute sites, and international and national legal databases, then the data were analyzed using the Nvivo12 software package. The sample of 24 documents includes policies, plans, guidelines, acts, and strategies from 12 East African countries. The emerging themes were screening, prevention, diagnosis, treatment, challenges, and mitigation efforts. A few binding policies, a significant discrepancy to international standards in at least four countries, patchy screening registries, and a lack of prophylactic vaccination against human papillomavirus incorporation into national immunization schedules are the main findings. This paper underlies the role of law in health and the need for transparent legal and regulatory tools to achieve a further reduction in cervical cancer mortality in East African countries.

Breast cancer in low-middle income countries: abnormality in splicing and lack of targeted treatment options

Breast cancer is a common malignancy among women worldwide. Regardless of the economic status of a country, breast cancer poses a burden in prevention, diagnosis and treatment. Developed countries such as the U.S. have high incidence and mortality rates of breast cancer. Although low incidence rates are observed in developing countries, the mortality rate is on the rise implying that low- to middle-income countries lack the resources for preventative screening for early detection and adequate treatment resources. The differences in incidence between countries can be attributed to changes in exposure to environmental risk factors, behaviour and lifestyle factors of the different population groups. Genomic modifications are an important factor that significantly alters the risk profile of breast tumourigenesis. The incidence of early-onset breast cancer is increasing and evidence shows that early onset of breast cancer is far more aggressive than late onset of the disease; possibly due to the difference in genetic alterations or tumour biology. Alternative splicing is a pivotal factor in the progressions of breast cancer. It plays a significant role in tumour prognosis, survival and drug resistance; hence, it offers a valuable option as a therapeutic target. In this review, the differences in breast cancer incidence and mortality rates in developed countries will be compared to low- to middle-income countries. The review will also discuss environmental and lifestyle risk factors, and the underlying molecular mechanisms, genetic variations or mutations and alternative splicing that may contribute to the development and novel drug targets for breast cancer.

Evaluation of drugs for potential repurposing against COVID-19 using a tier-based scoring system

BACKGROUND

As the coronavirus disease 2019 (COVID-19) pandemic grows daily, we remain with no prophylactic and only minimal therapeutic interventions to prevent or ameliorate severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). Prior to SARS-CoV-2 emergence, high throughput screens utilizing clinically developed drugs identified compounds with in vitro inhibitory effect on human coronaviruses that may have potential for repurposing as treatment options for COVID-19. However, caution should be applied to repurposing of these drugs when they are taken out of context of human pharmacokinetic parameters associated with normal therapeutic use.

METHODS

Our aim was to provide a tier-based scoring system to interrogate this data set and match each drug with its human pharmacokinetic criteria, such as route of administration, therapeutic plasma levels and half-life, tissue distribution and safety.

RESULTS

Our analysis excluded most previously identified drugs but identified members of four drug classes (antimalarial amino-quinolones, selective estrogen receptor modulators [SERMs], low potency tricyclic antipsychotics and tricyclic antidepressants) as potential drug candidates for COVID-19. Two of them, the tricyclic antipsychotics and tricyclic antidepressants were further excluded based on a high adverse event profile.

CONCLUSIONS

In summary, our findings using a new pharmacokinetic-based scoring system supports efficacy testing of only a minority of candidates against SARS-CoV-2 infection.

Awareness and Practice of Breast Self Examination among Women in Different African Countries: A 10-Year Review of Literature

Breast self examination (BSE) is an important screening technique in detecting breast abnormalities. This procedure enables women become familiar with their breasts, thus making it easier for them to detect any changes that may occur. Routine performance of BSE is recommended for females above 20 years. This review of literature was conducted to assess the awareness and practice of BSE among women in different countries in Africa. A total of 28 out of 80 articles were reviewed from 15 African countries based on relevance. Review identification was performed through the search of Google Scholar and PubMed/MEDLINE/PubMed Central databases. Search terms used were “BSE,” “awareness,” “practice,” and “Africa.” Reference lists of identified studies were also used to find more studies. Majority of the reviewed studies showed adequate awareness, mainly from the media, but poor practice of BSE among women in various countries in Africa. A major barrier identified was inadequate knowledge of BSE technique. Although awareness of BSE was relatively high in many of the reviewed studies, the practice was low. Educational intervention program should be carried out among women in various African countries, not only to raise awareness but also to educate on the skills required to carry out BSE effectively.

Patient navigation services for cancer care in low-and middle-income countries: A scoping review

Background

Nearly 70% of all cancer deaths occur in low- and middle-income countries (LMICs) and many of these cancer deaths are preventable. In high-income countries (HICs), patient navigation strategies have been successfully implemented to facilitate the patient’s journey at multiple points along the cancer care continuum. The purpose of this scoping review is to understand and describe the scope of patient navigation interventions and services employed in LMICs.

Methods

A systematic search of published articles was conducted including Medline, Biosis, Embase, Global Health, and Web of Science. Articles were examined for evidence of patient navigation interventions used in cancer care in LMICs. Evidence was synthesized by navigation service provided and by type of outcome.

Results

Fourteen studies reported on patient navigation interventions in cancer care in low-income and middle-income countries in Asia, South America, and Africa. Most studies reported on women’s cancers and included navigation interventions at most points along the cancer care continuum i.e. awareness, education, screening participation, adherence to treatment and surveillance protocols.

Conclusion

Few studies report on cancer patient navigation in LMICs. With the use of an implementation science framework, patient navigation research can explore a broader range of outcomes to better evaluate its potential role in improving cancer control in LMICs.