Incidence trends and patterns of breast cancer in Sri Lanka: an analysis of the national cancer database

Cost-utility and budget impact analysis of neoadjuvant dual HER2 targeted therapy for HER2-positive breast cancer in Sri Lanka

This study aimed to assess the cost-utility and budget impact of dual to single HER2 targeted neoadjuvant therapy for HER2-positive breast cancer in Sri Lanka. A five-health state Markov model with lifetime horizon was used to assess the cost-utility of neoadjuvant trastuzumab (T) plus pertuzumab (P) or lapatinib (L) compared to single therapy of T with chemotherapy (C), in public healthcare system and societal perspectives. Input parameters were estimated using local data, network meta-analysis, published reports and literature. Costs were adjusted to year 2021 (1USD = LKR194.78). Five-year budget impact for public healthcare system was assessed. Incremental cost-effectiveness ratios in societal perspective for neoadjuvantLTC plus adjuvantT (strategy 3), neoadjuvantPTC plus adjuvantT (strategy 2), neoadjuvantLTC plus adjuvantLT (strategy 5), and neoadjuvantPTC plus adjuvantPT (strategy 4) compared to neoadjuvantTC plus adjuvantT (strategy 1) were USD2716, USD5600, USD6878, and USD12127 per QALY gained, respectively. One GDP per-capita (USD3815) was considered as the cost-effectiveness threshold for the analysis. Even though only the ICER for strategy 3 was cost-effective, uncertainty of efficacy parameter was revealed. For strategy 2 neoadjuvant PTC plus adjuvant T, a 25% reduction of neoadjuvant regimen cost was required to be cost effective for use in early HER2 positive breast cancer.

Breast cancer surveillance in BRCA positive Sri Lankan women: health equity for a high-risk group at a limited resource setting

BACKGROUND

BRCA1 and BRCA2 pathogenic variants account for 90% of hereditary breast malignancies, incurring a lifetime breast cancer risk of 85% and 40-45% respectively, in affected individuals. Well-resourced health care settings offer genetic counselling and genetic screening for susceptible individuals, followed by intense breast cancer surveillance programmes for those identified at high risk of breast cancer. Such high standards of care are not available in countries with limited resources. This study assessed breast cancer surveillance behaviors among a cohort of BRCA positive Sri Lankan women.

METHODS

A retrospective case review of all patients diagnosed with pathogenic variants in BRCA1 and BRCA2 genes from 2015 to 2022 at the Human Genetics Unit, Faculty of Medicine, University of Colombo was carried out followed by telephone interviews of the respondents. Patients who were not contactable, deceased, undergone bilateral mastectomy and males were excluded from the interview component of the study. Standard descriptive statistics were used to analyze the data using SPSS statistics version 25.

RESULTS

Only 25 patients were diagnosed during the study period:14/25 women responded (6/25 deceased, 3/25 non-contactable; 2/25 excluded). 71.4% (10/14) had performed breast self-examination during the preceding month; 35.7% (5/14) had a clinical breast examination (CBE), and 50% (7/14) had undergone a screening/diagnostic mammogram during the last one year. 28.5% (4/14) had undergone both mammography and CBE; 21.45% (3/14) mammogram only, 7.1% (1/14) had CBE only. 42.8%(6/14) had not undergone any surveillance(mammography, CBE or MRI). None had dual screening with mammogram and MRI. 85.71% (12/14) women expressed willingness to participate in a regular screening programme if made available.

CONCLUSION

Fifty percent of BRCA1/2 positive women in our study had not undergone annual imaging-based surveillance by mammography or MRI, and none had undergone annual dual screening with mammography and MRI, indicating inadequate breast cancer surveillance in this high-risk group.

Oncoplastic breast conserving surgery versus standard breast conserving surgery for early and locally advanced breast cancer: a retrospective analysis from Sri Lanka

BACKGROUND

Breast aesthetics is becoming increasingly important in breast cancer surgery due to changes in patient expectations and greater emphasis been placed on the psychosocial outcomes. Studies have shown no difference in local recurrence risk between mastectomy and breast conserving surgery (BCS) and also a higher overall survival rate after BCS. Breast preservation improves the quality of life substantially compared to mastectomy. Oncoplastic breast-conserving surgery (O-BCS) involves tumour excision whilst overcoming the limitations of standard breast conserving surgery (S-BCS) by allowing larger resection volumes, avoiding deformities with better aesthetic results. Our study aims to compare the oncosurgical and aesthetic outcomes of O-BCS versus S-BCS among women in Sri Lanka.

METHODS

We conducted a retrospective study over a 4-year period including patients who underwent breast conservation surgery for primary non-metastatic breast cancer in two tertiary care units. We assessed outcomes in terms of re-excision rates, resection margin, complications and aesthetic outcomes using a Likert scale questionnaire to grade specific outcomes such as symmetry, volume, nipple position, scar visibility. Non-parametric tests were used for statistical analyses.

RESULTS

Fifty-four and seventy-three patients underwent S-BCS and O-BCS respectively. The median specimen volume and the maximum tumour diameter were significantly higher in O-BCS [160(range:65-220); 4.2(range: 1.2-5.2)] compared to S-BCS [65(range:45-86); 2.4(range: 1.0-2.6)]. The median closest tumour margin was 16 mm (range:4-25 mm) in O-BCS while 6 mm (range:<1 - 12 mm) in S-BCS (p = 0.01). Close (< 1 mm) and positive margins needing re-excision were seen mostly in S-BCS. Superior aesthetic outcomes with statistical significant difference were reported in the O-BCS compared to S-BCS group with better symmetry, volume, nipple position and scar visibility. The re-excision rates were significantly lower in O-BCS group. There was no significant difference in the operative time and complications while the aesthetic outcomes were significantly superior in OBCS.

CONCLUSIONS

Overall, Level 2 perforator flap based reconstruction had superior aesthetic outcomes. O-BCS is safe and more aesthetically acceptable with no difference in oncological outcome and operative time. More consideration should be given to aesthetic parameters such as scar visibility, nipple position, breast volume and shape when considering the best surgical option for the patients.

Germline variants of uncertain significance, their frequency, and clinico-pathological features in a cohort of Sri Lankan patients with hereditary breast cancer

BACKGROUND

Next-Generation Sequencing (NGS)-based testing in cancer patients has led to increased detection of variants of uncertain significance (VUS). VUS are genetic variants whose impact on protein function is unknown. VUS pose a challenge to clinicians and patients due to uncertainty regarding their cancer predisposition risk. Paucity of data exists on the pattern of VUS in under-represented populations. This study describes the frequency of germline VUS and clinico-pathological features in Sri Lankan hereditary breast cancer patients.

METHODS

Data of 72 hereditary breast cancer patients who underwent NGS-based testing between January 2015 and December 2021 were maintained prospectively in a database and analyzed retrospectively. Data were subjected to bioinformatics analysis and variants were classified according to international guidelines.

RESULTS

Germline variants were detected in 33/72(45.8%) patients, comprising 16(48.5%) pathogenic/likely pathogenic variants and 17(51.5%) VUS. Distribution of VUS in breast cancer predisposing genes were :APC:1(5.8%), ATM:2(11.7%), BRCA1:1(5.8%), BRCA2:5(29.4%), BRIP1:1(5.8%), CDKN2A:1(5.8%), CHEK2:2(11.7%), FANC1:1(5.8%), MET:1(5.8%), STK11:1(5.8%), NF2:1(5.8%). Mean age at cancer diagnosis in patients with VUS was 51.2 years. Most common tumour histopathology was ductal carcinoma 11(78.6%). 50% of tumours in patients having VUS in BRCA1/2 genes were hormone receptor negative. 73.3% patients had family history of breast cancer.

CONCLUSIONS

A significant portion of patients had a germline VUS. Highest frequency was in BRCA2 gene. Majority had family history of breast cancer. This highlights the need to undertake functional genomic studies to determine the biological effects of VUS and identify potentially clinically actionable variants that would be useful for decision-making and patient management.

Mitochondrial genome in sporadic breast cancer: A case control study and a proteomic analysis in a Sinhalese cohort from Sri Lanka

Breast cancer is the commonest malignancy in women and the majority occurs sporadically with no hereditary predisposition. However, sporadic breast cancer has been studied less intensively than the hereditary form and to date hardly any predictive biomarkers exist for the former. Furthermore, although mitochondrial DNA variants have been reported to be associated with breast cancer, findings have been inconsistent across populations. Thus we carried out a case control study on sporadic breast cancer patients and healthy controls of Sinhalese ethnicity (N = 60 matched pairs) in order to characterize coding region variants associated with the disease and to identify any potential biomarkers. Mitochondrial genome was fully sequenced in 30 pairs and selected regions were sequenced in the remaining 30 pairs. Several in-silico tools were used to assess functional significance of the variants observed. A number of variants were identified among the patients and the controls. Missense variants identified were either polymorphisms or rare variants. Their prevalence did not significantly differ between patients and the healthy controls (matched for age, body mass index and menopausal status). MT-CYB, MT-ATP6 and MT-ND2 genes showed a higher mutation rate. A higher proportion of pre-menopausal patients carried missense and pathogenic variants. Unique combinations of missense variants were seen within genes and these occurred mostly in MT-ATP6 and MT-CYB genes. Such unique combinations that occurred exclusively among the patients were common in obese patients. Mitochondrial DNA variants may have a role in breast carcinogenesis in obesity and pre-menopause. Molecular dynamic simulations suggested the mutants, G78S in MT-CO3 gene and T146A in MT-ATP6 gene are likely to be more stable than their wild type counterparts.

Patient Satisfaction With Breast Cancer Care Delivery at the National Cancer Institute of Sri Lanka: Does Language Play a Role?

PURPOSE

This study sought to examine whether there was an association between language barriers and patient satisfaction with breast cancer care in Sri Lanka.

METHODS

A telephone-based survey was conducted in the three official languages (Sinhala, Tamil, or English) among adult women (older than 18 years) who had been treated for breast cancer within 6-12 months of diagnosis at the National Cancer Institute of Sri Lanka. The European Organisation for Research and Treatment of Cancer Satisfaction with Cancer Care core questionnaire was adapted to assess three main domains (physicians, allied health care professionals, and the organization). All scores were linearly transformed to a 0-100 scale, and subscores for domains were summarized using means and standard deviations. These were also calculated for the Sinhalese and Tamil groups and compared.

RESULTS

The study included 72 participants (32 ethnically Tamil and 40 Sinhalese, with 100% concordance with preferred language). The most commonly reported best aspect of care (n = 25) involved affective behaviors of the physicians and nurses. Ease of access to the hospital performed poorest overall, with a mean satisfaction score of 54 (30.5). Clinic-related concerns were highlighted as the worst aspect of the care (n = 10), including long waiting times during clinic visits. Sixty-three percent of Tamil patients reported receiving none of their care in Tamil and 18% reported experiencing language barriers during their care. Tamil patients were less satisfied overall and reported lower satisfaction with care coordination (P = .005) and higher financial burden (P = 0.014).

CONCLUSION

Ethnically Tamil patients were significantly less satisfied than their Sinhalese counterparts and experienced more language barriers, suggesting there is a need to improve access to language-concordant care in Sri Lanka.

Breast cancer in lactating mothers: A case series of delayed diagnosis

INTRODUCTION AND IMPORTANCE

Due to pregnancy related changes in the breast, a breast feeding mother as well as the health care professionals may attribute a change in the breast for lactation resulting in a delay in evaluation and diagnosis. We report a cases series of delayed diagnosis of breast cancer during lactation in three young patients from a developing country who had sought medical attention on time but was unfortunately diagnosed late.

PRESENTATION OF CASE

We report three breast feeding mothers aged 38-39 years presenting with breast lump and edema. All patients had an ultrasonography of breast performed at least once and the radiological findings were attributed to physiological changes initially despite non-resolving symptoms for 3-4 months. Triple assessment revealed invasive breast cancers of T4N1M0, T2N1M0, T3N2M1 staging. Two patients were treated with a curative intent and the patient with metastatic cancer was referred for palliative chemotherapy.

CLINICAL DISCUSSION

Lactational mastitis, breast abscesses, galactoceles, breast edema are benign conditions that are unique in lactation period, but it is important not to overlook that the lactating women may develop any of the other breast problems seen in the non-lactating female population.

CONCLUSION

Our case series represent very similar scenarios of delayed or missed diagnosis of breast cancer in young lactating women. A lactating patient should be referred to a specialist center and/or a complete assessment of the breast should be performed in case of any red flags findings to avoid missing a sinister diagnosis.

Circulating Biomarkers in the Management of Breast Cancer

Circulating biomarkers have become a promising modality in the management of many cancers. Similarly, in breast cancer, circulatory biomarkers are useful, non-invasive methods in the diagnosis, prognostication, and evaluation of response to treatment. Invasive surgical biopsies can be potentially replaced by “liquid biopsy,” which involves analysing circulatory biomarkers that may reveal features of primary and metastatic disease. Therefore, providing an insight into the cancer biology can be utilised to monitor treatment response, treatment-induced adaptation and tumour and disease progression through non-invasive means. The objective of this review is to provide an overview of the current status of the circulating biomarkers highlighting their promising impact on the management of patients with breast cancer.

Incidence and Patterns of Liver Cancers in Sri Lanka from 2001 to 2010: Analysis of National Cancer Registry Data

Sanjeewa SeneviratneObjectives  Varying trends in the incidence of liver cancer have been observed in many Asian countries. We conducted this study to examine trends in liver cancer incidence and histological patterns in Sri Lanka. Materials and Methods  All newly diagnosed patients with liver cancer included in Sri Lanka National Cancer Registry during 2001 to 2010 were analyzed. Statistical Analysis  Joinpoint regression analysis was performed. A p -value of less than 0.05 was considered statistically significant. Results  Overall, 1,482 (male:female = 2.7:1; mean age = 57.5 years) liver cancers were analyzed. Majority were hepatocellular carcinomas ( n = 1,169; 78.9%), followed by intrahepatic cholangiocarcinomas ( n = 100; 6.75%). Highest incidence of liver cancer was observed in 70-74-year age group (5.1/100,000). Overall, the World Health Organization age-standardized rate (ASR) has increased during 2001 to 2004, from 0.6/100,000 (95% confidence interval [CI] = 0.48-0.72) to 1.0/100,000 (95% CI = 0.85-1.15), with an estimated annual percentage change (EAPC) of 17.8 (95% CI = 5.0-46.2); p > 0.05. From 2004 to 2010, a gradual decline in the incidence was observed. ASR in 2010 was 0.96 (95% CI = 0.81-1.1), with an EAPC of -0.9 (95% CI = -6.7 to 5.4); p > 0.05. Similar patterns of incidence change were observed in both genders. Conclusions  Overall, the incidence of liver cancer appears to be steadily declining in Sri Lanka. Similar patterns of incidence change were observed in both genders. The actual decline is likely to be greater as it is likely that diagnostic scrutiny and reporting would have improved during the study period.

Male breast cancer: a Sri Lankan case report and review of literature

Male breast cancers account for 1% of worldwide breast malignancies and are on the rise. Sri Lankan accounts are limited due to lack of healthcare seeking behavior among men. A 63-year-old male presented with a right sided hard breast lump and a Breast Imaging Reporting and Database System score 5 lesion with axillary lymph node metastasis was observed on ultrasonography. Core biopsy revealed invasive ductal breast cancer. Tumor staging revealed a T2N1M0 cancer for which mastectomy with level 2 axillary clearance was performed followed by radiotherapy and systemic therapy. Male breast cancer even though similar to female breast cancers have important distinctions with regard to molecular biology, lymphatic metastasis and age of presentation. Management; however, still relies on studies based on the female counterpart.

Cytotoxic and Apoptotic Effect of Iris taochia Plant Extracts on Human Breast Cancer (MCF-7) Cells

Introduction:

Iris taochia is an endemic plant in Turkey. Iris species has many biological effects such as antibacterial, antiinflammatory, antioxidant and anticancer properties. Apoptosis is a programmed cell death and this mechanism regulates the death of cancer cells.

Purpose:

The aim of our work is to investigate how the Iris taochia extracts affect the apoptotic activity in the MCF7 cells.

Methods:

Cytotoxic dose and cell viability is determined by the MTT assay. Bad, Bax, Bcl-2, Bcl- W, Bid, Bim, Caspase 3, Caspase 8, CD40, CD40L, cIAP-2, CytoC, DR6, Fas, FasL, HSP27, HSP60, HSP70, HTRA, IGF-I, IGF-II, IGFBP-1, IGFBP-2, IGFBP-3, IGFBP-4, IGFBP-5, IGFBP-6, IGF-1sR, Livin, p21, p27, p53, SMAC, Survivin, sTNF-R1, sTNF-R2, TNF-α, TNF-β, TRAILR-1, TRAILR-2, TRAILR-3, TRAILR-4 and XIAP proteins were measured by the membrane array kit.

Results:

Iris taochia extracts exhibited significant cytotoxic effects on MCF7 cells and IC50 values ranging from 1.56 to 100 μg/mL. Our results indicate that MeOH extract of Iris taochia in MCF7 cells may be a regulator of cell death proteins, cell cycle and growth factors. DCM and EtOH extracts of Iris taochia have a limited effect on MCF7 cells, especially, HSPs, which play a significant role in chemoresistance, downregulating DCM and EtOH extracts of Iris taochia, whereas ligands and receptors of extrinsic apoptotic pathway are upregulated by these extracts.

Conclusion:

This is the first study to investigate the cytotoxic and apoptotic effect of Iris taochia extracts on MCF7 cells. Results also showed that Iris taochia reduced cell viability and induced apoptotic pathways as a potential regulator of cancer cell death.

Squamous cell carcinoma of the uterine cervix metastasising to the thyroid gland: a case report

Background

Carcinoma of the uterine cervix (cervical cancer) metastasising to the thyroid gland is a rare phenomenon and only a few cases have been reported. We discuss a patient with cervical cancer presenting with thyroid and cervical lymph node metastasis, exploring the diagnostic difficulty, evaluation and treatment options.

Case presentation

A previously well 56-year-old female presented with multiple neck lumps for 4 months duration. Examination of the neck revealed multiple firm/hard left cervical lymph nodes with a hard thyroid nodule. There were no abdominal masses however, vaginal examination revealed a hard, unhealthy cervix. Contrast enhanced computed tomography revealed a growth in the uterine cervix with lymph node enlargement in the abdomen, chest and neck along with multiple thyroid nodules. Biopsy of the cervix and cervical lymph node and fine needle aspiration cytology of the thyroid nodules were performed, all revealing a squamous cell carcinoma. Pan-endoscopy performed to rule out any concurrent cancer of the upper aerodigestive tract was negative. The patient was started on palliative therapy, but succumbed to the disease after 6 months.

Discussion and conclusion

Patients who present with a thyroid nodule along with multiple cervical lymph nodes should be thoroughly assessed for possible metastatic cancers. Metastasis to the thyroid gland indicates a poor prognosis in the background of carcinoma or the uterine cervix. More awareness among the public and primary care providers is necessary regarding freely available screening programmes for early detection of cervical cancer.

Healthcare delivery for non-communicable diseases among breast cancer survivors in Sri Lanka: Is there a missed opportunity?

Purpose

Breast cancer is the most common cancer globally as well as in Sri Lanka. Improvements in cancer care have allowed patients to live to an older age. With advancing age, incidence of non-communicable diseases (NCDs) increases. Cancer diagnoses tend to take attention away from the treatment of other comorbidities, given its importance. The objective of this study was to describe healthcare delivery for NCDs among female breast cancer survivors treated at the National Cancer Institute of Sri Lanka (NCISL) and identify opportunities to optimise non-cancer medical care in this cohort.

Methods

A total of 420 women were identified from the breast cancer database at the NCISL, who were 50-80 years at the time of their breast cancer diagnosis, were within 12-24 months from the date of diagnosis, had completed their active cancer treatment and were in complete remission. Of this population, 228 (54%) women who had documented NCDs at the time of diagnosis were identified and were followed-up via telephone to collect details regarding existing comorbidities and the screening and development of new comorbidities.

Results

At the time of cancer diagnosis, 216/228 (95%) of patients had hypertension, 104/228 (46%) had type 2 diabetes and 17/228 (8%) had ischaemic heart disease (IHD). The prevalence of other comorbidities was very low. During the post diagnosis period, 11 patients developed type 2 diabetes, while 2 developed IHD. Osteoporosis screening using dual-energy X-ray absorptiometry scanning was very low at diagnosis 21/228 (9%) but improved in post cancer treatment follow-up 112/228 (49%, p < 0.001). Only 95/228 (42%) were screened for other cancers.

Conclusions

Hypertension was the most prevalent comorbidity while type 2 diabetes and dyslipidaemia were the most common diagnoses post-treatment. In these patients, screening for osteoporosis and other cancers remains very low, emphasising a missed opportunity.

Demographic, tumour, and treatment characteristics of female patients with breast cancer in Sri Lanka; results from a hospital-based cancer registry

Background

Although breast cancer is the most common cancer among Sri Lankan women, there is little published data on patient characteristics and treatment in the local context. We aimed to describe disease characteristics and management in a large contemporary cohort of women with breast cancer at the National Cancer Institute of Sri Lanka (NCISL).

Methods

All women with invasive primary breast cancers diagnosed during 2016–2020 were identified from the NCISL breast cancer registry. The NCISL sees approximately 40% of all cancer patients in Sri Lanka. Cancer stage at diagnosis was defined according to the Tumour, Node, and Metastasis (TNM) staging system and the Estrogen (ER) and progesterone (PR) receptor status was determined based on the results of immunohistochemistry tests. Descriptive statistics were used to describe the study cohort and treatment patterns.

Results

Over 5100 patients were diagnosed with breast cancer during the study period at the NCISL. The mean age of the women was 56 (SD 12) years. Common co-morbidities were hypertension (n = 1566, 30%) and diabetes mellitus (n = 1196, 23%). Two thirds (66%) of the cancers were early stage (stage I & II) at diagnosis. ER/PR positivity rate was 72% and HER-2 positivity rate was 22%. Two thirds of the women had undergone mastectomy while 68% had undergone axillary clearance. The rate of chemotherapy delivery was 91% for women with node positive disease while 77% of eligible women (i.e., after wide local excision or with > 3 positive lymph nodes) had received adjuvant radiotherapy. Endocrine therapy was initiated in 88% of eligible women with hormone receptor positive disease while rate of trastuzumab use was 59% among women with HER2 positive breast cancer.

Conclusions

High percentage of advanced breast cancer at diagnosis and high prevalence of comorbidities are some of the major challenges faced in the management of breast cancer in Sri Lanka. Given that stage at diagnosis is the most important prognostic factor determining survival, greater efforts are needed to promote early diagnosis of breast cancer. Considerable lapses in the concordance between guideline recommendations and the delivery of cancer care warrants closer assessment and intervention.

Overview of Medical Management of Transgender Men: Perspectives from Sri Lanka

Transgender medicine is an evolving field of medicine due to the rising awareness of individuals with a non-binary gender identity. Individuals with nonconforming gender identities have been on the rise in many societies and it is becoming an increasingly discussed issue. Their management is multidisciplinary, which includes mental health, endocrine therapy, and surgery. Although their general healthcare needs are similar to those of the general population, special considerations in primary and preventive care are also necessary in relation to the gender-affirming medical issues. Their quality of life is largely affected by psychological, social, and economic difficulties they face due to acceptance issues in the society and healthcare. This review explores the primary care, medical, and surgical management of transgender men with perspectives from Sri Lanka.

Perception of breast cancer risk factors: Dysregulation of TGF-β/miRNA axis in Pakistani females

Breast cancer poses a serious health risk for women throughout the world. Among the Asian population, Pakistani women have the highest risk of developing breast cancer. One out of nine women is diagnosed with breast cancer in Pakistan. The etiology and the risk factor leading to breast cancer are largely unknown. In the current study the risk factors that are most pertinent to the Pakistani population, the etiology, molecular mechanisms of tumor progression, and therapeutic targets of breast cancer are studied. A correlative, cross-sectional, descriptive, and questionnaire-based study was designed to predict the risk factors in breast cancer patients. Invasive Ductal Carcinoma (90%) and grade-II tumor (73.2%) formation are more common in our patient’s data set. Clinical parameters such as mean age of 47.5 years (SD ± 11.17), disturbed menstrual cycle (> 2), cousin marriages (repeated), and lactation period (< 0.5 Y) along with stress, dietary and environmental factors have an essential role in the development of breast cancer. In addition to this in silico analysis was performed to screen the miRNA regulating the TGF-beta pathway using TargetScanHuman, and correlation was depicted through Mindjet Manager. The information thus obtained was observed in breast cancer clinical samples both in peripheral blood mononuclear cells, and biopsy through quantitative real-time PCR. There was a significant dysregulation (**P>0.001) of the TGF-β1 signaling pathway and the miRNAs (miR-29a, miR-140, and miR-148a) in patients’ biopsy in grade and stage specifically, correlated with expression in blood samples. miRNAs (miR-29a and miR-140, miR-148a) can be an effective diagnostic and prognostic marker as they regulate SMAD4 and SMAD2 expression respectively in breast cancer blood and biopsy samples. Therefore, proactive therapeutic strategies can be devised considering negatively regulated cascade genes and amalgamated miRNAs to control breast cancer better.

Cancer services in Sri Lanka: current status and future directions

BACKGROUND

The burden of cancer in Sri Lanka is on the rise. The overall incidence of cancer in Sri Lanka has doubled over the past 25 years with a parallel rise in cancer-related mortality. Cancer has become the second commonest cause of hospital mortality in Sri Lanka. In this review, we aim to provide an overview of the current status and future direction of cancer care in Sri Lanka.

MAIN BODY

In Sri Lanka, cancer services are predominantly provided by the state sector free of charge to the general public. With the establishment of national cancer policy on cancer prevention and control, there has been a commendable improvement in the cancer services provided island-wide. An increasing number of breast, oropharyngeal, thyroid, oesophageal, colorectal, lung, and gastric cancers are being diagnosed and treated annually. Primary prevention measures include restrictions in tobacco and HPV vaccination. Screening programs for selected cancers such as breast, oral and cervical cancers are delivered. Medical oncology units with facilities for systemic therapy and adequately supported by surgical, pathology, and radiology departments have been established in each district general hospital island-wide. Although the current progress is commendable, future changes are necessary to overcome the current limitations and to cater the ever increasing burden of cancer. Measures are necessary to enhance the coverage of Sri Lanka Cancer Registry. Timely high-quality research and audits are essential. Community participation in planning strategies for cancer prevention and treatment is minimal. Community-based palliative care facilities and radiation and other systemic therapy should be made available in all provinces. A culture of multi-disciplinary care with proper referral pathways would help to improve the current setting.

CONCLUSION

In conclusion, Sri Lanka has a reasonably balanced and continuously expanding program for prevention, screening, and treatment of cancers. Emphasis on preventive strategies related to reducing tobacco smoking, chewing betel, and obesity, making cancers a notifiable disease, involving the community in planning cancer care and prevention strategies, conducting research to evaluate cost-effectiveness of existing treatment and increasing radiotherapy facilities would further improve the cancer services in Sri Lanka.

Exploring the psychosocial morbidity of women undergoing chemotherapy for breast cancer in a post-war setting: experiences of Northern Sri Lankan women

PURPOSE

A breast cancer diagnosis leads to considerable internal conflict and social disruption. Coping with breast cancer may be especially challenging where psychosocial services are not integrated to cancer care. This exploratory descriptive qualitative study delves into breast cancer-associated psychosocial morbidity among women diagnosed with breast cancer at a cancer centre in post-war northern Sri Lanka.

METHODS

Fifteen women with non-metastatic breast cancer and treated with curative intent, who were undergoing or had completed adjuvant chemotherapy, were included in the study. Data were gathered through semi-structured interviews and thematically analysed.

RESULTS

Aside from the immediate effects of chemotherapy, participants grappled with concerns of body image, social stigma, and dependency while straddling anxieties about the fate of their families and expenses on cancer care. Demonstrating remarkable strength and resilience, however, they drew on their families and communities for support in the absence of a formal system of psychosocial care. These women's narratives shed light on certain universal aspects of the breast cancer experience as well as its specificity in a region devastated by war, where cancer care is delivered with minimal resources.

CONCLUSION

The findings underscore the need to invest in integrating psychosocial services to chronic illness care in low- and middle-income settings.

Post treatment quality of life among Sri Lankan women with breast cancer

BACKGROUND

Breast cancer and its treatment imposes a significant effect in the quality of life (QOL) of women. Being a developing country with contrasting social and cultural norms to the West, Sri Lankan women may have a different experience on QOL following surgical treatment of breast cancer. This study was conducted to evaluate post-treatment QOL in breast cancer patients and to determine its association with the type of surgery.

METHODS

A cross sectional study was carried out. Fifty four women with non-metastatic breast cancer who underwent surgery for breast cancer at the Professorial Surgical Unit, Colombo during 2015-2018 and completed a minimum of one year follow up after surgery were invited to participate. Fifty-four women who responded were assessed using the validated EORTC QLQ-C30 and QLQ-BR23 questionnaires. Non-parametric tests were used for statistical analyses.

RESULTS

The mean age was 59 years (range 36-81). A majority (61%, n = 35) underwent mastectomy and the rest (n = 19, 45%) breast conservation surgery (BCS). The mean QLQ-C30 score was 68.8 (range 8.3-100) and the mean scores for physical function, role function, emotional function, cognitive function, and social function were 71.4, 81.5, 77.0, 80.2, and 86.4, respectively. The mean scores for body image, sexual functioning, sexual enjoyment, future perspective, systemic therapy, breast symptoms, arm symptoms, and hair loss assessed by the QLQ-BR23 were 76.4, 18.3, 33.3, 73.6, 30.5, 16.2, 23.4 and 32.7, respectively. No significant differences (P > 0.05) were noted in global health status, physical function, role function, emotional function, cognitive function and social function between BCS and mastectomy. QLQ-BR23 body image, sexual functioning, sexual enjoyment and future perspective also did not differ significantly (p > 0.05) between the two groups.

CONCLUSIONS

Sexual functioning and enjoyment, breast and arm symptoms and hair loss contributed to poor QOL while the impact on global health status including physical, social and emotional functions were minimal. Type of surgery did not appear to be associated with QOL. Future studies with a larger sample sizes will be helpful to further study these factors.

Does the choice of care pathways matter in timely breast cancer care in Sri Lanka?

BACKGROUND

An understanding on the use of care pathways facilitates identification of timeliness in breast cancer care. Aims of this study were to describe different breast cancer care pathways used by female breast cancer patients in Sri Lanka and to identify whether they experienced timely breast cancer care.

METHODS

We conducted a cross-sectional study among 800 female breast cancer patients with a histological/ cytological confirmation, from four state cancer treatment centers. We conceptualized five different care pathways with essential care points and in-between time intervals to be explored using an interviewer administered tool. Dates were cross-checked with the medical record. The difference of time intervals spent in different care pathways was tested for significance using one-way ANOVA test.

RESULTS

Mean (SD) age was 55.5 (10.7) years. A vast majority of 98.4 % (n = 787) self-detected the breast lesion, while only 13 had been detected through screening. Following self-detection, two thirds (n = 473, 59.1 %, 95 % CI = 55.7-62.5) had first consulted a primary healthcare physician, and a third n = 287, 35.8 %, 95 % CI = 32.6-39.3) had consulted an appropriate specialist first. Presentation interval among those who visited an Ayurvedic physician first was significantly longer than other pathways (p < 0.0001). Diagnosis interval for those who consulted an appropriate consultant was significantly shorter than other pathways (p < 0.0001).

CONCLUSIONS

Women take up numerous care paths following self-detection of a breast lesion. Empowering women on appropriate care pathways and expanding dedicated breast clinics where women to be first seen by an appropriate specialist are likely to improve timely breast cancer care in Sri Lanka.

The incidence and patterns of lung cancers in Sri Lanka from 2001 to 2010: Analysis of national cancer registry data

OBJECTIVES

Epidemiological studies carried out on lung cancer have shown varying incidence patterns in Asia. We aimed to examine the trends in lung cancer incidence and patterns in Sri Lanka.

METHODS

All newly diagnosed lung cancer patients in Sri Lanka during 2001-2010 included in the National Cancer Registry were analysed. Trends in incidence were analysed using the Joinpoint regression software.

RESULTS

A total of 8482 lung cancer patients (males = 6831, 80.5%, mean age: 60.2 years) were analysed. The WHO age-standardised incidence rate (ASR) has increased from 3.77 per 100,000 in 2001 (95% confidence interval [95% CI]: 3.47-4.07) to 5.74 per 100,000 in 2010 (95% CI: 5.38-6.09; a 1.52-fold increase (p < 0.05 for trend), with an estimated annual percentage change (EAPC) of 5.4 (95% CI: 3.9-7.0). The proportional increase in incidence was higher for females [ASR: 1.2 to 2.3, EAPC = 6.8(95% CI: 4.0-9.7)] than males [ASR: 6.6 to 9.55, EAPC = 5.2(95% CI: 3.8-6.6)] and with similar patterns.

CONCLUSIONS

In Sri Lanka, the incidence of lung cancer has shown as increasing trend with a greater proportional rise in females. Although the observed trends could be partly due to better reporting, the greater increase in females who are generally non-smokers is intriguing. Further studies are required to identify reasons for observed incidence trends in lung cancer in Sri Lanka.

Prophylactic prednisolone for the prevention of early and intermediate adverse effects of radioactive iodine therapy in patients with thyroid cancer: study protocol for a single-centre, phase II/III, randomized, double-blinded, placebo-controlled clinical trial

Background

Radioactive iodine (RAI) therapy is the standard adjuvant treatment for differentiated thyroid cancer (i.e. papillary and follicular). RAI is associated with troublesome early, intermediate and late adverse effects. Although glucocorticoids are used for the management of these adverse effects, there is little evidence regarding the effectiveness of prophylactic glucocorticoids to prevent these complications. This trial will evaluate the efficacy of a short course of prophylactic glucocorticoids in the prevention of adverse effects of RAI treatment in patients with differentiated thyroid cancer.

Methods

A phase II/III, single-centre, randomized, double-blinded, placebo-controlled, parallel-arm clinical trial will be conducted. Patients with differentiated thyroid cancer who are referred to RAI therapy at the National Cancer Institute, Sri Lanka, will be randomized into two arms consisting of 200 patients each. The experimental group will receive prophylactic oral prednisolone 0.5 mg/kg and omeprazole 20 mg single dose 6 h before RAI therapy followed by oral prednisolone 0.5 mg/kg and omeprazole 20 mg daily for 3 days. The control group will receive oral placebo and omeprazole 20 mg single dose 6 h before RAI therapy followed by oral placebo and omeprazole 20 mg daily for 3 days. Clinically significant adverse effects assessed as related to RAI as well as prednisolone therapy and the quality of life parameters will be compared between the two groups.

Discussion

If proven beneficial, this intervention can be incorporated into the standard practice to reduce early and intermediate adverse effects of RAI for thyroid cancer with a potential improvement of quality of life.

Trial registration

Sri Lanka Clinical Trials Registry SLCTR/2020/009. Registered prospectively on 23 February 2020. Items of the WHO Trial Registration Data Set are provided in the supplementary file.

The incidence and patterns of gastric cancers in Sri Lanka from 2001 to 2012: Analysis of National Cancer Registry Data

OBJECTIVES

Varying patterns in incidence of gastric cancer (GC) have been reported globally. We aimed to examine the trends of GC incidence in Sri Lanka.

METHODS

All newly diagnosed patients with GC in Sri Lanka during 2001-2012 included in the National Cancer Registry were analyzed. Joinpoint regression analysis was used to determine the trends in incidence by age and gender. The minimum number of joinpoints were added to the model and statistical significance was checked using the Monte-Carlo permutation method.

RESULTS

Overall, 3353 (male : female = 2.7:1, mean age: 59.5 years) GCs were included in the analysis. Histology findings were available in 2835 patients. Of those, 14.3% (n = 404) were classified as nonspecified neoplasm/carcinoma. Of the remaining 2431 patients, majority (84.1%, n = 2044) were adenocarcinoma/its variants and 9.4% (n = 228) were squamous cell carcinoma. The WHO age-standardized incidence of GC was found to have significantly increased from 1.06 in 2001 (95% CI = 0.9-1.21) to 2.41/100 000 population in 2012 (95% CI = 2.2-2.61); with an estimated annual percentage change (EAPC) of 7.7 (95% CI = 6.1-9.4). Highest incidence of GC was seen in 65-69 year age group (8.2/100 000). The proportional rise in incidence was higher for females (from 0.5 to 1.36, EAPC: 9.0 [95% CI = 6.4-11.8], P < .05 for trend) compared with males (from 1.71 to 3.66, EAPC: 7.5 [95% CI = 5.5-9.6], P < .05 for trend).

CONCLUSIONS

A rise in the incidence of GC was noted in Sri Lanka during the period 2001-2012, which was predominately observed in females. A combination of true increase in incidence and improved reporting may have contributed to this increase. Future studies analyzing tumor characteristics and mortality would enable better understand the burden of GC and potential underlying reasons.

The incidence and patterns of colorectal cancers in Sri Lanka from 2001 to 2010: Analysis of national cancer registry data

OBJECTIVES

The incidence of colorectal cancer (CRC) has been increasing in many Asian countries. This study aims to analyse trends in CRC incidence and histological patterns in Sri Lanka.

METHODS

All newly diagnosed patients with CRC in Sri Lanka during 2001-2010 included in the National Cancer Registry were analysed for trends in incidence using Joinpoint regression software.

RESULTS

A total of 7,694 CRC (male:female = 1.02:1, mean age = 58.7 years) were analysed. The incidence of CRC in Sri Lanka has increased from a WHO age-standardised rate of 2.9/100,000 in 2001 (95%-confidence interval [95%-CI]: 2.64-3.16) to 6.08/100,000 in 2010 (95%-CI: 5.71-6.44). This is an estimated annual percentage change (EAPC) of 8.9 (95%-CI: 7.5-10.4). The proportional increase in incidence was observed to be greater for females (2.8 to 5.6, EAPC: 9.4 (95%-CI: 7.7-11.2), p < .05) than males (3.02 to 6.62, EAPC: 8.5 (95%-CI: 6.9-10.2), p < .05).

CONCLUSIONS

Similar to other Asian countries, a significant increase in the incidence of CRC was observed in Sri Lanka. Rate of the increase may have been artificially inflated due to better case reporting and diagnostic scrutiny. Future studies focussing on trends in tumour stage and fatality will help shed light on changing patterns in the burden of CRC in Sri Lanka.

Unusual Presentation of Bilateral Radiation-Induced Angiosarcoma of the Breast

Radiation-induced sarcoma of the breast is an iatrogenic malignancy that occurs secondary to radiotherapy, which is most commonly given following breast conservation surgery. It has an incidence of 3.2 per 1,000 patients at 15 years and is associated with a poor prognosis. We report a 62-year-old female with a history of bilateral breast conservation surgery and radiotherapy 5 years ago presenting with bilateral angiosarcoma. This case report highlights the importance of considering radiation-induced angiosarcoma of the breast as a differential diagnosis in a patient with recurrent breast neoplasms. The challenges in the management with recent evidence on new treatment modalities are discussed.

The Emergence of Breast Care Nursing in A Developing Nation: A Sri Lankan-Australian Training Partnership

Objective:

In Sri Lanka, the incidence of breast cancer is increasing. Yet, Sri Lankan nurses have limited specialist education opportunities and no formal recognition of the breast care nurse (BCN) role to address this growing need. This project aimed to encourage the emergence of the BCN role in Sri Lanka by delivering a workshop for nurses to increase the knowledge and confidence in delivering breast cancer care.

Methods:

This project was initiated by Zonta, a nonprofit, service organization, in collaboration with the National Cancer Control Programme of the Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka. A 2-day intensive workshop was designed by a collaborative team of Australian and Sri Lankan health professionals and delivered in Colombo. Its effectiveness was evaluated by measuring the knowledge about breast cancer, confidence with clinical care, and satisfaction with the workshop.

Results:

Fifty nursing participants attended the workshop. Outcomes included a statistically significant increase in knowledge about breast cancer (P = 0.012) and confidence in clinical care (P < 0.003 for all aspects of confidence). All participants were highly satisfied with the workshop, agreeing that the content was relevant and that they developed new skills.

Conclusions:

Nurses in Sri Lanka have unmet needs for specialty training and education. A 2-day workshop can improve knowledge and confidence, with the potential to improve patient care and increase the recognition of the BCN role. Lessons learnt from the collaboration between the nongovernment and government partners provide a model for the development of specialist nursing education.

Estimates of past and future time trends in age-specific breast cancer incidence among women in Karachi, Pakistan: 2004-2025

Background

The current demographic trends indicate that breast cancer will pose an even greater public health concern in future for Pakistan. Details on the incidence, disease severity and mortality in respect of breast cancer are limited and without such data, therefore, future health policies or systems in respect of this disease cannot be strategically planned or implemented. The aim of this study was to examine past trends of age-specific breast cancer incidence rates (2004–2015), and to estimate the future volume of breast cancer cases in Karachi through the year 2025.

Methods

Two statistical methods, namely the functional time series models and the log-linear regression model were used; additionally, their real forecasting efficacy in epidemic time series was also evaluated.

Results

In the past, women aged 60–64 years had the highest overall breast cancer incidence rates, while from 2016 to 2025, large increases in breast cancer rates among women aged 50 to 64 years are expected. The total projected breast cancer incidence will increase by approximately 23.1% in 2020 to 60.7% in 2025. Cases of breast cancer diagnosed in younger women, aged 30–34 years, will increase from 70.7 to 130.6% in 2020 and 2025 relative to 2015.

Conclusions

The breast cancer incidence appeared to have been rising more rapidly among post-menopausal women (aged 55 to 59), while a stable increase in incidence in the youngest age group (15–29 years) of women is expected. The results also infer an expected increase in incidence cases of breast cancer among middle aged women in Karachi, Pakistan. An increase in the number of incident cases of cancer has implications for understanding the health-care needs of growing population and the subsequent demands on health-care system.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7330-z) contains supplementary material, which is available to authorized users.

Novel mechanism of cannabidiol-induced apoptosis in breast cancer cell lines

Studies have emphasized an antineoplastic effect of the non-psychoactive, phyto-cannabinoid, Cannabidiol (CBD). However, the molecular mechanism underlying its antitumor activity is not fully elucidated. Herein, we have examined the effect of CBD on two different human breast cancer cell lines: the ER-positive, well differentiated, T-47D and the triple negative, poor differentiated, MDA-MB-231 cells. In both cell lines, CBD inhibited cell survival and induced apoptosis in a dose dependent manner as observed by MTT assay, morphological changes, DNA fragmentation and ELISA apoptosis assay. CBD-induced apoptosis was accompanied by down-regulation of mTOR, cyclin D1 and up-regulation and localization of PPARγ protein expression in the nuclei and cytoplasmic of the tested cells. The results suggest that CBD treatment induces an interplay among PPARγ, mTOR and cyclin D1 in favor of apoptosis induction in both ER-positive and triple negative breast cancer cells, proposing CBD as a useful treatment for different breast cancer subtypes.