Surgical Management of Breast Cancer in Africa: A Continent-Wide Review of Intervention Practices, Barriers to Care, and Adjuvant Therapy

Real-world breast cancer treatment patterns and guideline-concordant treatment completion among Malawian women

PURPOSE

In Sub-Saharan Africa (SSA), resource-stratified guidelines for breast cancer treatment are increasingly recommended, but treatment receipt and outcomes according to these guidelines are underreported. Here, we describe breast cancer treatment patterns by stage and curative-intent guideline-concordant treatment (GCT) receipt among Malawian women.

METHODS

A prospective cohort of breast cancer patients were enrolled from December 2016 to October 2018 at Kamuzu Central Hospital with an assessment of demographics, stage, and treatment received, including neoadjuvant (NAC), adjuvant (AdC) and palliative chemotherapy and breast surgery. Curative-intent GCT was defined as having completed breast surgery and at least 4 cycles of chemotherapy. Overall survival (OS) was calculated using Kaplan Meier methods and odds ratios using logistic regression.

RESULTS

91 patients were included, of whom 13 (14%) presented as stage II, 54 (59%) as stage III, and 24 (26%) as stage IV. Curative treatment was recommended for 65 of 91 (71%) patients, of whom 47 (72%) were initiated on NAC, 14 (22%) on upfront breast surgery, and 4 (6%) received no treatment. Only 63% (41/65) of patients received curative-intent GCT as recommended with non-GCT associated with stage III (vs. stage II) disease (OR 0.10 CI (0.01-0.89)), HIV positivity ((OR 0.25 CI (0.06-0.99)) and hormone receptor (HR) negative/HER2 positive subtype ((OR 0.07 CI (0.01-0.49)). Curative-intent GCT was associated with improved OS (44.1 vs. 23.2 months; p = 0.00) compared to non-GCT.

CONCLUSION

While curative-intent GCT was associated with improved survival in this Malawian cohort, treatment completion rates were suboptimal. Resource-stratified guidelines must be paired with locally relevant, multilevel implementation strategies to target barriers to treatment completion.

The patterns of presentation, management and outcomes of breast cancer patients at a tertiary health facility in Sierra Leone

BACKGROUND

Breast cancer is the leading cause of cancer among women globally and the most common cancer among women in Sierra Leone. This study aimed to evaluate the patterns of clinical presentation, management and outcomes among breast cancer patients who presented at the Connaught Teaching Hospital Complex in Sierra Leone.

METHOD

A retrospective, cross-sectional study was conducted at the specialist outpatient clinic at the Connaught Hospital. The medical records of 253 breast cancer patients were selected through convenience sampling on the basis of the completeness of their data from 2018 to 2021. The patients' sociodemographics, obstetrics-gynecological history, clinicopathological characteristics, treatment modalities, and outcomes were analysed via SPSS version 24.

RESULTS

Among the 253 patients with breast cancer, 246 (97.2%) were female, and the mean age of the patients was 47 ± 14 years. The mean age at menarche was 12 ± 3 years, and 35 (13.8%) patients had a family history of breast cancer. The left breast of 130 (51.2%) patients was the most commonly affected; approximately 119 (47%) patients presented with stage III B disease, and 35 (13.8%) presented with metastasis. With respect to treatment modalities, surgery, chemotherapy, and hormonal therapy were provided to patients - with 120 (48%) mastectomies, 73 (29.2%) neoadjuvant chemotherapy, 84 (33.6%) adjuvant chemotherapy, 98 (39.2%) hormonal therapy, 35 (14.0%) palliative care and approximately 38 (15.2%) refused or did not initiate any treatment. Among the outcomes of breast cancer patients, 19 (32.8%) was the highest mortality rate in 2019, and 10 (27.8%) was the lowest in 2018.

CONCLUSION

Our study revealed that over half of our breast cancer patients presented with advanced-stage disease, and mastectomy was the most common modality of treatment. Further studies are needed to understand the factors responsible for their late presentation and improve histological services and access to radiotherapy facilities for our patients.

Assessing the continuum of care in Sub-Saharan African hospitals performing surgery for breast cancer: a secondary analysis of the GlobalSurg 3 study

BACKGROUND

While breast cancer incidence rates in Sub-Saharan Africa (SSA) are among the lowest worldwide, mortality rates remain among the highest, reflecting particularly poor survival. Only a few studies in SSA have investigated the capabilities of treatment services to adequately provide a continuum of care for breast cancer. Our aim was to assess the availability of diagnostic facilities and adjuvant therapies in hospitals performing breast cancer surgery in SSA.

METHODS

We performed a secondary analysis of the GlobalSurg3 study data collected in the SSA region. The GlobalSurg 3 study is a multicenter, international, prospective, observational study of hospitals providing surgical services for cancer patients (including breast cancer) around the world. A total of 47 hospitals from 15 SSA countries and 43 cities were included between April 1, 2018, and Jan 31, 2019.

RESULTS

One-third of hospitals covered a population greater than two million (n = 17; 36.2%). Ultrasound was available in all hospitals; however, it was not consistently functional in 11 hospitals (23.4%). Only half of the included hospitals (n = 26, 55.3%) had access to a full-time pathologist, whilst the multidisciplinary team (MDT) approach was absent in 42.4% of hospitals. Radiotherapy equipment was only available in nine hospitals (19.1%). Only half of the hospitals (n = 25, 53.1%) had chemotherapy drugs available on site. In nine hospitals (19.1%), patients had to travel more than 50 km to access chemotherapy drugs.

CONCLUSIONS

Outcomes for breast cancer patients in SSA cannot be improved without significant investments in pathology, surgical and oncological treatment pathways to provide timely diagnostic and effective treatment.

Perioperative Analgesic Effect of Serratus Anterior Plane Block for Breast Surgery: A Randomized Control Study at a Large Teaching Hospital in Ghana

Background Pain after breast surgery has been described as moderate to severe in intensity and, if inadequately treated, increases postoperative morbidity, hospital cost, and the incidence of persistent postoperative pain. Serratus anterior plane (SAP) block is an interfascial injection technique for analgesia of the chest wall. There is a lack of data with regard to its analgesic and possible opioid-sparing effects in Sub-Saharan Africa. This study aimed to determine the perioperative analgesic effect of serratus anterior plane block administered for breast surgery. Methods This was a prospective, randomized, double-blinded study involving 52 patients and was randomized into the intervention (n = 26) and control (n = 26) groups. One patient in the control group did not receive the allocated intervention, while one in the intervention group lost to follow-up. Complete data of 50 participants, comprising intervention (n=25), was used in the analysis. Patients' demographic and health characteristics, pre-induction, intra-operative, and postoperative hemodynamic parameters were noted. After induction of anesthesia, a blinded anesthetist performed an ultrasound-guided serratus anterior plane block with 0.25% plain bupivacaine or a sham block using 0.9% normal saline (control). Numerical rating scale (NRS) score and incidence of postoperative nausea and vomiting (PONV) were recorded immediately after surgery and at 1, 4, 8, and 24 postoperative hours. Patient satisfaction with analgesic management within the first 24 postoperative hours was also assessed. Results Patients who received SAP block had lower NRS scores at all measured time points, but this was only statistically significant at the fourth postoperative hour (p-value = 0.002). Compared to controls, patients who received SAP had lower intraoperative (11.3±1.5 mg vs. 11.9±1.5 mg, p value = 0.131) and postoperative (4.6±5.7mg vs. 10.5±6 mg, p value=0.001) mean opioid consumption. However, only the reduction in postoperative opioid consumption was found to be statistically significant. Most participants (> 90%) in this study did not experience PONV and were very satisfied with their postoperative pain management. Conclusion Serratus anterior plane block reduces NRS pain scores postoperatively. It also significantly reduces postoperative opioid consumption but does not significantly reduce intraoperative opioid consumption.

Translating Evidence into Practice: A Review of Clinical Practice and Outcomes following the Adoption of an Early Post-Mastectomy Discharge Protocol in a Nigerian Hospital

Introduction

In Nigeria, mastectomy is the most common surgical treatment for breast cancer. Patients are often kept on admission for days until wound drains are removed. An early discharge programme was piloted in a Nigerian hospital in 2017 with very satisfactory outcomes. The impact of this evidence on clinical practice and surgical outcomes was evaluated over 5 years.

Methods

From a prospectively maintained institutional database, the details of patients who underwent mastectomy between 2018 and 2022 were obtained. The duration of post-operative stay was obtained and analysed per year to determine the trend. Post-operative surgical complications such as seroma, haematoma, flap necrosis, and surgical site infection were analysed.

Results

Overall, 147 patients (69%) had early discharge during the review period. Twenty-two patients (10.3%) were discharged within 24 h of surgery, 61 patients (28.6%) were discharged within 24-48 h, and 64 patients (30%) were discharged between 48 and 72 h. There was a steady increase in the adoption of the early discharge protocol over time with a 50% adoption rate in 2018 and 95% in 2022. The mean duration of hospital stay declined steadily from 3.9 days in 2018 to 2.2 days in 2022. Early discharge did not result in any compromise to post-operative outcomes.

Conclusion

This study demonstrates the sustainability of early post-mastectomy discharge in a resource-limited setting with very satisfactory outcomes. It also provides a unique example of how locally generated evidence can guide local practice. We consider these findings generalisable in other Nigerian hospitals and low- and middle-income countries with similar contexts.

Amazons in Mali? Women's experiences of breast cancer and gender (re)negotiation

Breast cancer is the second most common cancer, with more than 2.31 million cases diagnosed worldwide in 2022. Cancer medicine subjects the body to invasive procedures in the hope of offering a chance of recovery. In the course of treatment, the body is pricked, burned, incised and amputated, sometimes shattering identity and often changing the way women perceive the world. In sub-Saharan Africa, incidence rates are steadily increasing and women are particularly young when they develop breast cancer. Despite this alarming situation, the scientific literature on breast cancer in sub-Saharan Africa is poor and largely dominated by medical literature. Using a qualitative approach and a theoretical framework at the intersection of the sociology of gender and the sociology of the body, we explore the discourse strategies of women with breast cancer in Mali regarding their relationship to the body and to others. Based on 25 semi-directive interviews, we analyse the experiences of these women. Using the image of the Amazon woman, whose struggle has challenged gender because of its masculine attributes, we explore whether these women's fight against their breast cancer could be an opportunity to renegotiate gender relations. The experience of these women is characterised by the deconstruction of their bodies, pain and suffering. The masculinisation of their bodies and their inability to perform certain typically female functions in society (such as cooking or sexuality) challenges their female identity. The resistance observed through the sorority, discreet mobilisation and display of their bodies does not seem to be part of a renegotiation of gender relations, but it does play an active role in women's acceptance of the disease and their reconstruction.

Pharmacogenetics of tamoxifen in breast cancer patients of African descent: Lack of data

Tamoxifen, a selective estrogen receptor modulator, is used to treat hormone receptor-positive breast cancer. Tamoxifen acts as a prodrug, with its primary therapeutic effect mediated by its principal metabolite, endoxifen. However, tamoxifen has complex pharmacokinetics involving several drug-metabolizing enzymes and transporters influencing its disposition. Genes encoding enzymes involved in tamoxifen disposition exhibit genetic polymorphisms which vary widely across world populations. This review highlights the lack of data on tamoxifen pharmacogenetics among African populations. Gaps in data are described in this study with the purpose that future research can address this dearth of research on the pharmacogenetics of tamoxifen among African breast cancer patients. Initiatives such as the African Pharmacogenomics Network (APN) are crucial in promoting comprehensive pharmacogenetics studies to pinpoint important variants in pharmacogenes that could be used to reduce toxicity and improve efficacy.

Translation and psychometric assessment of the mastectomy module of the BREAST-Q questionnaire for use in Nigeria

BACKGROUND

The majority of non-metastatic breast cancer patients in sub-Saharan Africa are recommended to have mastectomy. The impact of mastectomy on a predominantly young African patient population requires evaluation. The BREAST-Q is a validated patient-reported outcome measure of quality-of-life following breast surgery that has been translated into 30 languages-none in Africa. This study aimed to translate and assess the psychometric properties of the mastectomy module of the BREAST-Q for use in Nigeria.

METHODS

The BREAST-Q mastectomy module was translated from English to Yoruba and its psychometric properties assessed using best practice guidelines. Translation was performed in 4 steps: forward translation (x2), back translation, back translation review, and cognitive interviews with post-mastectomy patients. The translated BREAST-Q instrument was administered to post-mastectomy patients (n = 21) alongside the EORTC-QLQ BR23 to evaluate construct validity. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC); surveys were re-administered 4 weeks apart.

RESULTS

The translation process identified English phrases not amenable to direct translation, including "emotionally healthy" and descriptions of pain ("nagging," "throbbing," "sharp"). Translations were amended to reflect local context and question intent. During cognitive interviews, patients provided suggestions to simplify complex phrases, e.g. "discomfort in your breast area.". Internal consistency within scales was over 0.70 for psychosocial wellbeing (α = 0.84-0.87), sexual wellbeing (α = 0.98-0.99), physical wellbeing in chest (α = 0.84-0.86), and satisfaction with care (α = 0.89-0.93). ICC for test-retest reliability was moderate (0.46-0.63).

CONCLUSIONS

The Yoruba version of the BREAST-Q mastectomy module presents a unique opportunity to adequately capture the experiences of Nigerian women post mastectomy. This instrument is being used in a pilot study of Nigerian patients to identify targets for intervention to improve the patient experience and compliance with breast cancer surgery.

"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.

Anticancer, Immunomodulatory, and Phytochemical Screening of Carthamus oxyacantha M.Bieb Growing in the North of Iraq

Carthamus oxyacantha M.Bieb is a promising repository of active phytochemicals. These bioactive compounds work synergistically to promote the plant's antioxidant, anticancer, and immunomodulatory capabilities. The present study aimed to discover the potential immunomodulatory and cytotoxicity of different extracts of Carthamus oxycantha roots. Aqueous ethanol (70%), aqueous methanol (90%), ethyl acetate, and n-hexane extracts were tested against five cell lines (T47D, MDA-MB231, Caco-2, EMT6/P, and Vero). Among these extracts, ethyl acetate and n-hexane extracts showed significant activity in inhibiting the proliferation of cancerous cells because of the presence of several phytochemical compounds, including flavonoids, phenolics, and alkaloids. The n-hexane extract was the most potent extract against T47D and Caco-2 cell lines and had IC50 values of 0.067 mg/mL and 0.067 mg/mL, respectively. In comparison, ethyl acetate extract was active against T47D and MDAMB231, and IC50 values were 0.0179 mg/mL and 0.03 mg/mL, respectively. Both n-hexane and ethyl acetate extracts reduced tumor size (by 49.981% and 51.028%, respectively). Remarkably, Carthamus oxyacantha extracts decreased the average weight of the tumor cells in the in vivo model. The plant induced significant apoptotic activity by the activation of caspase-3, immunomodulation of macrophages, and triggering of pinocytosis. The implications of these intriguing findings demand additional research to broaden the scope of the understanding of this field, opening the doors to the possibilities of using Carthamus oxyacantha M.Bieb as an effective cancer treatment adjuvant in the future.

Immediate lymph node extraction improves retrieval rate following axillary lymph node dissection: an effective approach to improving guideline-concordant breast cancer care in Nigeria

Background

Axillary lymph node staging is essential for making therapeutic decisions and for prognostication. A minimum of ten lymph nodes is recommended for accurate staging. This study describes the process and outcomes of an audit cycle that resulted in a novel intervention instituted to improve concordance with guidelines.

Methods

The study began with a retrospective audit of lymph node retrieval following axillary lymph node dissection (ALND). Subsequent phases evaluated the efficacy of immediate lymph node extraction before fixation by comparing the mean number of lymph nodes and the proportion of guideline-concordant cases to retrospective data and concurrent cases without the intervention.

Results

The mean number of lymph nodes retrieved in the retrospective phase was 5.2, which is less than the recommended threshold. The intervention resulted in a significant increase in lymph node retrieval over the baseline rate (13.7 versus 5.2, p = 0.026). There was also a significantly higher number of lymph nodes following the intervention compared to concurrent cases managed during the same period without the intervention (13.7 versus 7.9, p = 0.004). The concordance rate was 89% in the intervention group compared to 47% in the non-intervention group (p = 0.019). There was no significant difference when the intervention was administered by either surgeons or pathologists (13.5 versus 12, p = 0.25).

Conclusion

Immediate extraction of lymph nodes resulted in significant improvement of concordant lymph node retrieval in all phases of the study. We recommend that this practice be validated in larger cohorts for possible recommendation as an effective way of improving lymph node retrieval following ALND.

How Can Oncoplastic Breast Surgery Contribute to the Management of Locally Advanced Breast Cancer in Sub-Saharan Africa?

Background

Because of resource constrains in sub-Saharan African countries, breast-conserving surgery (BCS) has no role in patients with locally advanced breast cancer (LABC) following neoadjuvant chemotherapy (NACT), and mastectomy remains the standard surgical treatment for these patients.

Objectives

The first objective of the study was to assess the safety of oncoplastic BCS in patients with LABC who showed good clinical response to NACT in a breast center with enhanced level of resources in Sudan. The second objective was to assess the cosmetic outcome.

Patients and Methods

Two hundred and fifty patients with LABC were treated with NACT at Khartoum Breast Care Center during the period 2013-2019. Out of this, 52 patients were surgically treated with oncoplastic breast-conserving surgery. Kaplan-Meier curve was used to calculate the survival rates. The cosmetic outcome was subjectively assessed by the Harris scale.

Results

The median follow-up period was 53 months. The 3- and 5-years distant metastasis-free survival rates were 92.9% and 82.2%, respectively. One patient developed regional recurrence, and 6 patients developed distant metastasis. Eighty percentage of patients were admitted to have good to excellent cosmetic outcome.

Conclusion

This Sudanese experience showed that oncoplastic BCS is oncologically safe and aesthetically satisfactory in patients with LABC who demonstrated good clinical response to NACT in a setting with enhanced levels of resources for breast cancer care.

Has_circ_0048764 promotes breast cancer progression by sponging miR-578 and regulating HMGA2 expression

BACKGROUND

Circular RNAs (circRNAs) function as important regulators in the progression of cancers. The role of circRNA_0048764 (circ_0048764) in the development of breast cancer (BC) remains inconclusive. This work investigates the biological function and molecular mechanism of circ_0048764 in BC.

METHODS

Quantitative real-time PCR (qRT-PCR) was conducted to measure the expression levels of circ_0048764, microRNA-578 (miR-578) and high mobility group AT-hook 2 (HMGA2) mRNA. The viability of BC cells was examined by cell counting kit 8 (CCK-8) assay. Besides, cyclin D1, proliferating cell nuclear antigen (PCNA) and HMGA2 expression levels were detected by western blot. The migrative and invasive capability of BC cells were probed by transwell assay. The relationships between miR-578 and circ_0048764 or HMGA2 3'-UTR were validated by dual-luciferase reporter gene assay.

RESULTS

Circ_0048764 was highly expressed in BC tissues and cells, which was significantly associated with tumor size (≥2 cm), lymph node status (positive), and higher TNM stage of BC patients. Circ_0048764 depletion suppressed the proliferative, migrative, and invasive abilities of BC cells, which was rescued by transfection of miR-578 inhibitors. The binding sites were verified between circ_0048764 and miR-578. HMGA2 was identified to be a target of miR-578 in BC cells, and circ_0048764 positively regulated HMGA2 expression in BC cells via repressing miR-578.

CONCLUSION

Circ_0048764 promotes BC cell growth, migration and invasion via absorbing miR-578 and up-regulating HMGA2.

Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer

BACKGROUND

There are limited data on breast surgery completion rates and prevalence of care-continuum delays in breast cancer treatment programs in low-income countries.

METHODS

This study analyzes treatment data in a retrospective cohort of 312 female patients with non-metastatic breast cancer in Haiti. Descriptive statistics were used to summarize patient characteristics; treatments received; and treatment delays of > 12 weeks. Multivariate logistic regressions were performed to identify factors associated with receiving surgery and with treatment delays. Exploratory multivariate survival analysis examined the association between surgery delays and disease-free survival (DFS).

RESULTS

Of 312 patients, 249 (80%) completed breast surgery. The odds ratio (OR) for surgery completion for urban vs. rural dwellers was 2.15 (95% confidence interval [CI]: 1.19-3.88) and for those with locally advanced vs. early-stage disease was 0.34 (95%CI: 0.16-0.73). Among the 223 patients with evaluable surgery completion timelines, 96 (43%) experienced delays. Of the 221 patients eligible for adjuvant chemotherapy, 141 (64%) received adjuvant chemotherapy, 66 of whom (47%) experienced delays in chemotherapy initiation. Presentation in the later years of the cohort (2015-2016) was associated with lower rates of surgery completion (75% vs. 85%) and with delays in adjuvant chemotherapy initiation (OR [95%CI]: 3.25 [1.50-7.06]). Exploratory analysis revealed no association between surgical delays and DFS.

CONCLUSION

While majority of patients obtained curative-intent surgery, nearly half experienced delays in surgery and adjuvant chemotherapy initiation. Although our study was not powered to identify an association between surgical delays and DFS, these delays may negatively impact long-term outcomes.

GRWD1 affects the proliferation, apoptosis, invasion and migration of triple negative breast cancer through the Notch signaling pathway

Breast cancer is a highly heterogeneous tumor, among which triple negative breast cancer (TNBC) is the most invasive and prone to recurrence and metastasis. The present study aimed to investigate the regulatory mechanisms of glutamate-rich WD-repeat-containing protein 1 (GRWD1) in TNBC cells. The expression of GRWD1 in the normal human breast epithelial cells and human breast cancer cells was detected by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and western blot analysis. The transfection effects of small interfering RNA (siRNA)-GRWD1 and overexpression (Ov)-Notch1 were also confirmed by RT-qPCR and western blotting. The proliferation, apoptosis, invasion and migration of transfected cells were in turn analyzed by Cell Counting Kit-8, 5-Ethynyl-2'-deoxyuridine, Matrigel and wound healing assays. The expression of proteins related to proliferation, apoptosis, metastasis, epithelial-mesenchymal transition and the Notch signaling pathway was detected by western blotting. As a result, GRWD1 expression was upregulated in breast cancer cells and was revealed to be highest in MDA-MB-231 and HCC1937 cells. GRWD1 knockdown suppressed TNBC cell proliferation, invasion and migration and promoted TNBC cell apoptosis. Furthermore, the expression of Notch1 and Notch4 was inhibited by GRWD1 knockdown. The expression of downstream genes of the Notch signaling pathway Hes1, Hes5, Hey1, Hey2, p21, c-Myc, cyclin D1, human epidermal growth factor 2 receptor and NF-κB were all suppressed after siRNA-GRWD1 transfection. However, Notch1 overexpression reversed the effect of GRWD1 knockdown on biological behaviors of TNBC cells. In conclusion, GRWD1 knockdown could suppress the proliferation, invasion and migration and promoted apoptosis of TNBC cells through inhibiting the Notch signaling pathway.

The Impact of Breast Cancer Treatment Delays on Survival Among South African Women

BACKGROUND

In high-income settings, delays from breast cancer (BC) diagnosis to initial treatment worsen overall survival (OS). We examined how time to BC treatment initiation (TTI) impacts OS in South Africa (SA).

METHODS

We evaluated women enrolled in the South African BC and HIV Outcomes study between July 1, 2015 and June 30, 2019, selecting women with stages I-III BC who received surgery and chemotherapy. We constructed a linear regression model estimating the impact of sociodemographic and clinical factors on TTI and separate multivariable Cox proportional hazard models by first treatment (surgery and neoadjuvant chemotherapy (NAC)) assessing the effect of TTI (in 30-day increments) on OS.

RESULTS

Of 1260 women, 45.6% had upfront surgery, 54.4% had NAC, and 19.5% initiated treatment >90 days after BC diagnosis. Compared to the surgery group, more women in the NAC group had stage III BC (34.8% vs 81.5%). Living further away from a hospital and having hormone receptor positive (vs negative) BC was associated with longer TTI (8 additional days per 100 km, P = .003 and 8 additional days, P = .01, respectively), while Ki67 proliferation index >20 and upfront surgery (vs NAC) was associated with shorter TTI (12 and 9 days earlier; P = .0001 and.007, respectively). Treatment initiation also differed among treating hospitals (P < .0001). Additional 30-day treatment delays were associated with worse survival in the surgery group (HR 1.11 [95%CI 1.003-1.22]), but not in the NAC group.

CONCLUSIONS

Delays in BC treatment initiation are common in SA public hospitals and are associated with worse survival among women treated with upfront surgery.

Smurf2 suppresses the metastasis of hepatocellular carcinoma via ubiquitin degradation of Smad2

Purpose

Smurf2, one of C2-WW-HECT domain E3 ubiquitin ligases, is closely related to the development and progression in different cancer types, including hepatocellular carcinoma (HCC). This study aims to illustrate the expression and molecular mechanism of Smurf2 in regulating the progression of HCC.

Methods

The expression of Smurf2 in human HCC and adjacent non-tumor liver specimens was detected using tissue microarray studies from 220 HCC patients who underwent curative resection. The relationships of Smurf2 and HCC progression and survival were analyzed using the chi-square test, Kaplan–Meier analysis, and Cox proportional hazards model. For Smurf2 was low expression in HCC cell lines, Smurf2 overexpression cell lines were established. The effect of Smurf2 on cell proliferation and migration was detected by Cell Counting Kit-8 and colony formation assay, and the epithelial–mesenchymal transition (EMT) markers and its transcription factors were tested by immunoblotting. The interaction and ubiquitination of Smad2 by Smurf2 were detected by co-immunoprecipitation and immunoprecipitation assay. Finally, the effect of Smurf2 on HCC was verified using the mouse lung metastasis model.

Results

Smurf2 was downregulated in HCC tissues compared to that of corresponding non-tumor liver specimens. The low expression of Smurf2 in HCC was significantly associated with macrovascular or microvascular tumor thrombus and the impairment of overall survival and disease-free survival. In vitro and in vivo analysis showed that Smurf2 overexpression decreased the EMT potential of HCC cells by promoting the ubiquitination of Smad2 via the proteasome-dependent degradation pathway.

Conclusion

The expression of Smurf2 was downregulated in HCC specimens and affected the survival of patients. Smurf2 inhibited the EMT of HCC by enhancing Smad2 ubiquitin-dependent proteasome degradation.

Breast Cancer Diagnostics, Therapy, and Outcomes in Sub-Saharan Africa: A Population-Based Registry Study

BACKGROUND

Breast cancer (BC) is the most common cancer in sub-Saharan Africa (SSA). However, little is known about the actual therapy received by women with BC and their survival outcome at the population level in SSA. This study aims to describe the cancer-directed therapy received by patients with BC at the population level in SSA, compare these results with the NCCN Harmonized Guidelines for SSA (NCCN Harmonized Guidelines), and evaluate the impact on survival.

METHODS

Random samples of patients with BC (≥40 patients per registry), diagnosed from 2009 through 2015, were drawn from 11 urban population-based cancer registries from 10 countries (Benin, Congo, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mozambique, Namibia, Uganda, and Zimbabwe). Active methods were used to update the therapy and outcome data of diagnosed patients ("traced patients"). Excess hazards of death by therapy use were modeled in a relative survival context.

RESULTS

A total of 809 patients were included. Additional information was traced for 517 patients (63.8%), and this proportion varied by registry. One in 5 traced patients met the minimum diagnostic criteria (cancer stage and hormone receptor status known) for use of the NCCN Harmonized Guidelines. The hormone receptor status was unknown for 72.5% of patients. Of the traced patients with stage I-III BC (n=320), 50.9% received inadequate or no cancer-directed therapy. Access to therapy differed by registry area. Initiation of adequate therapy and early-stage diagnosis were the most important determinants of survival.

CONCLUSIONS

Downstaging BC and improving access to diagnostics and care are necessary steps to increase guideline adherence and improve survival for women in SSA. It will also be important to strengthen health systems and facilities for data management in SSA to facilitate patient follow-up and disease surveillance.

LncRNA SNHG1 promotes tumor progression and cisplatin resistance through epigenetically silencing miR-381 in breast cancer

The long-non-coding RNA (lncRNA) small nucleolar RNA host gene 1 (SNHG1) is a known cause of tumorigenesis. Nevertheless, it’s yet unclear how lncRNA SNHG1 influences breast cancer. Herein, we explored the mechanisms through which SNHG1 modulates breast cancer tumor progression. Our findings demonstrated that SNHG1 is significantly upregulated in breast cancer tissues and cells. High SNHG1 levels were closely linked to reduced survival rates in breast cancer patients. SNHG1 silencing has been shown to inhibit the proliferative, migratory, and invasive activity of breast cancer cells. Moreover, SNHG1 silencing enhanced cisplatin (DDP) sensitivity of these cells through improving DDP-induced cell apoptosis. Mechanistically, SNHG1 was found to interact with enhancer of zeste homolog 2 (EZH2), recruiting EZH2 to trigger trimethylation of histone H3 lysine 27 (H3K27me3), thus epigenetically inhibiting miR-381 transcription in these cells. Overexpression of miR-381 inhibited tumor progression and sensitized cells to the chemotherapeutic reagent DDP. More importantly, rescue experiments demonstrated that miR-381 inhibition could inverse the tumor-suppressive effect of SNHG1 silencing in breast cancer. In summary, SNHG1 silencing suppressed tumor progression and overcame breast cancer cell DDP resistance via the epigenetic suppression of miR-381 expression. Our study revealed that SNHG1 served as a novel therapeutic target for breast cancer chemoresistance.

Female breast cancer in sub-Saharan Africa: A PRISMA-S-compliant systematic review of surgery

BACKGROUND

In sub-Saharan countries (SSAs), the advanced stage at diagnosis and the limited surgical interventions of female breast cancer (FBC) lead to poor outcomes. This study assessed current modalities of FBC surgeries.

METHODS

Six literature databases (Medline, Embase, African Journal Online, Google Scholar, Web of Science, Cochrane Library) were searched, plus a manual search, in 2011-2021. We included primary data studies with any setting and presurgeries or postsurgeries treatments, we excluded non-English language studies, editorials, and grey literature.

RESULTS

The search yielded 21 observational studies (16 retrospective, 3 prospective, and 2 case reports). Of the total 6900 patients, 4121 (60%) patients underwent FBC surgical excision only, and 751/2779 (27%) conservative surgery (BCS) or therapy (BCT). All studies reported similar use of mastectomy (>60%), the FBC surgical excision/reconstruction studies displayed more neoadjuvant chemotherapy (536/2779, 19% vs. 215/4121, 5%), and radiotherapy or adjuvant radiotherapy (1461/2779, 52% vs. 411/3921, 4%). Patients' age, histological classification, staging, and follow-up data were often missing.

CONCLUSIONS

The FBC complexity requires structured management by general and plastic surgeons, radiotherapy specialists, and obstetrician-gynecologists through shared guidelines, protocols, and specific programs of public health. In SSAs, FBC surgical strategies should point at decreasing radical mastectomy and increasing BCS/BCT.

Premenopausal Breast Cancer Risk Factors and Associations with Molecular Subtypes: A Case-Control Study

Background

Breast cancer (BC) is the most prevalent cancer in women and the leading cause of women's cancer-related deaths and morbidity worldwide. In Rwanda, BC incidence is increasing with an unacceptably high mortality rate in premenopausal women.

Objectives

The purpose was to identify modifiable BC risk factors and assess associations between common breast cancer risks factors and molecular subtypes in premenopausal women in Rwanda.

Methods

This was a case-control study. Premenopausal women with histological confirmation of BC and frequency-matched for age controls were recruited. A preestablished questionnaire was administered to both cases and controls for sociodemographics, BC probable risk factors, and clinical and pathological characteristics. BC was classified into luminal A, luminal B, HER2-type, basal-like (triple negative), and unclassified molecular subtypes by immunohistochemistry (IHC). Odds ratio (OR) and 95% confidence interval (CI) were estimated using multivariate logistic regression analysis.

Results

340 participants were recruited into the study (170 cases vs. 170 controls). The median age was 39 years. The majority of cases presented at advanced stages of the disease (51.2% in stages III and IV) and had invasive ductal carcinoma (98.2%). 60.6% had subtypes of poor prognosis (HER2 enriched 14.7%, triple negative 12.9%, and unclassified 32.9%). Alcohol intake (AOR = 3.73, 95%CI 2.19 - 6.32, p < 0.001), obesity/overweight in adolescence or early adulthood (AOR = 10.86, 95%CI 4.82 - 24.4, p < 0.001), history of primary infertility (AOR = 33.8, 95%CI 3.5 - 321.5, p = 0.002), nulliparity (AOR = 3.75, 95%CI 1.61 - 8.75, p = 0.002), and a history of benign breast disease (AOR = 6.06, 95%CI 1.19 - 30.73, p = 0.03) were associated with the occurrence of premenopausal breast cancer. There was no significant difference between risk factor stratification per molecular subtype.

Conclusion

Several reproductive, environmental, and lifestyle risk factors have been identified to be associated with premenopausal BC. Among them, alcohol intake and obesity/overweight during adolescence/early adulthood can be modified. Interventions targeting alcohol consumption and obesity/overweight in adolescents and young adults may decrease the incidence of premenopausal breast cancer.

A review of breast cancer pathology reports in Nigeria

Background

Diagnosis and treatment of cancer rely heavily on imaging, histopathology and molecular information. Incomplete or missing tumour information can hinder the delivery of high-quality care in oncology practice, especially in resource-limited countries. To evaluate the completeness of histopathology reporting in a real-world setting and identify areas for future cancer care delivery research efforts, we retrospectively analysed reports from patients diagnosed with breast cancer who received care at a high-volume oncology department at a hospital in Lagos, Nigeria.

Methods

Demographic, institutional and histopathology characteristics were retrospectively obtained from 1,001 patient records from 2007 to 2016. Completeness was defined as reporting five tumour features (tumour histology, tumour grade, laterality, oestrogen receptor (ER) or progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2)) for biopsy specimens and seven tumour features (tumour size, tumour histology, tumour grade, laterality, ER/PR, HER2 and lymph node involvement) for surgical specimens.

Results

The mean age of patients was 48.6 ± 11.7 years with a predominantly female population (99.3%). A majority of pathologic reports were produced after 2011, and two-thirds of the reports originated from centres or labs within Lagos, Nigeria (67.7%). Most reports documented primary site (98.0%) and specimen type (85.0%) while other characteristics were less often recorded. This led to substantial variation in reporting between biopsy (13.4%) and surgical (6.1%) specimens for an overall low pathology report completeness <10%.

Conclusion

The majority of patient records analysed lacked complete documentation of breast cancer histopathological characteristics commonly used in oncology practice. Our study highlights a need to identify and address the contributing factors for incomplete histopathological reporting in Nigeria and will guide future clinical programmatic developments.

Limited access to care for persons with breast cancer in Africa: A systematic review

PURPOSE

To systematically review the available evidence and examine the factors that may limit patients' access to breast cancer care in Africa.

METHODS

We searched six databases (Google Scholar, Web of Science, PubMed, EMBASE, CINAHL, and Scopus) for studies conducted among breast cancer patients in Africa, highlighting patient challenges and barriers to care or treatment. The search was limited to studies published in the English language and from January 2000 until August 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. There were no limitations to the methodological design of the included studies.

RESULTS

In total, 18,154 articles were retrieved through electronic search; twenty-five were eligible for inclusion after quality appraisal. We analyzed the data using the deductive content analysis approach. Three categories emerged as barriers to breast cancer care: Socio-economic challenges, Institutional shortfalls, and Distinctiveness.

CONCLUSIONS

The findings support that economic hardships, fear, and scarcity of cancer treatments/equipment are critical in limiting access to breast cancer care. Sustainable strategies aimed at scaling-up breast cancer care in the region are necessary. The results also highlight the need for reduced treatment cost and aggressive educational campaigns across healthcare facilities and the local communities.

UBE2T promotes proliferation, invasion and glycolysis of breast cancer cells by regualting the PI3K/AKT signaling pathway

PURPOSE

Breast cancer (BCa) is one of the most common gynecological malignancies. Ubiquitin-coupled enzyme E2T (UBE2T) has been demonstrated to play crucial roles in various tumors.

METHODS

UBE2T levels were detected using quantitative real time PCR and western blot. CCK-8 and colony formation assays were used to evaluate cell proliferation. A xenograft model was used to evaluate the effects of UBE2T on tumor growth in mice, and immunohistochemistry (IHC) assay was performed to detect the expression of UBE2T and Ki-67. Transwell assay was performed to determine cell migration and invasion. The ATP level, glucose consumption and lactate production were measured using the corresponding commercial kits. Western blot assay was used to detect the levels of epithelial-mesenchymal transformation (EMT), glycolytic and the PI3K/AKT pathway related proteins regulated by UBE2T.

RESULTS

Upregulation of UBE2T expression in human BCa tissues was found in human clinical BCa tissues and The Cancer Genome Atlas (TCGA) dataset. The expression of UBE2T was confirmed to be up-regulated in BCa cells compared to normal breast epithelial cell line (MCF-10A). Overexpression of UBE2T promoted proliferation, migration, invasion and glycolysis in BCa cells, while UBE2T knockdown showed the opposite results. Moreover, UBE2T knockdown suppressed tumor growth in mice. Further mechanism analysis shows that UBE2T participated in the regulation of BCa progression through affecting the PI3K/AKT signaling pathway.

CONCLUSION

UBE2T promoted proliferation, invasion and glycolysis through modulating PI3K/AKT signaling pathway in BCa, implying that UBE2T may provide a promising therapeutic target for the therapy of BCa.

S100A6 promotes proliferation and migration of HepG2 cells via increased ubiquitin-dependent degradation of p53

Purpose

S100A6 protein (calcyclin), a small calcium-binding protein of the S100 family, is often upregulated in various types of cancers, including hepatocellular carcinoma (HCC). The aim of this study was to illustrate the molecular mechanism of S100A6 in regulating the proliferation and migration of HCC cells.

Methods

The expressions of S100A6 in human HCC and adjacent non-tumor liver specimens were detected using immunoblotting and quantitative PCR (qPCR). The recombinant glutathione S-transferase (GST)-tagged human S100A6 protein was purified and identified. After treatment with S100A6, the proliferation of HepG2 cells was detected by the MTT and colony formation assay, and the migration of HepG2 cells was investigated by the transwell migration assay; the protein levels of cyclin D1 (CCND1), E-cadherin, and vimentin were also tested by immunoblotting. The effect of S100A6 on p21 and nuclear factor-κB pathway was verified by performing the dual luciferase assay. Then, the expression of p21 and its transcription activator, p53, was examined using immunoblotting and qPCR, the ubiquitination of which was investigated through co-immunoprecipitation.

Results

It was found that the level of S100A6 was higher in the HCC tissues than in the adjacent non-tumor liver specimens. Exogenous overexpression of S100A6 promoted the proliferation and migration of HepG2 cells. S100A6 was observed to regulate p21 mRNA and protein expression levels and decrease p53 protein expression level, not mRNA level, by promoting the ubiquitination of p53 via the proteasome-dependent degradation pathway.

Conclusion

Our study indicated that S100A6 overexpression could promote the proliferation and migration of HCC cells by enhancing p53 ubiquitin-dependent proteasome degradation, ultimately regulating the p21 expression level.

Circ_0006528 Contributes to Paclitaxel Resistance of Breast Cancer Cells by Regulating miR-1299/CDK8 Axis

Background

Circular RNAs (circRNAs) have been reported to be involved in regulating the development of breast cancer. Paclitaxel (PTX) can be used for the chemotherapy of breast cancer. The study aimed to explore the role and mechanism of circ_0006528 in PTX-resistant breast cancer progression.

Methods

The levels of circ_0006528, microRNA-1299 (miR-1299) and cyclin-dependent kinase 8 (CDK8) were measured by quantitative real-time polymerase chain reaction (qRT-PCR). RNase R treatment was used to confirm that the circ_0006528 was a circular RNA. PTX resistance and cell proliferation were determined by Cell counting kit-8 (CCK-8) assay. Cell apoptosis, migration and invasion were analyzed by flow cytometry and Transwell assays, respectively. The levels of all proteins were examined by Western blot. The interaction between circ_0006528 and miR-1299 or CDK8 was predicted by online database confirmed by dual-luciferase reporter and RNA immunoprecipitation (RIP) assays. Xenograft mice model was constructed to reveal the role of circ_0006528 on tumor growth in vivo.

Results

Circ_0006528 was significantly up-regulated and miR-1299 was down-regulated in PTX-resistant breast cancer tissues and cells compared with control groups. CDK8 protein expression was dramatically upregulated in PTX-resistant breast cancer tissues and cells as compared to control groups. Loss-of-function experiments revealed that circ_0006528 knockdown decreased IC50 value of PTX and restrained proliferation, migration, invasion and autophagy, whereas induced apoptosis of PTX-resistant breast cancer cells in vitro. The inhibitory effects of sh-circ_0006528 on the progression of PTX-resistant breast cancer cells were reversed by decreasing miR-1299 or increasing CDK8 expression. Furthermore, circ_0006528 could modulate CDK8 expression by sponging miR-1299. Circ_0006528 silencing impeded the growth of PTX-resistant tumors by regulating miR-1299/CDK8 axis in vivo.

Conclusion

Circ_0006528 partially contributed to PTX resistance of breast cancer cells through up-regulating CDK8 expression by sponging miR-1299.

Socio-demographic, pattern of presentation and management outcome of breast cancer in a semi-urban tertiary health institution

Introduction

breast cancer is the most common malignancy in females worldwide and a major cause of cancer-related deaths in both developing and developed countries. The objective of this study was to determine the socio-demographics, pattern of presentation and management outcome of breast cancer patients.

Methods

clinical records of confirmed breast cancer patients between January 2011 and December 2015 at the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria were reviewed.

Results

eighty two breast cancer patients were seen. Their ages ranged from 26-95 years (mean 48.9 ± 14.9 years, median 47.5 years). Eighty one (98.8%) were females and the majority (65.4%) were premenopausal. The peak age of incidence was in the 4^th decade. All patients presented with breast lump with mean duration of 9.49±6.1 months and size ranging from 2 to 16cm (mean 7.9±3.4 cm). Ten (12.2%) patients presented early, 61 (74.4%) were locally advanced while 11 (13.4%) had distant metastases. Fifty one (62.2%) patients had mastectomy. Only 38 (46.3%) patients completed six courses of chemotherapy. None had immunohistochemistry but they all routinely took tamoxifen. Only 4 (4.9%) had radiotherapy. Nineteen (23.2%) died within a year of presentation. The follow-up period ranged between 1 and 44 months (mean, 10.3 months). Thirty one (37.8%), 19 (23.2%) and 8 (9.8%) patients were seen during the first, second and third year of follow up respectively.

Conclusion

breast cancer mostly affects young premenopausal women presenting in advanced stage in our setting. The generally poor outcome is not unconnected with late presentation and inadequate diagnostic and treatment facilities.

Circ-RNF111 contributes to paclitaxel resistance in breast cancer by elevating E2F3 expression via miR-140-5p

Background

Circular RNAs (circRNAs) have been demonstrated to act as key regulators in the chemoresistance of human cancers, including breast cancer (BC). Here, we aimed to explore the role of circ‐RNF111 in paclitaxel (PTX) resistance of BC.

Methods

Quantitative real‐time polymerase chain reaction (qRT‐PCR) was employed to determine the expression of circ‐RNF111, microRNA‐140‐5p (miR‐140‐5p) and E2F transcription factor 3 (E2F3) mRNA. The half maximal inhibitory concentration (IC₅₀) of PTX, cell viability, colony formation and cell invasion were assessed by cell counting kit‐8 (CCK‐8) assay, colony formation assay and transwell assay, respectively. Glucose consumption and lactate production were determined by specific kits. A murine xenograft model was established to investigate the role of circ‐RNF111 in PTX resistance of BC in vivo. Dual‐luciferase reporter assay and RNA immunoprecipitation (RIP) assay were performed to verify the relationship between miR‐140‐5p and circ‐RNF111 or E2F3. Western blot assay was conducted to examine the protein level of E2F3.

Results

Circ‐RNF111 was upregulated in PTX‐resistant BC tissues and cells. Circ‐RNF111 knockdown restrained IC₅₀ of PTX, cell viability, colony numbers, cell invasion and glycolysis in PTX‐resistant BC cells in vitro and enhanced PTX sensitivity in vivo. MiR‐140‐5p was a target of circ‐RNF111 and miR‐140‐5p expression was negatively correlated with circ‐RNF111 expression in BC tissues. The effect of circ‐RNF111 knockdown on PTX resistance was rescued by miR‐140‐5p deletion. Additionally, miR‐140‐5p could interact with E2F3 and negatively regulate E2F3 expression. Moreover, miR‐140‐5p suppressed IC₅₀ of PTX, cell viability, colony numbers, cell invasion and glycolysis by targeting E2F3.

Conclusions

Circ‐RNF111 improved PTX resistance of BC by upregulating E2F3 via sponging miR‐140‐5p.

Breast Cancer Care Quality in South Africa's Public Health System: An Evaluation Using American Society of Clinical Oncology/National Quality Forum Measures

PURPOSE

The quality of breast cancer care in sub-Saharan Africa contributes to the region’s dismal breast cancer mortality. ASCO has issued quality measures focusing on delivery of adjuvant chemotherapy, radiotherapy, and endocrine therapy. We applied these measures in five South African public hospitals and analyzed factors associated with care concordance.

MATERIALS AND METHODS

Among 1,736 women with breast cancer who were enrolled in the South African Breast Cancer and HIV Outcomes study over 24 months, we evaluated care using ASCO’s three measures. We also evaluated adjuvant chemotherapy receipt in 957 women with an indication. We used logistic regression to estimate associations between measure-concordant care and patient factors.

RESULTS

Of 235 women with hormone receptor–negative cancer, 173 (74%) began adjuvant chemotherapy within 120 days from diagnosis. Of 194 patients who received breast-conserving surgery, 73 (37%) began radiotherapy within 365 days from diagnosis. Of 999 women with hormone receptor–positive cancer, 719 (72%) initiated endocrine therapy within 365 days from diagnosis. Chemotherapy and radiotherapy measure-concordant care were more common among women residing < 20 km from the hospital (odds ratio [OR], 1.79; 95% CI, 1.32 to 2.44 and OR, 3.17; 95% CI, 1.57 to 6.42). Endocrine therapy measure-concordant care was more common among English-speaking women (OR, 2.12; 95% CI, 1.12 to 4.02). Participating hospitals varied in care concordance. HIV infection did not affect care quality.

CONCLUSION

More timely delivery of chemotherapy, radiotherapy, and endocrine therapy is needed in South Africa, particularly for women living > 20 km from the hospital or not speaking English. Focused quality improvement efforts could support that goal.

Overexpression of NuSAP1 is predictive of an unfavourable prognosis and promotes proliferation and invasion of triple-negative breast cancer cells via the Wnt/β-catenin/EMT signalling axis

OBJECTIVE

We analysed the effect of expression of nucleolar spindle-associated protein 1 (NuSAP1) on the prognosis of breast cancer (BC) and investigated its potential mechanism of tumourigenicity in triple-negative breast cancer (TNBC) cell lines.

MATERIALS AND METHODS

We downloaded the RNA-seq breast cancer (BC) data from The Cancer Genome Atlas (TCGA) and screened for the NuSAP1 gene using R software. The clinical data for patients with BC were screened and analysed using R software. A survival curve was drawn using the Kaplan-Meier Plotter. Cell proliferation and invasion were verified by the Cell Counting Kit-8 and Transwell assays. Expression of NuSAP1, the Wnt/β-catenin pathway, and epithelial-mesenchymal-transition-related proteins in TNBC was detected using real-time quantitative polymerase chain reaction (qRT-PCR) and western blotting (WB).

RESULTS

Expression of NuSAP1 was upregulated in BC. The change in NuSAP1 expression levels was associated with multiple clinicopathological factors, and the higher the expression of NuSAP1 was, the shorter the survival time. In MDA-MB-231 and BT549 cells, knockdown of NuSAP1 expression resulted in a significant decrease in cell proliferation and invasion; a decrease in expression of cyclin D1, vimentin, Slug, Twist, wnt3a, and pβ-catenin; and an increase in expression of e-cadherin. The results of the sh-NuSAP1 + ov-NuSPA1 group were the opposite of the results of the sh-NuSAP1 group.

CONCLUSION

NuSAP1 is a carcinogen that facilitates progression of TNBC through the Wnt/β-catenin and epithelial-mesenchymal transition pathways.

Patient Advocacy Approaches to Improving Care for Breast and Cervical Cancer in East and Southern Africa

PURPOSE

Breast and cervical cancer are the most common cancers among women in East and Southern Africa, where mortality remains high because of late diagnosis and limited access to treatment. We explored local approaches to breast and cervical cancer advocacy to identify the most pressing issues and opportunities for increasing the impact of civil society activities in the region.

METHODS

Focus group discussions were conducted with participants of the 2016 Women's Empowerment Cancer Advocacy Network (WE CAN) Summit in Nairobi, Kenya. Discussions were audio-recorded, transcribed, coded, and analyzed for emergent themes. Results were presented to participants of 2019 WE CAN summit for cross-validation.

RESULTS

Four focus group discussions were conducted with 50 participants. Thirty-six (70%) identified as advocates, 30 (59%) as cancer survivors, 14 (27%) as nongovernmental organization representatives, 13 (25%) as researchers, 4 (8%) as clinicians, and 6 (8%) as policymakers. Although most participants focused on cancer awareness and screening/early detection, some noted that treatment was often unavailable and advocated for a broader strategy to improving access to care. Challenges to designing and implementing such a strategy included knowledge gaps in addressing late diagnosis and access to care, difficulty collaborating with like-minded organizations, approaching policymakers, and addressing treatment financing. Cancer coalitions, although rare, were crucial to building collaborations with ministries of health, policymakers, and international organizations that advanced breast and cervical cancer care.

CONCLUSION

Participants indicated that they would benefit from additional training about resource-appropriate best practices for improving breast and cervical cancer care and outcomes. Coalition-building and collaborations, including with oncologists and other medical professionals involved in cancer care, were crucial to leveraging limited resources, sharing lessons learned, and developing local solutions to common challenges.

SNHG15 Contributes To Cisplatin Resistance In Breast Cancer Through Sponging miR-381

Background

Increasing evidence implies the participation of long non-coding RNAs (lncRNAs) in chemoresistance to cancer treatment. Their role and molecular mechanisms in breast cancer chemoresistance, nevertheless, are yet not considerably elucidated. In this work, we research the function of small nucleolar RNA host gene 15 (SNHG15) in cisplatin (DDP) resistance of breast cancer and uncover the underlying molecular mechanism.

Methods

SNHG15 and miR-381 expression levels were detected using Quantitative real-time PCR (qRT-PCR) analysis. The functional roles of SNHG15 and miR-381 in breast cancer were determined using MTT assay and flow cytometry analysis. The effect of SNHG15 on miR-381 expression was determined using Luciferase reporter assay, RNA immunoprecipitation (RIP) assay and qRT-PCR analysis.

Results

SNHG15 was found to be up-regulated in cisplatin resistant breast cancer tissues and cell lines. Breast cancer patients with high SNHG15 expression had a poor prognosis. SNHG15 silencing enhanced cisplatin sensitivity of MCF-7/DDP and MDA-MB-231/DDP cells. Additionally, SNHG15 could function as a miR-381 sponge. miR-381 overexpression could overcome cisplatin resistance. miR-381 knockdown countered SNHG15 knockdown-mediated enhancement of cisplatin sensitivity in MCF-7/DDP and MDA-MB-231/DDP cells. Besides, SNHG15 knockdown facilitated cisplatin sensitivity of cisplatin resistant breast cancer cells in vivo.

Conclusion

In summary, SNHG15 knockdown overcame cisplatin resistance of breast cancer by sponging miR-381, providing a novel therapeutic target for breast cancer.

Barriers to timely surgery for breast cancer in Rwanda

BACKGROUND

Ensuring timely and high-quality surgery must be a key element of breast cancer control efforts in sub-Saharan Africa. We investigated delays in preoperative care and the impact of on-site versus off-site operation on time to operative treatment of patients with breast cancer at Butaro Cancer Center of Excellence in Rwanda.

METHODS

We used a standardized data abstraction form to collect demographic data, clinical characteristics, treatments received, and disease status as of November 2017 for all patients diagnosed with breast cancer at Butaro Cancer Center of Excellence in 2014 to 2015.

RESULTS

From 2014 to 2015, 89 patients were diagnosed with stage I to III breast cancer and treated with curative intent. Of those, 68 (76%) underwent curative breast operations, 12 (14%) were lost to follow-up, 7 (8%) progressed, and 2 declined the recommended operation. Only 32% of patients who underwent operative treatment had the operation within 60 days from diagnosis or last neoadjuvant chemotherapy. Median time to operation was 122 days from biopsy if no neoadjuvant treatments were given and 51 days from last cycle of neoadjuvant chemotherapy. Patients who received no neoadjuvant chemotherapy experienced greater median times to operation at Butaro Cancer Center of Excellence (180 days) than at a referral hospital in Kigali (93 days, P = .04). Most patients (60%) experienced a disruption in preoperative care, frequently at the point of surgical referral. Documented reasons for disruptions and delays included patient factors, clinically indicated treatment modifications, and system factors.

CONCLUSION

We observed frequent delays to operative treatment, disruptions in preoperative care, and loss to follow-up, particularly at the point of surgical referral. There are opportunities to improve breast cancer survival in Rwanda and other low- and middle-income countries through interventions that facilitate more timely surgical care.

EZH2 Contributes To Cisplatin Resistance In Breast Cancer By Epigenetically Suppressing miR-381 Expression

BACKGROUND

Emerging evidence reveals the vital role of enhancer of zeste homolog 2 (EZH2) in cancer chemoresistance. However, its function and molecular mechanisms in breast cancer chemoresistance remain largely unknown.

METHODS

Gene expression was evaluated using quantitative real-time PCR (qRT-PCR) and Western blot analysis. The functional roles of EZH2 and miR-381 in breast cancer were explored using cell MTT assay and flow cytometry analysis. The effect of EZH2 on miR-381 expression in transcriptional level was determined using Chromatin immunoprecipitation (ChIP) assay and Luciferase reporter assay.

RESULTS

In this study, we found that EZH2 was up-regulated in CDDP-resistant breast cancer tissues and cell lines. Breast cancer patients with high EZH2 expression had a poor prognosis. EZH2 silencing improved the sensitivity of MCF-7/CDDP and MDA-MB-231/CDDP cells towards CDDP. Moreover, EZH2 could epigenetically silence miR-381. miR-381 overexpression could overcome CDDP resistance in CDDP-resistant breast cancer cells. miR-381 knockdown weakened the inductive effect of EZH2 silencing on CDDP sensitivity of MCF-7/CDDP and MDA-MB-231/CDDP cells. Furthermore, EZH2 knockdown facilitated CDDP sensitivity of CDDP-resistant breast cancer cells in vivo.

CONCLUSIONS

Collectively, EZH2 depletion overcame CDDP resistance of breast cancer through epigenetically silencing miR-381, providing a novel therapeutic target for breast cancer chemoresistance.

Downregulation of miR-302b is associated with poor prognosis and tumor progression of breast cancer

BACKGROUND

MicroRNAs (miRNAs) are well known to play crucial role in various types of cancers, including breast cancer (BC).

METHODS

The present study aimed to investigate the expression, clinical value, and functional role of miR-302b in BC. The expression level of miR-302b was determined by quantitative real-time polymerase chain reaction (qRT-PCR). The clinical value of miR-302b in BC prognosis was calculated via Kaplan-Meier survival analysis and Cox regression analysis. Cell experiments were applied to investigate the functional role of miR-302b in BC.

RESULTS

miR-302b was significantly downregulated in BC tissues and cell lines compared to the corresponding controls (all P < 0.01). Notably, the expression of miR-302b was significantly associated with lymph node metastasis and TNM stage (all P < 0.05). Patients with lower miR-302b expression had shorter survival time than those with higher miR-302b expression (log-rank P = 0.002). Furthermore, miR-302b expression and TNM stage were proven to be independent prognostic factors for BC. Overexpression of miR-302b inhibited BC cell proliferation, migration, and invasion in BT549 and MCF-7 cell lines, while silence of miR-302b exhibited an opposite effects on BC cells (all P < 0.05). RUNX2 was determined to be the target gene of miR-302b.

CONCLUSIONS

The present study suggests that miR-302b functions as a tumor suppressor in BC and inhibits the tumor progression of BC via targeting RUNX2. Downregulation of miR-302b might be a significant prognostic factor for poor survival in BC patients.

Inequities in breast cancer treatment in sub-Saharan Africa: findings from a prospective multi-country observational study

BACKGROUND

Improving breast cancer survival in sub-Saharan Africa (SSA) is urgently needed, requiring early diagnosis and improved access to treatment. However, data on the types of and barriers to receiving breast cancer therapy in this region are limited and have not been compared between different SSA countries and treatment settings.

METHODS

In different health care settings across Uganda, Nigeria and Namibian sites of the prospective African Breast Cancer - Disparities in Outcomes cohort study, we assessed the percentage of newly diagnosed breast cancer patients who received treatment (systemic, surgery and/or radiotherapy) for cancer and their socio-demographic and clinical determinants. Treatment data were systematically extracted from medical records, as well as self-reported by women during 6-month follow-up interviews, and were used to generate a binary indicator of treatment received within 12 months of diagnosis (yes/no), which was analysed via logistic regression.

RESULTS

Of 1325 women, cancer treatment had not been initiated treatment within 1 year of diagnosis for 227 (17%) women and 185 (14%) of women with stage I-III disease. Untreated percentages were highest in two Nigerian regional hospitals where 38% of 314 women were not treated (32% among stage I-III). At a national referral hospital in Uganda, 18% of 430 women were not treated (15% among stage I-III). In contrast, at a cancer care centre in Windhoek, Namibia, where treatment is provided free to the patient, all non-black (100%) and almost all (98.7%) black women had initiated treatment. Percentages of untreated women were higher in women from lower socio-economic groups, women who believed in traditional medicine and, in Uganda, in HIV+ women. Self-reported treatment barriers confirmed treatment costs and treatment refusal as contributors to not receiving treatment.

CONCLUSIONS

Financial support to ensure treatment access and education of treatment benefits are needed to improve treatment access for breast cancer patients across sub-Saharan Africa, especially at regional treatment centres, for lower socio-economic groups, and for the HIV-positive woman with breast cancer.

Breast cancer care in Uganda: A multicenter study on the frequency of breast cancer surgery in relation to the incidence of breast cancer

Background

Breast cancer is the most common cancer in women worldwide. Considerable funding and efforts are invested in breast cancer research and healthcare, but only a fraction of this reaches women and healthcare systems in low income countries. Surgical treatment is an essential part of breast cancer care, but access to surgery is in general very limited in low income countries such as Uganda. In this study, the previously unknown nationwide rate of breast cancer surgery was investigated.

Methods and findings

This was a multicenter, retrospective study, investigating breast cancer surgery in the public healthcare system in Uganda. Data were collected from operating theater registries at primary, secondary and tertiary level healthcare centres throught the country, including 14 general hospitals, the 14 regional referral hospitals and the national referral hospital. Patients who underwent major surgery for breast cancer at these hospitals during 2013 and 2014 were included. The number of breast cancer procedures performed, geographical variation, level of healthcare staff performing surgery and patient characteristics were investigated. After correction for missing data, a total of 137 breast cancer procedures were performed each year within the public healthcare system, corresponding to 5.7% of the breast cancer incidence in the country at that time. Most procedures (n = 161, 59.0%) were performed at the national referral hospital by qualified surgeons. Many of the patients were young; 30.1% being less than 40 years old. The proportion of male breast cancers in the study was large (6.2%).

Conclusions

The rate of breast cancer surgery in Uganda is minimal and in several parts of the country breast cancer surgery is not performed at all. More resources must be directed towards breast cancer in low income countries such as Uganda. The fact that the patients were young calls for further research, prevention and treatment specifically targeting young women in the study setting.

miR-381 overcomes cisplatin resistance in breast cancer by targeting MDR1

Increasing evidence suggests the involvement of microRNA-381 (miR-381) in chemoresistance of cancer treatment. However, its function and molecular mechanisms in breast cancer chemoresistance are still not well elucidated. In the present study, we aimed to investigate the functional role of miR-381 in cisplatin (DDP) resistance of breast cancer and discover the underlying molecular mechanism. The expression levels of miR-381 and MDR1 were detected by quantitative real-time PCR (qRT-PCR) and Western blot analysis in breast cancer tissues and cell lines. The DDP sensitivity and cell apoptosis of breast cancer cells were determined by MTT assay and flow cytometric analysis, respectively. The relationship between miR-381 and MDR1 was explored by target prediction and luciferase reporter analysis. miR-381 was decreased in DDP-resistant breast cancer tissues and cell lines. Low miR-381 expression was correlated with poor prognosis of breast cancer patients. miR-381 overexpression improved DDP sensitivity of MCF-7/DDP and MDA-MB-231/DDP cells. Conversely, miR-381 inhibition lowered the response of MCF-7 and MDA-MB-231 to DPP. Moreover, miR-381 could directly suppress multidrug resistance 1 (MDR1) expression. MDR1 knockdown could overcome DDP resistance in MCF-7/DDP and MDA-MB-231/DDP cells, while MDR1 overexpression led to DDP resistance in MCF-7 and MDA-MB-231 cells. Notably, MDR1 overexpression counteracted the inductive effect of miR-381 mimics on DDP sensitivity of MCF-7/DDP and MDA-MB-231/DDP cells. On the contrary, miR-381 inhibition-mediated DDP resistance in MCF-7 and MDA-MB-231 cells was reversed by MDR1 knockdown. In summary, miR-381 could overcome DDP resistance of breast cancer by directly targeting MDR1, providing a novel therapeutic target for breast cancer chemoresistance.

A Community-Based Assessment of Knowledge and Practice of Breast Self-Examination and Prevalence of Breast Disease in Southwest Cameroon

INTRODUCTION

Despite the rising trend in breast cancer incidence and mortality across Sub-Saharan Africa, there remains a critical knowledge gap about the burden and patterns of breast disease and breast cancer screening practices at the population level. This study aimed to identify socioeconomic factors associated with knowledge and practice of breast self-examination (BSE) as well as assess the prevalence of breast disease symptoms among a mixed urban-rural population of women in the Southwest region of Cameroon.

METHODS

We conducted a household-level community-based study in Southwest Cameroon between January and March 2017, using a three-stage cluster sampling framework. We surveyed 1287 households and collected self-reported data on 4208 female subjects, 790 of whom were household representatives. Each household representative provided information on behalf of all female household members about any ongoing breast disease symptoms. Moreover, female household representatives were questioned about their own knowledge and practice of BSE.

RESULTS

Women demonstrated low frequency of knowledge of BSE, as 25% (n=201) of household representatives reported any knowledge of BSE; and among these only 15% (n=30) practiced BSE on a monthly basis. Age (aOR: 1.04), usage of Liquid Petroleum Gas fuel, a marker of higher socioeconomic status (aOR: 1.86), and speaking English as a primary language in the household (aOR: 1.59) were significant predictors of knowledge of BSE. Eleven women reported ongoing breast disease symptoms resulting in an overall prevalence of 2.3 cases of breast disease symptoms per 1000 women.

CONCLUSIONS

Socioeconomic disparities in access to health education may be a determinant of knowledge of BSE. Community-based strategies are needed to improve dissemination of breast cancer screening methods, particularly for women who face barriers to accessing care.

Unraveling the South African Breast Cancer Story: The Relationship of Patients, Delay to Diagnosis, and Tumor Biology With Stage at Presentation in an Urban Setting

BACKGROUND

Adverse outcomes from breast cancer disproportionately affect women in sub-Saharan Africa, with delay the most studied contribution to advanced stage at presentation. However, tumor molecular biology and its contribution to advanced stage are yet to be explored.

MATERIALS AND METHODS

Patients newly diagnosed with breast cancer in a South African tertiary breast center completed a questionnaire and file review concerning socioeconomics, delay to care, stage at presentation, and molecular characteristics. Logistic regression was done to determine the relative risk of advanced stage presentation.

RESULTS

Advanced stage was present in 70.1% (n = 162) of the 231 participants, with 55.8% stage III (n = 129) and 32% (n = 72) having a T4 tumor. The median age was 56 y with 21.6% (n = 47) aged <45 y. Most common subtype was luminal B (57.7%, n = 128) followed by luminal A (21.6%, n = 48), triple negative (13.9%, n = 31), and HER2 positive (6.7%, n = 15). Lobular cancer (incidence risk ratio [IRR], 1.29; 95% confidence interval [CI], 1.03-1.62), high grade and intermediate grade tumors (IRR, 1.90; 95% CI, 1.15-3.13 and IRR, 1.95; 95% CI, 1.18-3.22, respectively), high Ki67 proliferation index (IRR, 1.30; 95% CI, 1.02-1.66), and HER2 overexpression (IRR, 1.32; 95% CI, 1.12-1.55) were more likely to present with advanced disease, as were luminal B (HER2+) cancers (adjusted IRR [aIRR], 1.46; 95% CI, 1.10-1.95). Although on univariate analysis Black and young participants were both more likely to have advanced stage (IRR, 1.23; 95% CI, 1.01-1.49 and IRR, 1.25; 95% CI, 1.04-1.51, respectively), in multivariate analysis controlling for tumor biology and delay, these were no longer significant (aIRR, 1.12; 95% CI, 0.91-1.37 and aIRR, 1.17; 95% CI, 0.94-1.48, respectively).

CONCLUSIONS

Tumor biology has a compelling role in the etiology of advanced-stage disease irrespective of socioeconomic factors. Accurate pathologic assessment is important in planning breast cancer care in Africa.

Long non-coding RNA FTH1P3 activates paclitaxel resistance in breast cancer through miR-206/ABCB1

Emerging evidence has indicated the important function of long non-coding RNAs (lncRNAs) in tumour chemotherapy resistance. However, the underlying mechanism is still ambiguous. In this study, we investigate the physiopathologic role of lncRNA ferritin heavy chain 1 pseudogene 3 (FTH1P3) on the paclitaxel (PTX) resistance in breast cancer. Results showed that lncRNA FTH1P3 was up-regulated in paclitaxel-resistant breast cancer tissue and cells (MCF-7/PTX and MDA-MB-231/PTX cells) compared with paclitaxel-sensitive tissue and parental cell lines (MCF-7, MDA-MB-231). Gain- and loss-of-function experiments revealed that FTH1P3 silencing decreased the 50% inhibitory concentration (IC50) value of paclitaxel and induced cell cycle arrest at G2/M phase, while FTH1P3-enhanced expression exerted the opposite effects. In vivo, xenograft mice assay showed that FTH1P3 silencing suppressed the tumour growth of paclitaxel-resistant breast cancer cells and ABCB1 protein expression. Bioinformatics tools and luciferase reporter assay validated that FTH1P3 promoted ABCB1 protein expression through targeting miR-206, acting as a miRNA "sponge." In summary, our results reveal the potential regulatory mechanism of FTH1P3 on breast cancer paclitaxel resistance through miR-206/ABCB1, providing a novel insight for the breast cancer chemoresistance.

Development of multi-disciplinary breast cancer care in Southern Malawi

The Edinburgh Malawi Breast Cancer Project, a collaborative partnership project between the Queen Elizabeth Central Hospital (QECH) Oncology Unit, Blantyre, Malawi and the Edinburgh Cancer Centre, UK, was established in 2015. The principal objective of the project is to help to develop high quality multi-disciplinary breast cancer care in Malawi. A needs assessment identified three priority areas for further improvement of breast cancer services: multi-disciplinary working, development of oestrogen receptor (ER) testing and management of clinical data. A 3-year project plan was implemented which has been conducted through a series of reciprocal training visits. Key achievements to date have been: (1) Development of a new specialist breast care nursing role; (2) Development of multi-disciplinary meetings; (3) Completion of a programme of oncology nursing education; (4) Development of a clinical database that enables prospective collection of data of all new patients with breast cancer; (5) Training of local staff in molecular and conventional approaches to ER testing. The Edinburgh Malawi Breast Cancer Project is supporting nursing education, data use and cross-specialty collaboration that we are confident will improve cancer care in Malawi. Future work will include the development of a breast cancer diagnostic clinic and a breast cancer registry.