Barriers to early presentation of breast cancer among women in Soweto, South Africa

Breast Cancer Clinical Characteristics, Management, and Outcomes in Women Living With HIV/AIDS Globally: A Systematic Review and Meta-Analysis

Although associations between HIV and breast cancer (BC) have been investigated, the global literature remains inconsistent regarding clinical features and outcomes in HIV-positive patients. This study aims to clarify the clinicopathologic characteristics, management strategies, and survival in HIV-positive versus HIV-negative patients with BC. We searched PubMed, Scopus, and Cochrane Library for articles published until June 2023. We included observational studies presenting original data on tumor stage, receptor status, management, and survival in HIV-infected patients. We retrieved 5214 records and, after abstract and full-text screening, identified 17 papers that met inclusion criteria. Risk of bias and study quality were assessed with a modified Newcastle-Ottawa Scale. The I2 statistic was used to assess inter-study heterogeneity. Results were analyzed using a random-effects model. A total of 1201 HIV-positive and 4077 HIV-negative patients diagnosed with BC were identified. No significant differences in receptor status or stage at presentation were observed between the two groups in our pooled analysis. Management in HIV-positive patients was similar to HIV-negative for surgery (pooled odds ratio [pOR]: 1.43, 95% confidence interval [CI]: 0.82-2.04), radiation (pOR: 1.63, 95% CI 0.84-2.43), and chemotherapy (pOR: 1.27, 95% CI: 0.72-1.83). Despite presenting with similar clinicopathologic characteristics and management patterns as HIV-negative, HIV-positive patients had worse overall survival (pooled hazard ratio: 1.51, 95% CI: 1.21-1.88). Further research is needed to optimize treatment strategies and establish standardized guidelines for HIV-positive patients with BC, particularly in resource-limited settings where a high HIV burden and barriers to timely cancer care access may contribute to poor survival outcomes.

Time to pathologic diagnosis of suspicious breast lesions: An institution-based study in five Ethiopian hospitals

Most breast cancer (BC) patients in sub-Saharan Africa are diagnosed at advanced stages. The World Health Organization's Global Breast Cancer Initiative Pillar II has a benchmark to diagnose BC within 2 months of the first contact with a health care provider (HCP). In this study, we interviewed 345 women who received a diagnostic workup of a suspicious breast lesion (eventually diagnosed as benign or malignant) at five Ethiopian hospitals in 2022. We assessed the length of the diagnostic journey encompassing the pre-contact interval between the first experience of symptoms and the first HCP visit, and the post-contact interval between HCP visit and diagnostic pathology procedures. We used negative binomial regression models to identify factors influencing these time intervals. The median pre-contact interval was 2.8 months (interquartile range [IQR] 0.5-9.8). The median post-contact interval was 1.7 months (IQR 0.6-3.9). Regarding the post-contact interval, 55% of patients received their pathologic diagnosis within the recommended 2 months after the first HCP visit and met the Global Breast Cancer Initiative's benchmark. Increased travel times, limited social support, and consulting multiple HCPs before seeking pathology evaluation prolonged post-contact intervals. Older patients (>45 years) and those referred for pathology evaluation during the initial HCP visit experienced shorter post-contact intervals. Of all 345 women, 39% were diagnosed with BC. The relatively low proportion of women diagnosed within the recommended time frame makes it evident that increased awareness for BC, easily accessible diagnostic services, and specific training for HCPs are essential for the timely diagnosis of BC in Ethiopia.

Predictors of advanced-stage presentation among patients with a diagnosis of breast and cervical cancer in Ethiopia

BACKGROUND

Breast and cervical cancers are the most common causes of cancer incidence and mortality in women in Africa. Women with breast and cervical cancers in Sub-Saharan Africa are frequently diagnosed with their disease at advanced stages. Delays in seeking health, diagnosis, and treatment are contributing factors to high mortality in Ethiopia. This study aimed to assess predictors of advanced stage presentation among patients with breast and cervical cancer attending public hospitals in Addis Ababa, Ethiopia.

METHODS

A cross-sectional study was conducted with a total of 418 patients at Tikur Anbessa specialized hospital and Saint Pauls' Hospital Millennium Medical College from October to November 2021. Stages III and IV were considered advanced stages. Data were collected by reviewing medical records and face-to-face interviews with a structured questionnaire. Bivariate and multivariable analyses were performed to examine the association between independent and outcome variables.

RESULTS

A total of 269 patients with breast cancer and 149 patients with cervical cancer were included in the study, and the mean age was 44 years (SD = 10.9 years) and 50 years (SD = 11.2) years, respectively. About 66.9% of breast cancers and 71.1% of cervical cancers were diagnosed at an advanced disease stage. Rural residence (adjusted odds ratio [AOR] = 2.041, 95% CI, 1.108-3.758), indirect referral (AOR = 3.8, 95% CI, 1.485-9.946), financial difficulty (AOR = 10, 95% CI,1.859-56.495), and cancer screening recommended during their visit (AOR = 4.029 95% CI, 1.658-10.102) were independent predictors of advanced-stage presentation.

CONCLUSIONS

This study revealed a high prevalence of advanced-stage breast and cervical cancer diagnosis in Ethiopia, like data collected 10 years ago, despite the introduction of a cancer control plan in 2015. For better implementation, interventions should aim to improve referral pathways, adapt screening and early detection services, and increase cancer awareness at the community level in a culturally accepted way.

Comparison of Ante-Mortem Clinical Diagnosis and Final Autopsy Diagnosis: Experience from a Single Academic Centre in Pretoria, South Africa

Background/Objectives: There seems to be a global reduction in the number of clinical post-mortems requested and performed worldwide, suggesting a decreasing need for post-mortem examinations. Despite advances in medical technology, autopsies remain a relevant tool to determine cause of death. Methods: A total of 276 post-mortem results were extracted from the NHLS lab track database, of which only 152 were included in this study. Discrepancies between ante and post-mortem diagnoses were evaluated using the Goldman classification. Data were analysed using STATA-18. Results: The sample consisted largely of females (n = 101, 66.45%) aged 30 and above (n = 58, 33.80%), with a mean age of 28.3. Of the 152 samples analysed, 60% (n = 92) of all postmortems showed a correlation between ante- and post-mortem diagnoses. However, 29.1% (n = 45) of cases showed major discrepancies which could have been prevented if correct diagnoses were made. Metabolic diseases were most frequently misdiagnosed (p = 0.020), with more cases of Class I discrepancies than Class V discrepancies (15.5% (n = 7) vs. 2.1% (n = 2), respectively. Additionally, infections (n = 59; 39%) were the most common cause of death. Conclusions: Even with marked improvements in diagnostic technology, a post-mortem examination is a necessary quality control tool that can be used to verify cause of death, and thus improve clinical practice.

Breast cancer in women by HIV status: A report from the South African National Cancer Registry

BACKGROUND

Breast cancer (BC) is the leading cause of cancer-related morbidity and mortality in women living in South Africa, a country with a high HIV burden. However, characteristics of the double burden of HIV and BC in South Africa have not been properly investigated. We described characteristics of BC cases by HIV status in South Africa.

METHODS

In this nationwide South African study, we obtained BC records for women aged ≥15 years diagnosed in the public health sector between January 2004 and December 2014. We included records from the National Cancer Registry that had been linked to HIV-related laboratory records from the National Health Laboratory Service. We assessed the odds of being HIV positive versus HIV negative in relation to patient-, cancer-, and municipality-related characteristics.

RESULTS

From 2004-2014, 40 520 BC cases were diagnosed in women aged ≥15 years. Of these, 73.5% had unknown HIV status, 18.7% were HIV negative, and 7.7% were HIV positive. The median age at BC diagnosis was 43 years (interquartile range [IQR]: 37-52) in HIV positive and 57 years (IQR: 46-68) in HIV negative women, respectively. The odds of being HIV positive was higher for women who were aged 30-34 years compared to women aged 35-39 years at cancer diagnosis (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.10-1.71), Black versus non-Black (OR 6.41, 95% CI 5.68-7.23), diagnosed with cancer in rural versus urban areas (OR 1.59, 95% CI 1.40-1.82) and diagnosed in municipalities with low and middle (OR 3.46, 95% CI 2.48-4.82) versus high socioeconomic position (OR 2.69, 95% CI 2.11-3.42).

CONCLUSION

HIV status was unknown for the majority of BC patients. Among those with known HIV status, being HIV positive was associated with a younger age at cancer diagnosis, being Black and receiving care in municipalities of poor socioeconomic position. Future studies should examine opportunities to integrate HIV and BC control programs.

Caring for cancer patients in acute cancer care settings: Voices of South African nurses

Little is known about the experience of nurses in Africa caring for cancer patients. This study was undertaken to provide a straightforward description of the experiences of South African nurses caring for patients in acute cancer care settings. Purposive sampling selected 20 nurses with whom there were in-depth interviews. Most of the participants were female registered oncology nurses with more than five years' experience. Three themes were identified: defining the cancer nursing experience, the challenges experienced in caring for cancer patients, and challenges imposed by the healthcare system. Most of the participants believed they were called by God to care for cancer patients. However, the challenges they experienced led to guilt feelings and believing the care they provided was insufficient. They were subjected to workplace violence, missed the support from senior nursing management, and displayed signs of burnout. Addressing these challenges could limit their emotional distress and prevent burnout.

S’occuper des patients atteints de cancer : l’expérience d’infirmières et d’infirmiers d’Afrique du Sud travaillant en soins aigus

On sait peu de choses de l’expérience des infirmières et infirmiers d’Afrique du Sud qui soignent les patients atteints de cancer. La présente étude avait pour but de décrire en termes simples l’expérience du personnel infirmier travaillant dans les milieux de soins aigus. Par échantillonnage dirigé, on a sélectionné 20 infirmières et infirmiers qui ont ensuite passé des entrevues détaillées. Il s’agissait pour la plupart de femmes, infirmières autorisées en oncologie, ayant plus de 5 ans d’expérience. Trois thèmes sont ressortis des discussions : la définition de l’expérience des soins infirmiers oncologiques, les difficultés de la prestation de soins aux patients atteints de cancer, et les problèmes attribuables au système de santé. Pour la plupart, les personnes ayant participé à l’étude croyaient que Dieu les avait appelées à travailler auprès des patients atteints de cancer. Toutefois, à cause des difficultés vécues, elles se sentaient coupables et n’avaient pas l’impression de donner des soins adéquats. En outre, elles étaient victimes de violence dans leur milieu de travail, ne bénéficiaient pas du soutien des cadres de gestion des soins infirmiers, et montraient des signes d’épuisement professionnel. Pour réduire la détresse émotionnelle et prévenir l’épuisement, il faudra trouver une solution à ces problèmes.

The South African breast cancer and HIV outcomes study: Profiling the cancer centres and cohort characteristics, diagnostic pathways, and treatment approaches

The South African Breast Cancer and HIV Outcomes prospective cohort (SABCHO) study was established to investigate survival determinants among HIV-positive and HIV-negative SA women with breast cancer. This paper describes common and unique characteristics of the cancer centres and their participants, examining disparities in pathways to diagnosis, treatment resources and approaches adopted to mitigate resource constraints. The Johannesburg (Jhb), Soweto (Sow), and Durban (Dbn) sites treat mainly urban, relatively better educated and more socioeconomically advantaged patients whereas the Pietermaritzburg (Pmb) and Empangeni (Emp) sites treat predominantly rural, less educated and more impoverished communities The Sow, Jhb, and Emp sites had relatively younger patients (mean ages 54 ±14.5, 55±13.7 and 54±14.3 respectively), whereas patients at the Dbn and Pmb sites, with greater representation of Asian Indian women, were relatively older (mean age 57 ±13.9 and 58 ±14.6 respectively). HIV prevalence among the cohort was high, ranging from 15%-42%, (Cohort obesity (BMI ≥ 30 kg/m2) at 60%, self-reported hypertension (41%) and diabetes (13%). Direct referral of patients from primary care clinics to cancer centre occurred only at the Sow site which uniquely ran an open clinic and where early stage (I and II) proportions were highest at 48.5%. The other sites relied on indirect patient referral from regional hospitals where significant delays in diagnostics occurred and early-stage proportions were a low (15%- 37.3%). The Emp site referred patients for all treatments to the Dbn site located 200km away; the Sow site provided surgery and endocrine treatment services but referred patients to the Jhb site 30 Km away for chemo- and radiation therapy. The Jhb, Dbn and Pmb sites all provided complete oncology treatment services. All treatment centres followed international guidelines for their treatment approaches. Findings may inform policy interventions to address national and regional disparities in breast cancer care.

Validation of the Xpert Breast Cancer STRAT 4 Assay on the GeneXpert instrument to Assess Hormone Receptor, Ki67, and HER2 Gene Expression Status in Breast Cancer Tissue Samples

Breast cancer is the commonest cause of cancer-related mortality in African females where patients often present later and with advanced disease. Causes for delayed diagnosis include restricted diagnostic access and international controversy on interpretation of ancillary tests like immunohistochemistry (IHC). Fine needle aspirates (FNAC) are an attractive alternative although may have reduced sensitivity. The Xpert Breast Cancer STRAT4 (STRAT4) (CE-IVD*) assay (Cepheid, Sunnyvale) is a semi-quantitative reverse-transcription polymerase chain reaction assay which detects messenger RNA (mRNA) expression in breast samples for estrogen receptor ( ESR1 ), progesterone receptor ( PGR1 ), human epidermal growth factor receptor/Erb-B2 receptor tyrosine kinase 2 (HER2/ ERBB2 ) and the proliferation marker, MKi67 . We assessed the performance of this assay on both formalin-fixed paraffin-embedded (FFPE, n=31) and matched FNAC (n=20) samples from patients presenting with breast cancer to the Johannesburg academic hospitals. IHC and Fluorescent in situ hybridization analysis (performed on HER2-indeterminate samples) was compared with the mRNA expression of the corresponding target genes in FFPE samples, and mRNA expression on FNAC samples was compared with the FFPE results for both mRNA expression and IHC. Concordance between IHC/FISH and Xpert Breast Cancer STRAT4 in FFPE and FNAC samples using the Quick lysis (Q) method (a research-use-only modification of the validated FFPE-lysis method), showed an overall percentage agreement for ESR1 expression of 90.3% and 81.3%, and for PGR1 expression at 86.7% and 81.3% respectively in FFPE and FNAC samples. Concordance was lowest for Ki67 expression, using a binary IHC cutoff for Ki67 positivity at ≥20% staining) at 83.9% and 62.5%, for FFPE and FNAC samples, respectively. This suggests that the STRAT4 assay may be a useful ancillary test in determining HR and Ki67 status in FFPE samples and that use on FNAC samples may be feasible. Future studies should expand the sample numbers and establish locally relevant cutoffs.

A qualitative study to explore healthcare providers' perspectives on barriers and enablers to early detection of breast and cervical cancers among women attending primary healthcare clinics in Johannesburg, South Africa

Low-and-middle income countries (LMICs) contribute approximately 70% of global cancer deaths, and the cancer incidence in these countries is rapidly increasing. Sub-Saharan African (SSA) countries, including South Africa (SA), bear some of the world's highest cancer case fatality rates, largely attributed to late diagnosis. We explored contextual enablers and barriers for early detection of breast and cervical cancers according to facility managers and clinical staff at primary healthcare clinics in the Soweto neighbourhood of Johannesburg, South Africa. We conducted qualitative in-depth interviews (IDIs) between August and November 2021 amongst 13 healthcare provider nurses and doctors as well as 9 facility managers at eight public healthcare clinics in Johannesburg. IDIs were audio-recorded, transcribed verbatim, and entered into NVIVO for framework data analysis. Analysis was stratified by healthcare provider role and identified apriori around the themes of barriers and facilitators for early detection and management of breast and cervical cancers. Findings were conceptualised within the socioecological model and then explored within the capability, opportunity and motivation model of behaviour (COM-B) for pathways that potentially influence the low screening provision and uptake. The findings revealed provider perceptions of insufficient South African Department of Health (SA DOH) training support and staff rotations resulting in providers lacking knowledge and skills on cancer, screening policies and techniques. This coupled with provider perceptions of poor patient cancer and screening knowledge revealed low capacity for cancer screening. Providers also perceived opportunity for cancer screening to be undermined by the limited screening services mandated by the SA DOH, insufficient providers, inadequate facilities, supplies and barriers to accessing laboratory results. Providers perceived women to prefer to self-medicate and consult with traditional healers and access primary care for curative services only. These findings compound the low opportunity to provide and demand cancer screening services. And because the National SA Health Department is perceived by providers not to prioritize cancer nor involve primary care stakeholders in policy and performance indicator development, overworked, unwelcoming providers have little motivation to learn screening skills and provide screening services. Providers reported that patients preferred to go elsewhere and that women perceived cervical cancer screening as painful. These perceptions must be confirmed for veracity among policy and patient stakeholders. Nevertheless, cost-effective interventions can be implemented to address these perceived barriers including multistakeholder education, mobile and tent screening facilities and using existing community fieldworkers and NGO partners in providing screening services. Our results revealed provider perspectives of complex barriers to the early detection and management of breast and cervical cancers in primary health clinic settings in Greater Soweto. These barriers together appear potentially to produce compounding effects, and therefore there is a need to research the cumulative impact but also engage with stakeholder groups to verify findings and create awareness. Additionally, opportunities do exist to intervene across the cancer care continuum in South Africa to address these barriers by improving the quality and volume of provider cancer screening services, and in turn, increasing the community demand and uptake for these services.

Delays in seeking, reaching and access to quality cancer care in sub-Saharan Africa: a systematic review

OBJECTIVES

Late presentation and delays in diagnosis and treatment consistently translate into poor outcomes in sub-Saharan Africa (SSA). The aim of this study was to collate and appraise the factors influencing diagnostic and treatment delays of adult solid tumours in SSA.

DESIGN

Systematic review with assessment of bias using Risk of Bias in Non-randomised Studies of Exposures (ROBINS-E) tool.

DATA SOURCES

PubMed and Embase, for publications from January 1995 to March 2021.

ELIGIBILITY CRITERIA

Inclusion criteria: quantitative or mixed-method research, publications in English, on solid cancers in SSA countries.

EXCLUSION CRITERIA

paediatric populations, haematologic malignancies, and assessments of public perceptions and awareness of cancer (since the focus was on patients with a cancer diagnosis and treatment pathways).

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted and validated the studies. Data included year of publication; country; demographic characteristics; country-level setting; disease subsite; study design; type of delay, reasons for delay and primary outcomes.

RESULTS

57 out of 193 full-text reviews were included. 40% were from Nigeria or Ethiopia. 70% focused on breast or cervical cancer. 43 studies had a high risk of bias at preliminary stages of quality assessment. 14 studies met the criteria for full assessment and all totaled to either high or very high risk of bias across seven domains. Reasons for delays included high costs of diagnostic and treatment services; lack of coordination between primary, secondary and tertiary healthcare sectors; inadequate staffing; and continued reliance on traditional healers and complimentary medicines.

CONCLUSIONS

Robust research to inform policy on the barriers to quality cancer care in SSA is absent. The focus of most research is on breast and cervical cancers. Research outputs are from few countries. It is imperative that we investigate the complex interaction of these factors to build resilient and effective cancer control programmes.

Drivers of disparities in stage at diagnosis among women with breast cancer: South African breast cancers and HIV outcomes cohort

OBJECTIVE

In low- and middle-income countries (LMICs), advanced-stage diagnosis of breast cancer (BC) is common, and this contributes to poor survival. Understanding the determinants of the stage at diagnosis will aid in designing interventions to downstage disease and improve survival from BC in LMICs.

METHODS

Within the South African Breast Cancers and HIV Outcomes (SABCHO) cohort, we examined factors affecting the stage at diagnosis of histologically confirmed invasive breast cancer at five tertiary hospitals in South Africa (SA). The stage was assessed clinically. To examine the associations of the modifiable health system, socio-economic/household and non-modifiable individual factors, hierarchical multivariable logistic regression with odds of late-stage at diagnosis (stage III-IV), was used.

RESULTS

The majority (59%) of the included 3497 women were diagnosed with late-stage BC disease. The effect of health system-level factors on late-stage BC diagnosis was consistent and significant even when adjusted for both socio-economic- and individual-level factors. Women diagnosed in a tertiary hospital that predominantly serves a rural population were 3 times (OR = 2.89 (95% CI: 1.40-5.97) as likely to be associated with late-stage BC diagnosis when compared to those diagnosed at a hospital that predominantly serves an urban population. Taking more than 3 months from identifying the BC problem to the first health system entry (OR = 1.66 (95% CI: 1.38-2.00)), and having luminal B (OR = 1.49 (95% CI: 1.19-1.87)) or HER2-enriched (OR = 1.64 (95% CI: 1.16-2.32)) molecular subtype as compared to luminal A, were associated with a late-stage diagnosis. Whilst having a higher socio-economic level (a wealth index of 5) reduced the probability of late-stage BC at diagnosis, (OR = 0.64 (95% CI: 0.47-0.85)).

CONCLUSION

Advanced-stage diagnosis of BC among women in SA who access health services through the public health system was associated with both modifiable health system-level factors and non-modifiable individual-level factors. These may be considered as elements in interventions to reduce the time to diagnosis of breast cancer in women.

Population-based temporal trends and ethnic disparity in breast cancer mortality in South Africa (1999-2018): Joinpoint and age-period-cohort regression analyses

Globally, breast cancer is the leading cause of cancer deaths, accounting for 15.5% of female cancer deaths in 2020. Breast cancer is also the leading cause of female cancers in South Africa. The rapid epidemiological transition in South Africa may have an impact on the trends in breast cancer mortality in the country. We therefore evaluated the trends in the breast cancer mortality in SA over 20 years (1999-2020).

Methods

Joinpoint regression analyses of the trends in crude and age-standardized mortality rates (ASMR) of breast cancer among South African women were conducted from 1999 to 2018 using mortality data from Statistics South Africa. Age-period-cohort regression analysis was then conducted to evaluate the independent effect of age, period, and cohort on breast cancer mortality, and analysis was stratified by ethnicity.

Results

The mortality rate of breast cancer (from 9.82 to 13.27 per 100,000 women) increased at around 1.4% per annum (Average Annual Percent Change (AAPC): 1.4%, 95% CI:0.8-2.0, P-value< 0.001). Young women aged 30-49 years (1.1%-1.8%, P-value< 0.001) had increased breast cancer mortality. The risk of breast cancer mortality increased among successive birth cohorts from 1924 to 1928 but decreased among recent cohorts born from 1989 to 1993. In 2018, the breast cancer mortality rate among Blacks (9.49/100,000 women) was around half of the rates among the non-Blacks. (Coloreds: 18.11 per 100,000 women; Whites: 17.77/100,000 women; Indian/Asian: 13.24 per 100,000 women).

Conclusions

Contrary to the trends in high- and middle-income countries, breast cancer mortality increased in South Africa especially among young women. Breast cancer prevention programs should be intensified and should also target young women. The marked disparity in ethnic burden of breast cancer should be considered during planning and implementation of interventions.

The Impact of Breast Awareness on the Early Detection of Breast Cancer in Young Women: A Systematic Review

Background

"Breast awareness" is a recommendation that women understand the symptoms of breast cancer and become familiar with the usual look and feel of their breasts. It is recommended for women of all ages in breast cancer screening guidelines around the world. The objective of this study was to assess the evidence for breast awareness by investigating its effect on breast cancer outcomes in women of pre-mammographic-screening age (under age 40), at average risk of breast cancer.

Methods

A systematic review was performed using PRISMA methodology. Following the search, abstracts and full-text articles were assessed against eligibility criteria. Data were extracted into evidence tables, risk of bias was assessed, narrative synthesis was performed, and results were described. Eligible studies were original research studies assessing the impact of breast awareness on cancer outcomes (such as stage at diagnosis or survival) in women ≤40. Medline, PubMed, and Cochrane Library were searched.

Results

After screening the 6,204 abstracts identified in the search, no studies meeting all eligibility criteria were found. Two partially eligible studies were identified. These met the intervention and outcomes criteria but included mixed-age cohorts that included but were not limited to women ≤40. These studies provided low-level (Level IV) evidence of moderate quality that there is some benefit (earlier stage at diagnosis and/or improved survival) of breast awareness in a mixed-age cohort that included some younger women.

Conclusions

No studies evaluating the impact of breast awareness exclusively in young women were identified. Limited evidence of benefit of breast awareness was found. Guidelines that recommend breast awareness should be reviewed and qualified with an explanation that the evidence of benefit is weak. Women have limited screening options available to them for the early detection of breast cancer until they reach mammographic screening age. The study was registered on Prospero (ID: CRD42021279457).

Implementation of multigene panel testing for breast and ovarian cancer in South Africa: A step towards excellence in oncology for the public sector

Translation of genomic knowledge into public health benefits requires the implementation of evidence-based recommendations in clinical practice. In this study, we moved beyond BRCA1/2 susceptibility testing in breast and ovarian cancer patients to explore the application of pharmacogenetics across multiple genes participating in homologous recombination DNA damage repair. This involved the utilisation of next-generation sequencing (NGS) at the intersection of research and service delivery for development of a comprehensive genetic testing platform in South Africa. Lack of international consensus regarding risk categorization of established cancer susceptibility genes and the level of evidence required for prediction of drug response supported the development of a central database to facilitate clinical interpretation. Here we demonstrate the value of this approach using NGS to 1) determine the variant spectrum applicable to targeted therapy and implementation of prevention strategies using the 15-gene Oncomine™ BRCA Expanded Panel, and 2) searched for novel and known pathogenic variants in uninformative cases using whole exome sequencing (WES). Targeted NGS performed as a routine clinical service in 414 South African breast and/or ovarian cancer patients resulted in the detection of 48 actionable variants among 319 (15%) cases. BRCA1/2-associated cancers were identified in 70.8% of patients (34/48, including two double-heterozygotes), with the majority (35.3%, 12/34) representing known South African founder variants. Detection of actionable variants in established non-BRCA1/2 risk genes contributed 29% to the total percentage (14/48), distributed amongst ATM, CHEK2, BARD1, BRIP1, PALB2 and TP53. Experimental WES using a virtually constructed multi-cancer NGS panel in 16 genetically unresolved cases (and four controls) revealed novel protein truncating variants in the basal cell carcinoma gene PTCH1 (c.4187delG) and the signal transmission and transduction gene KIT (c.930delA) involved in crucial cellular processes. Based on these findings, the most cost-effective approach would be to perform BRCA1/2 founder variant testing at referral, followed by targeted multigene panel testing if clinically indicated and addition of WES in unresolved cases. This inventive step provides a constant flow of new knowledge into the diagnostic platform via a uniquely South African pathology-supported genetic approach implemented for the first time in this context to integrate research with service delivery.

Lung Cancer Patients' Conceptualization of Care Coordination in Selected Public Health Facilities of KwaZulu-Natal, South Africa

BACKGROUND

Cancer patients commonly receive care, including comprehensive treatment options, from multiple specialists within and across facilities offering varying levels of care. Given this multi-layered approach to cancer care, there is a need for coordinated care enhanced through integrated information flow for optimal patient care and improved health outcomes.

OBJECTIVE

This study aimed to explore how patients conceptualized cancer care coordination in an integrated health care system in KwaZulu-Natal.

METHODS

The study employed a grounded theory design to qualitatively explore the patients' experiences and views on cancer care coordination using in-depth interviews. Guided by the grounded theory principles, data generation and analysis were conducted iteratively, followed by systematic thematic analysis to organize data, and review and interpret comprehensive findings. This process culminated in the development of themes relating to barriers to cancer care coordination and the interface between the primary and tertiary settings. Theoretical saturation was achieved at 21 in-depth interviews with consenting respondents.

RESULTS

This study revealed that care coordination was affected by multilevel challenges, including pertinent health system-level factors, such as difficulty accessing specialty care timeously, weak communication between patients and healthcare providers, and unmet needs concerning supportive care. We found that negative experiences with cancer care erode patient trust and receptiveness to cancer care, and patients advocated for better and proactive coordination amongst different care facilities, services, and providers.

CONCLUSIONS

An integrated care coordination setup is essential to create and sustain a high-performance health care system. These findings make a case for developing, implementing, and evaluating interventions to enhance the quality of cancer care for patients and ultimately improve health outcomes for patients in KwaZulu-Natal. This study will provide comprehensive data to inform professionals, policymakers, and related decisionmakers to manage and improve cancer care coordination.

Impact of HIV infection on survival among women with stage I-III breast cancer: Results from the South African breast cancer and HIV outcomes study

In some countries of sub-Saharan Africa, the prevalence of HIV exceeds 20%; in South Africa, 20.4% of people are living with HIV. We examined the impact of HIV infection on the overall survival (OS) of women with nonmetastatic breast cancer (BC) enrolled in the South African Breast Cancer and HIV Outcomes (SABCHO) study. We recruited women with newly diagnosed BC at six public hospitals from 1 July 2015 to 30 June 2019. Among women with stages I-III BC, we compared those with and without HIV infection on sociodemographic, clinical, and treatment factors. We analyzed the impact of HIV on OS using multivariable Cox proportional hazard models. Of 2367 women with stages I-III BC, 499 (21.1%) had HIV and 1868 (78.9%) did not. With a median follow-up of 29 months, 2-year OS was poorer among women living with HIV (WLWH) than among HIV-uninfected women (72.4% vs 80.1%, P < .001; adjusted hazard ratio (aHR) 1.49, 95% confidence interval (CI) = 1.22-1.83). This finding was consistent across age groups ≥45 years and <45 years, stage I-II BC and stage III BC, and ER/PR status (all P < .03). Both WLWH with <50 viral load copies/mL and WLWH with ≥50 viral load copies/mL had poorer survival than HIV-uninfected BC patients [aHR: 1.35 (1.09-1.66) and 1.54 (1.20-2.00), respectively], as did WLWH who had ≥200 CD4+ cells/mL at diagnosis [aHR: 1.39 (1.15-1.67)]. Because receipt of antiretroviral therapy has become widespread, WLWH is surviving long enough to develop BC; more research is needed on the causes of their poor survival.

South African men's perceptions of breast cancer: impact of gender norms on health care accessibility

Women in low- and middle-income countries (LMICs) often present to the health care system at advanced stages of breast cancer (BC), leading to poor outcomes. A lack of BC awareness and affordability issues are proposed as contributors to the delayed presentation. In many areas of the world, however, women lack the autonomy to deal with their health needs due to restrictive gender norms. The role of gender norms has been relatively underexplored in the BC literature in LMICs and little is known about what men know about BC and how they are involved in women's access to care. To better understand these factors, we conducted a qualitative descriptive study in South Africa. We interviewed 20 low-income Black men with current woman partners who had not experienced BC. Interviewees had limited knowledge and held specific misconceptions about BC symptoms and treatment. Cancer is not commonly discussed within their community and multiple barriers prevent them from reaching care. Interviewees described themselves as having a facilitative role in their partner's access to health care, facets of which could inadvertently prevent their partners from autonomously seeking care. The findings point to the need to better consider the role of the male partner in BC awareness efforts in LMICs to facilitate prevention, earlier diagnosis and treatment.

Prevalence of Clinically Relevant Germline BRCA Variants in a Large Unselected South African Breast and Ovarian Cancer Cohort: A Public Sector Experience

Breast cancer is a multifaceted disease that currently represents a leading cause of death in women worldwide. Over the past two decades (1998–2020), the National Health Laboratory Service’s Human Genetics Laboratory in central South Africa screened more than 2,974 breast and/or ovarian cancer patients for abnormalities characteristic of the widely known familial breast cancer genes, Breast Cancer gene 1 (BRCA1) and Breast Cancer gene 2 (BRCA2). Patients were stratified according to the presence of family history, age at onset, stage of the disease, ethnicity and mutation status relative to BRCA1/2. Collectively, 481 actionable (likely-to pathogenic) variants were detected in this cohort among the different ethnic/racial groups. A combination of old (pre-2014) and new (post-2014) laboratory techniques was used to identify these variants. Additionally, targeted genotyping was performed as translational research revealed the first three recurrent South African pathogenic variants, namely BRCA1 c.1374del (legacy name 1493delC), BRCA1 c.2641G&gt;T (legacy name E881X) and BRCA2 c.7934del (legacy name 8162delG). This initial flagship study resulted in a cost-effective diagnostic test that enabled screening of a particular ethnic group for these variants. Since then, various non-Afrikaner frequent variants were identified that were proven to represent recurrent variants. These include BRCA2 c.5771_5774del (legacy name 5999del4) and BRCA2 c.582G&gt;A, both Black African founder mutations. By performing innovative translational research, medical science in South Africa can adopt first-world technologies into its healthcare context as a developing country. Over the past two decades, the progress made in the public sector enabled a pivotal shift away from population-directed genetic testing to the screening of potentially all breast and ovarian cancer patients, irrespective of ethnicity, family history or immunohistochemical status. The modifications over the years complied with international standards and guidelines aimed at universal healthcare for all. This article shares all the cohort stratifications and the likely-to pathogenic variants detected.

Pre-diagnosis lifestyle, health history and psychosocial factors associated with stage at breast cancer diagnosis - Potential targets to shift stage earlier

BACKGROUND

Early detection of breast cancer improves survival, so identifying factors associated with stage at diagnosis may help formulate cancer prevention messages tailored for higher risk women. The goal of this study was to evaluate associations between multiple potential risk factors, including novel ones, measured before a breast cancer diagnosis and stage at diagnosis in women from Alberta, Canada.

METHODS

Women enrolled in Alberta's Tomorrow Project completed health and lifestyle questionnaires on average 7 years before their breast cancer diagnosis. The association of previously identified and novel predictors with stage (I, II and III + IV) at diagnosis were simultaneously evaluated in partial proportional odds ordinal (PPO) regression models.

RESULTS

The 492 women in this study were predominantly diagnosed in Stage 1 (51.4%), had college or university education (75.4%), were married or had a partner (74.6%), had been pregnant (90.2%), had taken birth control pills for any reason (86.8%), and had an average body mass index of 26.6. Most had at least one mammogram (83%) with five mammograms the average number. Nearly all reported previously having a breast health examination from a medical practitioner (92.5%). Statistically significant factors identified in the PPO model included protective ones (older age at diagnosis, high household income, parity, smoking, spending time in the sun during high ultraviolet times, having a mammogram and high daily protein intake) and ones that increased risk of later stage at diagnosis (a comorbidity, current stressful situations and high daily caloric intake).

CONCLUSION

Shifting breast cancer stage at diagnosis downwards may potentially be achieved through cancer prevention programs that target higher risk groups such as women with co-morbidities, non-smokers and younger women who may be eligible for breast cancer screening.

The experiences of caregivers of patients living with cancer admitted to a hospice in South Africa

BACKGROUND

Caregivers share cancer experiences with patients, but little is known about their own experiences in the end-of-life phase, the most difficult phase in the caregiving journey.

AIMS

To describe the experiences of caregivers of cancer patients admitted to a hospice in South Africa.

METHODS

A qualitative design was used; 22 (n=22) participants were purposively selected and in-depth interviews were conducted. Analysis of the data was by qualitative content analysis.

FINDINGS

A total of three themes arose from the data: emotional responses towards the caregiver role, personal cost of caregiving and spiritual issues relating to caregiving.

CONCLUSION

Caring for cancer patients during the last phase of life was not easy. Responsibilities overwhelmed the participants and they were emotionally exhausted. They lacked knowledge of how to care and experienced a heavy financial burden. Despite the challenges that they faced, faith and religious practices served as a coping mechanism and kept some going.

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.

Improving Timely Access to Diagnostic and Treatment Services for Lung Cancer Patients in KwaZulu-Natal, South Africa: Priority-Setting through Nominal Group Techniques

Background: Lung cancer is the most common cancer worldwide, and it disproportionately affects low-income countries (LICs), where over 58% of cases occur. It is an important public health concern, given its poor healthcare outcomes, yet it is under-researched compared to other cancers. Lung cancer is also very difficult for primary care physicians to diagnose. In many settings, health researchers and clinicians’ resort to engaging in collaborative efforts to determine the best way to implement evidence into routine clinical practice. Methods: This was a grounded theory study comprising seven experts providing oncological services. A Nominal Group Technique (NGT) was used to articulate ideas, identify key problems and reach consensus on the order of priorities for the identified problems. Results: The study findings revealed that access to healthcare facilities providing oncology services and diagnosis was the major barrier to lung cancer care. This was further exacerbated by the manner in which health systems are configured in South Africa. The priorities for the health providers were focused on the lack of specialized resources, whereby referral of patients suspected to have lung cancer was delayed and compounded by the limited availability of treatment. Conclusion: The inadequacy of supportive systems for access to healthcare services negates the government efforts to curb the rising lung cancer-related fatalities in South Africa.

Associations between comorbidities and advanced stage diagnosis of lung, breast, colorectal, and prostate cancer: A systematic review and meta-analysis

Comorbidities and advanced stage diagnosis (ASD) are both associated with poorer cancer outcomes, but the association between comorbidities and ASD is poorly understood. We summarized epidemiological evidence on the association between comorbidities and ASD of selected cancers in a systematic review and meta-analysis. We searched PubMed and Web of Science databases up to June 3rd, 2021 for studies assessing the association between comorbidities and ASD of lung, breast, colorectal, or prostate cancer. Summary odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated using random-effects models. Also, potential variations in the associations between comorbidities and ASD by cancer type were investigated using random-effects meta-regression. Thirty-seven studies were included in this review, including 8,069,397 lung, breast, colorectal, and prostate cancer patients overall. The Charlson comorbidity index score was positively associated with ASD (stages III-IV) of breast cancer but was inversely associated with ASD of lung cancer (p_interaction = 0.004). Regarding specific comorbidities, diabetes was positively associated with ASD (OR = 1.17, 95%CI = 1.09-1.26), whereas myocardial infarction was inversely associated with ASD (OR = 0.84, 95%CI = 0.75-0.95). The association between renal disease and ASD differed by cancer type (p_interaction < 0.001). A positive association was found with prostate cancer (OR = 2.02, 95%CI = 1.58-2.59) and an inverse association with colorectal cancer (OR = 0.84, 95%CI = 0.70-1.00). In summary, certain comorbidities (e.g., diabetes) may be positively associated with ASD of several cancer types. It needs to be clarified whether closer monitoring for early cancer signs or screening in these patients is reasonable, considering the problem of over-diagnosis particularly relevant in patients with short remaining life expectancy such as those with comorbidities. Also, evaluation of the cost-benefit relationship of cancer screening according to the type and severity of comorbidity (rather than summary scores) may be beneficial for personalized cancer screening in populations with chronic diseases.

Survival of south african women with breast cancer receiving anti-retroviral therapy for HIV

PURPOSE

Breast cancer outcomes in sub-Saharan Africa is reported to be poor, with an estimated five-year survival of 50% when compared to almost 90% in high-income countries. Although several studies have looked at the effect of HIV in breast cancer survival, the effect of ARTs has not been well elucidated.

METHODS

All females newly diagnosed with invasive breast cancer from May 2015-September 2017 at Charlotte Maxeke Johannesburg Academic and Chris Hani Baragwanath Academic Hospital were enrolled. We analysed overall survival and disease-free survival, comparing HIV positive and negative patients. Kaplan-Meier survival curves were generated with p-values calculated using a log-rank test of equality while hazard ratios and their 95% confidence intervals (CIs) were estimated using Cox regression models.

RESULTS

Of 1019 patients enrolled, 22% were HIV positive. The overall survival (95% CI) was 53.5% (50.1-56.7%) with a disease-free survival of 55.8% (52.1-59.3) after 4 years of follow up. HIV infection was associated with worse overall survival (HR (95% CI): 1.50 (1.22-1.85), p < 0.001) and disease-free survival (OR (95% CI):2.63 (1.71-4.03), p < 0.001), especially among those not on ART at the time of breast cancer diagnosis. Advanced stage of the disease and hormone-receptor negative breast cancer subtypes were also associated with poor survival.

CONCLUSION

HIV infection was associated with worse overall and disease-free survival. HIV patients on ARTs had favourable overall and disease-free survival and with ARTs now being made accessible to all the outcome of women with HIV and breast cancer is expected to improve.

Breast Cancer Early Detection in Eswatini: Evaluation of a Training Curriculum and Patient Receipt of Recommended Follow-Up Care

[Figure: see text].

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

BACKGROUND

Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

METHODS

PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization's six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

RESULTS

From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

CONCLUSION

The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

Cancer care reform in South Africa: A case for cancer care coordination: A narrative review

OBJECTIVE

This review provides an overview of the existing literature on the importance of care coordination for lung cancer care and other cancers in general. The review is inclusive of the burden of cancer, with a special reference to lung cancer, as well as challenges and achievements relating to cancer care coordination.

METHOD

We conducted a search of online databases of peer-reviewed studies published in the English language. The analysis for this review has been packaged into themes in order to generate results that can inform researchers and cancer health professionals, on the existing gaps necessary for developing appropriate intervention strategies and policy guidelines.

RESULTS

Cancer is a complex condition that often requires multiple interventions provided by a variety of health professionals within the healthcare continuum. This paper reviewed research studies that explored the supportive care needs of cancer patients. The results are presented in three superordinate themes, namely (a) cancer as a healthcare priority in South Africa (SA), (b) making a case for coordinated cancer care in SA, and (c) care coordination: a poorly defined, yet complex concept. One major need identified was the requirement of informational support. Other essential needs included referral, emotional, and financial support.

SIGNIFICANCE OF RESULTS

The identification of current obstacles has the potential to guide the development of a model to improve quality coordinated cancer health care. It remains that limited research exists around cancer services and cancer care in the South African region. This narrative review identified common elements and barriers to care for lung cancer patients and survivors, and offers recommendations for developing clinical care models.

Determinants of Delayed Presentation and Advanced-Stage Diagnosis of Breast Cancer in Africa: A Systematic Review and Meta-Analysis

Background/Objective:

Breast cancer (BC) mortality is exceptionally high in Africa due to late presentation and advanced-stage diagnosis. Previous studies examining barriers to early BC presentation are markedly inconsistent, showing conflicting findings within and between African regions, making resource allocation and designing interventional campaigns challenging. Our objective was to assess the strength or magnitude of the association between determinants/risk factors and delayed presentation/advanced-stage diagnosis of BC in Africa.

Methods:

Electronic searches in PubMed, AJOL, Google, ResearchGate, ScienceDirect, and PubMed Central found eligible articles between 2000 and 2020. The meta-analytical procedure in Meta-XL used the quality effect model. I-squared (I²) above 75% indicated high heterogeneity. The summary effect size was the odds ratio with 95% confidence intervals.

Results:

The effect of socio-economic and demographic determinants on delay varies across African regions. Low level of education (1.63, 95% CI 1.01-2.63), and not performing breast self examination (BSE) (13.59, 95% CI 3.33-55.4) were significantly associated with delayed presentation. Younger patients had more significant delays in West Africa (WA, 1.41, 95%CI 1.08-1.85), and the reverse occurred in North Africa (0.68, 95%CI 0.48-0.97). Lack of BC knowledge (1.59, 95% CI 1.29-1.97), not performing BSE, or no history of undergoing clinical breast examination (CBE) (2.45, 95% CI 1.60-3.40), were associated with advanced-stage disease at diagnosis. Older patients had significantly more advanced disease in WA, and the reverse occurred in South Africa. Aggressive molecular BC subtypes [Triple negative (OR 1.62, 95% CI 1.27-2.06) or HER2 positive (1.56, 95% CI 1.10-2.23)] were significant determinants of advanced-stage diagnosis.

Conclusion:

Promoting early presentation and reducing advanced-stage BC throughout Africa should focus on modifiable factors, including providing quality education, improving breast health awareness and BC knowledge, and developing strategies to increase BSE and CBE. Interventions targeting socio-demographic determinants should be context-specific.

Factors associated with advanced-stage diagnosis of breast cancer in north-west Ethiopia: a cross-sectional study

Background

Breast cancer tumours are the most common malignant tumours among women in Ethiopia. Although advanced-stage diagnosis of breast cancer is a common problem, evidence-based information is lacking about the magnitude and determinants of advanced-stage presentation in north-west Ethiopia.

Methods

An institution-based, cross-sectional study was conducted at the oncology units of the University of Gondar and Felege Hiwot specialised hospitals. Stages III and IV were considered advanced stage, whereas stages I and II were considered early stages. Data were collected prospectively on newly diagnosed breast cancer patients and entered using the EPI Info version 7.2 and analysed using Statistical Package for the Social Sciences version 23. Multivariable logistic regression was used to identify the determinants of advanced-stage diagnosis of breast cancer. A p-value < 0.05 was used as the cut-off point to select the determinants of the advanced stage.

Result

About 71.2% of breast cancer patients presented with advanced-stage disease. The median age of patients was 40 years. Rural residence (adjusted odds ratio (AOR) = 1.7; 95% confidence interval (CI): 1.02, 2.96), painless breast lump/wound (AOR = 2.5; 95% CI: 1.45, 4.13), travel distance ≥5 km (AOR = 3.2; 95% CI: 1.72, 5.29), not practising breast self-examination (BSE) (AOR = 2.9; 95% CI: 1.30, 6.52), time to presentation ≥3 months (AOR = 1.4; 95% CI: 1.02, 2.37) and misdiagnosed at first visit (AOR = 1.9; 95% CI: 1.09, 3.59) were determinants of advanced-stage breast cancer.

Conclusion

Nearly three-quarters of the patients were diagnosed with advanced-stage breast cancer. Not practising BSE, travel distance ≥5 km, rural residence, painless breast wound/lump and being misdiagnosed at first visit were important determinants of advanced-stage diagnosis of breast cancer. Focused awareness creation programmes for the public and increasing cancer diagnostic centres in the country are crucial to downstage breast cancer at presentation.

Factors Associated with Delay in Breast Cancer Presentation at the Only Oncology Center in North East Ethiopia: A Cross-Sectional Study

BACKGROUND

Female breast cancer is becoming an emerging public health problem which accounts for 33% of all cancers in women and 23% of all cancer cases in Ethiopia. The majority of women with breast cancer are diagnosed at later stages due to delayed presentation to seek treatment.

OBJECTIVE

To determine the prevalence and factors associated with patient delay at presentation among breast cancer patients at Dessie Referral Hospital, the only oncology center in North East Ethiopia.

METHODS

We conducted an institution-based cross-sectional study among 204 female patients with pathology-confirmed breast cancer at the only oncology center of North East Ethiopia from January to June 2020. An interviewer administered questionnaire and a medical record data extraction tool were used to address the objective of the study. Patients were said to be delayed for diagnosis if the time duration between first clinical presentations to first clinical consultation was more than 3 months. Then, bivariable and multivariable logistic regression was employed to analyze the association between dependent and independent variables.

RESULTS

Among a total of 209 eligible participants, 5 refused to participate with a response rate of 97.6%. The proportion of patients with delayed presentation was 103 (50.5%), with the median time taken to visit a healthcare provider after recognition of the first symptom was 4 months. Age above 40 years (AOR=4.81; 95% CI=1.26-18.65) P<0.024, college and above educational status (AOR=0.05; 95% CI=0.01-0.77) p<0.036, government employee (AOR=0.19, 95% CI=0.03-0.91) P<0.002, urban residence (AOR= 0.21; 95% CI=0.01-0.82) p<0.001, visit traditional healer (AOR=0.38; 95% CI=0.2-0.69) P<0.0037, and no lump in under armpit (AOR= 9.05; 95% CI=1.14-22.69) P<0.002 were associated with delayed presentation.

CONCLUSION

Delays to seek treatment is generally high in our study. Age, educational status, occupation, residence, visiting traditional healer, and absence of lump in under armpit were significant factors for delayed presentation. Intervention programs focusing on reducing delayed presentation should be employed.

Delayed help-seeking for symptomatic breast cancer: reasons for delay among participants receiving treatment at a public healthcare facility in South Africa

We explored delayed help-seeking behaviour for symptomatic breast cancer among a sample of female patients attending an outpatient breast cancer clinic at a tertiary public hospital in the Western Cape. The objective of the research was to explore the perceived personal and structural barriers to help-seeking among women with breast cancer from this low-resource setting, as this information has not been documented. Purposive sampling was used to recruit 25 breast cancer patients. Patients participated in individual interviews that were audio-recorded and transcribed. We conducted a thematic analysis using both inductive and deductive coding. Participants’ limited knowledge of breast cancer, negative views of the healthcare system, and challenging life experiences, such as marital discord, perceived lack of support, and caring for sick loved ones, contributed to their help-seeking delays. We used a combination of the Common-Sense Model of Self-Regulation and Bronfenbrenner’s Ecological Systems theory to conceptualize and organize these findings. A general lack of breast cancer knowledge was a major contributing factor to help-seeking delays among participants in the study. This finding was surprising considering that several breast cancer awareness campaigns have been run both nationally in South Africa and internationally. We call attention to the need for accessible breast cancer information at primary healthcare and community levels.

Symptom appraisal, help-seeking and perceived barriers to healthcare seeking in Uganda: an exploratory study among women with potential symptoms of breast and cervical cancer

OBJECTIVE

We assessed the process of recognising abnormal bodily changes, interpretations and attributions, and help-seeking behaviour among community-based Ugandan women with possible symptoms of breast and cervical cancer, in order to inform health interventions aiming to promote timely detection and diagnosis of cancer.

DESIGN

Qualitative in-depth interviews.

SETTING

Rural and urban communities in Uganda.

PARTICIPANTS

Women who participated in the African Women Awareness of CANcer cross-sectional survey who disclosed potential breast and cervical cancer symptoms were eligible; recruitment was purposive. Interviews were conducted in women's homes, lasted between 40 and 90 min, were audio-recorded, transcribed verbatim and translated to English. Thematic analysis was used to identify themes and subthemes, underpinned by the conceptual framework of the Model of Pathways to Treatment.

RESULTS

23 women were interviewed: 10 had potential symptoms of breast cancer and 13 of cervical cancer. Themes regarding symptom appraisal and help-seeking included the: (1) detection and interpretation of abnormal bodily sensations; (2) lay consultations regarding bodily changes; (3) iterative process of inferring and attributing illnesses to the bodily changes; (4) restricted disclosure of symptoms to lay people due to concerns about privacy and fear of stigmatisation; (5) help-seeking from multiple sources including both traditional and biomedical health practitioners, and (6) multiple perceived barriers to help-seeking including long waiting times, lack of medicines, absenteeism of healthcare professionals, and lack of money for transport and medical bills.

CONCLUSION

Women with potential symptoms of breast and cervical cancer undergo complex processes of symptom interpretation, attributing symptoms or inferring illness, and lay consultations before undertaking help-seeking and management. Increasing community understanding of breast and cervical cancer symptoms, and tackling perceived barriers to health-seeking, could lead to prompt and appropriate symptom appraisal and help-seeking, and contribute to improving cancer outcomes.

Dissecting the journey to breast cancer diagnosis in sub-Saharan Africa: Findings from the multicountry ABC-DO cohort study

Most breast cancer patients in sub-Saharan Africa are diagnosed at advanced stages after prolonged symptomatic periods. In the multicountry African Breast Cancer-Disparities in Outcomes cohort, we dissected the diagnostic journey to inform downstaging interventions. At hospital presentation for breast cancer, women recalled their diagnostic journey, including dates of first noticing symptoms and health-care provider (HCP) visits. Negative binomial regression models were used to identify correlates of the length of the diagnostic journey. Among 1429 women, the median (inter-quartile range) length (months) of the diagnostic journey ranged from 11.3 (5.7-21.2) in Ugandan, 8.2 (3.4-16.4) in Zambian, 6.5 (2.4-15.7) in Namibian-black to 5.6 (2.3-13.1) in Nigerian and 2.4 (0.6-5.5) in Namibian-non-black women. Time from first HCP contact to diagnosis represented, on average, 58% to 79% of the diagnostic journey in each setting except Nigeria where most women presented directly to the diagnostic hospital with advanced disease. The median number of HCPs visited was 1 to 4 per woman, but time intervals between visits were long. Women who attributed their initial symptoms to cancer had a 4.1 months (absolute) reduced diagnostic journey than those who did not, while less-educated (none/primary) women had a 3.6 months longer journey than more educated women. In most settings the long journey to breast cancer diagnosis was not primarily due to late first presentation but to prolonged delays after first presentation to diagnosis. Promotion of breast cancer awareness and implementation of accelerated referral pathways for women with suspicious symptoms are vital to downstaging the disease in the region.

Health system experiences of breast cancer survivors in urban South Africa

BACKGROUND

Breast cancer is the most common cancer globally and among South African women. Women from socioeconomically disadvantaged South African communities more often present later and receive total mastectomy compared to those from more affluent communities who have more breast conserving surgery (which is less invasive but requires mandatory radiation treatment post-operatively). Standard chemotherapy and total mastectomy treatments are known to cause traumatizing side effects and emotional suffering among South African women; moreover, many women face limited communication with physicians and psychological support.

OBJECTIVE

This article investigates the experiences of women seeking breast cancer treatment at the largest public hospital in South Africa.

METHODS

We interviewed 50 Black women enrolled in the South African Breast Cancer Study to learn more about their health system experiences with detection, diagnosis, treatment, and follow-up care for breast cancer. Each interview was between 2-3 hours, addressing perceptions, experiences, and concerns associated with breast cancer and comorbidities such as HIV and hypertension.

RESULTS

We found most women feared diagnosis, in part, because of the experience of chemotherapy and physical mutilation related to mastectomy. The importance of social support from family, religion, and clinical staff was fundamental for women coping with their condition and adhering to treatment and medication.

CONCLUSIONS

These findings exemplify how interventions might promote early detection of breast cancer and better adherence to treatment. Addressing community perceptions of breast cancer, patient needs and desires for treatment, structural barriers to intensive therapies, and the burden of invasive treatments are imperative next steps for delivering better breast cancer care in Soweto and other resource-constrained settings.

A scoping review: Facilitators and barriers of cervical cancer screening and early diagnosis of breast cancer in Sub-Saharan African health settings

To address gaps in access to cervical cancer screening and early diagnosis of breast cancer services in Sub-Saharan African (SSA), this scoping review was conducted to explore facilitators and barriers that exist on the patient-, provider-, and system-level. An extensive literature search was conducted in accordance with scoping review methodology and the Cochrane guidelines. Our search criteria were limited to original research studies conducted in community or clinical settings in SSA within the last 10 years (2010-2020). Themes found from this review included patient knowledge and provider education, access to screening services, trust, health-related behaviors, attitudes, values, and practices, community and social values, health infrastructure, resource allocation, and political will. Identified barriers included lack of knowledge about cervical and breast cancer among patients, gaps in education and training among providers, and lack of resources and health infrastructure at the facility level and within the overall health system. Facilitators included perceived risk of cancer, support and encouragement of the provider, and utilization of novel approaches in low-resource settings by health systems. To better address individual-, provider-, and health system and facility-based facilitators and barriers to care, there is a need for political and financial investment and further research on the health service delivery in specific national health systems, especially in the context of the global campaign to eliminate cervical cancer as a public health problem.

The multimorbidity profile of South African women newly diagnosed with breast cancer

Multimorbidity in women with breast cancer may delay presentation, affect treatment decisions and outcomes. We described the multimorbidity profile of women with breast cancer, its determinants, associations with stage at diagnosis and treatments received. We collected self-reported data on five chronic conditions (hypertension, diabetes, cerebrovascular diseases, asthma/chronic obstructive pulmonary disease, tuberculosis), determined obesity using body mass index (BMI) and tested HIV status, in women newly diagnosed with breast cancer between January 2016 and April 2018 in five public hospitals in South Africa. We identified determinants of ≥2 of the seven above-mentioned conditions (defined as multimorbidity), multimorbidity itself with stage at diagnosis (advanced [III-IV] vs. early [0-II]) and multimorbidity with treatment modalities received. Among 2,281 women, 1,001 (44%) presented with multimorbidity. Obesity (52.8%), hypertension (41.3%), HIV (22.0%) and diabetes (13.7%) were the chronic conditions that occurred most frequently. Multimorbidity was more common with older age (OR = 1.02; 95% CI 1.01-1.03) and higher household socioeconomic status (HSES) (OR = 1.06; 95% CI 1.00-1.13). Multimorbidity was not associated with advanced-stage breast cancer at diagnosis, but for self-reported hypertension there was less likelihood of being diagnosed with advanced-stage disease in the adjusted model (OR 0.80; 95% CI 0.64-0.98). Multimorbidity was associated with first treatment received in those with early-stage disease, p = 0.003. The prevalence of multimorbidity is high among patients with breast cancer. Our findings suggest that multimorbidity had a significant impact on treatment received in those with early-stage disease. There is need to understand the impact of multimorbidity on breast cancer outcomes.

Metastatic Breast Cancer in Kenya: Presentation, Pathologic Characteristics, and Patterns-Findings From a Tertiary Cancer Center

PURPOSE

The purpose of this research was to describe the sociodemographic and clinical characteristics of Kenyan women with metastatic breast cancer diagnosed and treated at Aga Khan University Hospital in Nairobi, Kenya from 2012 to 2018.

PATIENTS AND METHODS

We reviewed charts of Kenyan women with metastatic breast cancer and analyzed sociodemographic data, breast cancer risk factors, and tumor characteristics associated with stage at diagnosis, receptor status (ie, estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 [HER2]), and site of metastasis using χ², analysis of variance, two-sample t tests, and logistic regressions.

RESULTS

A total of 125 cases with complete medical records were included in the analysis. Forty women (32%) had metastases at diagnosis. Of the others, those diagnosed in stage III developed metastases sooner than those diagnosed in stage II (P < .001). Fifty-eight percent of patients had metastases to bone, 14% to brain, 57% to lungs, and 50% to liver. Seventy-four percent of patients presented with more than one metastatic site. Metastases to bone were associated with greater age at diagnosis (P = .02) and higher parity (P = .04), and metastases to the brain were associated with early menopause (P = .04), lower parity (P = .04), and lack of breastfeeding (P = .01). Patients whose tumors were triple negative (estrogen receptor-negative, progesterone receptor-negative, and HER2 negative) were more likely to develop brain metastases (P = .01), and those whose tumors were HER2 positive were more likely to develop liver metastases (P = .04).

CONCLUSION

Although our data on patterns of metastases and pathologic subtypes are similar to those in published literature, some unique findings concerning hormonal risk factors of women with metastatic breast cancer and specific metastatic sites need additional exploration in larger patient populations.

Psychological factors related to time to help-seeking for cancer symptoms: a meta-analysis across cancer sites

The time patients wait before seeking help for cancer symptoms is among the most important factors contributing to diagnostic delays in cancer. We reviewed the association between time to help-seeking and three psychological factors: symptom knowledge, symptom interpretation, and beliefs about cancer. Forty-seven studies met the inclusion criteria, providing data from 22 countries concerning seven cancer sites. Better symptom knowledge was related to lower odds of a long help-seeking interval in both studies with healthy populations (OR = .73, 95% CI [.63, .84], k = 19) and patients (OR = .40, 95% CI [.23, .69], k = 12), and so was interpreting experienced symptoms as cancer-related (OR = .52, 95% CI [.36, .75], k = 13 studies with patients). More positive beliefs about cancer (i.e., that cancer is treatable) were associated with lower odds of a long help-seeking interval in both studies with healthy populations (OR = .70, 95% CI [.52, .92], k = 11) and with patients (OR = .51, 95% CI [.32, .82], k = 7). Symptom knowledge, interpretation, and beliefs about cancer are likely to be universal predictors of help-seeking and should be incorporated into theoretical models of patient help-seeking and interventions aiming to reduce delays.

Prevalence of Themes Linked to Delayed Presentation of Breast Cancer in Africa: A Meta-Analysis of Patient-Reported Studies

PURPOSE

The prevalence of themes linked to delay in presentation of breast cancer (BC) and their underlying factors vary considerably throughout Africa. Regional differences and trends are largely unreported. The purpose of this research was to provide summary estimates of the prevalence and distribution of the themes and underlying factors linked to delay in the presentation of BC, regional variation, and trends in an effort to identify targets for intervention.

DESIGN

We screened articles found through PubMed/Medline, African Journal OnLine, Science Direct, Google/Google Scholar, and ResearchGate. We included patient-reported surveys on the reasons linked to delayed presentation under 6 previously identified themes: symptom misinterpretation, fear, preference for alternative care, social influence, hospital-related factors, and access factors. The meta-analytical procedure in MetaXL used the quality-effect model.

RESULTS

Twelve of the 236 identified articles were eligible for this review. The overall summary estimate of late presentation (> 90 days) was 54% (95% CI, 23 to 85) and was worst in the eastern and central regions. Symptom misinterpretation was the most common theme (50%; 95% CI, 21 to 56), followed by fear (17%; 95% CI, 3 to 27), hospital-related theme (11%; 95% CI, 1 to 21), preference for alternative care (10%; 95% CI, 0 to 21), social influence (7%; 95% CI, 0 to 14), and access-related theme (6%; 95% CI, 0 to 13). The most common factor underlying symptom misinterpretation was mischaracterizing the breast lesion as benign (60%; 95% CI, 4 to 100) which surpassed lack of awareness in the last decade. Misdiagnosis and failure to refer were the dominant hospital-related factors.

CONCLUSION

Modifiable factors such as mischaracterizing malignant masses as benign, fear, misdiagnosis, and failure to refer were the prevalent factors contributing to delays throughout Africa. These factors are promising targets for intervention.

Epidemiological, clinical and diagnostic profile of breast cancer patients treated at Potchefstroom regional hospital, South Africa, 2012-2018: an open-cohort study

Introduction

Breast cancer is the second most diagnosed cancer worldwide. We aimed to depict the diagnostic approach as well as the epidemiological and clinical profile of patients with breast cancer at Potchefstroom regional hospital, South Africa.

Methods

This descriptive open-cohort study included patients with primary invasive breast cancer, confirmed by histology results and treated at the hospital from 01 January 2012 to 31 December 2018. Data such as demographics, patient history, histology, breast clinical findings, physical mass description and diagnostic investigations were captured from hospital registries and patient files.

Result

One-hundred thirty-eight patients (mean age 56.2 (SD: 14.4) (95% CI 54.6-59.7) years) met inclusion criteria. Most patients were female (98.6%), from African (67.4%) or Caucasian (23.9%) descent. Findings included mostly left-sided breast involvement (51.8%), lesions in the upper-outer quadrant (43.1%), extensions to the skin (25.6%, N = 39), and tumour size of 2 ≤ 5 cm (49.3%), or > 5 cm (39.1%). Most patients (57.9%, N = 135) were categorised as BIRADS-5, with a ductal pattern (89.6%) (p < 0.01). Patients mostly presented in stages II to IV of disease (89.1%; p < 0.05). Late-stage (stages III-IV) at time of diagnosis (n = 84) was significantly associated with mass location (p = 0.006; Cramér's V = 0.280), tumour size (p < 0.001, Cramér's V = 0.239), and skin changes (p = 0.027, Cramér's V = 0.492).

Conclusion

Most patients consulted at a late-stage of the disease, indicating a need for the promotion of breast awareness campaigns, early detection, and timeous referral.

Breast cancer survival in sub-Saharan Africa by age, stage at diagnosis and human development index: A population-based registry study

Breast cancer is the leading cancer diagnosis and second most common cause of cancer deaths in sub-Saharan Africa (SSA). Yet, there are few population-level survival data from Africa and none on the survival differences by stage at diagnosis. Here, we estimate breast cancer survival within SSA by area, stage and country-level human development index (HDI). We obtained data on a random sample of 2,588 breast cancer incident cases, diagnosed in 2008-2015 from 14 population-based cancer registries in 12 countries (Benin, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Uganda and Zimbabwe) through the African Cancer Registry Network. Of these, 2,311 were included for survival analyses. The 1-, 3- and 5-year observed and relative survival (RS) were estimated by registry, stage and country-level HDI. We equally estimated the excess hazards adjusting for potential confounders. Among patients with known stage, 64.9% were diagnosed in late stages, with 18.4% being metastatic at diagnosis. The RS varied by registry, ranging from 21.6%(8.2-39.8) at Year 3 in Bulawayo to 84.5% (70.6-93.5) in Namibia. Patients diagnosed at early stages had a 3-year RS of 78% (71.6-83.3) in contrast to 40.3% (34.9-45.7) at advanced stages (III and IV). The overall RS at Year 1 was 86.1% (84.4-87.6), 65.8% (63.5-68.1) at Year 3 and 59.0% (56.3-61.6) at Year 5. Age at diagnosis was not independently associated with increased mortality risk after adjusting for the effect of stage and country-level HDI. In conclusion, downstaging breast cancer at diagnosis and improving access to quality care could be pivotal in improving breast cancer survival outcomes in Africa.

Self-Efficacy and Perceived Barriers as Determinants of Breast Self-Examination Among Female Nonmedical Students of the University of Ghana

Breast cancer mortality in sub-Saharan Africa is comparatively high largely because of low levels of knowledge and late presentation at hospitals. Breast self-examination (BSE) provides an important way of early detection of breast cancer, particularly for resource constrained countries. This study therefore examined the factors which influence the performance of BSE among female undergraduate nonmedical students of the University of Ghana. A cross-sectional survey was conducted between April and May 2018. It involved 308 students drawn from the University of Ghana. The instrument was based on the Health Belief Model and the Breast Cancer Knowledge questionnaires. The results suggest that about a quarter (23.4%) of the participants performed BSE at least once every month, despite 75.3% believing that checking the breast every month helps in early detection of breast cancer. As expected, those who had ever performed BSE had higher knowledge of breast cancer (M = 6.722, standard deviation [SD] = 2.090) compared with those who had never performed BSE (M = 4.850, SD = 1.982), p = . 000. Similarly, they perceived barriers to performing BSE to be lower (M = 17.900, SD = 5.733) compared with nonperformers (M = 19.850, SD = 6.976), p < .05. Results of logistic regression analysis indicated that knowledge level, self-efficacy, and level at the university were statistically significant predictors of BSE. Educational and training programs that focus on equipping women with the skill to perform BSE are therefore recommended.

Impact of Primary Care Delay on Progression of Breast Cancer in a Black African Population: A Multicentered Survey

BACKGROUND

Reports are scanty on the impact of long primary care interval in breast cancer. Exploratory reports in Nigeria and other low-middle-income countries suggest detrimental impact. The primary aim was to describe the impact of long primary care interval on breast cancer progression, and the secondary aim was to describe the factors perceived by patients as the reason(s) for long intervals.

METHOD

Questionnaire-based survey was used in 9 Nigerian tertiary institutions between May 2017 and July 2018. The study hypothesis was that the majority of patients stayed >30 days, and the majority experienced stage migration in primary care interval. Assessment of the impact of the length of interval on tumor stage was done by survival analysis technique, and clustering analysis was used to find subgroups of the patient journey.

RESULTS

A total of 237 patients presented to primary care personnel with tumor ≤5cm (mean 3.4±1.2cm). A total of 151 (69.3%, 95% CI 62.0-75.0) stayed >30 days in primary care interval. Risk of stage migration in primary care interval was 49.3% (95% CI 42.5%-56.3%). The most common reasons for long intervals were symptom misinformation and misdiagnosis. Clustering analysis showed 4 clusters of patients' experience and journey: long interval due to distance, long interval due to misinformation, long interval due to deliberate delaying, and not short interval-prepared for treatment.

CONCLUSION

The majority of patients stayed longer than 30 days in primary care interval. Long primary care interval was associated with a higher risk of stage migration, and more patients reported misinformation and misdiagnosis as reasons for a long interval.

Perspectives of patients, family members, and health care providers on late diagnosis of breast cancer in Ethiopia: A qualitative study

BACKGROUND

Most women with breast cancer in Ethiopia are diagnosed at an advanced stage of the disease, but the reasons for this have not been systematically investigated. This study, therefore, aimed to explore the main reasons for diagnosis of advanced stage breast cancer from the perspective of patients, family members, and health care providers.

METHODS

A qualitative study with in-depth interviews was conducted with 23 selected participants at Tikur Anbessa Specialized Hospital, Oncology Clinic using a semi-structured interview guide. These participants were 13 breast cancer patients, 5 family members, and 5 health care providers. Data were transcribed into English, coded and analyzed using thematic analysis.

RESULTS

Awareness about the causes, risk, initial symptoms, early detection methods, and treatment of breast cancer were uncommon, and misconceptions about the disease prevailed among breast cancer patients and family members. There was a sense of hopelessness and uncertainty about the effectiveness of conventional medicine amongst patients and family members. Consequently, performing spiritual acts (using holy water) or seeking care from traditional healers recurred amongst the interviewees. Not taking initial symptoms of breast cancer seriously by the patients, reliance on traditional medicines, competing priorities, financial hardship, older age, fear of diagnosis of cancer, and weak health systems (e.g., delay in referral and long waiting period for consultation) were noted as the main contributors to late diagnosis. In contrast, persuasion by family members and friends, higher educational attainment, and prior experience of neighboring women with breast cancer were mentioned to be facilitators of early diagnosis of breast cancer.

CONCLUSIONS

The causes of late diagnosis of breast cancer in Ethiopia are multi-factorial and include individual, cultural, and health system factors. Interventions targeting these factors could alleviate the misconceptions and knowledge gap about breast cancer in the community, and shorten waiting time between symptom recognition and diagnosis of breast cancer.

Cancer, chemotherapy, and HIV: Living with cancer amidst comorbidity in a South African township

Cancer is on the rise in Sub-Saharan Africa. In South Africa, where cancer detection, intervention, and care are available for many citizens, cancer is poorly detected and understood among politically and economically marginalized communities in rural and urban centers. These trends are reflected in a history of systematic marginalization of such contexts from public resources, including education and health care, stemming from racism and wealth inequity. This article investigates how Black South Africans residing in Soweto, a township of Johannesburg, perceive and experience breast and prostate cancers amidst multiple, concurrent medical conditions. We used convenience sampling to recruit 80 study participants already enrolled in longitudinal studies of breast and prostate cancers at a tertiary hospital in Soweto between June and August 2017. This included 50 women diagnosed with breast cancer and 30 men diagnosed with prostate cancer; three-quarters of the sample had two or more comorbidities, including HIV, hypertension, diabetes, anxiety, and others. Many described sickness in terms of any physical ill-health that affected daily routines, but rarely was it associated exclusively with a specific disease. Men and women described more fear associated with cancer than HIV or hypertension-two of the most common diseases. We found that this may be in part a reflection of how people feared and demonized their cancer diagnoses, calling it "a demon!", and framing cancer through the trauma of aggressive treatments like chemotherapy ("the red devil!") and physical disfiguration from mastectomy. In contrast, men's prostate cancer treatments were often hormonal therapy and men associated cancer to a normal side effect of aging. Intervening in how people think about cancer may improve how people live well with the condition amidst other cascading social and health problems they face.

Is a Family History of the Breast Cancer Related to Women's Cancer Prevention Behaviors?

Families share behavioral risk factors that can increase the risk of cancer development. We examined whether having a positive family breast cancer history is associated with health behaviors/screening practices. Analyses were based on a cross-sectional sample of 545 Brazilian National Cancer Institute Hospital patients with newly diagnosed breast cancer in 2013/2014. Women were categorized according to their breast cancer family history. Age-adjusted Poisson regressions with robust variance were performed to estimate the association between breast cancer family history and selected health-related behaviors and screening practices. About one fourth of women reported a positive family history of breast cancer. Contrary to expectation, we found that women with a family history of breast cancer did not report healthier behaviors more often than those without a family history. However, those with a family history were more likely to report a mammographic exam prior to the mammographic diagnosis. Our study suggests that having a family history of cancer is not sufficient to change women's behaviors about physical activity, weight control and diet, smoking, and drinking, but it seems to influence their breast cancer screening behavior. Our results suggest the need to increase women's information and/or understanding that healthier lifestyles contribute to cancer prevention.