Quality of life of patients one year after breast-conserving surgery versus modified radical mastectomy for early breast cancer: a Kenyan tertiary hospital five-year review

Introduction

Breast conserving surgery (BCS) followed by radiotherapy (BCT) and modified radical mastectomy (MRM) are the most common surgical techniques utilized in treatment of early breast cancer (EBC) with similar overall survival and recurrence rates. Western literature suggests that these treatments impact the quality of life (QOL) of patients variably. There are no comparison studies on these treatments as per patient's QOL in East Africa. The objectives were to compare the QOL of patients with EBC at least one year after BCT or MRM and assess the factors that affect this QOL.

Methods

this was a cross-sectional study conducted at Aga Khan University Hospital-Nairobi (AKUHN). Eligible female patients with EBC who had undergone either BCT or MRM between January 2013 and December 2018 were invited to fill out European Organization for the Treatment and Research of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30). Data on participant demographics and clinical information was also obtained. Average scores for each aspect of QOL were obtained and overall means for each surgical treatment were compared. Linear regression was done to assess the factors that affected this QOL.

Results

forty-two patients had BCS/BCT and 39 had MRM. Patients who had undergone BCS/BCT had a better overall QOL than those who had undergone MRM (p=0.0149). Multivariate analysis revealed that five years from time of surgery, level of education and diabetes mellitus significantly (p<0.05) affected the QOL of these patients.

Conclusion

after one year from surgery for EBC, patients who had undergone BCS/BCT had a better QOL as compared to MRM.

Breast cancer risk factors in relation to molecular subtypes in breast cancer patients from Kenya

BACKGROUND

Few studies have investigated risk factor heterogeneity by molecular subtypes in indigenous African populations where prevalence of traditional breast cancer (BC) risk factors, genetic background, and environmental exposures show marked differences compared to European ancestry populations.

METHODS

We conducted a case-only analysis of 838 pathologically confirmed BC cases recruited from 5 groups of public, faith-based, and private institutions across Kenya between March 2012 to May 2015. Centralized pathology review and immunohistochemistry (IHC) for key markers (ER, PR, HER2, EGFR, CK5-6, and Ki67) was performed to define subtypes. Risk factor data was collected at time of diagnosis through a questionnaire. Multivariable polytomous logistic regression models were used to determine associations between BC risk factors and tumor molecular subtypes, adjusted for clinical characteristics and risk factors.

RESULTS

The median age at menarche and first pregnancy were 14 and 21 years, median number of children was 3, and breastfeeding duration was 62 months per child. Distribution of molecular subtypes for luminal A, luminal B, HER2-enriched, and triple negative (TN) breast cancers was 34.8%, 35.8%, 10.7%, and 18.6%, respectively. After adjusting for covariates, compared to patients with ER-positive tumors, ER-negative patients were more likely to have higher parity (OR = 2.03, 95% CI = (1.11, 3.72), p = 0.021, comparing ≥ 5 to ≤ 2 children). Compared to patients with luminal A tumors, luminal B patients were more likely to have lower parity (OR = 0.45, 95% CI = 0.23, 0.87, p = 0.018, comparing ≥ 5 to ≤ 2 children); HER2-enriched patients were less likely to be obese (OR = 0.36, 95% CI = 0.16, 0.81, p = 0.013) or older age at menopause (OR = 0.38, 95% CI = 0.15, 0.997, p = 0.049). Body mass index (BMI), either overall or by menopausal status, did not vary significantly by ER status. Overall, cumulative or average breastfeeding duration did not vary significantly across subtypes.

CONCLUSIONS

In Kenya, we found associations between parity-related risk factors and ER status consistent with observations in European ancestry populations, but differing associations with BMI and breastfeeding. Inclusion of diverse populations in cancer etiology studies is needed to develop population and subtype-specific risk prediction/prevention strategies.

Upper Arm Disability after Axillary Surgery for Early Breast Cancer

Background: The treatment of early breast cancer includes surgical removal of the tumor and evaluation of axillary lymph nodes. Axillary lymph node surgery is associated with upper arm morbidity. The impact of this upper arm limitation has a direct effect on the patient’s quality of life. Objectives: To quantify the symptoms of upper extremity disability, and identify correlations between severity of symptoms and type of axillary surgery. Methods: An observational study of 2 groups of patients who had undergone surgery for breast cancer. Data were collected using the DASH® questionnaire and analyzed using SPSS v13®. Results: All 102 participants reported upper extremity symptoms. The mean DASH score for all participants was 51.7. Participants in the retrospective arm had a higher DASH score of 53; those in the prospective arm had a score of 47.3. Conclusion: There was no correlation between severity of symptoms and type of axillary surgery performed. Targeted rehabilitation services should be implemented after the primary surgery. Keywords: Early breast cancer, Axillary dissection, DASH score, Upper arm disability

Breast cancer recurrence rate in patients treated for early breast cancer

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Background: Recurrence rates for early breast cancer vary in different studies from 7% to 18%. Recurrent breast cancer is associated with poorer outcome and higher mortality rates. The recurrence rate in the Kenyan population remains unknown despite high prevalence of known risk factors. Methods: Single institution retrospective study of all women (18 -75 years) treated for early breast cancer at a single center private tertiary unit from 2009 to 2017. Results: 239 patient records were reviewed. The mean age at diagnosis was 51 (SD13.1). 98% of women presented with a palpable breast lesion. The molecular sub-type’s prevalence was: ER/PR+ (76%), triple negative (12.1%), HER2+ (2.9%). The overall recurrence rate was 7.2%, 66% recurrences were loco-regional, while 27% were metastatic disease, with 61% of the recurrences being detected initially on clinical/ self-breast examination. 77% of the recurrences were in women with ER/PR+ molecular sub-types. Recurrences in women with DCIS (2/27) were invasive breast cancers. There were no identified risk factors on uni-variate and multivariate regression analysis which conferred a risk of breast cancer recurrence. Discussion: The mean age at diagnosis in this group is younger than the western average (65 - 75 years). Majority of the women presented with symptoms – a presentation that differs from that of countries with a national breast cancer screening program. The molecular distribution of breast cancers is comparable to western populations. Conclusions: Recurrence rate for early breast cancer in this series is 7.2%, which is comparable with documented western data, with majority of the recurrences being detected initially on clinical/self-breast examination.

Sentinel Lymph Node Biopsy Pathology and 2-Year Postsurgical Recurrence of Breast Cancer in Kenyan Women

Purpose

The goal of this study was to describe the pathologic findings and early follow-up experience of patients who underwent a sentinel lymph node biopsy (SLNB) at Aga Khan University Hospital (AKUH) between 2008 and 2017.

Patients and Methods

We performed a retrospective analysis of women with breast cancer who underwent an SLNB at AKUH between 2008 and 2017. The SLNB was performed on patients with stage I and stage II breast cancer, and identification of the sentinel lymph node was made by radioactive tracer, blue dye, or both, per availability and surgeon preference. Demographic, surgical, and pathologic data, including immunohistochemistry of the surgical sample for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2, were abstracted from the patient records. Follow-up data were available for a subset of patients.

Results

Between 2008 and 2017, six surgeons performed SLNBs on 138 women, 129 of whom had complete records and were included in the study. Thirty-one of 129 (24%) had a positive SLNB, including 10 of 73 (14%) with stage I and 21 of 56 (38%) with stage II disease. Seventy-eight patients (60%) received systemic adjuvant chemotherapy and 79 (62%) received radiation therapy, and of the 102 patients who were estrogen receptor positive, 86 (85%) received endocrine therapy. Seventy-nine patients were observed for > 2 years, and, of these, four (5.1%) had a regional recurrence.

Conclusion

The SLNB positivity rates were similar to those of high-income country (HIC) cohorts. However, preliminary data suggest that recurrence rates are elevated at AKUH as compared with those of HIC cohorts, perhaps because of a lower use of radiotherapy and chemotherapy at AKUH compared with HIC cohorts or because of differences in the characteristics of the primary tumor in patients at AKUH as compared with those in HICs.

Abstract A12: Ethnic differences in the clinical and pathological characteristics of breast cancer among Kenyan women

Background: Breast cancer is the most common female malignancy worldwide. The effect of race and ethnicity on breast cancer has been the subject of much investigation. However, there are no published data from specific regions of sub-Saharan Africa with regards to the ethnic distribution of breast cancer and its subtypes.

Objective: To investigate the differences in clinical and pathological characteristics of breast cancer in three major ethno-cultural groupings (Bantus, Nilotes and Cushites) in Kenya.

Methods: A nationwide prospective study involving 15 public, faith-based and private institutions, which recruited patients with pathologically confirmed breast cancer between March 2012 and May 2015, was conducted. Relevant socio-demographic, clinical, reproductive and known breast cancer risk factor data were collected using a standardized questionnaire. Central pathology review and immunohistochemistry of all breast cancer tissue were done at Aga Khan University Hospital Nairobi. Proportions, chi-square tests, and logistic regression were used in the analysis of data.

Results: Among the 867 female study participants with malignant breast tumor, 675 (77.8%) were Bantus, 148 (17.0%) were Nilotes, 20 (2.4%) were Cushites, and 24 (2.8%) were patients of mixed ethnicity. Bantus were more likely than the other three ethnic groups to fall within the 40-49 year age group (32 vs 19, 15, and 25% respectively, p=0.002), more likely to have at most secondary education (27.6 vs 17.6, 0, and 16.7%, p=0.0003), and more likely to be farmers (33.9 vs 19.6, 0.0, and 16.7%, p&lt;0.0001). The majority of the study population overall was overweight or obese. When limited to Bantus and Nilotes only, Bantus were significantly more likely to be overweight than Nilotes (42.0 vs 29.9%, p=0.04). After adjusting for age, Nilotes seemed more likely to present with larger tumors and less likely to present with lymph node metastasis (OR: 0.39, 95% CI: 0.24-0.65), extra nodal extension (OR: 0.42, 95% CI: 0.23-0.75), and lymphovascular invasion (OR: 0.67, 95% CI: 0.47-0.97). The data suggest that Nilotes may be less likely to have ER positive cancers and more likely to have HER2+ cancers, though these associations were not statistically significant.

Conclusion: The differences observed for some of the clinical and pathologic features of Breast Cancer among the three distinct ethnic groups in Kenya could be multifactorial and attributable to socio economic indicators, lifestyle factors and probable genetic variations. The association of specific measurements and biomarkers of obesity from Breast cancer patients among the ethnic Kenyan population and the association of serum estradiol concentrations with ethnicity and breast cancer subtypes are areas of future research. Further research to explore the BC incidence among the ethnic groups may provide insight into yet unexplored risk factors and etiology of breast cancer.

Citation Format: Shahin Sayed, Zahir Moloo, Ronald Wasike, Asim Jamal, Peter Bird, Maya Palakal, Gretchen Gierach, Dhiren Govender, Mansoor Saleh. Ethnic differences in the clinical and pathological characteristics of breast cancer among Kenyan women [abstract]. In: Proceedings of the AACR International Conference: New Frontiers in Cancer Research; 2017 Jan 18-22; Cape Town, South Africa. Philadelphia (PA): AACR; Cancer Res 2017;77(22 Suppl):Abstract nr A12.

Effect of a breast navigation programme in a teaching hospital in Africa

<strong>Background:</strong> Breast cancer screening programmes have been developed in few developing countries to aid curb the increasing burden. However, breast cancer is still being detected in late stage, attributed to barriers in health care. Patient navigation programmes have been implemented in developed countries to help patients overcome these barriers, and they have been associated with early detection and timely diagnosis. Despite the consistent positive effects of breast navigation programmes, there are no studies conducted to show its effect in Africa where the needs are enormous.<br /><strong>Aim:</strong> To evaluate the effect of patient navigation programme on patient return after an abnormal clinical breast cancer screening examination finding at Aga Khan University Hospital, Nairobi(AKUH-N).<br /><strong>Setting:</strong> Women presenting for breast screening.<br /><strong>Methods:</strong> This was a before-and-after study conducted on 76 patients before and after the implementation of the navigation programme. They were followed up for 30 days. Measures included proportion of patient return and time to return.<br /><strong>Results:</strong> The proportion of return of patients in the navigated and non-navigated group was 57.9% and 23.7%, respectively (odds ratio [OR]: 4.43 [95% confidence interval, CI: 1.54– 12.78]; <em>p</em> = 0.0026).The proportion of timely return in the navigated group was 90.1% and 77.8% for the non-navigated group (OR: 2.85 [95% CI: 0.34–24.30], <em>p</em> = 0.34). The mean time to return in the non-navigated and navigated group was 7.33 days and 8.33 days, respectively (<em>p</em> = 0.67).<br /><strong>Conclusion:</strong> There was an increase in the proportion of patients who returned for follow-up following abnormal clinical breast examination finding after implementation of the breast navigation programme at AKUH-N.

Breast Camps for Awareness and Early Diagnosis of Breast Cancer in Countries With Limited Resources: A Multidisciplinary Model From Kenya

BACKGROUND

Breast cancer is the most common cancer of women in Kenya. There are no national breast cancer early diagnosis programs in Kenya.

OBJECTIVE

The objective was to conduct a pilot breast cancer awareness and diagnosis program at three different types of facilities in Kenya.

METHODS

This program was conducted at a not-for-profit private hospital, a faith-based public hospital, and a government public referral hospital. Women aged 15 years and older were invited. Demographic, risk factor, knowledge, attitudes, and screening practice data were collected. Breast health information was delivered, and clinical breast examinations (CBEs) were performed. When appropriate, ultrasound imaging, fine-needle aspirate (FNA) diagnoses, core biopsies, and onward referrals were provided.

RESULTS

A total of 1,094 women were enrolled in the three breast camps. Of those, 56% knew the symptoms and signs of breast cancer, 44% knew how breast cancer was diagnosed, 37% performed regular breast self-exams, and 7% had a mammogram or breast ultrasound in the past year. Of the 1,094 women enrolled, 246 (23%) had previously noticed a lump in their breast. A total of 157 participants (14%) had abnormal CBEs, of whom 111 had ultrasound exams, 65 had FNAs, and 18 had core biopsies. A total of 14 invasive breast cancers and 1 malignant phyllodes tumor were diagnosed

CONCLUSION

Conducting a multidisciplinary breast camp awareness and early diagnosis program is feasible in different types of health facilities within a low- and middle-income country setting. This can be a model for breast cancer awareness and point-of-care diagnosis in countries with limited resources like Kenya.

IMPLICATIONS FOR PRACTICE

This work describes a novel breast cancer awareness and early diagnosis demonstration program in a low- and middle-income country within a limited resource setting. The program includes breast self-awareness and breast cancer education, clinical exams, and point-of-care diagnostics for women in three different types of health facilities in Kenya. This pilot program has the potential of being replicated on a national scale to create awareness about breast cancer and downstage its presentation.

Is breast cancer from Sub Saharan Africa truly receptor poor? Prevalence of ER/PR/HER2 in breast cancer from Kenya

OBJECTIVES

Studies on ER/PR/HER2 in breast cancer from Sub Saharan Africa (SSA) are fraught with inconsistencies in the prevalence of hormone receptor status. In Kenya, ER/PR/HER2 for breast cancers is not part of routine assessment and available in only three to four centers across the country. Variability in methodology and interpretation makes comparison between data difficult. Our aim was to accurately determine the prevalence of ER/PR/HER2 using standardized techniques and double reporting. Prognostic tumor parameters were also correlated with clinical features and receptor status.

MATERIALS AND METHODS

Consecutive invasive breast cancers (IBC) accrued between September 2011 and December 2012 were analyzed at Aga Khan University Hospital, Nairobi (AKUHN). Tumor blocks were stained for ER/PR/HER2 on an automated platform. Double reporting of ER/PR/HER2 was done using the Allred system and the ASCO/CAP guidelines respectively.

RESULTS

A total of 301 cases of IBC were analyzed for pathology and ER/PR/HER2. The age range of patients was 19-94 years with a median of 47.5 years. Invasive ductal carcinoma (NOS) was the most common histologic type (84.2%). ER positivity was seen in 72.8%, PR in 64.8% and HER2 in 17.6% of all cases. Triple negative breast cancers (TNBC) constituted 20.2% of the cases. There was a significant association between receptor status and histologic grade (p < 0.001) and statistically significant trend of increasing pathological stage of tumor (pT) associated with TNBC (p = 0.020).

CONCLUSIONS

We present a definitive prospective analysis of ER/PR/HER2 from a single center and demonstrate that prevalence of receptor status from SSA is comparable with that in the West.

Breast cancer diagnosis in a resource poor environment through a collaborative multidisciplinary approach: the Kenyan experience

INTRODUCTION

The majority of women with breast cancer in Kenya present with node-positive (stage II) or locally advanced Q7 disease (stage IIIB). Diagnosis is made on fine needle aspirate cytology and treatment is with surgery if resectable. Diagnostic core biopsy is available only at subspecialty hospitals. Processing and reporting of biopsy tissue are not standardised. Hormone receptor and HER2 analyses are rarely done preoperatively.

METHODS

As part of a larger study investigating the prevalence of triple negative breast cancer in Kenya, a multidisciplinary workshop of collaborators from 10 healthcare facilities was held. Process gaps were identified, preanalytic variables impacting on ER/PR/HER2 discussed and training in core biopsy provided. Local remedial strategies were deliberated.

CONCLUSION

We describe our experience and outcome from the workshop, which can be modelled for other resource poor settings.

Optimizing breast cancer diagnosis in Kenya: Importance of standardization of technical methodologies for comparative breast cancer data

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Background: An analysis of 322 cases referred to Aga Khan University, Nairobi, revealed 56% estrogen receptor (ER) positive tumors and 35% prevalence of triple-negative breast cancer (TNBC). Findings were retrospective and limited by inability to control pre-analytical variables that could potentially impact results. Methods: As part of an ongoing prospective study assessing prevalence of TNBC in the three major ethnic groups in Kenya, we gathered a multidisciplinary team from 10 collaborating health facilities around Kenya for an educational workshop. The objectives were to assess baseline capabilities and pre-analytic variables at each center, identify gaps and provide hands-on training in order to ensure accuracy and validity of ER/PR/HER2 prevalence data gathered as part of the study. Results: See table. Breast cancer biopsies ranged from one to 20 per month per center. Diagnosis was predominantly by FNA and ER/PR/HER2 was not routinely performed. Buffered formalin fixative and standardized CAP reporting format was employed only at one center. A survey 3 months following the workshop demonstrated increase in diagnostic core biopsiesby 90%, and uniform use of buffered formalin fixative, and adoption of synoptic reporting. 66 prospective cases of breast cancer from the 10 institutions with patients from different ethnic backgrounds have been subsequently collected and IHC data will be presented. Conclusions: Much has been made of the difference in prevalence of TNBC in Africa as compared to North America, yet little attention has been paid to differences in diagnostic methodologies and basic tissue handling techniques that can potentially alter results. Despite limitations of resources, educational workshops make it possible to improve the practice of breast cancer diagnosis, and thereby enable accurate comparative analysis between breast cancers in the developing and the developed world. [Table: see text]

Pathologic characteristics of breast cancer with special emphasis on prevalence of triple-negative breast cancer from Kenya: A 4-year experience

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Background: Previous sub classification of breast cancer in Kenya has been fraught by small sample size, non uniform staining methodology and lack of independent review. Triple Negative Breast Cancer (TNBC) is a “special interest” cancer since it represents a significant proportion of breast cancer patients and is associated with a poorer prognosis. We aimed to determine the estrogen receptor (ER), progesterone receptor (PR) and Her2/neu receptor characteristics of breast cancers and the prevalence of TNBC diagnosed at Aga Khan University Hospital, Nairobi (AKUHN) between 2007 to date.

Methods: Slides and blocks of archived invasive breast cancers diagnosed at AKUHN were identified, retrieved and reviewed by two independent pathologists. Histological type, grade and pathological stage were documented. Representative sections from available blocks were stained for ER, PR, Her2 with appropriate internal controls. Scores for ER/PR were interpreted based on the ALLRED system, Her2 /neu scoring followed CAP guidelines. The initial 111 cases were validated and confirmed at Sunnybrook Health Sciences Centre, Toronto.

Results: 456 cases of invasive breast cancers were diagnosed at AKUHN during the study period. 91% of cases were invasive ductal carcinomas (NOS).The rest were special types. 37% of the tumors were grade 3 and 63% were grade 2. Blocks for 318 of 456 cases were available for receptor analysis. 54% were ER and/or PR positive, with 52% of these in women < 50 yrs. 86% of the ER and/or PR positive tumors were grade 2. Only 12% were Her2/neu positive. Of the 318 cases studied, 111 (32%) were identified as TNBC. Median age was 53 yrs. 88% were grade 3.

Conclusions: Invasive ductal carcinoma (NOS) was the most common breast cancer in our study. Nearly half of our cases were ER and/or PR positive and a third were TNBC. Both occurred predominantly in women less than 50 yrs. This represents the largest validated pathologic sub classification of breast cancer from a tertiary academic hospital in Kenya. Expansion of this study to encompass all breast cancers diagnosed in Kenya is underway.

Fine-needle aspiration in suspected inflammatory breast cancer: case series with emphasis on approach to specimen adequacy

OBJECTIVES

To highlight the utility of a tangential approach in the fine-needle aspiration (FNA) technique for obtaining cellular material adequate for a conclusive diagnosis in diffusely enlarged breast without a discrete lump.

STUDY DESIGN

FNA was performed on 5 women clinically suspected to have inflammatory breast cancer (IBC). All had unilateral diffusely enlarged breasts with peau d'orange changes of the skin. No distinct lump was palpable. The procedure was performed using a 10 cm(3) syringe with a tangential approach of a 23-gauge needle in all 4 quadrants with extra passes in the antigravity areas. Rapid on-site evaluation for adequacy was done.

RESULTS

All women were of African descent within the age range of 34-57 years. One case had a recent history of lactation. FNA smears showed low-to-moderate cellularity. One case was suspicious and 4 were positive for ductal carcinoma. Core biopsy confirmed IBC in 3 cases. Two cases had a mastectomy; 1 of these cases had preoperative neoadjuvant chemotherapy.

CONCLUSION

The approach of FNA used in these cases helped to establish the diagnosis of IBC in 4 women presenting with a diffusely enlarged and tender breast, resulting in the timely initiation of appropriate management. The technique needs to be assessed in a larger cohort of women with diffusely enlarged breast to evaluate its diagnostic utility.

Cytological diagnosis of molluscum contagiosum with an unusual clinical presentation at an unusual site

BACKGROUND

Molluscum contagiosum, is a common skin infection caused by a pox virus usually present as raised nodule with umbilicated centre. Cytologic diagnosis has been documented in very few case reports as the lesion is subjected to fine needle aspiration rarely and awareness of the cytological features of Molluscum contagiosum is limited. The cytological diagnosis is further challenging in clinically unsuspected lesions.

MAIN OBSERVATIONS

A 45-year-old female patient presented with 10 months history of a nodular nipple lesion which ulcerated after local application of caustic pencil. There was no associated breast lump. Cheesy material was expressed from the ulcer on the nipple and crush smeared on slides for cytological evaluation. Cytology smears revealed nucleate and anucleate squames in an inflammatory background. Characteristic intracytopalsmic and extracytopalsmic molluscum bodies were seen.

CONCLUSION

The nipple is an unusual site of presentation for Molluscum contagiosum. Ulcerated lesions are rarer. In the present case, the cytological examination facilitated the diagnosis in a clinically unsuspected case. Cytology can be a useful rapid diagnostic aid in planning the management of these patients and help in avoiding unnecessary biopsies.

Reverse sural island flap in coverage of defects lower third of leg: a series of nine cases

The distally based sural island flap was first described by Masquelet, et al., in 1992. It is a skin island flap supplied by the vascular axis of the sural nerve. The aim of this paper is to demonstrate that it can be applied in coverage of difficult wound in the lower third of the leg. We treated nine patients with nine distally based sural island flaps. All the flaps survived, most of the flaps had venous congestion. The largest flap was 10 x 8 cm and Doppler was used in only one flap. This technique is easy and quick to execute without sacrificing major arteries.

Perforated Meckel's diverticulitis presenting as a mesenteric abscess: case report

Only 2% of patients with Meckel's diverticulae (MD) will manifest clinical problems. Diverticulitis occurs in approximately 10-20% of patients with symptomatic MD and more often in the elderly population. We report a case of Meckels diverticulitis presenting with perforation and mesenteric abscess in a young African man. The authors present information on diagnostic pitfalls and advise a lower threshold for consideration of MD as a differential diagnosis of acute right iliac fossa pain especially when the CT scan denotes a normal appendix in a male patient.