The descriptive epidemiology of female breast cancer: an international comparison of screening, incidence, survival and mortality

Disparities in the Management of Pediatric Breast Masses

INTRODUCTION

Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass.

METHODS

A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses.

RESULTS

A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis.

CONCLUSIONS

We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Decolonising medical knowledge - The case of breast cancer and ethnicity in the UK

National and global efforts have led to significant improvements in breast health and diagnosis, globally (Lukong, 2017). These achievements, however, are not even. Focusing on the case of breast cancer in the UK, we argue that enduring forms of medical racism leave Black women more vulnerable to advanced forms of the disease, explaining higher mortality rates and later-stage diagnosis. In particular, we show how a lack of dedicated policy, inadequate data collection, and a lack of representation conspire to place Black women at additional and unnecessary risk of worse breast cancer outcomes. We thus propose key recommendations to address the ethnic disparities in and make steps to decolonise breast cancer care. These are early screening for at-risk groups, community-led interventions, and more and better representation of Black women and their risks in breast cancer resources.

Health system cost of breast cancer treatment in Addis Ababa, Ethiopia

BACKGROUND

Breast cancer is the leading cancer among women with an annual crude incidence of 27.4 per 100,000 in Ethiopia. The aims of this study were to (a) estimate the unit cost of breast cancer treatment for the standard Ethiopian patient, (b) identify the cost drivers, (c) project the total cost of breast cancer treatment for the next five years, and (d) estimate the economic burden of the disease in the main specialized tertiary hospital-Tikur Anbessa Specialized Hospital (TASH) Addis Ababa.

METHODS

Primary data were collected from health and non-health professionals. Secondary data were collected from patient`s charts and official reports from various national and international organisations including data from TASH. To establish work-time estimates, we asked professionals on their time usage.

RESULT

A total of US$ 33,261 was incurred to treat 52 Addis Ababa resident female breast cancer patients in TASH between July 2017 and June 2019. The unit cost of treatment for a hypothetical breast cancer patient to complete her treatment was US$ 536 for stage I and US$ 705 for stage II and III using the existing infrastructure. This cost increased to US$ 955 for stage I and US$ 1157 for stage II and III when infrastructure amortization was considered. The projected total costs of breast cancer treatment in TASH is between US$ 540,000 and US$ 1.48million. However, this will increase to US$ 870,000 and US$ 2.29 million when the existing fixed assets are changed.

CONCLUSION

The economic burden of breast cancer treatment is high compared to the economic status of the country. Thus, it is recommended that TASH should revise its charges and breast cancer should be included in the Social and Community based health insurance scheme. JEL classification: H51, H75, I18, P46.

Evaluation of an artificial intelligence support system for breast cancer screening in Chinese people based on mammogram

BACKGROUND

To evaluate the diagnostic performance of radiologists on breast cancer with or without artificial intelligence (AI) support.

METHODS

A retrospective study was performed. In total, 643 mammograms (average age: 54 years; female: 100%; cancer: 62.05%) were randomly allocated into two groups. Seventy-five percent of mammograms in each group were randomly selected for assessment by two independent radiologists, and the rest were read once. Half of the 71 radiologists could read mammograms with AI support, and the other half could not. Sensitivity, specificity, Youden's index, agreement rate, Kappa value, the area under the receiver operating characteristic curve (AUC) and the reading time of radiologists in each group were analyzed.

RESULTS

The average AUC was higher if the AI support system was used (unaided: 0.84; with AI support: 0.91; p < 0.01). The average sensitivity increased from 84.77% to 95.07% with AI support (p < 0.01), but the average specificity decreased (p = 0.07). Youden's index, agreement rate and Kappa value were larger in the group with AI support, and the average reading time was shorter (p < 0.01).

CONCLUSIONS

The AI support system might contribute to enhancing the diagnostic performance (e.g., higher sensitivity and AUC) of radiologists. In the future, the AI algorithm should be improved, and prospective studies should be conducted.

Potential of Anti-inflammatory Molecules in the Chemoprevention of Breast Cancer

Breast cancer is a global issue, affecting greater than 1 million women per annum. Over the past two decades, there have been numerous clinical trials involving the use of various pharmacological substances as chemopreventive agents for breast cancer. Various pre-clinical as well as clinical studies have established numerous anti-inflammatory molecules, including nonsteroidal anti-inflammatory drugs (NSAIDs) and dietary phytochemicals as promising agents for chemoprevention of several cancers, including breast cancer. The overexpression of COX-2 has been detected in approximately 40% of human breast cancer cases and pre-invasive ductal carcinoma in-situ lesions, associated with aggressive elements of breast cancer such as large size of the tumour, ER/PR negative and HER-2 overexpression, among others. Anti-inflammatory molecules inhibit COX, thereby inhibiting the formation of prostaglandins and inhibiting nuclear factor-κBmediated signals (NF-kB). Another probable explanation entails inflammation-induced degranulation, with the production of angiogenesis-regulating factors, such as vascular endothelial growth factor, which can be possibly regulated by anti-inflammatory molecules. Apart from NSAIDS, many dietary phytochemicals have the ability to decrease, delay, or stop the progression and/or incidence of breast cancer by their antioxidant action, regulating inflammatory and proliferative cell signalling pathways as well as inducing apoptosis. The rapid progress in chemoprevention research has also established innovative strategies that can be implemented to prevent breast cancer. This article gives a comprehensive overview of the recent advancements in using antiinflammatory molecules in the chemoprevention of breast cancer along with their mechanism of action, supported by latest preclinical and clinical data. The merits of anti-inflammatory chemopreventive agents in the prevention of cardiotoxicity have been described. We have also highlighted the ongoing research and advancements in improving the efficacy of using antiinflammatory molecules as chemopreventive agents.

A Scoping Review on the Status of Female Breast Cancer in Asia with a Special Focus on Nepal

This study aimed to provide updated evidence on the status of female breast cancer and cancer treatment facilities in Asia, with a special focus on Nepal. This review used search phrases that included, breast neoplasm or cancer, health status, epidemiology, breast cancer survivors, cancer care facilities, Asia, Nepal. Researchers examined databases from January 2011 to December 2020 (PubMed, PMC, Google Scholar, and the reference lists of included papers). Studies of any design and reviews, were included in the study, except for qualitative studies. The study findings are presented in a narrative synthesis format using Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. An initial search resulted in 974 papers, and 896 were reviewed after being checked for duplication using the Zotero software. Accordingly, utilizing the inclusion and exclusion criteria, 188 publications were selected, and after review of titles and abstracts, an additional 98 papers were removed for different reasons. Finally, the study looked at 90 female breast cancer papers. Results showed that the number of cases of breast cancer is growing all around the world, including in Asia and Nepal. Age, early menarche, late menopause, nulliparity, positive family history, excessive fat consumption, alcohol, and smoking are all frequent risk factors for breast cancer found in Asian women. Breast self-examination, clinical breast examination, and mammography screening are common methods for detecting breast carcinoma. Chemotherapy, radiation, and modified mastectomy are commonly used options for treatment. The number of breast cancer survivors is growing throughout the world, indicating better clinical care. There is a paucity of survival data in many Asian countries, including Nepal. There is also a scarcity of health workforce specialized in cancer care and treatment, as well as a few health facilities that are available to treat cancer cases in many Asian countries, including Nepal.

Burden, trends, and risk factors for breast cancer in China from 1990 to 2019 and its predictions until 2034: an up-to-date overview and comparison with those in Japan and South Korea

BACKGROUND

The difference in epidemiological characteristics of breast cancer (BC) across countries is valuable for BC management and prevention. The study evaluated the up-to-date burden, trends, and risk factors of BC in China, Japan and South Korea during 1990-2019 and predicted the BC burden until 2034.

METHODS

Data on incident cases, deaths, disability-adjusted life-years (DALYs) and age-standardized rate (ASR) of BC were extracted from the Global Burden of Disease Study 2019. Trend analysis and prediction until 2034 were conducted by estimated annual percentage change and a Bayesian age-period-cohort model, respectively. Besides, the attributable burden to BC risk factors was also estimated.

RESULTS

In 2019, the number of BC incident cases, deaths and DALYs in China were 375,484, 96,306 and 2,957,453, respectively. The ASR of incidence increased, while that of death and DALYs decreased for Chinese females and Japanese and South Korean males during 1990-2019. High body-mass-index (BMI) was the largest contributor to Chinese female BC deaths and DALYs, while alcohol use was the greatest risk factor for Japanese and South Korean as well as Chinese males. The incident cases and deaths were expected to continue increase during 2020-2034 (except for Japanese female incident cases).

CONCLUSIONS

China had the greatest burden of BC among the three countries. Incident cases and deaths of BC were projected to increase over the next 15 years in China, particularly among Chinese males. Effective prevention and management strategies are urgently necessary for BC control in China.

Knowledge of breast cancer and breast self-examination practices and its barriers among university female students in Bangladesh: Findings from a cross-sectional study

Early diagnosis of breast cancer is the best approach towards its control that may result in alleviating related mortality and morbidity. This study aimed to evaluate knowledge about breast cancer and both practices and perceived barriers to breast self-examination among female university students in Bangladesh. A cross-sectional study was carried out with 400 female students of Jahangirnagar University, Bangladesh. Participants were sampled from female dormitories at the university from January to April 2020. Proportionate stratified random sampling was conducted to calculate the study sample from each dormitory. A validated semi-structured self-reported questionnaire was employed to collect data from participants during the survey periods. The questionnaire consisted of demographic variables, items about knowledge about breast cancer, breast self-examination practices and its barriers. We applied descriptive and inferential statistics and data were analyzed using the Statistical Package for the Social Sciences (SPSS). Participants were aged between 18–26 years and comprised university students of first year (20%), second year (24%), third year (22%), fourth year (21%) and Master’s (14%). 18% of them reported positive family history (mother, aunt, sister/cousin, grandmother) of breast cancer. The overall mean score of total knowledge items was 15 (SD = 3) out of 43, with an overall correct rate of 34%. The mean score of total knowledge items was significantly higher (p<0.001) among Master’s students and students with family members who have had breast cancer. Only one in five students (21%) ever practiced breast self-examination. The mean score of practice of breast self-examination was significantly higher (p<0.001) among participants who reported having family member of breast cancer. Total knowledge score about breast cancer and practice of breast self-examination were significantly correlated with each other (r = 0.54; p<0.001). About 33% participants reported ‘lack of knowledge’ as the main barrier to practicing breast self-examination followed by ‘I do not have the symptoms’ (22%), and ‘shyness/ uncomfortable feelings’ (17%). The study revealed low levels of knowledge about breast cancer and low breast self-examination practices. Our findings highlight the need to develop, implement and promote socially, culturally and demographically appropriate educational interventions programs aimed at breast cancer and breast self-examination awareness and practice in Bangladesh.

Global Burden of Female Breast Cancer: Age-Period-Cohort Analysis of Incidence Trends From 1990 to 2019 and Forecasts for 2035

Introduction

This study aimed to describe the latest epidemiology of female breast cancer globally, analyze the change pattern of the incidence rates and the disease’s association with age, period, and birth cohort, and subsequently present a forecast of breast cancer incidence.

Methods

Data for analysis were obtained from Global Burden of Disease (GBD) Study 2019 and World Population Prospects 2019 revision by the United Nations (UN). We described the age-standardized incidence rates (ASIRs) from 1990 to 2019 and then calculated the relative risks of period and cohort using an age-period-cohort model, and predicted the trends of ASIRs to 2035.

Results

In 2019, the global incidence of breast cancer in women increased to 1,977,212 (95% uncertainty interval = 1 807 615 to 2 145 215), with an ASIR of 45.86 (41.91 to 49.76) per 100 000 person-year. Among the six selected countries facing burdensome ASIRs, only the USA showed a downward trend from 1990 to 2019, whereas the others showed an increasing or stable trend. The overall net drift was similar in Japan (1.78%), India (1.66%), and Russia (1.27%), reflecting increasing morbidity from 1990 to 2019. The increase in morbidity was particularly striking in China (2.60%) and not significant in Germany (0.42%). The ASIRs were predicted to continue to increase globally, from 45.26 in 2010 to 47.36 in 2035. In most countries and regions, the age specific incidence rate is the highest in those aged over 70 years and will increase in all age groups until 2035. In high-income regions, the age specific incidence rates are expected to decline in women aged over 50 years.

Conclusions

The global burden of female breast cancer is becoming more serious, especially in developing countries. Raising awareness of the risk factors and prevention strategies for female breast cancer is necessary to reduce future burden.

Mapping Evidence on the Burden of Breast, Cervical, and Prostate Cancers in Sub-Saharan Africa: A Scoping Review

Background

Cancer remains a major public health problem, especially in Sub-Saharan Africa (SSA) where the provision of health care is poor. This scoping review mapped evidence in the literature regarding the burden of cervical, breast and prostate cancers in SSA.

Methods

We conducted this scoping review using the Arksey and O'Malley framework, with five steps: identifying the research question; searching for relevant studies; selecting studies; charting the data; and collating, summarizing, and reporting the data. We performed all the steps independently and resolved disagreements through discussion. We used Endnote software to manage references and the Rayyan software to screen studies.

Results

We found 138 studies that met our inclusion criteria from 2,751 studies identified through the electronic databases. The majority were retrospective studies of mostly registries and patient files (n = 77, 55.8%), followed by cross-sectional studies (n = 51, 36.9%). We included studies published from 1990 to 2021, with a sharp increase from 2010 to 2021. The quality of studies was overall satisfactory. Most studies were done in South Africa (n = 20) and Nigeria (n = 17). The majority were on cervical cancer (n = 93, 67.4%), followed by breast cancer (67, 48.6%) and the least were on prostate cancer (48, 34.8%). Concerning the burden of cancer, most reported prevalence and incidence. We also found a few studies investigating mortality, disability-adjusted life years (DALYs), and years of life lost (YLL).

Conclusions

We found many retrospective record review cross-sectional studies, mainly in South Africa and Nigeria, reporting the prevalence and incidence of cervical, breast and prostate cancer in SSA. There were a few systematic and scoping reviews. There is a scarcity of cervical, breast and prostate cancer burden studies in several SSA countries. The findings in this study can inform policy on improving the public health systems and therefore reduce cancer incidence and mortality in SSA.

Invasive Lobular Carcinoma Has Worse Outcome Compared with Invasive Ductal Carcinoma in Stage IV Breast Cancer with Bone-Only Metastasis

BACKGROUND

Invasive lobular carcinoma (ILC) is more likely to have bone metastasis than invasive ductal carcinoma (IDC). However, the prognosis for bone metastasis in ILC and IDC is barely known. So, the aim of this study was to investigate the difference of prognosis between ILC and IDC accompanied by bone metastasis.

METHODS

We evaluated the women with bone-only metastasis of defined IDC or ILC reported to the Surveillance, Epidemiology and End Results program from 2010 to 2016. Pearson's χ² test was used to compare the differences of clinicopathologic factors between IDC and ILC. Univariate and multivariate analyses were performed to verify the effects of histological types (IDC and ILC) and other clinicopathologic factors on the overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Overall, 3,647 patients with IDC and 945 patients with ILC met the inclusion criteria and were analyzed in our study. The patients with ILC were more likely to be older and to have lower histological grade and a higher proportion of the HR*/HER2- subtype. However, less treatment was administered to ILC than IDC, such as surgery of the breast, radiation, and chemotherapy. Compared to patients with IDC, patients with ILC showed worse OS (median OS, 36 and 42 months, respectively, p < 0.001) and CSS (median CSS, 39 and 45 months, respectively, p < 0.001), especially in subgroups with HR*/HER2- subtype (OS, hazard ratio: 1.501, 95% CI 1.270-1.773, p < 0.001; CSS, hazard ratio: 1.529, 95% CI 1.281-1.825, p < 0.001), lower histological grade (I-II) (OS, hazard ratio: 1.411, 95% CI 1.184-1.683, p < 0.001; CSS, hazard ratio: 1.488, 95% CI 1.235-1.791, p < 0.001), or tumor burden, such as T_0-2 (OS, hazard ratio: 1.693, 95% CI 1.368-2.096, p < 0.001; CSS, hazard ratio: 1.76, 95% CI 1.405-2.205, p < 0.001) and N_1-2 (OS, hazard ratio: 1.451, 95% CI 1.171-1.799, p = 0.001; CSS, hazard ratio: 1.488, 95% CI 1.187-1.865, p = 0.001). Furthermore, older age, black race, unmarried status, higher tumor burden (T_3-4 and N₃), triple-negative subtype, and higher histological grade were independent risk factors for both OS and CSS. Surgery of the breast and chemotherapy could significantly improve the prognosis for patients.

CONCLUSION

Patients with ILC have worse outcomes compared to those with IDC when associated with bone-only metastasis, especially in subgroups with lower histological grade or tumor burden. More effective treatment measures may be needed for ILC, such as cyclin-dependent kinase 4/6 inhibitors, new targeted drugs, etc.

Quality of Informed Consent in Mammography Screening-The Polish Experience

Breast cancer is one of the leading forms of cancers in women worldwide. In Poland, it accounts for approx. 20% of all cancers diagnosed, with approximately 11,000 new cases and 5000 deaths from this disease annually. To prevent unfavourable statistics, Poland introduced free breast cancer screening programmes, available to women aged 50-69. Over a million women take advantage of this programme each year. The aim of the research was to assess the quality of consent women give prior to mammography screening and address the question of whether this quality is sufficient to make an informed choice. The study was conducted on a representative group of 600 Polish women over 50 years old (475 of them had undergone mammography screening), who agreed to take part in the study. Using the computer-assisted interview technology (CATI) method, all women were asked about their perception of breast cancer and screening and those who had undergone mammography were quizzed about the consent process. They will form the focus of this research. The validated tool contained items on both the benefits and risks of screening. The results indicate that the quality of informed consent was insufficient. A discrepancy was observed in the awareness between the benefits and risks of mammography screening. The main motivations to undergo screening were: prophylactic purposes and the free-of-charge nature of this health service. Population-based screening programmes for breast cancer should be reconsidered in terms of information policy, and the quality of informed consent should be increased.

Notch signaling in female cancers: a multifaceted node to overcome drug resistance

Drug resistance is one of the main challenges in cancer therapy, including in the treatment of female-specific malignancies, which account for more than 60% of cancer cases among women. Therefore, elucidating the underlying molecular mechanisms is an urgent need in gynecological cancers to foster novel therapeutic approaches. Notably, Notch signaling, including either receptors or ligands, has emerged as a promising candidate given its multifaceted role in almost all of the hallmarks of cancer. Concerning the connection between Notch pathway and drug resistance in the afore-mentioned tumor contexts, several studies focused on the Notch-dependent regulation of the cancer stem cell (CSC) subpopulation or the induction of the epithelial-to-mesenchymal transition (EMT), both features implicated in either intrinsic or acquired resistance. Indeed, the present review provides an up-to-date overview of the published results on Notch signaling and EMT- or CSC-driven drug resistance. Moreover, other drug resistance-related mechanisms are examined such as the involvement of the Notch pathway in drug efflux and tumor microenvironment. Collectively, there is a long way to go before every facet will be fully understood; nevertheless, some small pieces are falling neatly into place. Overall, the main aim of this review is to provide strong evidence in support of Notch signaling inhibition as an effective strategy to evade or reverse resistance in female-specific cancers.

Probiotic Yeast Saccharomyces: Back to Nature to Improve Human Health

Saccharomyces cerevisiae var. boulardii is best known for its treatment efficacy against different gastrointestinal diseases. This probiotic yeast can significantly protect the normal microbiota of the human gut and inhibit the pathogenicity of different diarrheal infections. Several clinical investigations have declared S. cerevisiae var. boulardii a biotherapeutic agent due to its antibacterial, antiviral, anti-carcinogenic, antioxidant, anti-inflammatory and immune-modulatory properties. Oral or intramuscular administration of S. cerevisiae var. boulardii can remarkably induce health-promoting effects in the host body. Different intrinsic and extrinsic factors are responsible for its efficacy against acute and chronic gut-associated diseases. This review will discuss the clinical and beneficial effects of S. cerevisiae var. boulardii in the treatment and prevention of different metabolic diseases and highlight some of its health-promising properties. This review article will provide fundamental insights for new avenues in the fields of biotherapeutics, antimicrobial resistance and one health.

Breast Cancer Knowledge, Attitudes and Practices amongst Women in Qatar

This cross-sectional study examines knowledge, attitudes, and practices surrounding breast cancer awareness and screening among women residents in Qatar. Females, >18 years old, registered with the Primary Health Care Corporation were invited to complete an Arabic or English online survey using a modified version of the Breast Cancer Awareness Module. Of the 9008 participants, 69% report awareness of breast cancer warning signs, but the results did not substantiate these claims. There remains a disconnect between participants’ perceived awareness of their ability to detect breast cancer and their actual recognition of individual signs and symptoms. Nearly half (45.4%) report rarely or never checking their breasts for abnormalities (44.6%). Breast self-examination (BSE) and Breast Cancer Screening (BCS) uptake is low and many are unaware of the starting age for invitation to Qatar’s BCS program. While only 18% of women report receiving an invitation, 94% attended, indicating that the BCS invitation is a remarkably effective means of improving screening uptake. Policymakers should capitalize on early recognition, which is possible in the youthful population. Broadening awareness campaigns and interventions targeting a broader audience including males, community and religious leaders and healthcare professionals may prove more effective in Arab communities.

Epidemiological and sociodemographic transitions of female breast cancer incidence, death, case fatality and DALYs in 21 world regions and globally, from 1990 to 2017: An Age-Period-Cohort Analysis

Introduction

Breast cancer (BC) is the most widely studied disease due to its higher prevalence, heterogeneity and mortality.

Objectives

This study aimed to compare female BC trends among 21 world regions and globally over 28 year of data and to assess the association between sociodemographic transitions and female BC risks.

Methods

We used Global burden of disease study data and measure the female BC burden according to 21 world regions and sociodemographic indices (SDI). Age-period-cohort (APC) analysis was used to estimate time and cohort trend of BC in different SDI regions.

Results

By world regions, age-standardised rate of female BC incidence were high in high-income-North America (ASR, 92.9; (95 %UI, 89.2, 96.6)), Western Europe (84.7; (73.4, 97.2)) and Australia (86; (81.7, 90.2)) in 2017. Whereas this rate was significantly increased by 89.5% between 1990 and 2017 in East Asia. We observed negative association between SDI and death, and DALYs in 25th and below percentiles of death and DALYs for the worldwide regions. Further, there was observed a strong negative correlation between SDI and case fatality percent (r2017 = -0.93; r1990 = -0.92) in both 2017 and 1990 worldwide and highest case fatality percentage was observed in Central Sub-Saharan Africa. Overall, the risk of case-fatality rate tends to decrease most noticeably in high middle SDI countries, and the reduction of the risk of case-fatality rate in the recent cohort was the lowest in the low SDI countries.

Conclusions

Remarkable variations exist among various regions in BC burden. There is a need to reduce the health burden from BC in less developed and under developing countries, because under-developed countries are facing higher degree of health-related burden. Public health managers should execute more classified and cost-effective screening and treatment interferences to lessen the deaths caused by BC, predominantly among middle and low SDI countries having inadequate healthcare supplies.

Circulating proteins reveal prior use of menopausal hormonal therapy and increased risk of breast cancer

Accessible risk predictors are crucial for improving the early detection and prognosis of breast cancer. Blood samples are widely available and contain proteins that provide important information about human health and disease, however, little is still known about the contribution of circulating proteins to breast cancer risk prediction. We profiled EDTA plasma samples collected before diagnosis from the Swedish KARMA breast cancer cohort to evaluate circulating proteins as molecular predictors. A data-driven analysis strategy was applied to the molecular phenotypes built on 700 circulating proteins to identify and annotate clusters of women. The unsupervised analysis of 183 future breast cancer cases and 366 age-matched controls revealed five stable clusters with distinct proteomic plasma profiles. Among these women, those in the most stable cluster (N = 19; mean Jaccard index: 0.70 ± 0.29) were significantly more likely to have used menopausal hormonal therapy (MHT), get a breast cancer diagnosis, and were older compared to the remaining clusters. The circulating proteins associated with this cluster (FDR < 0.001) represented physiological processes related to cell junctions (F11R, CLDN15, ITGAL), DNA repair (RBBP8), cell replication (TJP3), and included proteins found in female reproductive tissue (PTCH1, ZP4). Using a data-driven approach on plasma proteomics data revealed the potential long-lasting molecular effects of menopausal hormonal therapy (MHT) on the circulating proteome, even after women had ended their treatment. This provides valuable insights concerning proteomics efforts to identify molecular markers for breast cancer risk prediction.

Dietary and physical activity changes and adherence to WCRF/AICR cancer prevention recommendations following a remotely delivered weight loss intervention for female breast cancer survivors: The Living Well after Breast Cancer randomized controlled trial

BACKGROUND

Diet, exercise, and weight management are key in improving outcomes for breast cancer survivors, with international recommendations for cancer survivors relating to these behaviors. However, few behavioral interventions have reported outcomes aligned specifically with these recommendations.

OBJECTIVE

To evaluate a remotely delivered weight loss intervention versus usual care for female breast cancer survivors, on changes in multiple diet and physical activity behaviors.

DESIGN

A randomized controlled trial with assessments at study baseline, 6-, 12- and 18 months (i.e., mid-intervention, post-intervention, and non-contact follow-up).

PARTICIPANTS/SETTING

Participants were recruited between October 2012 and December 2014 through hospitals in Brisbane (Australia) and the state-based cancer registry. Eligible participants (female, 18-75 years, BMI 25-45 kg/m², diagnosed with stage I-III breast cancer in previous two years) were randomly allocated to intervention (n=79) or usual care (n=80).

INTERVENTION

Participants randomized to the intervention group received 22 counseling telephone calls targeting diet and physical activity aimed at achieving 5-10% weight loss, and optional text messages, over 12 months. Usual care participants received their standard medical care and brief feedback following each assessment, which was similar to that provided to intervention participants with the exception that usual care participants' results were not compared to national and study recommendations.

MAIN OUTCOME MEASURES

Dietary intake (24-hour recalls); physical activity (hip-worn Actigraph); sitting time (thigh-worn activPAL3); and, adherence to World Cancer Research Fund/American Cancer Research Institute (WCRF/AICR) recommendations for cancer survivors (0-7 score) were measured at each assessment, with data collected between November 2012 and October 2016.

STATISTICAL ANALYSES PERFORMED

Intervention effects were assessed by linear mixed models, accounting for repeated measures and baseline values. Significance was set at P<0.05.

RESULTS

At baseline, participants were (mean±SD) aged 55±9 years, with a BMI of 31.4±5.0 kg/m², 10.7±5.0 months post-diagnosis, and primarily non-minority. At baseline, only 8% (n=12) of participants met ≥5/7 WCRF/AICR recommendations (mean±SD WCRF/AICR adherence score: 3.8±1.0). At 12 months, significant intervention effects were observed in walking/running ( +21 mins/week; 95%CI: 4, 38) and WCRF/AICR adherence scores (+0.3 points; 95%CI: 0.0, 0.6) only. At 18 months, significant intervention effects were observed for energy intake (-229 kcal/day energy; 95%CI: -373, -84), total fat (-10 g/day; 95%CI: -18, -2), and saturated fat (-5 g/day; 95%CI: -9, -1), and were sustained for WCRF/AICR adherence scores (+0.5 points; 95%CI: 0.2, 0.8).

CONCLUSIONS

This remotely delivered weight loss intervention led to sustained improvements in WCRF/AICR adherence scores, and some improvements in diet and physical activity. These findings provide support for the health benefit of programs targeting lifestyle behaviors in line with cancer survivor recommendations, and the potential for dissemination of such programs following treatment for early-stage female breast cancer.

Metabolic Features of Saliva in Breast Cancer Patients

The aim of the work was to study the metabolic characteristics of saliva in breast cancer and the subsequent assessment of the potential information content of its individual biochemical indicators. The study included 487 patients of the Omsk Clinical Oncology Center with morphologically verified breast cancer and 298 volunteers without breast pathologies. Saliva samples were obtained from all patients before the start of treatment, and the values of 34 biochemical indicators were determined. It has been shown that concentration of total protein, urea, uric acid (UA), the total content of α-amino acids and lipid peroxidation products, and the activity of metabolic and antioxidant enzymes (in particular catalase—CAT) of saliva changed significantly in breast cancer. Biochemical indicators characterizing early breast cancer have been identified, which can be used for timely diagnosis in addition to existing methods. The coefficients UA/Urea and UA·CAT/Urea are proposed, for which the maximum deviation from the norm was observed in the early stages of the disease. It was shown that for ductal breast cancer, changes in the activity of metabolic enzymes of saliva were more pronounced, while, for lobular breast cancer, the indicators of enzymatic and non-enzymatic components of antioxidant protection changed. The results confirmed the potential importance of saliva in the diagnosis of breast cancer.

Global and regional trends in incidence and mortality of female breast cancer and associated factors at national level in 2000 to 2019

BACKGROUND

Female breast cancer (FBC) has become the most prevalent malignancy worldwide. We aimed to evaluate the global and regional burden in epidemiological trends and factors associated with the incidence and mortality of FBC.

METHODS

FBC incidence and mortality in 60 selected countries by cancer registry data integrity in 2020 were estimated from the GLOBOCAN database, and their association with the human development index (HDI) was further evaluated. Trends of age-standardized rates of incidence and mortality in 60 countries from 2000 through 2019 were evaluated by joinpoint regression analysis using data of Global Burden of Disease 2019. The association between potential behavioral, metabolic, and socioeconomic risk factor exposure at the nation level retrieved from the World Bank and Global Health Observatory and the incidence and mortality of FBC were evaluated by multivariate linear regression.

RESULTS

FBC incidence and mortality varied greatly in the 60 included countries. Higher incidence and mortality rates were typically observed in countries with higher HDIs and vice versa. During 2000 to 2019, significantly increasing trends in incidence and mortality were observed in 26 (average annual percent changes [AAPCs], 0.35-2.96) and nine countries (AAPC, 0.30-1.65), respectively, while significantly decreasing trends in both incidence and mortality were observed in 22 countries, most of which were high-HDI countries. Among the population aged ≥40 years, there were 26 and 11 countries showing significantly increased trends in incidence and mortality, respectively. Ecological analysis showed that countries with higher prevalence rates of high cholesterol and higher health expenditures were more likely to have higher FBC incidence, and countries with higher rates of obesity and poorer universal health coverage were more likely to have higher FBC mortality.

CONCLUSIONS

Despite decreased or stabilized FBC incidence and mortality rates were observed in some countries with high HDI over the past decades, disease burden became even severer in developing countries, especially for the population aged ≥40 years. Effective targeted preventive programs are strongly encouraged to reduce the FBC disease burden worldwide.

Antigen presentation and interferon signatures in B cells driven by localized ablative cancer immunotherapy correlate with extended survival

Rationale: B cells have emerged as key regulators in protective cancer immunity. However, the activation pathways induced in B cells during effective immunotherapy are not well understood. Methods: We used a novel localized ablative immunotherapy (LAIT), combining photothermal therapy (PTT) with intra-tumor delivery of the immunostimulant N-dihydrogalactochitosan (GC), to treat mice bearing mouse mammary tumor virus-polyoma middle tumor-antigen (MMTV-PyMT). We used single-cell RNA sequencing to compare the transcriptional changes induced by PTT, GC and PTT+GC in B cells within the tumor microenvironment (TME). Results: LAIT significantly increased survival in the tumor-bearing mice, compared to the treatment by PTT and GC alone. We found that PTT, GC and PTT+GC increased the proportion of tumor-infiltrating B cells and induced gene expression signatures associated with B cell activation. Both GC and PTT+GC elevated gene expression associated with antigen presentation, whereas GC elevated transcripts that regulate B cell activation and GTPase function and PTT+GC induced interferon response genes. Trajectory analysis, where B cells were organized according to pseudotime progression, revealed that both GC and PTT+GC induced the differentiation of B cells from a resting state towards an effector phenotype. The analyses confirmed upregulated interferon signatures in the differentiated tumor-infiltrating B cells following treatment by PTT+GC but not by GC. We also observed that breast cancer patients had significantly longer survival time if they had elevated expression of genes in B cells that were induced by PTT+GC therapy in the mouse tumors. Conclusion: Our findings show that the combination of local ablation and local application of immunostimulant initiates the activation of interferon signatures and antigen-presentation in B cells which is associated with positive clinical outcomes for breast cancer. These findings broaden our understanding of LAIT's regulatory roles in remodeling TME and shed light on the potentials of B cell activation in clinical applications.

A review of screening mammography: The benefits and radiation risks put into perspective

INTRODUCTION/BACKGROUND

In medical imaging a benefit to risk analysis is required when justifying or implementing diagnostic procedures. Screening mammography is no exception and in particular concerns around the use of radiation to help diagnose cancer must be addressed.

METHODS

The Medline database and various established reports on breast screening and radiological protection were utilised to explore this review.

RESULTS/DISCUSSION

The benefit of screening is well argued; the ability to detect and treat breast cancer has led to a 91% 5-year survival rate and 497 deaths prevented from breast cancer amongst 100,000 screened women. Subsequently, screening guidelines by various countries recommend annual, biennial or triennial screening from ages somewhere between 40-74 years. Whilst the literature presents different perspectives on screening younger and older women, the current evidence of benefit for screening women <40 and ≥75 years is currently not strong. The radiation dose and associated risk delivered to each woman for a single examination is dependent upon age, breast density and breast thickness, however the average mean glandular dose is around 2.5-3 mGy, and this would result in 65 induced cancers and 8 deaths per 100,000 women over a screening lifetime from 40-74 years. This results in a ratio of lives saved to deaths from induced cancer of 62:1.

CONCLUSION

Therefore, compared to the potential mortality reduction achievable with screening mammography, the risk is small.

Survival and Predictors of Mortality among Breast Cancer Patients in Northwest Ethiopia: A Retrospective Cohort Study

BACKGROUND

Breast cancer is the most common malignant tumor and the leading cause of cancer death in over 100 countries. Despite the high burden of difficulty, the survival status and the predictors for mortality are not yet determined in Ethiopia. Studies related to this area are scarce. Therefore, we aimed to estimate the survival status and predictors of mortality among breast cancer patients in Northwest Ethiopia.

METHODS

A retrospective cohort study design was carried out from September 2015 to August 2020 among 482 women who had breast cancer in Northwest Ethiopia. A systematic sampling technique was employed to select the required representative sample. The Cox regression model was used to identify the predictors of mortality among breast cancer patients.

RESULTS

For this study, 482 participants had followed for 8824 person-months total analysis time or at-risk time. In our findings, the overall survival of breast cancer patients at the end of two and five years was 54.24% and 25.8%, respectively. In the multivariable Cox regression model, age, stage of BC, menopausal status, and surgical therapy were significant predictors of death.

CONCLUSION

The overall survival after two years was 54.24%, and after five years was 25.8%. This result is lower than the recently published report and indicates that in LMIC, especially in rural cancer centers, the infrastructure and resources for routine screening mammography are often unavailable. Therefore, there is a need to promote early diagnosis of BC at each level of health-care delivery point.

Breast cancer burden in Africa: evidence from GLOBOCAN 2018

BACKGROUND

Breast cancer is the leading malignancy in African females. This study aims to examine the breast cancer burden in Africa using recently released GLOBOCAN 2018 estimates.

METHODS

The incidence and mortality estimates of age- and country-wise burden of breast cancer in 54 African countries were obtained from GLOBOCAN 2018.

RESULTS

In Africa, breast cancer caused 74 072 deaths, and 168 690 cases were estimated to have occurred in 2018. The age-standardized incidence rate stood at 37.9/100 000 in Africa, varying from 6.9/100 000 in the Gambia to 69.6/100 000 in Mauritius. The age-standardized mortality rate stood at 17.2/100 000 in 2018, ranging from 4/100 000 in the Gambia to 29.1/100 000 in Somalia in 2018. Nigeria was the leading country in terms of absolute burden with 26 310 cases and 11 564 deaths, followed by Egypt with 23 081 new cases and 9254 deaths. The mortality-to-incidence ratio for Africa stood at 0.44, varying from 0.24 in Libya to 0.68 in the Central African Republic.

CONCLUSION

To tackle breast cancer burden in Africa, the main challenges are late-stage disease presentation, lack of screening and therapeutic infrastructure, lack of awareness and limited resources.

Metastatic Pattern Discriminates Survival Benefit of Type of Surgery in Patients With De Novo Stage IV Breast Cancer Based on SEER Database

Background: The role of surgery and surgery type in de novo stage IV breast cancer (BC) is unclear.

Methods: We carried out a retrospective cohort study that included the data of 4,108 individuals with de novo stage IV BC abstracted from SEER (Surveillance, Epidemiology, and End Results) data resource from 2010 to 2015. The patients were stratified into the non-surgery group, breast-conserving (BCS) surgery group, and mastectomy group. Inverse probability propensity score weighting (IPTW) was then used to balance clinicopathologic factors. Overall survival (OS), as well as the breast cancer-specific survival (BCSS), was assessed in the three groups using Kaplan–Meier analysis and COX model. Subgroups were stratified by metastatic sites for analysis.

Results: Of the 4,108 patients, 48.5% received surgery and were stratified into the BCS group (574 cases) and mastectomy group (1,419 cases). After IPTW balance demographic and clinicopathologic factors, BCS and mastectomy groups had better OS (BCS group: HR, 0.61; 95% CI: 0.49–0.75; mastectomy group: HR, 0.7; 95% CI: 0.63–0.79) and BCSS (BCS group: HR, 0.6; 95% CI, 0.47–0.75; mastectomy group: HR, 0.71; 95% CI, 0.63–0.81) than the non-therapy group. Subgroup analyses revealed that BCS, rather than mastectomy, was linked to better OS (HR, 0.66; 95% CI: 0.48–0.91) and BCSS (HR, 0.63; 95% CI: 0.45–0.89) for patients with bone-only metastasis. For patients with viscera metastasis or bone+viscera metastases, BCS achieved similar OS (viscera metastasis: HR, 1.05; 95% CI: 0.74–1.48; bone+viscera metastases: HR, 1.01; 95% CI: 0.64–1.61) and BCSS (viscera metastasis: HR, 0.94; 95% CI: 0.64–1.38; bone+viscera metastases: HR, 1.06; 95% CI: 0.66–1.73) in contrast with mastectomy.

Conclusions: Local surgery for patients with distant metastasis (DS) exhibited a remarkable survival advantage in contrast with non-operative management. BCS may have more survival benefits for patients with de novo stage IV BC with bone-only metastasis than other metastatic sites. Decisions on de novo stage IV BC primary surgery should be tailored to the metastatic pattern.

The Significance of Topoisomerase II Alpha in Invasive Breast Carcinoma

Background

Topoisomerase II alpha (Top 2 A) protein has been shown to be a proliferation marker associated with tumour grade. The current study evaluated the prognostic impact of Top 2 A protein on luminal breast cancer and its utility as an independent prognostic marker. Immunohistochemical expression of Top 2 A in breast cancer and its correlation with the tumour type, size, lymph node metastases, grade and ER/PR positivity.

Methodology

Ethics committee approval was taken and 65 cases of Invasive breast carcinoma presenting to the Department of Pathology at a tertiary care centre in South India were studied. Patient details including age, tumour type, tumour size, tumour grading, estrogen receptor (ER)/progesterone receptor (PR)/human epidermal growth factor receptor 2 (HER2/neu) status and pathologic stage was studied. Immunohistochemistry (IHC) work-up for Top 2 A expression was done and evaluated.

Results

Of the 65 histological sections of breast cancers, 29/65 showed nuclear positivity for Top 2 A. Node positive tumours 17/65 stained positive for Top 2 A. Stage I tumours 2/65, stage II tumours 12/65 and stage III 14/65 stained positive for Top 2 A. Among the HER2/neu-positive tumours, 22/65 stained for Top 2 A and among ER/PR-positive 9/65 cases were positive for Top 2 A. Triple-negative tumours 5/65 stained for Top 2 A.

Conclusion

Higher Top 2 A expression was seen in higher stage tumours. HER2/neu-positive tumours significantly showed a correlation with Top 2 A positivity. Therefore, Top 2 A expression can be considered an individual prognostic factor in breast carcinoma.

Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy

OBJECTIVE

To examine the accuracy of artificial intelligence (AI) for the detection of breast cancer in mammography screening practice.

DESIGN

Systematic review of test accuracy studies.

DATA SOURCES

Medline, Embase, Web of Science, and Cochrane Database of Systematic Reviews from 1 January 2010 to 17 May 2021.

ELIGIBILITY CRITERIA

Studies reporting test accuracy of AI algorithms, alone or in combination with radiologists, to detect cancer in women's digital mammograms in screening practice, or in test sets. Reference standard was biopsy with histology or follow-up (for screen negative women). Outcomes included test accuracy and cancer type detected.

STUDY SELECTION AND SYNTHESIS

Two reviewers independently assessed articles for inclusion and assessed the methodological quality of included studies using the QUality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. A single reviewer extracted data, which were checked by a second reviewer. Narrative data synthesis was performed.

RESULTS

Twelve studies totalling 131 822 screened women were included. No prospective studies measuring test accuracy of AI in screening practice were found. Studies were of poor methodological quality. Three retrospective studies compared AI systems with the clinical decisions of the original radiologist, including 79 910 women, of whom 1878 had screen detected cancer or interval cancer within 12 months of screening. Thirty four (94%) of 36 AI systems evaluated in these studies were less accurate than a single radiologist, and all were less accurate than consensus of two or more radiologists. Five smaller studies (1086 women, 520 cancers) at high risk of bias and low generalisability to the clinical context reported that all five evaluated AI systems (as standalone to replace radiologist or as a reader aid) were more accurate than a single radiologist reading a test set in the laboratory. In three studies, AI used for triage screened out 53%, 45%, and 50% of women at low risk but also 10%, 4%, and 0% of cancers detected by radiologists.

CONCLUSIONS

Current evidence for AI does not yet allow judgement of its accuracy in breast cancer screening programmes, and it is unclear where on the clinical pathway AI might be of most benefit. AI systems are not sufficiently specific to replace radiologist double reading in screening programmes. Promising results in smaller studies are not replicated in larger studies. Prospective studies are required to measure the effect of AI in clinical practice. Such studies will require clear stopping rules to ensure that AI does not reduce programme specificity.

STUDY REGISTRATION

Protocol registered as PROSPERO CRD42020213590.

Silver Nanoparticles Modulate the Epithelial-to-Mesenchymal Transition in Estrogen-Dependent Breast Cancer Cells In Vitro

Silver nanoparticles (AgNPs) are frequently detected in many convenience goods, such as cosmetics, that are applied directly to the skin. AgNPs accumulated in cells can modulate a wide range of molecular pathways, causing direct changes in cells. The aim of this study is to assess the capability of AgNPs to modulate the metastasis of breast cancer cells through the induction of epithelial-to-mesenchymal transition (EMT). The effect of the AgNPs on MCF-7 cells was investigated via the sulforhodamine B method, the wound healing test, generation of reactive oxygen species (ROS), the standard cytofluorimetric method of measuring the cell cycle, and the expression of EMT marker proteins and the MTA3 protein via Western blot. To fulfill the results, calcium flux and HDAC activity were measured. Additionally, mitochondrial membrane potential was measured to assess the direct impact of AgNPs on mitochondria. The results indicated that the MCF-7 cells are resistant to the cytotoxic effect of AgNPs and have higher mobility than the control cells. Treatment with AgNPs induced a generation of ROS; however, it did not affect the cell cycle but modulated the expression of EMT marker proteins and the MTA3 protein. Mitochondrial membrane potential and calcium flux were not altered; however, the AgNPs did modulate the total HDAC activity. The presented data support our hypothesis that AgNPs modulate the metastasis of MCF-7 cells through the EMT pathway. These results suggest that AgNPs, by inducing reactive oxygen species generation, alter the metabolism of breast cancer cells and trigger several pathways related to metastasis.

Exploring the influence of rural residence on uptake of organized cancer screening - A systematic review of international literature

Lower screening uptake could impact cancer survival in rural areas. This systematic review sought studies comparing rural/urban uptake of colorectal, cervical and breast cancer screening in high income countries. Relevant studies (n = 50) were identified systematically by searching Medline, EMBASE and CINAHL. Narrative synthesis found that screening uptake for all three cancers was generally lower in rural areas. In meta-analysis, colorectal cancer screening uptake (OR 0.66, 95 % CI = 0.50-0.87, I² = 85 %) was significantly lower for rural dwellers than their urban counterparts. The meta-analysis found no relationship between uptake of breast cancer screening and rural versus urban residency (OR 0.93, 95 % CI = 0.80-1.09, I² = 86 %). However, it is important to note the limitation of the significant statistical heterogeneity found which demonstrates the lack of consistency between the few studies eligible for inclusion in the meta-analyses. Cancer screening uptake is apparently lower for rural dwellers which may contribute to poorer survival. National screening programmes should consider geography in planning.

Mortality due to breast cancer in a region of high socioeconomic vulnerability in Brazil: Analysis of the effect of age-period and cohort

INTRODUCTION

Breast cancer is an important public health problem worldwide, with important disparities in incidence, mortality, and survival rates between developed and developing countries due to inequalities regarding access to measures for the prevention and treatment of the disease. In Brazil, there are higher rates of incidence and a downward trend in mortality in regions of greater socioeconomic development.

OBJECTIVE

To evaluate the effect of age, period, and birth cohort on breast cancer mortality in women aged 20 years and older in the states of the Northeast Region of Brazil, an area of high socioeconomic vulnerability, from 1980 to 2019.

METHODS

The death records were extracted from the DATASUS Mortality Information System website (Department of National Health Informatics) from the Ministry of Health of Brazil. Estimable functions were used to estimate the age-period and cohort models (APC) using the Epi library from the R statistical software version 6.4.1.

RESULTS

The average breast cancer mortality rate for the period was 20.45 deaths per 100,000 women. The highest coefficients per 100,000 women were observed in the states of Pernambuco (21.09 deaths) and Ceará (20.85 deaths), and the lowest in Maranhão (13.58 deaths) and Piauí (15.43 deaths). In all of the locations, there was a progressive increase in mortality rates in individuals over 40 years of age, with higher rates in the last five-year period (2015-2019). There was an increase in the risk of death for the five-year period of the 2000s in relation to the reference period (1995-1999) in the Northeast region and in the states of Alagoas, Bahia, Maranhão, Paraíba, and Piauí. In addition, there was an increased risk of death for women born after the 1950s in all locations.

CONCLUSION

The highest mortality rates in all five-year periods analyzed were observed in states with greater socioeconomic development, with an increase in mortality rates in the 2000s, and a higher risk of death in the younger cohorts.

Survival Outcomes of Breast Cancer in Sudanese Women: A Hospital-Based Study

PURPOSE

Breast cancer (BC) is the leading malignancy among Sudanese women. Yet, data on survival are limited. This study aimed to determine 5-year overall survival (OS) of BC in Sudanese women, and identify prognostic demographic and clinicopathologic factors.

PATIENTS AND METHODS

A hospital-based retrospective study was conducted by reviewing data of women with BC diagnosed and treated at the National Cancer Institute—University of Gezira during 2012, and followed up to end of August 2018. Data were retrieved from medical records and analyzed, OS was determined, and the prognostic factors were explored.

RESULTS

A total of 225 cases were recruited. The median age at presentation was 45 years (range, 22-85 years). Clinical stage I, II, III, and IV represented 3.1%, 31.6%, 48%, and 17.3%, respectively. Most women (81.3%) were treated with curative intent. Of those, 25.1% received neoadjuvant chemotherapy. Mastectomy was the commonest (61.7%) type of surgery. The median follow-up period was 59.8 months with mean OS time of 55.7 months. The 5-year cumulative survival rate was 58%. The 5-year OS rates for stages I, II, III, and IV were 71.5%, 82.4%, 56.5%, and 8.4%, respectively. For lymph node (LN)-positive cases, 5-year OS rate was 63% and for LN-negative was 83.5%. Presenting with advanced-stage disease and positive LN status associated with short OS times (P < .005).

CONCLUSION

OS of women with BC in Central Sudan is worse than in the developed world, but similar to African countries. Our findings indicate that advanced stage at diagnosis and lymph nodal involvement are strong predictors of short survival times. Raising awareness and introducing early detection programs are critical for better survival of these patients.

Global breast cancer incidence and mortality trends by region, age-groups, and fertility patterns

BACKGROUND

Breast cancer (BC) has been increasing globally, though it is unclear whether the increases are seen across all age groups and regions and whether changes in rates can be primarily attributed to decreasing fertility rates. We investigated age-specific trends in BC incidence and mortality from 1990 to 2017, worldwide and by region, and evaluated whether incidence trends are explained by decreases in fertility.

METHODS

We used country-level data to examine trends in BC incidence and mortality rates from 1990 to 2017 by region and age group. Linear mixed models were used to estimate age-specific rates from baseline models of year and were compared to fertility-adjusted models for incidence.

RESULTS

The global BC mortality rate increased overall by 0.23% per year (95% CI=0.20, 0.25), with statistically significant increases in the under 50 and 70 and over age groups, and in 5 out of 7 regions. The global BC incidence rate increased overall by 1.44% per year (95% CI=1.42, 1.47), with statistically significant increases in all age groups, and in 6 out of 7 regions. After adjusting for fertility, the incidence annual percent change (APC) remained statistically significant (APC=0.84, 95% CI=0.81, 0.88), in all age groups, and in 6 of 7 regions.

INTERPRETATION

The global increase in BC mortality is seen in most age groups and regions. The global increase in BC incidence is seen in all age groups and is highest in women under 50; increases remained in most regions even after considering declining fertility rates.

FUNDING

Breast Cancer Research Foundation and National Cancer Institute.

Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis

BACKGROUND

Cancer is a leading cause of death, and although screening can reduce cancer morbidity and mortality, participation in screening remains suboptimal.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the effectiveness of social media and mobile health (mHealth) interventions for cancer screening.

METHODS

We searched for randomized controlled trials and quasi-experimental studies of social media and mHealth interventions promoting cancer screening (breast, cervical, colorectal, lung, and prostate cancers) in adults in MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Communication & Mass Media Complete from January 1, 2000, to July 17, 2020. Two independent reviewers screened the titles, abstracts, and full-text articles and completed the risk of bias assessments. We pooled odds ratios for screening participation using the Mantel-Haenszel method in a random-effects model.

RESULTS

We screened 18,008 records identifying 39 studies (35 mHealth and 4 social media). The types of interventions included peer support (n=1), education or awareness (n=6), reminders (n=13), or mixed (n=19). The overall pooled odds ratio was 1.49 (95% CI 1.31-1.70), with similar effect sizes across cancer types.

CONCLUSIONS

Screening programs should consider mHealth interventions because of their promising role in promoting cancer screening participation. Given the limited number of studies identified, further research is needed for social media interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42019139615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139615.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035411.

Cardiotoxicity screening of long-term, breast cancer survivors-The CAROLE (Cardiac-Related Oncologic Late Effects) Study

Background

Long‐term breast cancer survivors are at risk for cardiotoxicity after treatment, but there is insufficient evidence to provide long‐term (~10 years) cardiovascular disease (CVD) screening recommendations. We sought to evaluate a tri‐modality CVD screening approach.

Methods

This single‐arm, feasibility study enrolled 201 breast cancer patients treated ≥6 years prior without CVD at diagnosis. Patients were sub‐grouped: cardiotoxic (left‐sided) radiation (RT), cardiotoxic (anthracycline‐based) chemotherapy, both cardiotoxic chemotherapy and RT, and neither cardiotoxic treatment. Patients underwent electrocardiogram (EKG), transthoracic echocardiogram with strain (TTE with GLS), and coronary artery calcium computed tomography (CAC CT). The primary endpoint was preclinical or clinical CVD.

Results

Median age was 50 (29–65) at diagnosis and 63 (37–77) at imaging; median interval was 11.5 years (6.7–14.5). Among sub‐groups, 44% had no cardiotoxic treatment, 31.5% had cardiotoxic RT, 16% had cardiotoxic chemotherapy, and 8.5% had both. Overall, 77.6% showed preclinical and/or clinical CVD and 51.5% showed clinical CVD. Per modality, rates of any CVD and clinical CVD were, respectively: 27.1%/10.0% on EKG, 50.0%/25.3% on TTE with GLS, and 50.8%/45.8% on CAC CT. No statistical difference was seen among the treatment subgroups (NS, χ² test, p = 0.58/p = 0.15).

Conclusion

This study identified a high incidence of CVD in heterogenous long‐term breast cancer survivors, most >10 years post‐treatment. Over half had clinical CVD findings warranting follow‐up and/or intervention. Each imaging test independently contributed to the detection rate. This provides early evidence that long‐term cardiac screening may be of value to a wider group of breast cancer survivors than previously recognized.

The Role of ApoE Expression and Variability of Its Glycosylation in Human Reproductive Health in the Light of Current Information

Apolipoprotein E (ApoE), a 34-kDa glycoprotein, as part of the high-density lipoprotein (HDL), has antioxidant, anti-inflammatory and antiatherogenic properties. The variability of ApoE expression in the course of some female fertility disorders (endometriosis, POCS), and other gynecological pathologies such as breast cancer, choriocarcinoma, endometrial adenocarcinoma/hyperplasia and ovarian cancer confirm the multidirectional biological function of ApoE, but the mechanisms of its action are not fully understood. It is also worth taking a closer look at the associations between ApoE expression, the type of its genotype and male fertility disorders. Another important issue is the variability of ApoE glycosylation. It is documented that the profile and degree of ApoE glycosylation varies depending on where it occurs, the type of body fluid and the place of its synthesis in the human body. Alterations in ApoE glycosylation have been observed in the course of diseases such as preeclampsia or breast cancer, but little is known about the characteristics of ApoE glycans analyzed in human seminal and blood serum/plasma in the context of male reproductive health. A deeper analysis of ApoE glycosylation in the context of female and male fertility will both enable us to broaden our knowledge of the biochemical and cellular mechanisms in which glycans participate, having a direct or indirect relationship with the fertilization process, and also give us a chance of contributing to the enrichment of the diagnostic panel in infertile women and men, which is particularly important in procedures involved in assisted reproductive techniques. Moreover, understanding the mechanisms of glycoprotein glycosylation related to the course of various diseases and conditions, including infertility, and the interactions between glycans and their specific ligands may provide us with an opportunity to interfere with their course and thus develop new therapeutic strategies. This brief overview details some of the recent advances, mainly from the last decade, in understanding the associations between ApoE expression and some female and male fertility problems, as well as selected female gynecological diseases and male reproductive tract disorders. We were also interested in how ApoE glycosylation changes influence biological processes in the human body, with special attention to human fertility.

Risk factors associated with loss to follow-up of breast cancer patients: A retrospective analysis

BACKGROUND

Loss to follow-up (LTFU) during post-operative surveillance of breast cancer patients is detrimental. The pattern of LTFU and its risk factors in Chinese breast cancer patients remains unknown.

METHOD

Eligible non-metastatic breast cancer patients who underwent surgery at our institution between 2009 and 2012 were included. The clinicopathological features, as well as the LTFU status, were retrieved from the REDCap database. LTFU was defined as the absence of patients for at least 12 months since her last contact. 5-year LTFU was defined as the LTFU status of each patients at 5 years after surgery. The incidence and potential risk factors of LTFU were analyzed. A LTFU-risk score was developed to quantify the risk of LTFU.

RESULTS

A total of 1536 patients with breast cancer were included, and 411(26.8%) patients were 5-year LTFU. 198 patients were LTFU in the first year. Univariate and multivariate analysis revealed that age (younger and older), a lack of medical insurance, longer distance from residence to the hospital, pathology (DCIS/Paget's/Phyllodes), lymph node metastasis, the absence of endocrine therapy and fewer than five contact numbers were significantly and independently associated with the risk of LTFU. A LTFU-risk score was developed and was predictive of LTFU.

CONCLUSIONS

A series of risk factors were significantly associated with post-operative LTFU of breast cancer patients. Patients with different risks of LTFU could possibly be identified, and surveillance plans could be individualized for different patients, so as to effectively reduce the overall LTFU rate, and optimize the allocation of medical resources.

Knowledge and Acceptance Towards Mammography as Breast Cancer Screening Tool Among Yogyakarta Women and Health Care Providers (Mammography Screening in Indonesia)

Annual mammography remains the gold standard of asymptomatic breast cancer screening for women starting at the age of 40. However, Indonesia has not designated mammography as its national screening program. To help policymakers decide whether mammography should be introduced into a national program, it is important to comprehensively understand the knowledge and acceptance of both consumers and providers. A total of 25 subjects including a range of women and health care professionals (HCPs) in Yogyakarta Province were recruited using purposive, maximum variation sampling and then interviewed in-depth. The interviews were recorded and all data were taken and transcribed from the audio recording, which were subsequently translated to English and analyzed thematically. Almost all of Yogyakarta women had heard about the term of mammography. However, only few of them have let themselves be screened, mainly because of their perceived lack of urgency to screen for asymptomatic breast cancer. Another important reason was the high cost of mammography. Meanwhile, several HCPs believed that breast cancer has not been a priority for the government and hence the government limited mammography screening's access and excluded it from the national insurance coverage. Most women in Yogyakarta have a good understanding about breast cancer screening, but their acceptance of mammography as a breast cancer screening tool is significantly influenced by high cost, limited access, and lack of urgency.

Global Perceptions of Women on Breast Cancer and Barriers to Screening

PURPOSE OF REVIEW

Breast cancer (BC) is a public health dilemma across the globe and a leading cause of mortality for women. Approximately 2.1 million newly diagnosed female BC cases occurred in 2018, comprising nearly 1 in 4 cancer cases among women. When BC is recognized in its early stages, successful treatment results can be achieved. Therefore, screening for BC is of paramount significance and routine screening mammography has been shown to be effective in reducing mortality from BC. Despite being considered a global health issue, national screening programmes are offered only in developed countries and BC is still often diagnosed in advanced stages.

RECENT FINDINGS

Disparities in screening exist not only between different countries but also between local and immigrant populations within a particular country. Low screening is attributed to low public awareness as well as numerous social, psychological, and geographical barriers to screening. This review addresses (a) the differences in BC awareness and screening across the globe, (b) the most important barriers and facilitators to screening, and (c) the potential role of health education programmes to increase BC awareness and promote BC screening programmes with the ultimate goal to achieve earlier stage diagnosis of BC.

Current practices of plastic surgeons at King Abdulaziz University Hospital in requesting breast imaging studies prior to non-oncological breast surgeries

Background

In the context of the high incidence of breast cancer and the high frequency of breast cosmetic surgeries, malignant and/or premalignant lesions are frequently detected incidentally in postoperative histopathology specimens. The current literature does not provide clear practice guidelines for the use of preoperative imaging prior to non-oncological breast surgeries.

Objectives

In this study, we aimed to determine the current practices of plastic surgeons at King Abdulaziz University Hospital (KAUH) and their use of preoperative breast imaging before non-oncological breast surgeries.

Design

Non-intervention/ retrospective record review.

Settings

Department of Radiology at King Abdulaziz University Hospital (KAUH).

Methods

In 08/06/2017 at King Abdulaziz University Hospital, we conducted a single-center, retrospective chart review of the medical files of candidates for non-oncological breast surgery in order to examine preoperative imaging requests by plastic surgeons in the period 01/01/2013 to 08/06/2017.

Main outcome measures

The practice of plastic surgeons at KAUH in requesting preoperative imaging prior non-oncological breast surgeries.

Sample size

104 patients.

Results

We found that, in the period 2013 to 2017, 104 women who underwent non-oncological breast surgeries were evaluated for recent preoperative breast imaging. Only 37 patients (35.6%) were found to have had preoperative imaging, and only less than one fifth (19.4%) of those 37 patients had abnormal preoperative imaging results, all of which were negative for malignancy.

Conclusions

Although the yield of malignancy on preoperative breast imaging was zero in women seeking non-oncological breast surgeries at KAUH, we recommend the establishment of unified practice guidelines to be followed by plastic surgeons for better postoperative screening in different risk groups.

Limitations

Lack of follow up of patients postoperatively for any development of malignancy.

Ten-year survival outcome of breast cancer patients in India

INTRODUCTION:

Breast cancer is the most frequently diagnosed cancer among women in India; however, there are no studies addressing long-term survival (10 years and above). This study sought to evaluate long-term oncological outcome among women with breast cancer treated with a curative intent.

MATERIALS AND METHODS:

This is a retrospective cohort analysis of 1301 breast cancer patients of all stages who had received primary treatment with curative intent from 2004 to 2010 at a single cancer institution of India.

RESULTS:

A total of 1301 breast cancer patients were available for final analysis. The median age was 51 years (range, 21–86 years). 70.25% of the patients had early breast cancer (EBC), 21.9% had locally advanced breast cancer, and 7.85% of the patients with de novo metastatic disease also underwent surgery. 56.5% of the patients had hormone-sensitive tumors, human epidermal growth factor receptor 2 over expression was seen in 17%, and triple-negative tumors accounted for 26.2% of the patients. The 5- and 10-year overall survival (OS) of the entire cohort was 79% and 66%, and the 5- and 10-year breast cancer-specific survival (BCSS) was 79% and 70%, respectively. OS and BCSS were 51% and 58%, respectively, at 15-year follow-up after primary cancer treatment. On multivariate analysis, the factors associated with prolonged survival were age ≤50 years, EBC, and treatment during the later period (2008–2010).

CONCLUSION:

Difference between OS and BCSS was found to have an increasing trend during 10–15-year follow-up, the difference being 4% at 10 years and 7% at 15 years. Age ≤50 years, early-stage disease at presentation, and primary cancer treatment in later years (2008–2010) were favorable predictors for 10-year survival.

Metformin induces ferroptosis by targeting miR-324-3p/GPX4 axis in breast cancer

Metformin is a widely prescribed hypoglycemic drug. Many studies have shown its anti-cancer properties. In the present study, we aimed to explore the effect of metformin on breast cancer and clarify the underlying mechanism. Our results showed that metformin induced ferroptosis in MDA-MB-231 cells through upregulating miR-324-3p expression. Overexpression of miR-324-3p inhibited cancer cell viability. miR-324-3p inhibitor promoted cell viability. Further studies showed that the effect of miR-324-3p was mediated by directly targeting glutathione peroxidase 4 (GPX4). miR-324-3p bound to the 3'-UTR of GPX4 and led to the downregulation of GPX4. In vivo studies showed that metformin induced ferroptosis by upregulating miR-324-3p in the xenograft model of breast cancer in mice. Our study suggested that metformin promotes ferroptosis of breast cancer by targeting the miR-324-3p/GPX4 axis. Metformin could act as a potential anti-cancer agent through the induction of ferroptosis.

Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery

BACKGROUND

Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia.

OBJECTIVES

To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality.

SEARCH METHODS

On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome.

MAIN RESULTS

Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.

Twenty-year risks of breast cancer-specific mortality for stage III breast cancer in the surveillance, epidemiology, and end results registry

PURPOSE

We aimed to report the 20-year risk of breast cancer-specific mortality (BCSM), report the risk of BCSM conditional on having survived 5 years, and identify factors associated with late deaths in stage III breast cancer.

METHODS

Using Surveillance, Epidemiology, and End Results data, we included women with stage III breast cancer diagnosed from 1990 to 2005. We excluded women with unknown hormone receptor (HR) status, women who did not undergo resection of the primary tumor or axillary nodes, or unknown cause of death. We estimated risks of BCSM using cumulative incidence function and used Fine and Gray regression to identify factors associated with late deaths.

RESULTS

Final sample was 36,500 patients with 14 years of median follow-up. For each stage subgroup, the risk of BCSM at 20 years was significantly higher for HR-negative vs HR-positive tumors (IIIA: 49.8% vs 43.2%, P < 0.0001; IIIB: 60.9% vs 47.6%, P < 0.0001; IIIC: 68.7% vs 63.1%, P < 0.0001). Compared with the risks of non-BCSM, the risks of BCSM at 20 years were four times higher in stage IIIC HR-positive disease and seven times higher in stage IIIC HR-negative disease. Risks of BCSM conditional on having survived 5 years depended on tumor size, nodal status, race, and tumor grade for HR-positive disease and depended on tumor size, nodal status, and age for HR-negative disease.

CONCLUSIONS

In stage III breast cancer, the risk of BCSM at 20 years is very high and remains important even beyond the first 5 years in both HR-positive and HR-negative disease. Late BCSM depends on traditional clinicopathologic factors.

Global incidence and mortality of breast cancer: a trend analysis

This study aimed to evaluate the global incidence and mortality trends of breast cancer among females by region and age in the past decade. We retrieved country-specific incidence and mortality data from the Global Cancer Observatory up to 2018 and Cancer Incidence in Five Continents volumes I-XI, the Nordic Cancer Registries, the Surveillance, Epidemiology, and End Results, and WHO mortality database up to 2016. The temporal patterns were using Average Annual Percent Change (AAPC) with the 95% confidence interval (CI) by joinpoint regression analysis. Most countries showed an increasing trend in incidence. For the older population aged ≥ 50 years, Japan (5.63, 4.90-6.36), Slovakia (3.63, 3.03-4.22), China (2.86, 2.00-3.72) reported the most prominent increase. For young females (<50 years), Japan (AAPC=3.81, 95% CI=2.71-4.93), Germany (AAPC=2.60, 95% CI=1.41-3.81) and Slovakia (1.91, 1.13-2.69) reported the most drastic rise. Similarly, 12 countries showed an incidence increase among women aged <40 years. As for mortality, the Philippines (4.36, 3.65-5.07), Thailand (4.35, 3.12-5.59), Colombia (0.75, 0.08-1.42), and Brazil (0.44, 0.19-0.68) reported a significant increase. The disease burden of breast cancer showed an increasing trend in a large number of populations. More preventive efforts are recommended for these countries. Further research should explore the underlying reasons for these epidemiological trends.

Global, regional, national burden of breast cancer in 185 countries: evidence from GLOBOCAN 2018

PURPOSE

This study aims to examine the burden of breast cancer in 185 countries in 2018.

METHODS

The estimates of incidence, mortality, and prevalence of breast cancer were drawn from GLOBOCAN 2018. The overall burden of breast cancer was gauged using breast cancer burden index (BRCBI)-a novel index comprising age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), mortality-to-incidence ratio (MIR), prevalence-to-incidence ratio (PIR), and prevalence-to-mortality ratio (PMR). The socioeconomic status of countries was measured using human development index (HDI) RESULTS: Globally, breast cancer was responsible for an estimated 626,679 deaths at age-standardized rate of 13/100,000; there were 2.1 million cases diagnosed in 2018 at age-standardized rate of 46.3/100,000. The ASIR varied 22-fold from 5/100,000 (Bhutan) to 113.2/100,000 (Belgium). The ASMR varied 13-fold from 2.7/100,000 (Bhutan) to 36.9/100,000 (Fiji). The HDI exhibited a positive gradient with ASIR (r = 0.73), PIR (r = 0.98), and PMR (r = 0.85); with MIR, however, it exhibited a negative association (r = - 0.83). The BRCBI spanned from 0.70 in Somalia to 78.92 in South Korea and exhibited a positive association with HDI (r = 0.76). An additional 46,823 female lives in 2018 and a cumulative total of 333,304 lives could have been saved over 2013-2018, had countries performed as per their HDI.

CONCLUSIONS

The substantial burden of breast cancer in developing and low-resource economies calls for a holistic approach to cancer management and control that includes oncologic infrastructure to provide cost-effective screening, diagnostic, therapeutic, and palliative services, greater breast cancer awareness, and mitigation of risk factors.