Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study

Physical Activity and Breast Cancer Survival-Epidemiologic Evidence and Potential Biologic Mechanisms

PURPOSE OF REVIEW

To review the biologic mechanisms that may be operative between physical activity and survival after breast cancer.

RECENT FINDINGS

Physical activity decreases risk of mortality from breast cancer by up to 40%. Several biologic mechanisms have been hypothesized to explain this association. Previous cohort studies and randomized trials have examined the primary mechanisms that appear to be operative, which involve a decrease in sex hormone levels, insulin resistance, and inflammation. The evidence is still inconsistent and several limitations in the existing literature exist. Understanding the biologic mechanisms involved in the association of physical activity and breast cancer survival will provide more precision to physical activity guidelines for cancer survival. To achieve this objective, future research should include direct measurements of physical activity, sedentary behaviour, and health-related fitness to provide a more comprehensive assessment of these factors and their association with biomarkers and survival after breast cancer.

Survival of patients operated on for breast cancer in Ouagadougou/Burkina Faso

BACKGROUND AND OBJECTIVES

Breast cancer is the most common cancer in women. The objective is to study the survival of patients operated on for breast cancer.

METHODS

Descriptive and analytical study of the survival of patients operated on for breast cancer between January 1, 2013 and December 31, 2020 in Ouagadougou. Survival was assessed by the Kaplan-Meier method and comparisons by the log-rank test. Prognostic factors were determined using the Cox model.

RESULTS

We collected 550 cases. Overall survival at 5 years was 66.2%. Those under 30 years of age had a low 5-year overall survival (53%). The 5-year overall survival was poor in rural patients (63.5%), triple-negative patients (77.2%), HER2+ patients (50.5%) and stage IV patients (29.8%). In multivariate analysis, higher education (p < 0.001) and higher socioeconomic level (p < 0.001) were associated with better prognoses.

CONCLUSIONS

The survival of patients operated on for breast cancer remains to be improved. It is influenced by multiple factors especially the socio-economic and educational level of the patients.

Epigenetic oncogenesis, biomarkers and emerging chemotherapeutics for breast cancer

Breast cancer remains one of the leading causes of cancer-related deaths globally and the most prominent among females, yet with limited effective therapeutic options. Most of the current medications are challenged by various factors including low efficacy, incessant resistance, immune evasion and frequent recurrence of the disease. Further understanding of the prognosis and identification of plausible therapeutic channels thus requires multimodal approaches. In this review, epigenetics studies of several pathways to BC oncogenesis via the inducement of oncogenic changes on relevant markers have been overviewed. Similarly, the counter-epigenetic mechanisms to reverse such changes as effective therapeutic strategies were surveyed. The epigenetic oncogenesis occurs through several pathways, notably, DNMT-mediated hypermethylation of DNA, dysregulated expression for ERα, HER2/ERBB and PR, histone modification, overexpression of transcription factors including the CDK9-cyclin T1 complex and suppression of tumour suppressor genes. Scientifically, the regulatory reversal of the mechanisms constitutes effective epigenetic approaches for mitigating BC initiation, progression and metastasis. These were exhibited at various experimental levels by classical chemotherapeutic agents including some repurposable drugs, endocrine inhibitors, monoclonal antibodies and miRNAs, natural products, metal complexes and nanoparticles. Dozens of the potential candidates are currently in clinical trials while others are still at preclinical experimental stages showing promising anti-BC efficacy. The review presents a model for a wider understanding of epigenetic oncogenic pathways to BC and reveals plausible channels for reversing the unpleasant changes through epigenetic modifications. It advances the science of therapeutic designs for ameliorating the global burden of BC upon further translational studies.

Design, molecular docking, and molecular dynamics of thiourea-iron (III) metal complexes as NUDT5 inhibitors for breast cancer treatment

In research, anticancer agents, such as thiourea derivative compounds, and metal complexes, such as those complexed with iron (III) metal, are often studied. The metal complexes are presumably more active than thiourea derivatives as free ligands; some negative effects may be reduced. The computational studies used in this study involved molecular docking with AutoDock and molecular dynamics (MD) simulations using Desmond to evaluate the stability of the interactions. The docking and MD analysis results showed that compounds 2 and 6 had stable interactions with NUDIX hydrolase type 5 (NUDT5)—one of the therapeutic targets for breast cancer—where they had the lowest root mean square deviation (RMSD) and root mean square fluctuation (RMSF) values compared to the other compounds. Together, these compounds are anti-breast cancer drug candidates.

Development of an adverse outcome pathway network for breast cancer: a comprehensive representation of the pathogenesis, complexity and diversity of the disease

Adverse outcome pathways (AOPs), introduced in modern toxicology, intend to provide an evidence-based representation of toxicological effects and facilitate safety assessment of chemicals not solely based on laboratory animal in vivo experiments. However, some toxicological processes are too complicated to represent in one AOP. Therefore, AOP networks are developed that help understanding and predicting toxicological processes where complex exposure scenarios interact and lead to the emergence of the adverse outcome. In this study, we present an AOP network for breast cancer, developed after an in-depth survey of relevant scientific literature. Several molecular initiating events (MIE) were identified and various key events that link the MIEs with breast cancer were described. The AOP was developed according to Organization of Economic Co-Operation and Development (OECD) guidance, weight of evidence was assessed through the Bradford Hill criteria and confidence was tested by the OECD key questions. The AOP network provides a straightforward understanding of the disease onset and progression at different biological levels. It can be used to pinpoint knowledge gaps, identify novel therapeutic targets and act as a stepping stone for the development of novel in vitro test methods for hazard identification and risk assessment of newly developed chemicals and drugs.

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

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

Formulation, Optimization, and Evaluation of Moringa oleifera Leaf Polyphenol-Loaded Phytosome Delivery System against Breast Cancer Cell Lines

Moringa oleifera leaf polyphenols (Mopp) were encapsulated with phytosomes to enhance their efficacy on 4T1 cancer cell lines. The Mopp were extracted via microwave-assisted extraction. Moringa oleifera polyphenol-loaded phytosomes (MoP) were prepared with the nanoprecipitation method and characterized using the dynamic light scattering and dialysis membrane techniques. The in vitro cytotoxic and antiproliferative activity were investigated with the (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazole) MTT assay. Acute toxicity was assessed using Swiss albino mice. An MoP particle size of 296 ± 0.29 nm, −40.1 ± 1.19 mV zeta potential, and polydispersity index of 0.106 ± 0.002 were obtained. The total phenolic content was 50.81 ± 0.02 mg GAE/g, while encapsulation efficiency was 90.32 ± 0.11%. The drug release profiles demonstrated biphasic and prolonged subsequent sustained release. In vitro assays indicated MoP had a low cytotoxicity effect of 98.84 ± 0.53 μg/mL, doxorubicin was 68.35 ± 3.508, and Mopp was 212.9 ± 1.30 μg/mL. Moreover, MoP exhibited the highest antiproliferative effect on 4T1 cancer cells with an inhibitory concentration of 7.73 ± 2.87 μg/mL and selectivity index > 3. The results indicated a significant difference (p ≤ 0.001) in MoP when compared to Mopp and doxorubicin. The in vivo investigation showed the safety of MoP at a dose below 2000 mg/kg. The present findings suggest that MoP may serve as an effective and promising formulation for breast cancer drug delivery and therapy.

Treatment guideline concordance, initiation, and abandonment in patients with non-metastatic breast cancer from the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort in sub-Saharan Africa: a prospective cohort study

BACKGROUND

Comprehensive breast cancer management is essential to achieve high breast cancer survival; however, detailed reports of the treatment regimens received by patients are scarce in sub-Saharan Africa where survival is low. We aimed to examine treatment initiation, guideline concordance, and abandonment in patients with non-metastatic breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort.

METHODS

The ABC-DO prospective cohort study recruited women (aged ≥18 years) with newly diagnosed invasive breast cancer in eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, Uganda, South Africa, and Zambia). We analysed treatments received by women who were classified as non-metastatic (M0) at the initial presentation. Data on surgery, radiotherapy, and systemic therapies were obtained from medical records and a self-reported follow-up questionnaire at 6 months after the diagnosis, follow-up calls every 3 months, and a baseline questionnaire. Initiation, completion, and abandonment of treatment modalities and combined therapy regimens were examined overall, by country-specific groups, and by clinical factors relevant for guideline-based treatment.

FINDINGS

Of 2313 women recruited into the ABC-DO study between Sept 10, 2014, and Dec 31, 2017, 2226 had histologically or clinically confirmed breast cancer. Of these 2226 women, 510 were excluded from the present analysis because 378 had metastatic disease, 37 were prevalent cases (defined as those previously diagnosed with breast cancer >2 years before baseline), 82 had unknown TNM stage, and 13 were White or Asian women in South Africa (number was too small for analysis). After a median follow-up of 5·2 years (IQR 4·6-5·9), 1163 (68%) of 1716 women underwent breast cancer surgery. Surgery and systemic therapy (ie, multimodality treatment) with radiotherapy was initiated in 370 (36%) of 1028 women with localised tumours versus 156 (23%) of 688 women with locally advanced tumours, whereas multimodality treatment without radiotherapy was initiated in 386 (38%) versus 167 (24%) women, respectively. Of 1530 patients requiring chemotherapy (which excludes 105 who died within 6 months after baseline), 1013 (66%) initiated treatment of neoadjuvant chemotherapy or surgery within 3 months after baseline, which was adequately completed by 359 (35%) of 1013 women, marginally completed by 284 (28%), abandoned by 200 (20%), and unknown in 151 (15%). 19 (2%) women died within 6 months after chemotherapy initiation. Of 1375 women in whom endocrine therapy was indicated, this treatment was initiated in 920, and lasted at least 3 years in 367 (40%) women. Treatment disparities between country-specific groups were substantial for all therapy regimens.

INTERPRETATION

A high proportion of patients with non-metastatic breast cancer did not initiate, did not fully complete, or abandoned treatment with surgery, systemic therapy, radiotherapy, or an appropriate combination of these, highlighting the need for improved treatment access and completion in sub-Saharan Africa to potentially prevent premature breast cancer deaths.

FUNDING

National Institutes of Health (National Cancer Institute), Susan G Komen, and the International Agency for Research on Cancer.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

Leveraging breast cancer screening to promote timely detection, diagnosis and treatment among women in sub-Saharan Africa: a scoping review protocol

INTRODUCTION

Female breast cancer is now the most often diagnosed cancer in the world. Breast cancer screening aims to reduce mortalities related to cancer, and morbidity associated with advanced stages of the disease, through timely detection in asymptomatic women. This study aims to conduct a comprehensive assessment and evaluation of the evidence on the factors that influence the provision and uptake of breast cancer screening among women in sub-Saharan Africa (SSA).

METHODS AND ANALYSIS

PubMed, Web of Science, EMBASE and the Cumulative Index to Nursing and Allied Health Literature including Google Scholar will be searched to identify published studies on barriers and facilitators to breast cancer screening from January 2010 to 2021. Two reviewers will independently assess the quality of all the included studies using the Mixed Methods Appraisal Tool version 2018. We envisage that this review will adduce evidence on common barriers and facilitators to breast cancer screening in SSA. Identifying these barriers and facilitators will help guide the initialisation of effective interventions that will improve breast cancer screening uptake among women in SSA. This review will also guide future research in developing, implementing and evaluating appropriate interventions tailored toward increasing breast cancer screening uptake.

ETHICS AND DISSEMINATION

Ethics approval for this protocol is not required since it does not involve collecting data from human participants. The outcomes of this study will be published in a peer-reviewed journal.

Relative Dose Intensity and Pathologic Response Rates in Patients With Breast Cancer and With and Without HIV Who Received Neoadjuvant Chemotherapy

PURPOSE

Patients who are HIV-positive and have breast cancer have worse overall survival (OS) compared with patients who are HIV-negative. Pathologic complete response (pCR) and relative dose intensity (RDI) of chemotherapy are associated with survival. We assessed whether pCR and RDI rates were lower for patients who are HIV-positive and received neoadjuvant chemotherapy (NACT).

METHODS

This was a prospective cohort analysis of patients initiating NACT in Botswana (February 2017 to September 2019). Primary outcomes were pCR and RDI; secondary outcomes were OS and toxicity. HIV status and zidovudine (ZDV) treatment were stratification factors. Multivariable analysis was used to control for confounding.

RESULTS

In total, 26 of 110 enrolled individuals were HIV-positive. In univariable analysis, HIV-positive (odds ratio [OR] = 0.2; P = .048) and RDI < 0.85 (OR = 0.30; P = .025) were associated with pCR. In multivariable analysis, the magnitude of association decreased for HIV-positive (OR = 0.28; P = .11), but RDI < 0.85 remained independently associated with pCR (OR = 0.32; P = .035). Patients who are HIV-positive had significantly lower mean RDI, and those on ZDV had significantly lower RDI. Ninety-one (83%) were stage III with 2-year OS significantly worse for patients who are HIV-positive (58% v 74%). Hazard ratio for all-cause mortality was 2.68 (95% CI, 1.17 to 6.13; P = .028) in patients who are HIV-positive compared with patients who are HIV-negative. Toxicity rates were similar despite patients who are HIV-positive receiving significantly lower dose intensity chemotherapy.

CONCLUSION

Patients who are HIV-positive and have breast cancer in Botswana have lower pCR rates and also receive lower dose intensity therapy, which may contribute to worse OS. Patients who are HIV-positive on ZDV-containing regimens received even lower dose intensity of NACT. Administering optimal dose intensity in patients who are HIV-positive remains a challenge, and targeted interventions that address modifiable risk factors are needed to improve therapy delivery and outcomes.

Cancer Groundshot: Building a Robust Cancer Control Platform in Addition To Launching the Cancer Moonshot

Cancer Groundshot is a philosophy that calls for prioritization of strategies in global cancer control. The underlying principle of Cancer Groundshot is that one must ensure access to interventions that are already proven to work before focusing on the development of new interventions. In this article, we discuss the philosophy of Cancer Groundshot as it pertains to priorities in cancer care and research in low- and middle-income countries and the utility of technology in addressing global cancer disparities; we also address disparities seen in high-income countries. The oncology community needs to realign our priorities and focus on improving access to high-value cancer control strategies, rather than allocating resources primarily to the development of technologies that provide only marginal gains at a high cost. There are several "low-hanging fruit" actions that will improve access to quality cancer care in low- and middle-income countries and in high-income countries. Worldwide, cancer morbidity and mortality can be averted by implementing highly effective, low-cost interventions that are already known to work, rather than investing in the development of resource-intensive interventions to which most patients will not have access (i.e., we can use Cancer Groundshot to first save more lives before we focus on the "moonshots").

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis

BACKGROUND

Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.

METHODS

Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.

RESULTS

Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).

CONCLUSION

This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.

REVIEW REGISTRATION

Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

Mapping evidence on knowledge of breast cancer screening and its uptake among women in Ghana: a scoping review

INTRODUCTION

Female breast cancer is currently the most commonly diagnosed cancer globally with an estimated 2.3 million new cases in 2020. Due to its rising frequency and high mortality rate in both high- and low-income countries, breast cancer has become a global public health issue. This review sought to map literature to present evidence on knowledge of breast cancer screening and its uptake among women in Ghana.

METHODS

Five databases (PubMed, CINAHL, PsycINFO, Web of Science, and EMBASE) were searched to identify relevant published studies between January 2012 and August 2021 on knowledge of breast cancer screening and its uptake among women. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and the six-stage model by Arksey and O'Malley were used to select and report findings.

RESULTS

Of the 65 articles retrieved, 14 records were included for synthesis. The review revealed varied knowledge levels and practices of breast cancer screening among women across a few regions in Ghana. The knowledge level of women on breast cancer screening was high, especially in breast cancer screening practice. Breast cancer screening practice among women was observed to be low and the most identified barriers were lack of technique to practice breast self-examination, having no breast problem, lack of awareness of breast cancer screening, and not having breast cancer risk. The results further showed that good knowledge of breast cancer screening, higher educational level, increasing age, physician recommendation, and household monthly income were enabling factors for breast cancer screening uptake.

CONCLUSION

This review showed varied discrepancies in breast cancer screening uptake across the regions in Ghana. Despite the benefits of breast cancer screening, the utilization of the screening methods across the regions is very low due to some varied barriers from the different regions. To increase the uptake of breast cancer screening, health workers could employ various strategies such as community education and sensitization on the importance of breast cancer screening.

Breast cancer morbidity and mortality in rural Ethiopia: data from 788 verbal autopsies

INTRODUCTION

In Ethiopia, breast cancer is the leading cause of cancer among women. Little is known about the duration of disease and symptoms of patients who died from breast cancer in rural Ethiopia. The objective of this study was to assess breast cancer mortality with a particular focus on the self-reported duration of illness including suffering of symptoms, and need for medical care.

METHODS

The cause of death was determined among randomly selected Ethiopian women residing in western Ethiopia. A modified standard verbal autopsy (VA) questionnaire was completed by women whose sisters had died. The questionnaires were reviewed by two independent local physicians to assign a cause of death. We analyzed pattern of cause of deaths, duration of suffering, symptoms, and treatment received.

RESULT

In our study, the age at death was very similar to other population-based data from Ethiopia. We found 32% of 788 deaths were caused by communicable diseases, 12.1% by neoplasms, and 9.4% by pregnancy/maternal mortality. Breast cancer was the second leading neoplasm, responsible for 21 (2.7%) of all deaths (95% CI 1.5-3.7%), and was among the top five causes of non-communicable deaths. The median age of breast cancer death was 37 years, younger than for other causes of death. The median duration of illness with breast cancer was around 1 year. This was substantially more compared to the duration of infectious diseases, but less than the duration of reproductive neoplasms, diabetes, and epilepsy.

DISCUSSION/CONCLUSION

Breast cancer deaths are common causes of death in women of rural Ethiopia. When assessing the total duration of illness according to specific causes of death, breast and other cancers accounted for a large share of the burden. This has practical implications and highlights the need for palliative care for cancer patients. Substantial efforts are necessary to improve early detection and treatment for breast cancer to reduce premature death in women.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Disparities in breast cancer survival between women with and without HIV across sub-Saharan Africa (ABC-DO): a prospective, cohort study

BACKGROUND

Studies have shown increased mortality among women living with HIV diagnosed with breast cancer compared with HIV-negative women with breast cancer. We aimed to examine how this HIV differential varies by patient or breast tumour characteristics.

METHODS

The African Breast Cancer-Disparities in Outcomes (ABC-DO) study is a prospective cohort of women (aged ≥18 years) with incident breast cancer recruited consecutively at diagnosis (2014-17) from hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. Detailed clinical and epidemiological data, including self-reported or tested HIV status, were collected at baseline. Participants were actively followed up via telephone calls every 3 months. The primary outcome was all-cause mortality, assessed in all women who had at least one updated vital status after baseline interview. Using Cox regression, we examined differences in overall survival by HIV status in the cohort, and across country and patient subgroups, adjusted for age, tumour grade, and tumour stage at cancer diagnosis.

FINDINGS

Between Sept 8, 2014, and Dec 31, 2017, we recruited 2154 women with primary breast cancer, 519 of whom were excluded due to their countries having small numbers of women with HIV for comparison. Among the remaining 1635 women, 313 (19%) were living with HIV, 1184 (72%) were HIV negative, and 138 (9%) had unknown HIV status. At breast cancer diagnosis, women with HIV were younger and had lower body-mass index (BMI) than their HIV-negative counterparts, but had similar tumour stage, grade, and receptor subtypes. At the end of the follow-up (Jan 1, 2019), a higher proportion of women with HIV (137 [44%] of 313) had died than had HIV-negative women (432 [37%] of 1184). Crude 3-year survival was 9% lower for women with HIV (46% [95% CI 40-53]) than for HIV-negative women (55% [52-59]; hazard ratio (HR) 1·41 [1·15-1·74]). The HIV survival differential did not differ by age, BMI, tumour subtype, or tumour grade, but was stronger in women with non-metastatic disease (3-year survival 52% HIV-positive vs 63% HIV-negative women, adjusted HR 1·65 [1·30-2·10]), whereas women with metastatic cancer had low survival, regardless of HIV status.

INTERPRETATION

The larger survival deficit among women with HIV with non-metastatic breast cancer calls for a better understanding of the reasons underlying this differential (eg, biological mechanisms, health behaviours, detrimental HIV-breast cancer treatment interactions, or higher HIV background mortality) to inform strategies for reducing mortality among this patient group.

FUNDING

Susan G Komen, International Agency for Research on Cancer, National Cancer Institute, and UK-Commonwealth Scholarships.

Treatment outcomes and its associated factors among breast cancer patients at Kitui Referral Hospital

Objectives:

Despite breast cancer treatment outcomes being relatively poor or heterogeneous among breast cancer patients, there was a paucity of data in the African settings, especially in Kenya. Hence, this study aimed to determine treatment outcomes among breast cancer patients at Kitui Referral Hospital.

Methods:

A hospital-based retrospective cohort study design was conducted among adult patients with breast cancer. All eligible breast cancer patients undergoing treatment from January 2015 to June 2020 in the study setting were included. Hence, a total of 116 breast cancer patients’ medical records were involved in the study. Patients’ medical records were retrospectively reviewed using a predesigned data abstraction tool. The data were entered, cleaned, and analyzed using SPSS (Statistical Package for Social Sciences) version 26 software. Descriptive analysis—such as percentage, frequency, mean, and figures—was used to present the data. Kaplan–Meier survival analysis was used to estimate the mean survival estimate across different variables. A Cox regression analysis was employed to determine factors associated with mortality.

Results:

The study showed that the overall survival and mortality rate was 62.9% (73) and 37.1% (43), respectively. The regression analysis showed that patients who had an advanced stage of disease had a 3.82 times risk of dying (crude hazard ratio= 3.82, 95% confidence interval = 1.5–9.8) than an early stage of the disease. Besides, patients with distant metastasis had 4.4 times more hazards of dying than (crude hazard ratio = 4.4, 95% confidence interval = 2.1–9.4) their counterparts.

Conclusion:

The treatment outcome of breast cancer patients was poor, and its overall mortality among breast cancer patients was higher in the study setting. In the multivariate Cox regression analysis, the tumor size was the only statistically significant predictor of mortality among breast cancer patients. Stakeholders at each stage should, therefore, prepare a relevant strategy to improve treatment outcomes.

OUP accepted manuscript

Introduction

Many women in rural Ethiopia do not receive adjuvant therapy following breast cancer surgery despite the majority being diagnosed with estrogen-receptor-positive breast cancer and tamoxifen being available in the country. We aimed to compare a breast nurse intervention to improve adherence to tamoxifen therapy for breast cancer patients.

Methods and Materials

The 8 hospitals were randomized to intervention and control sites. Between February 2018 and December 2019, patients with breast cancer were recruited after their initial surgery. The primary outcome of the study was adherence to tamoxifen therapy by evaluating 12-month medication-refill data with medication possession ratio (MPR) and using a simplified medication adherence scale (SMAQ) in a subjective assessment.

Results

A total of 162 patients were recruited (87 intervention and 75 control). Trained nurses delivered education and provided literacy material, gave additional empathetic counselling, phone call reminders, and monitoring of medication refill at the intervention hospitals. Adherence according to MPR at 12 months was high in both the intervention (90%) and control sites (79.3%) (P = .302). The SMAQ revealed that adherence at intervention sites was 70% compared with 44.8% in the control sites (P = .036) at 12 months. Persistence to therapy was found to be 91.2% in the intervention and 77.8% in the control sites during the one-year period (P = .010).

Conclusion

Breast nurses can improve cost-effective endocrine therapy adherence at peripheral hospitals in low-resource settings. We recommend such task sharing to overcome the shortage of oncologists and distances to central cancer centers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bioactive cationic peptides as potential agents for breast cancer treatment

Breast cancer continues to affect millions of women worldwide, and the number of new cases dramatically increases every year. The physiological causes behind the disease are still not fully understood. One in every 100 cases can occur in men, and although the frequency is lower than among women, men tend to have a worse prognosis of the disease. Various therapeutic alternatives to combat the disease are available. These depend on the type and progress of the disease, and include chemotherapy, radiotherapy, surgery, and cancer immunotherapy. However, there are several well-reported side effects of these treatments that have a significant impact on life quality, and patients either relapse or are refractory to treatment. This makes it necessary to develop new therapeutic strategies. One promising initiative are bioactive peptides, which have emerged in recent years as a family of compounds with an enormous number of clinical applications due to their broad spectrum of activity. They are widely distributed in several organisms as part of their immune system. The antitumoral activity of these peptides lies in a nonspecific mechanism of action associated with their interaction with cancer cell membranes, inducing, through several routes, bilayer destabilization and cell death. This review provides an overview of the literature on the evaluation of cationic peptides as potential agents against breast cancer under different study phases. First, physicochemical characteristics such as the primary structure and charge are presented. Secondly, information about dosage, the experimental model used, and the mechanism of action proposed for the peptides are discussed.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

BACKGROUND

Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

AIMS

To describe the current landscape of digital health interventions in oncology in Africa.

METHODS

We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

RESULTS

The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

CONCLUSION

Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.

Assessment of Breast Cancer Management in Sub-Saharan Africa

PURPOSE

To document progress and bottlenecks in breast cancer management in sub-Saharan Africa, subsequent to a 2013 pilot survey conducted through the African Organization for Research and Treatment in Cancer (AORTIC) network.

METHODS

An anonymous survey of breast cancer management was conducted in 2018 among AORTIC members. Results concerning respondent specialty, access to tumor boards, treatment accessibility, diagnostic services, and factors influencing treatment outcomes were compared with the 2013 findings.

RESULTS

Thirty-seven respondents from 30 facilities in 21 sub-Saharan Africa countries responded. The majority (92%) were clinical oncologists. Radiotherapy facilities were available in 70% of facilities. Seventy-eight percent of these had linear accelerators, and 42% had cobalt⁶⁰ machines. Eighty percent of facilities had multidisciplinary tumor boards. Immunohistochemistry was routinely performed in 74% of facilities, computed tomography scan in 90%, bone scan in 16%, and positron emission tomography scans in 5%. Anthracyclines, taxanes, tamoxifen, letrozole, anastrozole, and zoledronic acid were available in the majority; trastuzumab, fertility, and genetic counseling were available in 66%, 58%, and 16%, respectively. There were a 50% increase in oncologist respondents over 2013 and a > 50% increase in radiotherapy facilities, particularly linear accelerators. Availability of trastuzumab, aromatase inhibitors, and taxanes increased. Immunohistochemistry capacity remained the same, whereas facilities harvesting at least 10 axillary lymph nodes increased. Bone scan facilities decreased. Responses suggested improved diagnostic services, systemic therapies, and radiotherapy. Sociocultural and economic barriers, system delays, and advanced stage at presentation remain.

CONCLUSION

Clinicians in sub-Saharan Africa have basic tools to improve breast cancer outcomes, recording positive strides in domains such as radiotherapy and systemic therapy. Socioeconomic and cultural barriers and system delays persist. Workforce expansion must be prioritized to improve quality of care to improve outcomes.

This study highlights the current state of breast cancer management in Sub Saharan Africa, documenting key advancements , challenges and bottlenecks encountered in the sub region. Aside the major aspects of management, pertinent areas such as multidisciplinary tumour board engagements, fertility , genetic counselling and factors affecting outcome were explored. Majority of institutions manage breast cancer patients within a multidisciplinary setting using standard treatment guidelines. The high out of pocket cost of cancer treatment and advanced stage at presentation transcends in many sub Saharan countries negatively impacting outcomes. These results should serve as a benchmark to stakeholders , to guide urgent interventions required to further improve outcomes.

Surveying and mapping breast cancer services in Ghana: a cross-sectional pilot study in the Eastern Region

OBJECTIVES

Define the services available for the care of breast cancer at hospitals in the Eastern Region of Ghana, identify areas of the region with limited access to care through geospatial mapping, and test a novel survey instrument in anticipation of a nationwide scale up of the study.

DESIGN

A cross-sectional, facility-based survey study.

SETTING

This study was conducted at 33 of the 34 hospitals in the Eastern Region of Ghana from March 2020 to May 2020.

PARTICIPANTS

The 33 hospitals surveyed represented 97% of all hospitals in the region. This included private, government, quasi-government and faith-based organisation owned hospitals.

RESULTS

Sixteen hospitals (82%) surveyed provided basic screening services, 11 (33%) provided pathological diagnosis and 3 (9%) provided those services in addition to basic surgical care.53%, 64% and 78% of the population lived within 10 km, 25 km and 45 km of screening, diagnostic and treatment services respectively. Limited chemotherapy was available at two hospitals (6%), endocrine therapy at one hospital (3%) and radiotherapy was not available. Twenty-nine hospitals (88%) employed a general practitioner and 13 (39%) employed a surgeon. Oncology specialists, pathology personnel and a plastic surgeon were only available in one hospital (3%) in the Eastern Region.

CONCLUSIONS

Although 16 hospitals (82%) provided screening, only half the population lived within reasonable distance of these services. Few hospitals offered diagnosis and surgical services, but 64% and 78% of the population lived within a reasonable distance of these hospitals. Geospatial analysis suggested two priorities to cost-effectively expand breast cancer services: (1) increase the number of health facilities providing screening services and (2) centralise basic imaging, pathological and surgical services at targeted hospitals.

Circulating tumor DNA is readily detectable among Ghanaian breast cancer patients supporting non-invasive cancer genomic studies in Africa

Circulating tumor DNA (ctDNA) sequencing studies could provide novel insights into the molecular pathology of cancer in sub-Saharan Africa. In 15 patient plasma samples collected at the time of diagnosis as part of the Ghana Breast Health Study and unselected for tumor grade and subtype, ctDNA was detected in a majority of patients based on whole- genome sequencing at high (30×) and low (0.1×) depths. Breast cancer driver copy number alterations were observed in the majority of patients.

High-burden Cancers in Middle-income Countries: A Review of Prevention and Early Detection Strategies Targeting At-risk Populations

Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system-related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

Patterns of Palliative Radiotherapy Utilization for Patients With Metastatic Breast Cancer in Harare, Zimbabwe

PURPOSE

In sub-Saharan Africa, radiotherapy (RT) utilization and delivery patterns have not been extensively studied in patients with metastatic breast cancer.

METHODS

A retrospective cohort study of female patients with metastatic breast cancer seen at Parirenyatwa Radiotherapy Centre in Zimbabwe from 2014 to 2018 was conducted. Demographics, pathology, staging, and treatment data were abstracted through chart review. Fisher's exact test and chi-squared test of independence were used to compare proportions, and independent two-sample t-tests were used to compare means.

RESULTS

Of 351 patients with breast cancer, 152 (43%) had metastatic disease, median age 51 years (interquartile range: 43-61 years). Of those with metastatic disease, 30 patients (20%) received radiation to various metastatic sites: 16 spine; three nonspine bone metastases; six whole brain; and five chest wall or supraclavicular. Patients who received radiation were younger (46 v 52 years; P = .019), but did not differ significantly by performance status than those who did not. The most common dose prescription was 30 Gy in 10 fractions (33%). Five (17%) patients had treatment interruption and two (7%) had treatment noncompletion. Province of origin and clinical tumor stage were significant predictors of RT receipt (P = .002; and P = .018, respectively).

CONCLUSION

A minority of patients with metastatic breast cancer received RT (20%), and these were likely to be younger, with advanced tumor stage, and resided in provinces where RT is available. Conventional courses were generally prescribed. There is a need to strongly consider palliative RT as an option for patients with metastatic breast cancer and use of hypofractionated courses (e.g. 8 Gy in one fraction) may support this goal.

Impact of HIV infection on overall survival among women with stage IV breast cancer in South Africa

PURPOSE

Advanced breast cancer (BC) at diagnosis is common in sub-Saharan Africa (SSA), including among women living with HIV (WLWH). In public hospitals across South Africa (SA), 10-15% of women present with stage IV BC, compared to < 5% in the United States (US); 20% of new BC diagnoses in SA are in WLWH. We evaluated the impact of HIV on overall survival (OS) among women with stage IV BC.

METHODS

We conducted a prospective cohort study of women diagnosed with stage IV BC between February 2, 2015 and September 18, 2019 at six public hospitals in SA. Multivariate Cox regression models were used to estimate the association between HIV status and OS.

RESULTS

Among 550 eligible women, 147 (26.7%) were WLWH. Compared to HIV-negative BC patients, WLWH were younger (median age 45 vs. 60 years, p < 0.001), predominantly black (95.9% vs. 77.9%, p < 0.001), and more likely to have hormone receptor-negative (hormone-negative) BC (32.7% vs. 22.6%, p = 0.016). Most women received systemic cancer-directed therapy (80.1%). HIV status was not associated with treatment or OS (Hazard Ratio (HR) 1.13 [95%CI 0.89-1.44]). On exploratory subgroup analysis, WLWH and hormone-negative BC had shorter OS compared to HIV-uninfected women (1-year OS: 27.1% vs. 48.8%, p = 0.003; HR 1.94 [95%CI 1.27-2.94]; p = 0.002), which was not observed for hormone receptor-positive BC.

CONCLUSION

HIV status was not associated with worse OS in women with stage IV BC in SA and cannot account for the poor survival in this cohort. Subgroup analysis revealed that WLWH with hormone-negative BC had worse OS, which warrants further investigation.

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.

Building a breast cancer detection and treatment platform in the Democratic Republic of the Congo by integrating training, service and infrastructure development

Background

Breast cancer is a leading cause of cancer-related morbidity and mortality in sub-Saharan Africa, a global region where opportunities for breast care of any type are extremely limited due to insufficient infrastructure, a paucity of clinical services and vast shortages of trained human resources.

Methods

A team of Zambian and US gynaecologic and breast oncology experts and nurse-specialists made multiple visits (each lasting 5 working days) to the Democratic Republic of the Congo (DRC), over a 2-year period. During each of five week-long site visits, hands-on training of local Congolese health providers was conducted during which time they were taught clinical breast exam (CBE), breast and axillary ultrasound, ultrasound-guided core needle biopsy/fine needle aspiration (FNA) and breast surgery. Simultaneous with the training exercises, a new breast care clinic was established and operationalised, and existing surgical theatres were upgraded. All activities were implemented in a private sector health care facility - Biamba Marie Mutombo Hospital - in the capital city of Kinshasa.

Results

From April 2017 to August 2020, a total of 5,211 women were identified as having breast abnormalities on CBE. Ages ranged from 26 to 86 years; median age: 42.0 (±14.1) years. Ultrasound abnormalities were noted in 1,420 (27%) clients, of which 516 (36%) met the criteria (indeterminate cystic lesion, solid or suspicious masses) for ultrasound-guided core needle biopsy or FNA. Pathology reports were available for 368 (71%) of the 516 clients who underwent biopsy, of which 164 were malignant and 204 benign. The majority (88%) of the cancers were advanced (TNM stages 3 and 4). Surgical procedures consisted of 183 lumpectomies, 58 modified radical mastectomies and 45 axillary lymph node dissections. Clinical competency for diagnostic and surgical procedures was reached early in the course of the training programme.

Conclusion

By integrating onsite training with simultaneous investments in clinical service and infrastructure development, the barriers to breast cancer diagnosis and treatment were disrupted and a modern breast care service platform was established in a private sector health care facility in the DRC.

Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018

Background

Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub‐Saharan Africa (SSA) with radiotherapy access.

Methods

A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non‐adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease.

Results

In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43–61). Receptor status was missing for 71% (248). 199 (57%) had non‐metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post‐mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study‐defined non‐adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non‐adherence (aOR: 0.18, 95% CI: 0.09, 0.36).

Conclusions

Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient‐level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.

PredTAD: A machine learning framework that models 3D chromatin organization alterations leading to oncogene dysregulation in breast cancer cell lines

Topologically associating domains, or TADs, play important roles in genome organization and gene regulation; however, they are often altered in diseases. High-throughput chromatin conformation capturing assays, such as Hi-C, can capture domains of increased interactions, and TADs and boundaries can be identified using well-established analytical tools. However, generating Hi-C data is expensive. In our study, we addressed the relationship between multi-omics data and higher-order chromatin structures using a newly developed machine-learning model called PredTAD. Our tool uses already-available and cost-effective datatypes such as transcription factor and histone modification ChIPseq data. Specifically, PredTAD utilizes both epigenetic and genetic features as well as neighboring information to classify the entire human genome as boundary or non-boundary regions. Our tool can predict boundary changes between normal and breast cancer genomes. Among the most important features for predicting boundary alterations were CTCF, subunits of cohesin (RAD21 and SMC3), and chromosome number, suggesting their roles in conserved and dynamic boundaries formation. Upon further analysis, we observed that genes near altered TAD boundaries were found to be involved in several important breast cancer signaling pathways such as Ras, Jak-STAT, and estrogen signaling pathways. We also discovered a TAD boundary alteration that contributes to RET oncogene overexpression. PredTAD can also successfully predict TAD boundary changes in other conditions and diseases. In conclusion, our newly developed machine learning tool allowed for a more complete understanding of the dynamic 3D chromatin structures involved in signaling pathway activation, altered gene expression, and disease state in breast cancer cells.

Preexisting morbidity profile of women newly diagnosed with breast cancer in sub-Saharan Africa: African Breast Cancer-Disparities in Outcomes study

The presence of preexisting morbidities poses a challenge to cancer patient care. There is little information on the profile and prevalence of multi-morbidities in breast cancer patients across middle income countries (MIC) to lower income countries (LIC) in sub-Saharan Africa (SSA). The African Breast Cancer-Disparities in Outcomes (ABC-DO) breast cancer cohort spans upper MICs South Africa and Namibia, lower MICs Zambia and Nigeria and LIC Uganda. At cancer diagnosis, seven morbidities were assessed: obesity, hypertension, diabetes, asthma/chronic obstructive pulmonary disease, heart disease, tuberculosis and HIV. Logistic regression models were used to assess determinants of morbidities and the influence of morbidities on advanced stage (stage III/IV) breast cancer diagnosis. Among 2189 women, morbidity prevalence was the highest for obesity (35%, country-specific range 15-57%), hypertension (32%, 15-51%) and HIV (16%, 2-26%) then for diabetes (7%, 4%-10%), asthma (4%, 2%-10%), tuberculosis (4%, 0%-8%) and heart disease (3%, 1%-7%). Obesity and hypertension were more common in upper MICs and in higher socioeconomic groups. Overall, 27% of women had at least two preexisting morbidities. Older women were more likely to have obesity (odds ratio: 1.09 per 10 years, 95% CI 1.01-1.18), hypertension (1.98, 1.81-2.17), diabetes (1.51, 1.32-1.74) and heart disease (1.69, 1.37-2.09) and were less likely to be HIV positive (0.64, 0.58-0.71). Multi-morbidity was not associated with stage at diagnosis, with the exception of earlier stage in obese and hypertensive women. Breast cancer patients in higher income countries and higher social groups in SSA face the additional burden of preexisting non-communicable diseases, particularly obesity and hypertension, exacerbated by HIV in Southern/Eastern Africa.

Geospatial barriers to healthcare access for breast cancer diagnosis in sub-Saharan African settings: The African Breast Cancer-Disparities in Outcomes Cohort Study

We examined the geospatial dimension of delays to diagnosis of breast cancer in a prospective study of 1541 women newly diagnosed in the African Breast Cancer-Disparities in Outcomes (ABC-DO) Study. Women were recruited at cancer treatment facilities in Namibia, Nigeria, Uganda and Zambia. The baseline interview included information used to generate the geospatial features: urban/rural residence, travel mode to treatment facility and straight-line distances from home to first-care provider and to diagnostic/treatment facility, categorized into country/ethnicity (population)-specific quartiles. These factors were investigated in relation to delay in diagnosis (≥3 months since first symptom) and late stage at diagnosis (TNM: III, IV) using logistic regression, adjusted for population group and sociodemographic characteristics. The median (interquartile range) distances to first provider and diagnostic and treatment facilities were 5 (1-37), 17 (3-105) and 62 (5-289) km, respectively. The majority had a delay in diagnosis (74%) and diagnosis at late stage (64%). Distance to first provider was not associated with delay in diagnosis or late stage at diagnosis. Rural residence was associated with delay, but the association did not persist after adjustment for sociodemographic characteristics. Distance to the diagnostic/treatment facility was associated with delay (highest vs lowest quartile: odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.08-2.27) and late stage (overall: OR = 1.47, CI = 1.05-2.06; without Nigerian hospitals where mostly local residents were treated: OR = 1.73, CI = 1.18-2.54). These findings underscore the need for measures addressing the geospatial barriers to early diagnosis in sub-Saharan African settings, including providing transport or travel allowance and decentralizing diagnostic services.

Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries

This article provides an update on the global cancer burden using the GLOBOCAN 2020 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer. Worldwide, an estimated 19.3 million new cancer cases (18.1 million excluding nonmelanoma skin cancer) and almost 10.0 million cancer deaths (9.9 million excluding nonmelanoma skin cancer) occurred in 2020. Female breast cancer has surpassed lung cancer as the most commonly diagnosed cancer, with an estimated 2.3 million new cases (11.7%), followed by lung (11.4%), colorectal (10.0 %), prostate (7.3%), and stomach (5.6%) cancers. Lung cancer remained the leading cause of cancer death, with an estimated 1.8 million deaths (18%), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and female breast (6.9%) cancers. Overall incidence was from 2-fold to 3-fold higher in transitioned versus transitioning countries for both sexes, whereas mortality varied <2-fold for men and little for women. Death rates for female breast and cervical cancers, however, were considerably higher in transitioning versus transitioned countries (15.0 vs 12.8 per 100,000 and 12.4 vs 5.2 per 100,000, respectively). The global cancer burden is expected to be 28.4 million cases in 2040, a 47% rise from 2020, with a larger increase in transitioning (64% to 95%) versus transitioned (32% to 56%) countries due to demographic changes, although this may be further exacerbated by increasing risk factors associated with globalization and a growing economy. Efforts to build a sustainable infrastructure for the dissemination of cancer prevention measures and provision of cancer care in transitioning countries is critical for global cancer control.

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

Background/Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Impact of HIV infection on baseline characteristics and survival of women with breast cancer

BACKGROUND

As women living with HIV (WLWH) become older, their risk of developing breast cancer increases. Nonetheless, literature is conflicting regarding tumor stage, distribution of subtypes and overall survival among WLWH vs. HIV-negative women with breast cancer. We assessed differences in clinicopathological characteristics and overall survival between these two groups.

METHODS

Systematic review and meta-analysis using MEDLINE, Scopus, ISI Web of Knowledge, LILACS, SciELO and conference abstracts up to 1 January 2020. Cross-sectional/cohort studies comparing baseline characteristics (stage and/or subtypes) and/or overall survival of WLWH vs. HIV-negative women with breast cancer were included. We performed random-effects meta-analyses to estimate summary statistics and subgroup analyses according to region of the world.

RESULTS

Eighteen studies [4 from North America, 14 from sub-Saharan Africa (SSA)] were included, with 3174 WLWH and 2 394 598 HIV-negative women. WLWH from North America and SSA were more likely to present with stage III/IV disease compared with HIV-negative women - pooled odds ratio (pOR) 1.76 [95% confidence interval (CI):1.58-1.95] and pOR 1.23 (95% CI: 1.06-1.42), respectively. WLWH from SSA were also less likely to have estrogen receptor-positive/HER2-negative tumors (pOR 0.81; 95% CI: 0.66-0.99). After adjustment, WLWH had worse overall survival compared with HIV-negative women, both in North America [pooled adjusted hazard ratio (aHR) 2.45; 95% CI: 1.11-5.41] and SSA (aHR 1.43; 95% CI: 1.06-1.92).

CONCLUSION

Compared with HIV-negative women, WLWH are diagnosed with breast cancer at a more advanced stage and have a worse overall survival. These results should raise awareness regarding the detection and survival gap among WLWH with breast cancer and further studies are needed to decipher the reasons behind these disparities.

Maternally Orphaned Children and Intergenerational Concerns Associated With Breast Cancer Deaths Among Women in Sub-Saharan Africa

IMPORTANCE

Low breast cancer survival in sub-Saharan Africa's young population increases the likelihood that breast cancer deaths result in maternal orphans, ie, children (<18 years) losing their mother.

OBJECTIVE

To estimate the number of maternal orphans and their ages for every 100 breast cancer deaths in sub-Saharan African settings during 2014-2019 and to describe family concerns about the orphaned children.

DESIGN, SETTING, AND PARTICIPANTS

Deaths occurring between September 1, 2014, and July 1, 2019, in the African Breast Cancer-Disparities in Outcomes (ABC-DO) were examined in a cohort of women diagnosed with breast cancer during 2014-2017 at major cancer treatment hospitals in Namibia, Nigeria, Uganda, and Zambia. The cohort was actively followed up for vital status via a trimonthly mobile phone call to each woman or her next of kin (typically a partner, husband, or child).

MAIN OUTCOMES AND MEASURES

The number (Poisson counts) and ages of new orphans at the time of maternal death.

RESULTS

This cohort study found that a total of 795 deaths resulted in 964 new maternal orphans, with deaths occurring in women younger than 50 years accounting for 85% of the orphans. For every 100 deaths in women younger than 50 years, there were 210 new orphans (95% CI, 196-225) overall, with country-specific estimates of 189 in Nigerian, 180 in Namibian, 222 in Ugandan, and 247 in Zambian Black women. For every 100 deaths of the women at any age, there were 121 maternal orphans, 17% of whom were younger than 5 years, 32% aged 5 to 9 years, and 51% aged 10 to 17 years at the time of maternal death. In follow-up interviews, families' concerns for children's education and childcare were reported to be exacerbated by the financial expenses associated with cancer treatment.

CONCLUSIONS AND RELEVANCE

This study provides evidence that the number of maternal orphans due to breast cancer exceeds the number of breast cancer deaths among women in sub-Saharan Africa. The intergenerational consequences associated with cancer deaths in sub-Saharan Africa appear to be large and support the need for continued action to improve survival.

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.

The Global, Regional, and National Burden and Trends of Breast Cancer From 1990 to 2019: Results From the Global Burden of Disease Study 2019

BACKGROUND

The burden of breast cancer has been increasing globally. The epidemiology burden and trends need to be updated. This study aimed to update the burden and trends of breast cancer incidences, deaths, and disability-adjusted life-years (DALYs) from 1990 to 2019, using the Global Burden of Disease 2019 study.

METHODS

The data of incidences, deaths, DALYs, and age-standardized rates were extracted. Estimated annual percentage changes were used to quantify the trends of age-standardized rates. Besides, the population attributable fractions of the risk factors of breast cancer were also estimated.

RESULTS

Globally, the incidences of breast cancer increased to 2,002,354 in 2019. High social-development index (SDI) quintiles had the highest incidence cases with a declining trend in age-standardized incidence rate. In 2019, the global deaths and DALYs of breast cancer increased to 700,660 and 20,625,313, respectively. From 1990 to 2019, the age-standardized mortality rates and age-standardized DALY rates declined globally, especially in high and high-middle SDI quintiles. Besides, the trends varied from different regions and countries. The proportion of the patients in the 70+ years age group increased globally. Deaths of breast cancer attributable to high fasting plasma glucose and high body mass index increased globally, and high fasting plasma glucose was the greatest contributor to the global breast cancer deaths.

CONCLUSION

The burden of breast cancer in higher SDI quintiles had gone down while the burden was still on the rise in lower SDI quintiles. It is necessary to appeal to the public to decrease the exposure of the risk factors.

Highlights from the 4th PALOP-AORTIC Conference on Cancer, 29-31 July 2020, Luanda, Angola

The 4th Países Africanos de Língua Oficial Portuguesa (PALOP)-African Organisation for Research and Training in Cancer (AORTIC) Conference on Cancer was held in July 2020 in Luanda, Angola, under the theme: 'Training to better care'. It was hosted by the Ministry of Health of Angola and AORTIC. It was held virtually using an online platform. The PALOP organisation comprises Lusophone African countries. The conference brought together 360 delegates from 12 countries. Key themes covered during the conference included: Instruments for Proficient Cancer Control in PALOP, oncology education and training in PALOP, CanScreen5-International Agency for Research on Cancer platform to improve quality in tracking cancer, International Gynecologic Cancer Society-Global Curriculum and Mentorship Programme, Oncology Training/Intervention-Support Programmes, Telepathology and Cancer: Challenges and Opportunities, Cancer Burden in PALOP region and Sub-Saharan Africa, Breast Cancer-The current situation in PALOP and The African Breast Cancer Coalition-Disparities in outcomes study in PALOP Countries (ABC-DO-PALOP) study: a proposal. It has been demonstrated that the collaboration and exchange of experiences between African countries and amongst PALOP, in particular, are crucial, whether in the organisation of population-based cancer registries, in the realization of national oncology plans, in the creation of therapeutic recommendations and in strengthening capacities in radiotherapy, amongst other important topics in oncology. The PALOP oncology school will be a fundamental training tool to be administered for better care for cancer patients.