Challenges to the early diagnosis and treatment of breast cancer in developing countries

From Awareness to Action: A Review of Efforts to Reduce Disparities in Breast Cancer Screening

Breast cancer is a significant public health concern, and addressing disparities in breast cancer screening is crucial for improving early detection and reducing mortality rates. This review article examines efforts to bridge the gap between awareness and action in reducing disparities in breast cancer screening. A systematic approach was employed to gather relevant literature using various databases. The selected studies encompassed a range of interventions, including policy changes, community-based programs, culturally competent interventions, technological advancements, and patient navigation. The review highlights the importance of policies and legislation in improving access to screening services and the impact of community-based initiatives in addressing disparities. Culturally competent interventions, tailored messaging, and language support were found to be effective in improving screening rates among diverse populations. Technological advancements, such as telemedicine and mobile health applications, were identified as promising approaches to increase access to screening services. Patient navigation programs effectively addressed barriers to screening and improved screening rates. The review also discusses evaluating efforts, limitations, and the need for continuous improvement. Future directions and recommendations include addressing gaps in the existing literature, proposing research directions, and providing recommendations for policymakers, healthcare providers, and researchers. By implementing these recommendations and working collaboratively, we can strive for equitable access to breast cancer screening for all populations, ultimately leading to improved outcomes and reduced disparities.

Projection of morbidity and mortality due to breast cancer between 2020 and 2050 across 42 low- and middle-income countries

Objective

Aim of the study is to predict trends in morbidity and mortality due to breast cancer in 42 LMICs between 2020 and 2050.

Design

and Setting: National level cross-sectional breast cancer related data between 1990 and 2019 were used. Recurrent Neural Network, Long-Short-Term Memory (RNN-LSTM) model was employed to forecast the trend in breast cancer burden.

Main outcomes and measures

Age standardized breast cancer incidence, mortality, and disability adjusted life years (DALYs) rates.

Results

By 2050, the age standardized breast cancer incidence rate is expected to increase in 38 LMICs with highest incidence rate in Namibia; 127.0 (78.0-176.0) followed by Nigeria 71.1 (53.9-88.3) and Papua New Guinea 70.6 (88.7-74.6). Similarly, the age standardized breast cancer mortality and DALYs rates in 2050 are expected to increase in 33 and 35 LMICs respectively. The highest mortality and DALYs rates in 2050 are expected to be 64.7 (42.6-86.7) in Namibia and 1543.6 (1463.1-1624.1) in Pakistan. The estimated annual percentage change (EAPC) is expected to increase uniformly in all the countries during the same period. Due to considerable variation in exposure risk, such as high plasma glucose level, high body mass index (BMI) and socio-demographic index (SDI), high regional disparity in burden of breast cancer is expected among the countries.

Conclusion

and Relevance: Breast cancer burden is expected to increase in most of the LMICs with high regional disparity by 2050. Our study's finding focuses on LMICs with high breast cancer burden that require tailored strategies and effective action plans to ensure prevention from catastrophic consequences in the future. Minimizing the exposure to behavioral and metabolic risk factors such as high plasma glucose, high BMI, along with tackling the issue of low fertility rate would be important in managing breast cancer burden in LMICs.

Assessing the cost-effectiveness of waiting list reduction strategies for a breast radiology department: a real-life case study

BACKGROUND

A timely diagnosis is essential for improving breast cancer patients' survival and designing targeted therapeutic plans. For this purpose, the screening timing, as well as the related waiting lists, are decisive. Nonetheless, even in economically advanced countries, breast cancer radiology centres fail in providing effective screening programs. Actually, a careful hospital governance should encourage waiting lists reduction programs, not only for improving patients care, but also for minimizing costs associated with the treatment of advanced cancers. Thus, in this work, we proposed a model to evaluate several scenarios for an optimal distribution of the resources invested in a Department of Breast Radiodiagnosis.

MATERIALS AND METHODS

Particularly, we performed a cost-benefit analysis as a technology assessment method to estimate both costs and health effects of the screening program, to maximise both benefits related to the quality of care and resources employed by the Department of Breast Radiodiagnosis of Istituto Tumori "Giovanni Paolo II" of Bari in 2019. Specifically, we determined the Quality-Adjusted Life Year (QALY) for estimating health outcomes, in terms of usefulness of two hypothetical screening strategies with respect to the current one. While the first hypothetical strategy adds one team made up of a doctor, a technician and a nurse, along with an ultrasound and a mammograph, the second one adds two afternoon teams.

RESULTS

This study showed that the most cost-effective incremental ratio could be achieved by reducing current waiting lists from 32 to 16 months. Finally, our analysis revealed that this strategy would also allow to include more people in the screening programs (60,000 patients in 3 years).

Identification and validation of miR-583 and mir-877-5p as biomarkers in patients with breast cancer: an integrated experimental and bioinformatics research

OBJECTIVES

Breast cancer (BC) is one of the most common cancers with a high mortality rate in women worldwide. The advantages of early cancer diagnosis are apparent, and it is a critical factor in increasing the patient's life and survival. According to mounting evidence, microRNAs (miRNAs) may be crucial regulators of critical biological processes. miRNA dysregulation has been linked to the beginning and progression of various human malignancies, including BC, and can operate as tumor suppressors or oncomiRs. This study aimed to identify novel miRNA biomarkers in BC tissues and non-tumor adjacent tissues of patients with BC. Microarray datasets GSE15852 and GSE42568 for differentially expressed genes (DEGs) and GSE45666, GSE57897, and GSE40525 for differentially expressed miRNAs (DEMs) retrieved from the Gene Expression Omnibus (GEO) database were analyzed using "R" software. A protein-protein interaction (PPI) network was created to identify the hub genes. MirNet, miRTarBase, and MirPathDB databases were used to predict DEMs targeted genes. Functional enrichment analysis was used to demonstrate the topmost classifications of molecular pathways. The prognostic capability of selected DEMs was evaluated through a Kaplan-Meier plot. Moreover, the specificity and sensitivity of detected miRNAs to discriminate BC from adjacent controls were assessed by area under the curve (AUC) using the ROC curve analysis. In the last phase of this study, gene expression on 100 BC tissues and 100 healthy adjacent tissues were analyzed and calculated by using the Real-Time PCR method.

RESULTS

This study declared that miR-583 and miR-877-5p were downregulated in tumor samples in comparison to adjacent non-tumor samples (|logFC|< 0 and P ≤ 0.05). Accordingly, ROC curve analysis demonstrated the biomarker potential of miR-877-5p (AUC = 0.63) and miR-583 (AUC = 0.69). Our results showed that has-miR-583 and has-miR-877-5p could be potential biomarkers in BC.

Experience of Pain and Unpleasantness during Mammography Screening: A Cross-Sectional Study on the Roles of Emotional, Cognitive, and Personality Factors

BACKGROUND

Breast cancer is the most frequent cause of malignant tumors among women worldwide. Its successful prevention depends on the degree of participation in screening programs, which can be influenced by psychological factors, including fear.

METHOD

A cross-sectional study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. Twenty-six healthy women aged 50-69 years took part in this study, all of whom were summoned for routine mammography screening and were randomly selected. Prior mammography screening, breast pain intensity, unpleasantness (visual analog scale), and psychological (catastrophizing, state anxiety, and fear of pain) and personality (neuroticism, psychoticism, and extraversion) variables were evaluated. Pain, unpleasantness, and state anxiety were further evaluated pre- and post-mammography screening.

RESULTS

During the mammography screening, pain and unpleasantness levels were higher than those observed pre- and post-screening. Residual unpleasantness remained post-screening. State anxiety was positively associated with pain, and psychoticism with unpleasantness, as reported by participants during the mammography screening.

CONCLUSIONS

Anxiety levels influence the pain experienced in association with the mammography procedure. Women subjected to mammography screenings might benefit from relaxation strategies aimed at reducing anxiety to pre-mammography levels and, by extension, pain and unpleasantness during mammography. The inclusion of these strategies in breast cancer prevention campaigns could improve the rates of mammography reattendance, and therefore, benefit cancer prevention efforts.

Neoadjuvant Therapy in Nonmetastatic Breast Cancer in Kurdistan, Iraq

PURPOSE

The core management of nonmetastatic breast cancer includes surgical tumor removal by either breast-conserving surgery (BCS) or mastectomy. The use of neoadjuvant chemotherapy (NACT) has shown the potential to downstage locally advanced breast cancer (LABC) and reduce the extent of breast or axillary surgery. This study aimed to assess the treatment approach for nonmetastatic breast cancer in the Kurdistan region of Iraq and to compare its alignment with the current international recommendations for cancer treatment.

METHODS

We retrospectively reviewed the records of 1,000 patients with prespecified eligible inclusion criteria who underwent either BCS or mastectomy for nonmetastatic invasive breast cancer at oncology centers in the Kurdistan region of Iraq between the period 2016 and 2021.

RESULTS

Of 1,000 patients (median age, 47 years [range, 22-85 years]), 60.2% underwent mastectomy and 39.8% underwent BCS. The proportion of patients treated with NACT has increased over time, with 8.3% of patients receiving neoadjuvant treatment in 2016 compared with 14.2% in 2021. Similarly, BCS increased from 36.3% in 2016 to 43.7% in 2021. Most patients who underwent BCS had early breast cancer with low nodal involvement burden.

CONCLUSION

The increasing trends of BCS practice in LABC along with the increased use of NACT in the Kurdistan region in recent years comply with international guidelines. Our large multicenter, real-life series emphasizes the need to implement and discuss more conservative surgical approaches, enhanced with the broader use of NACT, through education and information programs for health providers and patients, in the context of multidisciplinary team discussions, to deliver high-quality, patient-centric breast cancer care.

Patterns of better breast cancer care in countries with higher human development index and healthcare expenditure: Insights from GLOBOCAN 2020

Background

The huge burden of breast cancer (BC) necessitates the profound and accurate knowledge of the most recent cancer epidemiology and quality of care provided. We aimed to evaluate BC epidemiology and quality of care and examine the effects of socioeconomic development and healthcare expenditure on disparities in BC care.

Methods

The results from the GLOBOCAN 2020 study were utilized to extract data on female BC, including incidence and mortality numbers, crude rates, and age-standardized rates [age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs)]. The mortality-to-incidence ratio (MIR) was calculated for different locations and socioeconomic stratifications to examine disparities in BC care, with higher values reflecting poor quality of care and vice versa. In both descriptive and analytic approaches, the human development index (HDI) and the proportion of current healthcare expenditure (CHE) to gross domestic product (CHE/GDP%) were used to evaluate the values of MIR.

Results

Globally, 2,261,419 (95% uncertainty interval (UI): 2,244,260-2,278,710) new cases of female BC were diagnosed in 2020, with a crude rate of 58.5/100,000 population, and caused 684,996 (675,493-694,633) deaths, with a crude rate of 17.7. The WHO region with the highest BC ASIR (69.7) was Europe, and the WHO region with the highest ASMR (19.1) was Africa. The very high HDI category had the highest BC ASIR (75.6), and low HDI areas had the highest ASMR (20.1). The overall calculated value of female BC MIR in 2020 was 0.30, with Africa having the highest value (0.48) and the low HDI category (0.53). A strong statistically significant inverse correlation was observed between the MIR and HDI values for countries/territories (Pearson's coefficient = -0.850, p-value < 0.001). A significant moderate inverse correlation was observed between the MIR and CHE/GDP values (Pearson's coefficient = -0.431, p-value < 0.001).

Conclusions

This study highlighted that MIR of BC was higher in less developed areas and less wealthy countries. MIR as an indicator of the quality of care showed that locations with higher healthcare expenditure had better BC care. More focused interventions in developing regions and in those with limited resources are needed to alleviate the burden of BC and resolve disparities in BC care.

Breast Ultrasound Volume Sweep Imaging: A New Horizon in Expanding Imaging Access for Breast Cancer Detection

OBJECTIVE

The majority of people in the world lack basic access to breast diagnostic imaging resulting in delay to diagnosis of breast cancer. In this study, we tested a volume sweep imaging (VSI) ultrasound protocol for evaluation of palpable breast lumps that can be performed by operators after minimal training without prior ultrasound experience as a means to increase accessibility to breast ultrasound.

METHODS

Medical students without prior ultrasound experience were trained for less than 2 hours on the VSI breast ultrasound protocol. Patients presenting with palpable breast lumps for standard of care ultrasound examination were scanned by a trained medical student with the VSI protocol using a Butterfly iQ handheld ultrasound probe. Video clips of the VSI scan imaging were later interpreted by an attending breast imager. Results of VSI scan interpretation were compared to the same-day standard of care ultrasound examination.

RESULTS

Medical students scanned 170 palpable lumps with the VSI protocol. There was 97% sensitivity and 100% specificity for a breast mass on VSI corresponding to 97.6% agreement with standard of care (Cohen's κ = 0.95, P < .0001). There was a detection rate of 100% for all cancer presenting as a sonographic mass. High agreement for mass characteristics between VSI and standard of care was observed, including 87% agreement on Breast Imaging-Reporting and Data System assessments (Cohen's κ = 0.82, P < .0001).

CONCLUSIONS

Breast ultrasound VSI for palpable lumps offers a promising means to increase access to diagnostic imaging in underserved areas. This approach could decrease delay to diagnosis for breast cancer, potentially improving morbidity and mortality.

International development of a patient-centered core outcome set for assessing health-related quality of life in metastatic breast cancer patients

PURPOSE

For patients living with metastatic breast cancer (MBC), achieving best possible health-related quality of life, along with maximizing survival, is vital. Yet, we have no systemic way to determine if we achieve these goals. A Core Outcome Set (COS) that allows standardized measurement of outcomes important to patients, but also promotes discussing these outcomes during clinical encounters, is long overdue.

METHODS

An international expert group (EG) of patient advocates, researchers, medical specialists, nurse specialists, and pharmaceutical industry representatives (n = 17) reviewed a list of relevant outcomes retrieved from the literature. A broader group (n = 141: patients/patient advocates (n = 45), health care professionals/researchers (n = 64), pharmaceutical industry representatives (n = 28), and health authority representatives (n = 4)) participated in a modified Delphi procedure, scoring the relevance of outcomes in two survey rounds. The EG finalized the COS in a consensus meeting.

RESULTS

The final MBC COS includes 101 variables about: (1) health-related quality of life (HRQoL, n = 26) and adverse events (n = 24); (2) baseline patient characteristics (n = 9); and (3) clinical variables (n = 42). Many outcome that cover aspects of HRQoL relevant to MBC patients are included, e.g. daily functioning (including ability to work), psychosocial/emotional functioning, sexual functioning, and relationship with the medical team.

CONCLUSION

The COS developed in this study contains important administrative data, clinical records, and clinician-reported measures that captures the impact of cancer. The COS is important for standardization of clinical research and implementation in daily practice and has received accreditation by the International Consortium for Health Outcomes Measurement (ICHOM).

Relationship between Health Inequalities and Breast Cancer Survival in Mexican Women

OBJECTIVE

We aimed to analyze the relationship between the survival of patients with breast cancer and health inequalities.

METHODS

A retrospective cohort study of women with stage III breast cancer according to public healthcare was conducted. Groups were stratified according to the course of treatment and the presence of chronic disease other than cancer. Survival functions were estimated by using the Kaplan-Meier estimator, while the Cox proportional hazards model was employed for prognostic assessment.

RESULTS

The study was performed on 964 breast cancer patients. One hundred and seventy-six patients (18.23%) died during the follow-up period and 788 (81.77%) were alive at the end of the follow-up period. Education, marital status, personal history of prior biopsies, and socioeconomic status (SES) were found to be linked with survival. However, only SES exceeded the baseline risk of mortality when the treatment cycle was interrupted (full treatment: unadjusted 4.683, p = 0.001; adjusted 4.888 p = 0.001, partial treatment: unadjusted 1.973, p = 0.012; adjusted 4.185, p = 0.001). The same effect was observed when stratifying by the presence of chronic disease other than cancer (with chronic disease adjusted HR = 4.948, p = 0.001; unadjusted HR = 3.303, p = 0.001; without chronic disease adjusted HR = 4.850, p = 0.001; unadjusted HR = 5.121, p = 0.001).

CONCLUSION

Since lower SES was linked with a worse prognosis, strategies to promote preventive medicine, particularly breast cancer screening programs and prompt diagnosis, are needed.

Access to advanced cancer care services in the West Bank-occupied Palestinian territory

Introduction

Universal Health Coverage (UHC) identifies the provision of palliative care for people with advanced disease as an essential health service. Palliative care is also stipulated as a human right under existing covenants. Oncology services provided by the Palestinian Authority under Israeli military occupation are limited to surgery and chemotherapy treatment. Our study aimed to describe the experiences of patients with advanced-stage cancer in the West Bank in accessing oncology services and meeting their health care needs.

Methodology

We conducted a qualitative study among adult patients diagnosed with advanced lung, colon, or breast cancer in three Palestinian governmental hospitals, and with oncologists. Thematic analysis was conducted on the verbatim interview transcripts.

Results

The sample consisted of 22 Palestinian patients (10 men and 12 women) and 3 practicing oncologists. The findings reveal that cancer care is fragmented, with limited access to the services needed. Patients face referral delays in accessing treatment which worsen their health condition in some cases. Some patients reported difficulties in getting Israeli permits to access radiotherapy treatment in East-Jerusalem, and others experienced interruptions of their chemotherapy treatment sessions due to the unavailability of chemotherapy medications caused by Israeli-side delays. Other reported problems were related to the Palestinian health system and service delivery and quality, including fragmentation of services, infrastructure issues, and unavailability of medications. Advanced diagnostic services and palliative care are almost absent at Palestinian governmental hospitals, and patients need to seek these services in the private sector.

Conclusion

The data demonstrate specific access restrictions to cancer care in the West Bank due to Israeli military occupation of Palestinian land. This affects all stages of the care pathway, from restricted diagnosis services, to limited treatment and then poor availability of palliative care. Cancer patients will continue to suffer if the root causes of these structural constraints are not addressed.

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

Importance

Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments.

Objective

To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally.

Data Sources

A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022.

Study Selection

A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review.

Data Extraction and Synthesis

A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model.

Main Outcomes and Measures

FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis.

Results

Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries.

Conclusions and Relevance

Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

Electrochemical Genosensing of Overexpressed GAPDH Transcripts in Breast Cancer Exosomes

Exosomes are receiving highlighted attention as new biomarkers for the detection of cancer since they are profusely released by tumor cells in different biological fluids. In this paper, the exosomes are preconcentrated from the serum by immunomagnetic separation (IMS) based on a CD326 receptor as a specific epithelial cancer-related biomarker and detected by glyceraldehyde-3-phosphate dehydrogenase (GAPDH) transcripts. Following the lysis of the captured exosomes, the released GAPDH transcripts are amplified by reverse transcription polymerase chain reaction (RT-PCR) with a double-tagging set of primers on poly(dT)-modified-MPs to increase the sensitivity. The double-tagged amplicon is then quantified by electrochemical genosensing. The IMS/double-tagging RT-PCR/electrochemical genosensing approach is first demonstrated for the sensitive detection of exosomes derived from MCF7 breast cancer cells and compared with CTCs in terms of the analytical performance, showing an LOD of 4 × 102 exosomes μL-1. The genosensor was applied to human samples by immunocapturing the exosomes directly from serum from breast cancer patients and showed a higher electrochemical signal (3.3-fold, p < 0.05), when compared with healthy controls, suggesting an overexpression of GAPDH on serum-derived exosomes from breast cancer patients. The detection of GAPDH transcripts is performed from only 1.0 mL of human serum using specific magnetic particles, improving the analytical simplification and avoiding ultracentrifugation steps, demonstrating to be a promising strategy for minimal invasive liquid biopsy.

Prognostic implication and immunotherapy response prediction of a ubiquitination-related gene signature in breast cancer

Breast cancer (BC) is one of the most common tumor types and has poor outcomes. In this study, a ubiquitination-related prognostic signature was constructed, and its association with immunotherapy response in BC was explored. A list of ubiquitination-related genes was obtained from the molecular signatures database, and a ubiquitination-related gene signature was obtained by least absolute shrinkage and selection operator Cox regression. The genes, TCN1, DIRAS3, and IZUMO4, had significant influence on BC outcomes. Patients were categorized into two clusters-a high-risk group with poor survival and a low-risk group with greater chances of controlling BC progression. Univariate and multivariate Cox regression analyses revealed that the risk signature was an independent prognostic factor for BC. Gene set enrichment analysis suggested that the high-risk group was enriched in cell cycle and DNA replication pathways. The risk score was positively linked to the tumor microenvironment and negatively correlated with the immunotherapy response. The IC50 values for rapamycin were higher in the low-risk group, whereas those for axitinib, AZD6244, erlotinib, GDC0941, GSK650394, GSK269962A, lapatinib, and PD0325901 were higher in the high-risk group. Therefore, the ubiquitination-related signature is considered a promising tool for predicting a BC patient's immunotherapy response.

Look how far we have come: BREAST cancer detection education on the international stage

The development of screening mammography over 30 years has remarkedly reduced breast cancer-associated mortality by 20%-30% through detection of small cancer lesions at early stages. Yet breast screening programmes may function differently in each nation depending on the incidence rate, national legislation, local health infrastructure and training opportunities including feedback on performance. Mammography has been the frontline breast cancer screening tool for several decades; however, it is estimated that there are 15% to 35% of cancers missed on screening which are owing to perceptual and decision-making errors by radiologists and other readers. Furthermore, mammography screening is not available in all countries and the increased speed in the number of new breast cancer cases among less developed countries exceeds that of the developed world in recent decades. Studies conducted through the BreastScreen Reader Assessment Strategy (BREAST) training tools for breast screening readers have documented benchmarking and significant variation in diagnostic performances in screening mammogram test sets in different countries. The performance of the radiologists from less well-established breast screening countries such as China, Mongolia and Vietnam were significant lower in detecting early-stage cancers than radiologists from developed countries such as Australia, USA, Singapore, Italy. Differences in breast features and cancer presentations, discrepancies in the level of experiences in reading screening mammograms, the availability of high-quality national breast screening program and breast image interpretation training courses between developed and less developed countries are likely to have impact on the variation of readers' performances. Hence dedicated education training programs with the ability to tailor to different reader cohorts and different population presentations are suggested to ameliorate challenges in exposure to a range of cancer cases and improve the interpretation skills of local radiologists. Findings from this review provide a good understanding of the radiologist' performances and their improvement using the education interventions, primarily the BREAST program, which has been deployed in a large range of developing and developed countries in the last decade. Self-testing and immediate feedback loops have been shown to have important implications for benchmarking and improving the diagnostic accuracy in radiology worldwide for better breast cancer control.

Rapid Diagnosis of Ductal Carcinoma In Situ and Breast Cancer Based on Raman Spectroscopy of Serum Combined with Convolutional Neural Network

Ductal carcinoma in situ (DCIS) and breast cancer are common female breast diseases and pose a serious health threat to women. Early diagnosis of breast cancer and DCIS can help to develop targeted treatment plans in time. In this paper, we investigated the feasibility of using Raman spectroscopy combined with convolutional neural network (CNN) to discriminate between healthy volunteers, breast cancer and DCIS patients. Raman spectra were collected from the sera of 241 healthy volunteers, 463 breast cancer and 100 DCIS patients, and a total of 804 spectra were recorded. The pre-processed Raman spectra were used as the input of CNN to establish a model to classify the three different spectra. After using cross-validation to optimize its hyperparameters, the model's final classification performance was assessed using an unknown test set. For comparison with other machine learning algorithms, we additionally built models using support vector machine (SVM), random forest (RF) and k-nearest neighbor (KNN) methods. The final accuracies for CNN, SVM, RF and KNN were 98.76%, 94.63%, 80.99% and 78.93%, respectively. The values for area under curve (AUC) were 0.999, 0.994, 0.931 and 0.900, respectively. Therefore, our study results demonstrate that CNN outperforms three traditional algorithms in terms of classification performance for Raman spectral data and can be a useful auxiliary diagnostic tool of breast cancer and DCIS.

Survival and predictors of breast cancer mortality in South Ethiopia: A retrospective cohort study

BACKGROUND

Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in over 100 countries. In March 2021, the World Health Organization called on the global community to decrease mortality by 2.5% per year. Despite the high burden of the disease, the survival status and the predictors for mortality are not yet fully determined in many countries in Sub-Saharan Africa, including Ethiopia. Here, we report the survival status and predictors of mortality among breast cancer patients in South Ethiopia as crucial baseline data to be used for the design and monitoring of interventions to improve early detection, diagnosis, and treatment capacity.

METHODS

A hospital-based retrospective cohort study was conducted among 302 female breast cancer patients diagnosed from 2013 to 2018 by reviewing their medical records and telephone interviews. The median survival time was estimated using the Kaplan-Meier survival analysis method. A log-rank test was used to compare the observed differences in survival time among different groups. The Cox proportional hazards regression model was used to identify predictors of mortality. Results are presented using the crude and adjusted as hazard ratios along with their corresponding 95% confidence intervals. Sensitivity analysis was performed with the assumption that loss to follow-up patients might die 3 months after the last hospital visit.

RESULTS

The study participants were followed for a total of 4,685.62 person-months. The median survival time was 50.81 months, which declined to 30.57 months in the worst-case analysis. About 83.4% of patients had advanced-stage disease at presentation. The overall survival probability of patients at two and three years was 73.2% and 63.0% respectively. Independent predictors of mortality were: patients residing in rural areas (adjusted hazard ratio = 2.71, 95% CI: 1.44, 5.09), travel time to a health facility ≥7 hours (adjusted hazard ratio = 3.42, 95% CI: 1.05, 11.10), those who presented within 7-23 months after the onset of symptoms (adjusted hazard ratio = 2.63, 95% CI: 1.22, 5.64), those who presented more than 23 months after the onset of symptoms (adjusted hazard ratio = 2.37, 95% CI: 1.00, 5.59), advanced stage at presentation (adjusted hazard ratio = 3.01, 95% CI: 1.05, 8.59), and patients who never received chemotherapy (adjusted hazard ratio = 6.69, 95% CI: 2.20, 20.30).

CONCLUSION

Beyond three years after diagnosis, patients from southern Ethiopia had a survival rate of less than 60% despite treatment at a tertiary health facility. It is imperative to improve the early detection, diagnosis, and treatment capacities for breast cancer patients to prevent premature death in these women.

Health system barriers influencing timely breast cancer diagnosis and treatment among women in low and middle-income Asian countries: evidence from a mixed-methods systematic review

BACKGROUND

Globally, breast cancer is the most common cancer type and the leading cause of cancer mortality among women in developing countries. A high prevalence of late breast cancer diagnosis and treatment has been reported predominantly in Low- and Middle-Income Countries (LMICs), including those in Asia. Thus, this study utilized a mixed-methods systematic review to synthesize the health system barriers influencing timely breast cancer diagnosis and treatment among women in Asian countries.

METHODS

We systematically searched five electronic databases for studies published in English from 2012 to 2022 on health system barriers that influence timely breast cancer diagnosis and treatment among women in Asian countries. The review was conducted per the methodology for systematic reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, while health system barriers were extracted and classified based on the World Health Organization (WHO)'s Health Systems Framework. The mixed-methods appraisal tool was used to assess the methodological quality of the included studies.

RESULTS

Twenty-six studies were included in this review. Fifteen studies were quantitative, nine studies were qualitative, and two studies used a mixed-methods approach. These studies were conducted across ten countries in Asia. This review identified health systems barriers that influence timely breast cancer diagnosis and treatment. The factors were categorized under the following: (1) delivery of health services (2) health workforce (3) financing for health (4) health information system and (5) essential medicines and technology. Delivery of health care (low quality of health care) was the most occurring barrier followed by the health workforce (unavailability of physicians), whilst health information systems were identified as the least barrier.

CONCLUSION

This study concluded that health system factors such as geographical accessibility to treatment, misdiagnosis, and long waiting times at health facilities were major barriers to early breast cancer diagnosis and treatment among Asian women in LMICs. Eliminating these barriers will require deliberate health system strengthening, such as improving training for the health workforce and establishing more healthcare facilities.

Improving equity in access to early diagnosis of cancer in different healthcare systems of Latin America: protocol for the EquityCancer-LA implementation-effectiveness hybrid study

INTRODUCTION

Healthcare fragmentation, a main cause for delay in cancer diagnosis and treatment, contributes to high mortality in Latin America (LA), particularly among disadvantaged populations. This research focuses on integrated care interventions, which have been limitedly implemented in the region. The objective is to evaluate the contextual effectiveness of scaling-up an integrated care intervention to improve early diagnosis of frequent cancers in healthcare networks of Chile, Colombia and Ecuador.

METHODS AND ANALYSIS

This research is two pronged: (A) quasi-experimental design (controlled before and after) with an intervention and a control healthcare network in each LA country, using an implementation-effectiveness hybrid approach to assess the intervention process, effectiveness and costs; and (B) case study design to analyse access to diagnosis of most frequent cancers. Focusing on the most vulnerable socioeconomic population, it develops in four phases: (1) analysis of delays and barriers to early diagnosis (baseline); (2) intervention adaptation and implementation (primary care training, fast-track referral pathway and patient information); (3) intracountry evaluation of intervention and (4) cross-country analysis. Baseline and evaluation studies adopt mixed-methods qualitative (semistructured individual interviews) and quantitative (patient questionnaire survey) methods. For the latter, a sample size of 174 patients with cancer diagnosis per healthcare network and year was calculated to detect a proportions difference of 15%, before and after intervention (α=0.05; β=0.2) in a two-sided test. A participatory approach will be used to tailor the intervention to each context, led by a local steering committee (professionals, managers, policy makers, patients and researchers).

ETHICS AND DISSEMINATION

This study complies with international and national legal stipulations on ethics. It was approved by each country's ethical committee and informed consent will be obtained from participants. Besides the coproduction of knowledge with key stakeholders, it will be disseminated through strategies such as policy briefs, workshops, e-tools and scientific papers.

Understanding system barriers and facilitators in transnational clinical cancer research: The value of rapid and multimodal ethnographic inquiry

INTRODUCTION

In middle and low resource countries worldwide, up to 70% of breast cancer cases are diagnosed as locally advanced (stages IIB-IIIC). Delays in referral from primary to specialty care have been shown to prolong routes to diagnosis and may be associated with higher burdens of advanced disease, but specific clinical and organizational barriers are not well understood.

METHODS

This article reports on the use of rapid ethnographic research (RER) within a largescale clinical trial for locally advanced breast cancer (LABC) in India, Mexico, South Africa, and the US. Our purpose is twofold. First, we demonstrate the value of ethnography as a mode of evaluative listening: appraising the perspectives of diverse patients and clinicians regarding prolonged routes to LABC diagnosis and treatment. Second, we show the value of ethnography as a compass for navigating among discrepant clinical research styles, IRB protocols, and institutional norms and practices. We discuss advantages and limits involved in each use of RER.

RESULTS

On the one hand, ethnographic interviews carried out before and during the clinical trial enabled more regular communication among investigators and research sites. On the other hand, the logistics of doing the trial placed limits on the extent and duration of inductive, immersive inquiry characteristic of traditional fieldwork. As a partial solution to this problem, we developed a multimodal ethnographic research (MER) approach, an augmentation of video-chat, phone, text, and email carried out with, and built upon the initial connections established in, the in-person fieldwork. This style has its limits; but it did allow us to materially improve the ways in which the medical research proceeded.

DISCUSSION

In conclusion, we highlight the value of not deferring to a presumed incommensurability of ethnographic fieldwork and clinical trialwork while still being appropriately responsive to moments when the two approaches should be kept apart.

Over-the-Counter Breast Cancer Classification Using Machine Learning and Patient Registration Records

This study aims to determine the feasibility of machine learning (ML) and patient registration record to be utilised to develop an over-the-counter (OTC) screening model for breast cancer risk estimation. Data were retrospectively collected from women who came to the Hospital Universiti Sains Malaysia, Malaysia for breast-related problems. Eight ML models were used: k-nearest neighbour (kNN), elastic-net logistic regression, multivariate adaptive regression splines, artificial neural network, partial least square, random forest, support vector machine (SVM), and extreme gradient boosting. Features utilised for the development of the screening models were limited to information in the patient registration form. The final model was evaluated in terms of performance across a mammographic density. Additionally, the feature importance of the final model was assessed using the model agnostic approach. kNN had the highest Youden J index, precision, and PR-AUC, while SVM had the highest F2 score. The kNN model was selected as the final model. The model had a balanced performance in terms of sensitivity, specificity, and PR-AUC across the mammographic density groups. The most important feature was the age at examination. In conclusion, this study showed that ML and patient registration information are feasible to be used as the OTC screening model for breast cancer.

Inequality in mammography uptake: results from recruitment phase of first cohort study among Iranian Kurdish population

Background

Breast cancer is the most common malignant disease in women and is the leading cause of cancer deaths among women. Mammography is the best and the most available diagnostic method for breast cancer early detection. The aim of this study was to investigate the prevalence and inequality in the mammography uptake among Kurdish women in the west of Iran.

Methods

This cohort study was conducted using data extracted from the Ravansar Non-communicable Cohort Study among Kurdish women in the west of Iran from 2014 to 2018. The sample included 5289 women aged 35–65 years. The relative and generalized (absolute) concentration index (RC and GC, respectively) was used to quantify and decompose socioeconomic inequalities in mammography uptake.

Results

Overall concentration index for mammography was 0.2107, indicating that the mammography uptake concentration was greater in women with a higher socioeconomic status (SES). The predictor variables accounted for 44.6% of the inequality in the mammography uptake. Higher SES, living in urban areas, and age group of 51–55 years old increased the chance of having a mammogram. Available evidence supports the inequality of mammography uptake in favor of women with higher SES.

Conclusions

Cost-free screening services for low SES women, and the development of breast cancer prevention campaigns focusing on disadvantaged women could have an important role in mammography uptake and in the reduction of inequalities.

Initiatives to reduce the waiting time to initiate oncological treatment: a scoping literature review

Objective

To identify the managerial actions proposed and employed to reduce the waiting time to initiate oncological treatments in the public health system and its application in Latin America.

Method

We searched seven databases in December 2020. Search terms were conceptualized into three groups: waiting time, cancer, and terms related to public sector. The eligibility criteria included theoretical or empirical academic articles written in English, Spanish, or Portuguese, that focused on managerial solutions to face oncological healthcare queues' dilemma.

Results

The search returned 1 255 articles, and 20 were selected and analysed in this review. Results show that most of the proposals are related to the process and people dimensions. The actions related to the process dimension were mainly associated with programming new treatment pathways and integrating cancer systems. People's dimension initiatives referred mostly to task forces and groups of specialists. Some initiatives were related to implementing technological solutions and the technology dimension, mainly concerning radiotherapy devices' acquisition.

Conclusion

Few studies focus on analysing actions to minimize waiting time to initiate oncological treatments. The prevalence of conceptual and illustrative case studies indicates the lack of research maturity on this theme. Future studies should focus on setting the field's theoretical foundations, considering the existing paradigms, or developing new ones. There is a need for empirical studies applying a multidisciplinary approach to face the oncological treatment waiting time challenge and proposing new and innovative initiatives.

No sonographer, no radiologist: Assessing accuracy of artificial intelligence on breast ultrasound volume sweep imaging scans

Breast ultrasound provides a first-line evaluation for breast masses, but the majority of the world lacks access to any form of diagnostic imaging. In this pilot study, we assessed the combination of artificial intelligence (Samsung S-Detect for Breast) with volume sweep imaging (VSI) ultrasound scans to evaluate the possibility of inexpensive, fully automated breast ultrasound acquisition and preliminary interpretation without an experienced sonographer or radiologist. This study was conducted using examinations from a curated data set from a previously published clinical study of breast VSI. Examinations in this data set were obtained by medical students without prior ultrasound experience who performed VSI using a portable Butterfly iQ ultrasound probe. Standard of care ultrasound exams were performed concurrently by an experienced sonographer using a high-end ultrasound machine. Expert-selected VSI images and standard of care images were input into S-Detect which output mass features and classification as "possibly benign" and "possibly malignant." Subsequent comparison of the S-Detect VSI report was made between 1) the standard of care ultrasound report by an expert radiologist, 2) the standard of care ultrasound S-Detect report, 3) the VSI report by an expert radiologist, and 4) the pathological diagnosis. There were 115 masses analyzed by S-Detect from the curated data set. There was substantial agreement of the S-Detect interpretation of VSI among cancers, cysts, fibroadenomas, and lipomas to the expert standard of care ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), the standard of care ultrasound S-Detect interpretation (Cohen's κ = 0.79 (0.65-0.94 95% CI), p<0.0001), the expert VSI ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), and the pathological diagnosis (Cohen's κ = 0.80 (0.64-0.95 95% CI), p<0.0001). All pathologically proven cancers (n = 20) were designated as "possibly malignant" by S-Detect with a sensitivity of 100% and specificity of 86%. Integration of artificial intelligence and VSI could allow both acquisition and interpretation of ultrasound images without a sonographer and radiologist. This approach holds potential for increasing access to ultrasound imaging and therefore improving outcomes related to breast cancer in low- and middle- income countries.

Current and future applications of biomarkers in samples collected through minimally invasive methods for cancer medicine and population-based research

Despite advances in cancer medicine and research, invasive and potentially risky procedures such as biopsies, venous blood tests, imaging, colonoscopy, and pap smear tests are still primarily used for screening, staging, and assessing response to therapy. The development and interdisciplinary use of biomarkers from urine, feces, saliva, scent, and capillary blood collected with minimally invasive methods represents a potential opportunity for integration with biomarker analysis for cancers, both in clinical practice (e.g., in screening, treatment, and disease monitoring, and improved quality of life for patients) and population-based research (e.g., in epidemiology/public health, studies of social and environmental determinants, and evolutionary medicine). In this article, we review the scientific rationale, benefits, challenges, and potential opportunities for measuring cancer-related biomarkers in samples collected through minimally invasive methods.

The patient, diagnostic, and treatment intervals in adult patients with cancer from high- and lower-income countries: A systematic review and meta-analysis

BACKGROUND

Longer time intervals to diagnosis and treatment are associated with worse survival for various types of cancer. The patient, diagnostic, and treatment intervals are considered core indicators for early diagnosis and treatment. This review estimated the median duration of these intervals for various types of cancer and compared it across high- and lower-income countries.

METHODS AND FINDINGS

We conducted a systematic review with meta-analysis (prospectively registered protocol CRD42020200752). Three databases (MEDLINE, Embase, and Web of Science) and information sources including grey literature (Google Scholar, OpenGrey, EThOS, ProQuest Dissertations & Theses) were searched. Eligible articles were published during 2009 to 2022 and reported the duration of the following intervals in adult patients diagnosed with primary symptomatic cancer: patient interval (from the onset of symptoms to first presentation to a healthcare professional), diagnostic interval (from first presentation to diagnosis), and treatment interval (from diagnosis to treatment start). Interval duration was recorded in days and study medians were combined in a pooled estimate with 95% confidence intervals (CIs). The methodological quality of studies was assessed using the Aarhus checklist. A total of 410 articles representing 68 countries and reporting on 5,537,594 patients were included. The majority of articles reported data from high-income countries (n = 294, 72%), with 116 (28%) reporting data from lower-income countries. Pooled meta-analytic estimates were possible for 38 types of cancer. The majority of studies were conducted on patients with breast, lung, colorectal, and head and neck cancer. In studies from high-income countries, pooled median patient intervals generally did not exceed a month for most cancers. However, in studies from lower-income countries, patient intervals were consistently 1.5 to 4 times longer for almost all cancer sites. The majority of data on the diagnostic and treatment intervals came from high-income countries. Across both high- and lower-income countries, the longest diagnostic intervals were observed for hematological (71 days [95% CI 52 to 85], e.g., myelomas (83 days [47 to 145])), genitourinary (58 days [50 to 77], e.g., prostate (85 days [57 to 112])), and digestive/gastrointestinal (57 days [45 to 67], e.g., colorectal (63 days [48 to 78])) cancers. Similarly, the longest treatment intervals were observed for genitourinary (57 days [45 to 66], e.g., prostate (75 days [61 to 87])) and gynecological (46 days [38 to 54], e.g., cervical (69 days [45 to 108]) cancers. In studies from high-income countries, the implementation of cancer-directed policies was associated with shorter patient and diagnostic intervals for several cancers. This review included a large number of studies conducted worldwide but is limited by survivor bias and the inherent complexity and many possible biases in the measurement of time points and intervals in the cancer treatment pathway. In addition, the subintervals that compose the diagnostic interval (e.g., primary care interval, referral to diagnosis interval) were not considered.

CONCLUSIONS

These results identify the cancers where diagnosis and treatment initiation may take the longest and reveal the extent of global disparities in early diagnosis and treatment. Efforts should be made to reduce help-seeking times for cancer symptoms in lower-income countries. Estimates for the diagnostic and treatment intervals came mostly from high-income countries that have powerful health information systems in place to record such information.

The effect of the number of biopsies on the delay in the time from the delivery of mammography results to breast cancer histopathological diagnosis

PURPOSE

The delay in the time (in calendar days) from the delivery of mammography results to histopathological breast cancer (BC) diagnosis could be associated with more advanced clinical stages, a worse prognosis and higher mortality. Therefore, we assessed the association between the number of biopsies and the delay in the time (in calendar days) from the delivery of mammography results to histopathological BC.

METHODS

A survey was performed on 563 women aged between 35 and 69 years with histopathologically confirmed BC who attended 11 Mexican hospitals.

RESULTS

After adjusting for potential confounders, the odds of having a delay in the time (in calendar days) from the delivery of mammography results to histopathological BC diagnosis (≥ 60 days) among women with ≥ 3 biopsies were 2.99 times the odds of those who had only one biopsy (95% CI 1.35, 6.63).

CONCLUSION

The number of biopsies should be considered as a predictor of the time delay between the delivery of the mammography result and the diagnostic result.

Does Breast-Conserving Surgery with Radiotherapy have a Better Survival than Mastectomy? A Meta-Analysis of More than 1,500,000 Patients

BACKGROUND

There have been conflicting studies reporting on survival advantages between breast-conserving surgery with radiotherapy (BCS) in comparison with mastectomy. Our aim was to compare the efficacy of BCS and mastectomy in terms of overall survival (OS) comparing all past published studies.

METHODS

We performed a comprehensive review of literature through October 2021 in PubMed, Scopus, and EMBASE. The studies included were randomized controlled trials (RCTs) and cohorts that compare BCS versus mastectomy. We excluded studies that included male sex, stage 0, distant metastasis at diagnosis, bilateral synchronous cancer, neoadjuvant radiation/chemotherapy, and articles with incomplete data. We performed a meta-analysis following the random-effect model with the inverse variance method.

RESULTS

From 18,997 publications, a total of 30 studies were included in the final analysis: 6 studies were randomized trials, and 24 were retrospective cohorts. A total of 1,802,128 patients with a follow-up ranging from 4 to 20 years were included, and 1,075,563 and 744,565 underwent BCS and mastectomy, respectively. Among the population, BCS is associated with improved OS compared with mastectomy [relative risk (RR) 0.64, 95% confidence interval (CI) 0.55-0.74]. This effect was similar when analysis was performed in cohorts and multi-institutional databases (RR 0.57, 95% CI 0.49-0.67). Furthermore, the benefit of BCS was stronger in patients who had less than 10 years of follow-up (RR 0.54, 95% CI 0.46-0.64).

CONCLUSIONS

Patients who underwent BCS had better OS compared with mastectomy. Such results depicting survival advantage, especially using such a large sample of patients, may need to be included in the shared surgical decision making when discussing breast cancer treatment with patients.

Circulating Carnitine Levels and Breast Cancer: A Matched Retrospective Case-Control Study

Introduction

Epidemiological studies investigating the association between carnitine and breast cancer are scarce.

Materials and Methods

This 1:1 age-matched retrospective case-control study identified 991 female breast cancer cases and 991 female controls without breast cancer using pathological testing. We used targeted metabolomics technology to measure 16 types of whole blood carnitine compounds, such as free carnitine (C0) and octadecanoylcarnitine (C18).

Results

The average age for cases and controls was approximately 50 ± 8.7 years. After adjusting for covariates, each standard deviation (SD) increase in malonylcarnitine (C3DC; OR 0.91; 95% CI 0.83-1.00), decenoylcarnitine (C10:1; OR 0.87; 95% CI 0.79-0.96), and decadienoylcarnitine (C10:2; OR 0.90; 95% CI 0.82-0.99) level was associated with decreased odds of breast cancer. However, higher butyrylcarnitine (C4) levels were associated with increased odds of breast cancer (OR 1.12; 95% CI 1.02-1.23). No statistically significant relationship was noted between other carnitine compounds and breast cancer. The false discovery rates for C3DC, C4, C10:1 and C10:2 were 0.172, 0.120, 0.064 and 0.139, respectively.

Conclusions

Higher levels of C3DC, C10:1, and C10:2 were protective factors for breast cancer, whereas increased C4 levels were a risk factor for the disease.

Public Policies and Programs for the Prevention and Control of Breast Cancer in Latin American Women: Scoping Review

BACKGROUND

Breast cancer has positioned itself worldwide as one of the main public health problems, especially in Latin America. In some countries, several programs for the prevention and control of breast cancer in women have been developed and implemented on a permanent basis, but there are no public reports on the policies that originated such programs.

OBJECTIVE

A scoping review of scientific publications that identify the type, extent, and scope of policies and programs for the prevention and control of breast cancer in Latin American women was performed, and the main results were presented in this paper.

METHODS

This scoping review was carried out according to the method by Arksey and O'Malley based on 3 fundamental questions about breast cancer prevention and control policies in Latin America: their type, extent and scope, and reference framework. The search period was from 2000 to 2019, and the search was carried out in the following databases: MEDLINE (PubMed), MEDLINE (EbscoHost), CINAHL (EbscoHost), Academic Search Complete (EbscoHost), ISI Web of Science (Science Citation Index), and Scopus in English, Spanish, and Portuguese, and Scielo, Cochrane, and MEDES-MEDicina in Spanish and Portuguese. Of the 743 studies found, 20 (2.7%) were selected, which were analyzed using descriptive statistics and qualitative content analysis.

RESULTS

The selected studies identified several Latin American countries that have generated policies and programs to prevent and control breast cancer in women, focusing mainly on risk communication, prevention and timely detection, effective access to health services, improvement of the screening process, and evaluation of screening programs. Evaluation criteria and greater participation of civil society in policy design and program execution are still lacking. This could undoubtedly help eliminate existing barriers to effective action.

CONCLUSIONS

Although several Latin American countries have generated public policies and action programs for the prevention and control of breast cancer, a pending issue is the evaluation of the results to analyze the effectiveness and impact of their implementation given the magnitude of the public health problem it represents and because women and civil society play an important role in its prevention and control.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/12624.

Expansion of the quality of care index on breast cancer and its risk factors using the global burden of disease study 2019

BACKGROUND

Breast cancer (BC), as the top neoplasm in prevalence and mortality in females, imposes a heavy burden on health systems. Evaluation of quality of care and management of patients with BC and its responsible risk factors was the aim of this study.

METHODS

We retrieved epidemiologic data of BC from the Global Burden of Disease (GBD) 1990-2019 database. Epidemiology and burden of BC and its risk factors were explored besides the Quality of Care Index (QCI) introduced before, to assess the provided care for patients with BC in various scales. Provided care for BC risk factors was investigated by their impact on years of life lost and years lived with disability by a novel risk factor quality index (rQCI). We used the socio-demographic index (SDI) to compare results in different socio-economic levels.

RESULTS

In 2019, 1,977,212 (95% UI: 1,807,615-2,145,215) new cases of BC in females and 25,143 (22,231-27,786) in males was diagnosed and this major cancer caused 688,562 (635,323-739,571) deaths in females and 12,098 (10,693-13,322) deaths in males, globally. The all-age number of deaths and disability-adjusted life years attributed to BC risk factors in females had an increasing pattern, with a more prominent pattern in metabolic risks. The global estimated age-standardized QCI for BC in females in 2019 was 78.7. The estimated QCI was highest in high SDI regions (95.7). The top countries with the highest calculated QCI in 2019 were Iceland (100), Japan (99.8), and Finland (98.8), and the bottom countries were Mozambique (16.0), Somalia (8.2), and Central African Republic (5.3). The global estimated age-standardized rQCI for females was 82.2 in 2019.

CONCLUSION

In spite of the partially restrained burden of BC in recent years, the attributable burden to risk factors has increased remarkably. Countries with higher SDI provided better care regarding both the condition and its responsible risk factors.

Health system costs of a breast cancer early diagnosis programme in a rural district of Rwanda: a retrospective, cross-sectional economic analysis

OBJECTIVES

This study aimed to quantify the health system cost of the first 2 years of a Breast Cancer Early Detection (BCED) programme in a rural district in Rwanda. We also aimed to estimate the cost of implementing the programme in other districts with different referral pathways and identify opportunities for enhanced cost efficiency.

DESIGN

Retrospective, cross-sectional analysis using time-driven activity-based costing, based on timed patient clinical encounters, retrospective patient data and unit costs of resources abstracted from administrative and finance records.

SETTING

The BCED programme focused on timely evaluation of individuals with breast symptoms. The study evaluated the health system cost of the BCED programme at seven health centres (HCs) in Burera district and Butaro Cancer Centre of Excellence (BCCOE) at Butaro District Hospital.

OUTCOME MEASURES

Health system costs per patient visit and cost per cancer diagnosed were quantified. Total start-up and recurring operational costs were also estimated, as well as health system costs of different scale-up adaptations in other districts.

RESULTS

One-time start-up costswere US$36 917, recurring operational costswere US$67 711 and clinical costswere US$14 824 over 2 years. Clinical breast examinations (CBE) at HCs cost US$3.27/visit. At BCCOE, CBE-only visits cost US$13.47/visit, CBE/ultrasound US$14.79/visit and CBE/ultrasound/biopsy/pathology US$147.81/visit. Overall, clinical cost per breast cancer diagnosed was US$1482. Clinicalcost drivers were personnel at HCs (55%) and biopsy/pathology supplies at BCCOE (46%). In other districts, patients experience a longer breast evaluation pathway, adding about US$14.00/patient; this could be decreased if ultrasound services were decentralised.

CONCLUSION

Clinical costs associated with BCED services at HCs were modest, similar to other general outpatient services. The BCED programme's start-up and operational costs were high but could be reduced by using local trainers and virtual mentorship. In other districts, decentralising ultrasound and/or biopsies to district hospitals could reduce costs.

Presentation, Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country

AIMS

Delays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation.

MATERIALS AND METHODS

We interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance.

RESULTS

Nearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9-66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4-40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8-15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2-9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8-3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1-2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6-11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2-0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3-0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7-32.7) reduced the likelihood of treatment delays.

CONCLUSIONS

Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.

Stage at Diagnosis and Patient Delay among Breast Cancer Women in Kabul, Afghanistan

Background: Breast cancer is the commonest cause of mortality among women. According to WHO in 2012, about 7400 women died because of cancers in Afghanistan.   Aim: To obtain information about clinical stages of breast cancer of women at the time of diagnosis in Kabul, Afghanistan.   Patient and Method: This was a cross-sectional study of 240 women diagnosed with breast cancer from March 2016 to March 2019. The diagnosis of breast cancer was made by the surgeon on the basis of physical examination and Biopsy/Pathological reports. Clinical staging of the tumor was recorded according to the tumor, nodal, and metastasis (TNM) classification. The gap between knowing the problem and consulting a physician (Patient delay) was categorized: less than 3 months, 3-6 months and more than 6 months. Results: The mean age of patients was 49.31 years (SD ± 11.80) ranging from 18 to 76 years. The Patient delay was more than 6 months (65%). Infiltrating ductal carcinoma was the commonest morphological type (76.7%). Breast cancer in left breast of patients was 52.1%. Stage II was higher in left and stage III in right breast. The majority of patients were in stage II & III at the time of diagnosis. All stages were frequent in fourth decades of age group. The association between the clinical stages of breast cancer at the time of diagnosis, the age and breast R/L involvement of the patients was significant (P<0.001). The association between clinical stage and marital status was not significant (P<0.953). Conclusion: Late referrals, diagnosis delay and advanced stages of breast cancer are still a serious problem in Afghanistan. Cancer in right breast should be given more attention because higher stages of the disease are expected. Awareness and social education is great need.

Time to diagnosis and treatment for breast cancer in public and private health services

OBJECTIVE

To analyze the time to diagnosis and treatment for breast cancer and the associated factors, according to the type of care (public vs. private).

METHODOLOGY

Retrospective cohort study with 477 women diagnosed with breast cancer between 2014 and 2016. Data were collected in an oncology service in a municipality in Minas Gerais, in the 2018-2019 period. Analyzes were performed using the Kaplan-Meier method and Cox's proportional regression model.

RESULTS

The median time to diagnosis was 70 days, being shorter for women who discovered the disease through screening tests and who were diagnosed in early stages of the disease. The median time for treatment was 32 days, which was shorter for women assisted by private health service, with a high level of education and who were diagnosed in early stages.

CONCLUSIONS

Private care and facilitators of access to breast cancer care were associated with shorter waiting times.

Understanding linkage to biopsy and treatment for breast cancer after a high-risk telemammography result in Peru: a mixed-methods study

OBJECTIVES

This mixed-method study aimed to understand the effectiveness of linkage to biopsy and treatment in women with a high-risk mammography result (Breast Imaging Reporting and Data System, BI-RADS 4 and 5) in the national telemammography programme and to explore women's experiences during this process.

SETTING

Quantitative component: we collected and linked health data from the telemammography reading centre, the national public health insurance, the national centre for disease control and the national referral cancer centre. Qualitative component: we interviewed participants from different regions of the country representing diverse social and geographical backgrounds.

PARTICIPANTS

Quantitative: women who underwent telemammography between July 2017 and September 2018 and had high-risk results (BI-RADS 4-5) were collected. Qualitative: women with a high-risk telemammography result, healthcare providers and administrators.

OUTCOMES MEASURES

Quantitative: we determined biopsy and treatment linkage rates and delays. Qualitative: we explored barriers and facilitators for obtaining a biopsy and initiating treatment.

RESULTS

Of 126 women with high-risk results, 48.4% had documentation of biopsy and 37.5% experienced a delay of >45 days to biopsy. Of 51 women diagnosed with breast cancer, 86.4% had evidence of treatment initiation, but 69.2% initiated treatment >45 days after biopsy. Travelling to major cities for care, administrative factors and breast cancer misconceptions, among other factors, impeded timely, continuous care for breast cancer. A multidisciplinary and culturally tailored patient education facilitated understanding of the disease and prompt decision making about subsequent medical care.

CONCLUSIONS

Strengthened breast cancer care capacity outside the capital city, standardised referral pathways, ensured financial support for travel expenses, and enhanced patient education are required to secure linkage to the breast cancer care continuum. Robust information systems are needed to track patients and to evaluate the programme's performance.

Breast Cancer in Italy: Stage and Region Distribution

Purpose

Describe breast cancer in Italy by age, geographical area, stage and sites of metastases. In addition, incident and prevalent cases by region are provided.

Patients and Methods

This population-based study included all female patients with histologically confirmed breast cancer diagnosed in Italy between 2013 and 2019 in the eight participating Cancer Registries. Cases were described by geographic area (north, center, south), age group (<50, 50–69 and 70+) and site of metastases. In addition, the study also provided an estimate of the cases of metastatic breast cancer per single region.

Results

Of the total 5731 cases, the number of unknown stage cases (eliminated from our analyses) was 545 (10.5% of cases); therefore, the study was conducted on 5186 cases. Overall, 333 (6.5%) of tumors were metastatic at diagnosis but the distribution by geographical area was different: 5.1% in the north, 7.4% in the center and 7.8% in the south. Related to age, 5.6% were diagnosed before the age of 50 and 5.6% within the screening target group (50–69 years), while in elderly women the percentage rose to 8.1%. As regards the site of the metastases, 27.1% developed metastasis to the bone, 12.4% to the liver, 8.6% to the lung and 2.6% to the brain; in 34.9%, multiple sites were already present at the beginning of the cancer. Overall, 3520 cases of incident mBC are estimated in Italia every year (520 in Lombardy in northern Italy, 350 in Lazio in the center, followed by 330 in Campania in the south), and finally they are out of 52,000 prevalent cases.

Conclusion

A greater possibility of treating and living with the disease for a long time now requires careful monitoring of these tumors.

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.

Breast Cancer Care Timeliness Framework: A Quality Framework for Cancer Control

PURPOSE

The aim of this study is to determine the pathway that women follow for Breast Cancer Care (BCC) and the time intervals from symptom discovery to treatment initiation and to develop a quality matrix framework.

METHODS

A retrospective cohort study was conducted at six tertiary centers in Malaysia. All women with newly diagnosed breast cancer were interviewed, and a medical records review was conducted using a structured questionnaire. The BCC timeliness framework showed that the total time between a woman discovering their first breast changes and the date of initial treatment was divided into three distinct intervals: presentation interval, diagnostic interval, and treatment interval. Four diagnosis subintervals, referral, biopsy, report, and diagnosis resolution intervals, were also looked into.

RESULTS

The BCC timeliness framework was used to capture important time points. The median total time, presentation interval, diagnostic interval, and treatment interval were 4.9 months (range, 1 month to 10 years), 2.4 months (range, 7 days to 10 years), 26 days (range, 4 days to 9.3 months), and 21 days (range, 1 day to 7.2 months), respectively. Meanwhile, the median time for the diagnosis subinterval of referral, biopsy, report, and diagnosis resolution was 8 days (range, 0 day to 8 months), 0 day (range, 0 day to 20 days), 7 days (range, 3 days to 3.5 months), and 4 days (range, 1 day to 1.8 months), respectively.

CONCLUSION

The BCC timeliness framework is based on the current sequenced trajectory of the BCC journey. Clarity in the measurement of timeliness provides a standardized language for monitoring and outcome research. It can serve as a quality indicator for community and hospital-based breast cancer programs.

Global challenges in breast cancer detection and treatment

Breast cancer represents an urgent global priority. While this is a universal issue, and as the burden of the disease is increasing globally, current estimates indicate that in the next couple of decades, much of the incidence and mortality related to breast cancer will be seen in underserved populations. The fragile and ill-prepared healthcare systems in low- and middle-income countries (LMIC) need to address this challenge and find solutions with their limited resources. Significant disparities can be identified in stage at presentation as the ability to detect the disease in earlier stages is compromised in these scenarios leading to worse outcomes associated to late diagnoses. Furthermore, access to healthcare in general and to basic surgical, radiotherapy and systemic care is suboptimal additionally limiting treatment results. With a small portion of their budget allocated to healthcare, LMIC need to make the most of their resources prioritizing cost-effective strategies that could offer the best possible results. Countries that invest in women's health do develop into healthier, more educated, and importantly, more productive societies with benefits seen across generations. Finally, recognition of inequities should stimulate a concerted effort engaging all involved stakeholders to find context-adapted solutions to improve healthcare outcomes.

Challenges and opportunities in the establishment of a hereditary breast cancer clinic at an academic medical center in a low-middle income country

It is now standard of care to offer genetic testing to patients at risk of hereditary breast cancer and make management decisions based on these results. Although great strides have been made in ensuring access to genetic testing and genetic counseling by establishing hereditary breast cancer clinics in well-resourced countries, these are essentially non-existent in low-middle income countries like Pakistan. We established a hereditary breast cancer clinic involving a multidisciplinary team, including a medical geneticist and a genetic counselor. Our efforts were based on consensus guidelines and included educating medical providers about the importance of genetic testing in breast cancer care and the mandatory presence of a genetics team member at the weekly Breast Tumor Board meeting. This resulted in an increase in the number of referrals of breast cancer patients for genetic testing. In this report, we describe the challenges we faced in setting up such a system in Pakistan and the measures to overcome them. There is a need to establish such hereditary breast cancer clinics, which can also be replicated at other centers in low-resource settings, to improve standardized assessment and management of the patients with hereditary breast cancer according to consensus guidelines.

Tempo para diagnóstico e tratamento do câncer de mama na assistência pública e privada

RESUMO Objetivo: Analisar o tempo para o diagnóstico e tratamento do câncer de mama e os fatores associados, segundo o tipo de assistência (pública vs. privada). Métodos: Coorte retrospectiva com 477 mulheres diagnosticadas com câncer de mama entre 2014-2016. Os dados foram coletados em um serviço de oncologia de um município de Minas Gerais, entre 2018-2019. As análises foram realizadas pelo método de Kaplan-Meier e pelo modelo de regressão de Cox. Resultados: O tempo mediano para diagnóstico foi de 70 dias, sendo menor para aquelas que descobriram a doença por exames de rastreamento e diagnosticadas em estádios iniciais. O tempo mediano para o tratamento foi de 32 dias, sendo menor para as mulheres assistidas pela rede privada, com alta escolaridade e diagnosticadas em estádios iniciais. Conclusões: Assistência na rede privada e facilitadores do acesso ao cuidado do câncer de mama associaram-se a menores tempos de espera.

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.

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.

Health-Related Suffering and Palliative Care in Breast Cancer

Purpose of Review

Breast cancer continues to be the most frequently diagnosed cancer in women and the leading cause of cancer death worldwide. By the suffering that it causes in various domains of life, breast cancer seriously impacts the quality of life of affected individuals and causes a major burden of suffering in the community. The objectives of the review were to understand the health-related suffering in patients with breast cancer and to identify the scope of palliative care in improving the quality of life of patients with breast cancer.

Recent Findings

Breast cancer causes suffering in physical, psychological, social, financial, and spiritual domains of the lives of the patient and family. Management of breast cancer with surgery, chemotherapy, and radiation could have adverse effects, such as pain, nausea and vomiting, fatigue, shortness of breath, depression, and constipation. Both cancer and its treatment can impact the psychosocial and spiritual well-being of the patient and family members. Integrating palliative care into existing breast cancer treatment programs seems to be the best approach to diminish these sufferings.

Summary

In addition to pain and other physical symptoms, breast cancer can cause major psychological, social, and spiritual suffering. In the context of developing countries, out-of-pocket expenditure can cause major financial destruction which can impact generations. Integration of palliative care to breast cancer treatment is essential.

Cancer control in Latin America and the Caribbean: recent advances and opportunities to move forward

The increasing burden of cancer represents a substantial problem for Latin America and the Caribbean. Two Lancet Oncology Commissions in 2013 and 2015 highlighted potential interventions that could advance cancer care in the region by overcoming existing challenges. Areas requiring improvement included insufficient investment in cancer control, non-universal health coverage, fragmented health systems, inequitable concentration of cancer services, inadequate registries, delays in diagnosis or treatment initiation, and insufficient palliative services. Progress has been made in key areas but remains uneven across the region. An unforeseen challenge, the COVID-19 pandemic, strained all resources, and its negative effect on cancer control is expected to continue for years. In this Series paper, we summarise progress in several aspects of cancer control since 2015, and identify persistent barriers requiring commitment of additional resources to reduce the cancer burden in Latin America and the Caribbean.