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

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.

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.

Delay in the diagnosis and treatment of breast cancer in Vietnam

BACKGROUND

Delays in diagnosis and treatment from first noticeable breast cancer symptoms are associated with poor outcomes. Understanding the reasons and barriers for patients' delay in seeking medical care is critical to mitigating the problem.

METHODS

In-person surveys were conducted among 462 women, aged 18-79, with incident breast cancer cases, recruited from two cancer hospitals in North Vietnam. Delay, defined as the time interval between symptom recognition to the diagnosis and initiation of treatment equal to or exceeding 3 months, was categorized as follows: no delay (<3 months), moderate delay (3-8 months), and serious delay (≥9 months). Multivariable multinomial logistic regression was applied in data analyses.

RESULTS

Over one-quarter patients (31.5%) experienced moderate delays, and close to one-fifth (17.5%) experienced serious delays. Adjusted odds ratios and 95% confidence intervals for moderate and serious delays were 5.60 (3.00-10.47) and 4.25 (2.05-8.85) for financial and physical barriers, respectively. Moderate delay was positively associated with psychological barriers (5.55 [1.75-17.57]) and lack of proper knowledge (3.15 [1.47-6.74]). The associations of barriers with delays in diagnosis and treatment appeared stronger among women living in rural areas. A lack of proper knowledge was significantly associated with delay among young women (<45 years old) and those with high incomes, while psychological barriers were significantly associated with delay among older women (≥45 years old).

CONCLUSION

Delays in diagnosis and treatment are common among Vietnamese breast cancer patients and are affected by several noted barriers. Proper policy needs to be developed to address this public health issue.

Determinants of delay from cancer diagnosis to treatment initiation in a cohort of brazilian women with breast cancer

This objective this study was to identify the time interval between breast cancer (BC) diagnosis and treatment initiation and delay-associated factors. This is a prospective cohort study that followed breast cancer patients, enrolled and treated at the cancer center in Rio de Janeiro (RJ) - Brazil, from October 02, 2014 to April 30, 2015. Participants were interviewed at the first consultation. Treatment-related information was collected six months after recruitment. The median and interquartile range (IQR) were calculated. The interval between breast cancer diagnosis and treatment initiation of more than 60 days was considered the delay, according to the maximum term determined by Brazilian law. The association between independent variables and the outcome was performed using the crude odds ratios (OR). Variables presenting p < .20 in the univariate analysis were included in the multiple logistic regression model by the stepwise forward method, and those with p < .05 were retained in the final model. A total of 470 patients were included in the study. The median time was of 127 days (IQR: 85- 174). Delay was observed in 89.1% of the cases. After adjustment, the variables associated with delay were age ≥ 60 years (OR: 2.48; 95% CI 1.22-5.06), initial clinical staging (<2B) (OR: 2.01; 95% CI 1.05-3.86) and residence outside the city of Rio de Janeiro (OR: 2.75; 95% CI 1.38-5.51). Delays in starting treatment were associated with sociodemographic and clinical factors. Improving patient quality of care and restructuring the health service can minimise delays.

Factors affecting delay in diagnosis of colorectal cancer: A cross-sectional study from a tertiary care hospital of Karachi, Pakistan

BACKGROUND

Colorectal cancer (CRC) incidence is increasing in our region. There is no specific CRC control programme or national cancer registry in Pakistan. Previously, no data have been published on presentation delay and diagnosis delay of CRC in our region. This study is conducted to determine the factors affecting delay in presentation and diagnosis and to provide baseline information to launch a CRC control programme. The primary objective is to determine factors causing delay in diagnosis of CRC. The secondary objective is to evaluate the relationship between tumour site and stage of CRC with presenting symptoms and symptom duration.

METHODS

This project is a prospective cross-sectional study on 113 biopsy-proven CRC patients admitted to the surgical ward of Civil Hospital Karachi.

RESULTS

The total number of participants was 113. Presentation delay was observed in 83.2% of patients. The main reasons for a reported delay in the presentation were lack of patients' knowledge that these symptoms may be cancer (60.4%), the wrong diagnosis by the primary physician (34.6%) or the patient did not want to visit the doctor (0.04%). Most tumours (95%) originated from the sigmoid and rectum; 44.2% and 38.9% of the patients were diagnosed at Stages 3 and 4, respectively.

CONCLUSIONS

This study revealed that CRC patients in Pakistan are facing delays in presentation and diagnosis. This is the reason behind diagnosis at the advanced stage with a poor prognosis. On the basis of this study findings, CRC control programme should be introduced to detect CRC at an early stage.

What to Do for Increasing Cancer Burden on the African Continent? Accelerating Public Health Diagnostics Innovation for Prevention and Early Intervention on Cancers

No other place illustrates the increasing burden of cancer than in Africa and in particular, sub-Saharan Africa. Many of the individuals to be diagnosed with cancer will be in low-resource settings in the future due to, for example, an increase in populations and aging, and high co-morbidity with infections with viruses such as human immunodeficiency virus (HIV) and human papillomavirus (HPV), as well as the presence of infectious agents linked to cancer development. Due to lack of prevention and diagnostic innovation, patients present with advanced cancers, leading to poor survival and increased mortality. HIV infection-associated cancers such as B cell lymphomas, Kaposi's sarcoma, and HPV-associated cancers such as cervical cancer are particularly noteworthy in this context. Recent reports show that a host of other cancers are also associated with viral infection and these include lung, oral cavity, esophageal, and pharyngeal, hepatocellular carcinoma, and anal and vulvar cancers. This article examines the ways in which diagnostic innovation empowered by integrative biology and informed by public health priorities can improve cancer prevention or early intervention in Africa and beyond. In addition, I argue that because diagnostic biomarkers can often overlap with novel therapeutic targets, diagnostics research and development can have broader value for and impact on medical innovation.

Potential association of prolonged patient interval and advanced anatomic stage in breast cancer patients in the area affected by the 2011 triple disaster in Fukushima, Japan: Retrospective observational study

For five years after the 2011 triple disaster (earthquake, tsunami, and nuclear disaster) in Japan, the proportion of patients with undiagnosed symptomatic breast cancer remained elevated in the coastal area of Fukushima. These individuals experienced a prolonged interval from first symptom recognition to initial medical consultation (hereafter referred to as the patient interval). We aimed to investigate how this prolonged patient interval affected disease staging.Using patient records, we retrospectively extracted females with newly and pathologically diagnosed breast cancer who initially presented to Minamisoma Municipal General Hospital from March 2011 to March 2016. We estimated the proportion with advanced-stage disease (III, IV) according to the patient interval duration (<3 months, 3-12 months, and 12 months plus). A cut-off patient interval value was determined based on the previous evidence with regards to impacts on survival prospects. Logistic regression approaches were used to fulfill the study outcome.The proportion of patients with advanced-stage disease was 10.3% for < 3 months (7/68), 18.2% for 3-12 months (2/11), and 66.7% for more than 12 months (12/18). We found a similar trend using the multivariate logistic regression analyses.Prolongation of the patient interval was associated with advanced-stage disease among female patients with breast cancer.

Overall health information exposure, its barriers and impacts on attitude toward healthcare among cancer patients. The long-term aftermath of the 2011 triple disaster in Fukushima, Japan: A single institution cross-sectional study

Disasters can hinder access to health information among cancer patients. However, little is known regarding overall health information exposure (HIE), its barriers and its impacts on attitudes toward healthcare among cancer patients in the long-term aftermath of disasters. The aims of this study were threefold: assess the extent of HIE; identify associations between family composition and a non-engagement with HIE; and examine the effects of HIE on attitudes toward healthcare among local cancer patients-5 years after the 2011 triple disaster (earthquake, tsunami, and nuclear disaster) in Fukushima, Japan. We conducted self-administered surveys with all cancer and non-cancer surgery department outpatients at Minamisoma Municipal General Hospital (MMGH), Minamisoma City, from October 2016 to January 2017. In total, 404 patients (263 cancer patients and 141 non-cancer patients) voluntarily participated in the study. The results revealed that a regular level of HIE occurred among 90.5% of the cancer patients. In cancer patients, family composition was not significantly associated with HIE, and HIE was not associated with attitude toward healthcare. In conclusion, most cancer patients visiting the MMGH surgical department were regularly engaged in HIE.

The Importance of Clinical Data for the Diagnosis of Breast Tumours in North Afghanistan

Background

This study was performed in knowledge of the increasing gap between breast disease treatment in countries with restricted resources and developed countries with increasingly sophisticated examination methods.

Methods

The authors present the analysis of a breast disease register consisting of diagnostic cases from Mazar e Sharif and Herat in 2018 and 2019. The study comprises a total of 567 cases, which were presented to experts via telemedicine for final diagnosis. 62 cases (10.9%) were excluded due to inacceptable data or insufficient image quality. These data provided by daily diagnostic classification were used for the built-up of a profile for each frequent breast disease and a breast cancer register. All images and cases were seen by at least 3 independent experts. The diagnoses were made in 60% of cases by cytology of fine needle aspiration and in 40% by histological images.

Results

For each entity of breast diseases (e.g., fibroadenoma), a profile of context variables was constructed allowing to assist medical decisions, as “wait and see,” elective surgery or immediate surgical intervention with R0 (complete) resection. These “profiles” could be described for fibroadenoma, mastitis, galactocele, fibrous-cystic disease, and invasive breast cancer.

Conclusions

The presented preliminary data set could serve as a cost-effective basis for a North Afghan breast cancer registry, with option to extent to a national model. These preliminary data are transformed in profiles of breast diseases, which are used by the local physicians in charge of breast disease patients. Each new case can be compared by the local treating physician with the profile of all preceded cases with the same diagnosis.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Project ECHO Cancer Initiative: a Tool to Improve Care and Increase Capacity Along the Continuum of Cancer Care

Solving health problems requires not only the development of new medical knowledge but also its dissemination, particularly to underserved communities. The barriers to effective dissemination also contribute to the disparities in cancer care experienced most everywhere. This concern is particularly acute in low and middle-income countries which already bear a disproportionate burden of cancer, a situation that is projected to worsen. Project ECHO (Extension for Community Healthcare Outcomes) is a knowledge dissemination platform that can increase workforce capacity across many fields, including cancer care by scaling best practices. Here we describe how Project ECHO works and illustrate this with existing programs that span the cancer care continuum and the globe. The examples provided combined with the explanation of how to build effective Project ECHO communities provide an accessible guide on how this education strategy can be integrated into existing work to help respond to the challenge of cancer.

Recommendations for streamlining precision medicine in breast cancer care in Latin America

Background

The incidence of breast cancer (BC) in LMICs has increased by more than 20% within the last decade. In areas such as Latin America (LA), addressing BC at national levels evoke discussions surrounding fragmented care, limited resources, and regulatory barriers. Precision Medicine (PM), specifically companion diagnostics (CDx), links disease diagnosis and treatment for better patient outcomes. Thus, its application may aid in overcoming these barriers.

Recent findings

A panel of LA experts in fields related to BC and PM were provided with a series of relevant questions to address prior to a multi‐day conference. Within this conference, each narrative was edited by the entire group, through numerous rounds of discussion until a consensus was achieved. The panel proposes specific, realistic recommendations for implementing CDx in BC in LA and other LMIC regions. In these recommendations, the authors strived to address all barriers to the widespread use and access mentioned previously within this manuscript.

Conclusion

This manuscript provides a review of the current state of CDx for BC in LA. Of most importance, the panel proposes practical and actionable recommendations for the implementation of CDx throughout the Region in order to identify the right patient at the right time for the right treatment.

Quality of life of women living with metastatic breast cancer and receiving palliative care: A systematic review

The quality of life (QoL) of women living with metastatic breast cancer and receiving palliative care needs more attention. We reviewed published studies (1992-2019) examining QoL of women receiving palliative care. The findings were interpreted according to the World Health Organization's (WHO) definition of palliative care. Four themes emerged: (1) the impact of medical treatment on pain relief; (2) the need for psychosocial attention and support; (3) the necessity of an interdisciplinary approach; (4) ambiguous understanding of the term palliative care. A common understanding of the term palliative care and more research is needed to enhance the QoL of women living with metastatic breast cancer.

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

Background

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

Methods

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

Result

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

Conclusion

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Epidemiology and clinical features of patients with breast cancers hospitalized in the Department of Oncology in Fianarantsoa, Madagascar from 2011 to 2018]

Introduction

à notre connaissance, il s´agit d´une première étude épidémiologique des cancers du sein à Fianarantsoa. Notre objectif était de décrire les caractéristiques épidémio-cliniques de ces cancers au Service d´Oncologie de Fianarantsoa.

Méthodes

il s´agissait d´une étude rétrospective descriptive au Service d´Oncologie du Centre Hospitalier Universitaire de Tambohobe pendant 8 ans (2011 à 2018). Nous avons inclus toutes les patientes atteintes de cancer du sein avec une confirmation cytologique et/ou histologique. Les paramètres étudiés étaient l´âge, la profession, les antécédents familiaux de cancer du sein, la ménarche, la ménopause, la parité, la prise de contraception orale, le tabagisme, les circonstances de découverte, les symptômes mammaires, les signes d´extension, la localisation tumorale et le stade de la maladie.

Résultats

nous avons inclus 62 patientes d´âge moyen de 52,83 ± 10,47 ans. Les femmes au foyer constituaient 39% (n = 24) des cas. Aucune patiente n´avait une ménarche précoce. La ménopause tardive était survenue chez 6,45% (n = 4) et des antécédents familiaux de cancer du sein étaient retrouvés chez 8,06% (n = 5). La prise de tabac à chiquer a été retrouvée chez 17,74% (n = 11) des cas. Les symptômes mammaires étaient observés dans 95,2% (n = 59) des cas. Le quadrant supéro-externe était touché dans 53,23% (n = 33) des cas. Le stade III s´observait dans 55% (n = 34) des cas et le stade IV dans 32% (n = 20).

Conclusion

diagnostiqués à un stade avancé, les facteurs de risque de cancer du sein étaient peu observés.

Shorter delay to treatment by integrated diagnostic services and NGO-provided support among breast cancer patients in two Brazilian referral centres

BACKGROUND

The diagnosis of breast cancer requires a complicated series of diagnostic exams. The present study addressed the delay of patients who used publicly and privately financed diagnostic services. Non-governmental organizations (NGOs) donated diagnostic mammograms and biopsies.

DESIGN AND METHODS

Data from 304 patients were obtained from two Brazilian referral centres. In one referral centre (FAP), diagnostic mammography, clinic-histopathological exam and immunohistochemistry were outsourced, whereas in the other centre (HNL), these services were integrated. Cox regression, Kaplan-Meier analysis and non-parametric tests were used to compare variables and time intervals.

RESULTS

If diagnostic mammography was financed privately and covered by private health insurance, the likelihood of a delay of >90 days between the first medical visit and the initiation of treatment decreased 2.15-fold (95%CI: 1.06- 4.36; p=0.033) and 4.44-fold (95%CI: 1.58-12.46; p=0.004), respectively. If the clinic-histopathological exam was outsourced (FAP) and publicly or privately financed, the median time between diagnostic mammography and the diagnostic result was 53 and 65 days in the integrated (HNL) and outsourced public system, compared to 29 days in the outsourced private system (p<0.050). The median time between the first medical visit and the diagnostic results of patients who were supported by NGOs, who financed their diagnostic services privately, and who used exclusively public diagnostic services was, respectively, 28.0, 48.5 and 77.5 days (p<0.050).

CONCLUSION

Patients who used privately financed health services had shorter delays. Compared to outsourcing, the integration of the publicly financed clinic- histopathological exam diminished the delay. The support of patients by NGOs accelerated patient flow.

Improving Oncology-Pathology Collaboration in Resource-Limited Settings: An American Society of Clinical Oncology/College of American Pathologists Initiative

Accurate pathologic evaluation is essential for proper diagnosis and treatment of patients with cancer. ASCO and the College of American Pathologists have successfully collaborated over the last 15 years to improve collaboration between clinical oncologists and pathologists and to standardize pathologic assay techniques. Cancer is an increasingly recognized societal burden in low- and middle-income countries. In 2015, ASCO and the College of American Pathologists implemented an initiative to identify countries that could benefit from peer insights by jointly convening an international workshop among members of both organizations and pathologists and clinical oncologists from Haiti, Honduras, Vietnam, and Uganda. Honduras was chosen as a pilot site, and representatives of ASCO, the College of American Pathologists, and the Honduras pathology and clinical oncology communities have identified areas in which collaboration might be productive. Multiple barriers, including high poverty levels, poor cancer awareness educational programs, lack of human resources, and delayed diagnosis and treatment, have resulted in a higher cancer mortality rate in Honduras compared with high/moderate-income countries and are shared by other low-income countries. ASCO and the College of American Pathologists member faculty supported a symposium led by Honduras colleagues for interested Honduran pathologists and oncologists. The Honduran communities are now working to establish national resource-appropriate guidelines for both pathology and clinical oncology. Taken together, these efforts indicate that barriers to meet the needs of the clinical oncologists in a low-income country such as Honduras are challenging but not insurmountable.

A review of breast cancer pathology reports in Nigeria

Background

Diagnosis and treatment of cancer rely heavily on imaging, histopathology and molecular information. Incomplete or missing tumour information can hinder the delivery of high-quality care in oncology practice, especially in resource-limited countries. To evaluate the completeness of histopathology reporting in a real-world setting and identify areas for future cancer care delivery research efforts, we retrospectively analysed reports from patients diagnosed with breast cancer who received care at a high-volume oncology department at a hospital in Lagos, Nigeria.

Methods

Demographic, institutional and histopathology characteristics were retrospectively obtained from 1,001 patient records from 2007 to 2016. Completeness was defined as reporting five tumour features (tumour histology, tumour grade, laterality, oestrogen receptor (ER) or progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2)) for biopsy specimens and seven tumour features (tumour size, tumour histology, tumour grade, laterality, ER/PR, HER2 and lymph node involvement) for surgical specimens.

Results

The mean age of patients was 48.6 ± 11.7 years with a predominantly female population (99.3%). A majority of pathologic reports were produced after 2011, and two-thirds of the reports originated from centres or labs within Lagos, Nigeria (67.7%). Most reports documented primary site (98.0%) and specimen type (85.0%) while other characteristics were less often recorded. This led to substantial variation in reporting between biopsy (13.4%) and surgical (6.1%) specimens for an overall low pathology report completeness <10%.

Conclusion

The majority of patient records analysed lacked complete documentation of breast cancer histopathological characteristics commonly used in oncology practice. Our study highlights a need to identify and address the contributing factors for incomplete histopathological reporting in Nigeria and will guide future clinical programmatic developments.

Spatial distribution of advanced stage diagnosis and mortality of breast cancer: Socioeconomic and health service offer inequalities in Brazil

Breast cancer presents high incidence and mortality rates, being considered an important public health issue. Analyze the spatial distribution pattern of late stage diagnosis and mortality for breast cancer and its correlation with socioeconomic and health service offer-related population indicators. Ecological study, developed with 161 Intermediate Region of Urban Articulation (IRUA). Mortality data were collected from the Mortality Information System (MIS). Tumor staging data were extracted from the Hospital Cancer Registry (HCR). Socioeconomic variables were obtained from the Atlas of Human Development in Brazil; data on medical density and health services were collected from the National Registry of Health Institutions (NRHI) and Supplementary National Health Agency. Global Moran's Index and Local Indicator of Spatial Association (LISA) were utilized to verify the existence of territorial clusters. Multivariate analysis used models with global spatial effects. The proportion of late stage diagnosis of breast cancer was 39.7% (IC 39.4–40.0). The mean mortality rate for breast cancer, adjusted by the standard world population was 10.65 per 100,000 women (± 3.12). The proportion of late stage diagnosis presented positive spatial correlation with Gini’s Index (p = 0.001) and negative with the density of gynecologist doctors (p = 0.009). The adjusted mortality rates presented a positive spatial correlation with the Human Development Index (p<0.001) and density of gynecologist doctors (p<0.001). Socioeconomic and health service offer-related inequalities of the Brazilian territory are determinants of the spatial pattern of breast cancer morbimortality in Brazil.

Addressing disparities and challenges in underserved patient populations with metastatic breast cancer in Europe

People with metastatic breast cancer face many challenges and disparities in obtaining optimal cancer care. These challenges are accentuated in underserved patient populations across Europe, who are less likely to receive quality healthcare for reasons including socioeconomic inequalities, educational or cultural status, or geographic location. While there are many local and national initiatives targeted to address these challenges, there remains a need to reduce disparities and improve access to healthcare to improve outcomes, with a focus on multidisciplinary stakeholder engagement. In October 2019, a range of experts in metastatic breast cancer, including healthcare professionals, patient representatives, policymakers and politicians, met to discuss and prioritize the critical needs of underserved patient populations with metastatic breast cancer in Europe. Six key challenges faced by these communities were identified: the need for amplification of the metastatic breast cancer patient voice, better and wider implementation of high-quality guidelines for metastatic breast cancer, more collaboration between stakeholders, tailored support for patients from different cultural and ethnic backgrounds, improved data sharing, and work-related issues. The Expert Panel then conceived and discussed potential actionable goals to address each key challenge. Their conclusions present a set of interrelated approaches to address the different challenges and could serve as the basis for concerted improvement of the lives of patients with metastatic breast cancer in Europe.

A multilevel assessment of the social determinants associated with the late stage diagnosis of breast cancer

The advanced-stage diagnosis of breast cancer reveals the inequalities associated with socioeconomic conditions and the offer of health services. This study analyzes the prevalence of advanced breast cancer and its relationship with individual and contextual socioeconomic indicators and offer of health service. A cross-sectional study is presented herein, on the assessment of malignant breast neoplasms in women diagnosed between 2006 and 2015 (n = 195,201). Data were collected from the Hospital Cancer Registry (HCR), Atlas of Human Development in Brazil, and from the National Registry of Health Institutions (NRHI). A multilevel Poisson Regression was carried out with random intercept. The prevalence of advanced breast cancer diagnosis was 40.0%. Advanced staging was associated with younger age groups (PR 1.41), race/nonwhite (PR 1.13), lower education levels (PR 1.38), and public access to health services (PR 1.25). There was also an association with a low density of mammographic equipment (PR 1.08), and with low indices of local social inequality (PR 1.33) and human development (PR 0.80). This study maps and highlights the causes related to inequalities in the diagnosis of advanced breast cancer in Brazil, and presents essential data to reorient public policies and health-related actions to strengthen the control of breast cancer in Brazil.

Quantitative STAU2 measurement in lymphocytes for breast cancer risk assessment

Although mammograms play a key role in early breast cancer detection, the test is not applicable to all women, for example, women under the age of 40. The development of a noninvasive blood test with high sensitivity and accessibility will improve the effectiveness of breast cancer screening programmes. Secretory factors released from cancer cells can induce the expression of certain genes in a large number of white blood cells (WBCs). Therefore, cancer-dependent proteins in WBCs can be used as tumour markers with high sensitivity. Five proteins (LMAN1, AZI2, STAU2, MMP9 and PLOD1) from a systemic analysis of a variety of array data of breast cancer patients were subjected to immunofluorescence staining to evaluate the presence of fixed WBCs on 96-well plates from 363 healthy females and 358 female breast cancer patients. The results revealed that the average fluorescence intensity of anti-STAU2 and the percentage of STAU2-positive T and B lymphocytes in breast cancer patients (110.50 ± 23.38 and 61.87 ± 12.44, respectively) were significantly increased compared with those in healthy females (56.47 ± 32.03 and 33.02 ± 18.10, respectively) (p = 3.56 × 10^-71, odds ratio = 24.59, 95% CI = 16.64-36.34). The effect of secreted molecules from breast cancer cells was proven by the increase in STAU2 intensity in PBMCs cocultured with MCF-7 and T47D cells at 48 h (p = 0.0289). The test demonstrated 98.32%, 82.96%, and 48.32% sensitivity and 56.47%, 83.47%, and 98.62% specificity in correlation with the percentage of STAU2-positive cells at 40, 53.34 and 63.38, respectively. We also demonstrated how to use the STAU2 test for the assessment of risk in women under the age of 40. STAU2 is a novel breast cancer marker that can be assessed by quantitative immunofluorescence staining of fixed WBCs that are transportable at room temperature via mail, representing a useful risk assessment tool for women without access to mammograms.

Prioritization of Patients with Abnormal Breast Findings in the Alerta Rosa Navigation Program to Reduce Diagnostic Delays

INTRODUCTION

In Mexico, there are considerable health system delays in the diagnosis and treatment initiation of women with breast cancer. Alerta Rosa is a navigation program in Nuevo Leon that aims to reduce barriers that impede the timely management of these patients.

PATIENTS AND METHODS

Since December 2017, women who registered to receive medical evaluations by Alerta Rosa were stratified based on their clinical characteristics into three priority groups ("Red," "Yellow," and "Green"). According to the category assigned, patients were scheduled imaging studies and medical appointments with breast specialists on a preferential basis.

RESULTS

Up until December 2019, 561 patients were scheduled for medical evaluations. Of them, 59% were classified as "Red," 25% "Yellow," and 16% "Green" priority. The median time from stratification to first medical evaluation was 4, 6, and 7 days, respectively (p = .003). Excluding those who had a prior breast cancer diagnosis, 21 patients were diagnosed by Alerta Rosa, with the initial "Red" priority classification demonstrating a sensitivity of 95% (95% confidence interval [CI], 75.1%-99.9%) and specificity of 42% (95% CI, 37.1%-47.1%) for breast cancer. The median time elapsed from initial patient contact to diagnosis and treatment initiation was 16 days and 39 days, respectively. The majority (72%) of patients were diagnosed at an early stage (0-II).

CONCLUSION

This patient prioritization system adequately identified women with different probabilities of having breast cancer. Efforts to replicate similar triage systems in resource-constrained settings where screening programs are ineffective could prove to be beneficial in reducing diagnostic intervals and achieving early-stage diagnoses.

IMPLICATIONS FOR PRACTICE

Low- and middle-income countries such as Mexico currently lack the infrastructure to achieve effective breast cancer screening and guarantee prompt access to health care when required. To reduce the disease burden in such settings, strategies targeting early detection are urgently needed. Patient navigation programs aid in the reduction of health system intervals and optimize the use of available resources. This article presents the introduction of a triage system based on initial patient concern. Appointment prioritization proved to be successful at reducing health system intervals and achieving early-stage diagnoses by overcoming barriers that impede early access to quality medical care.