Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007

Global cancer consortiums: moving from consensus to practice

PURPOSE AND DESIGN

The failure to translate cancer knowledge into action contributes to regional, national, and international health inequities. Disparities in cancer care are the most severe in low-resource settings, where delivery obstacles are compounded by health infrastructure deficits and inadequate basic services. Global cancer consortiums (GCCs) have developed to strengthen cancer care expertise, advance knowledge on best practices, and bridge the cancer gap worldwide. Within the complex matrix of public health priorities, consensus is emerging on cost-effective cancer care interventions in low- and medium-resource countries, which include the critical role of surgical services. Distinct from traditional health partnerships that collaborate to provide care at the local level, GCCs collaborate more broadly to establish consensus on best practice models for service delivery. To realize the benefit of programmatic interventions and achieve tangible improvements in patient outcomes, GCCs must construct and share evidence-based implementation strategies to be tested in real world settings.

REVIEW AND CONCLUSIONS

Implementation research should inform consensus formation, program delivery, and outcome monitoring to achieve the goals articulated by GCCs. Fundamental steps to successful implementation are: (1) to adopt an integrated, multisectoral plan with local involvement; (2) to define shared implementation priorities by establishing care pathways that avoid prescriptive but suboptimal health care delivery; (3) to build capacity through education, technology transfer, and surveillance of outcomes; and (4) to promote equity and balanced collaboration. GCCs can bridge the gap between what is known and what is done, translating normative sharing of clinical expertise into tangible improvements in patient care.

Breast cancer in low and middle income countries (LMICs): a shifting tide in global health

Cancer control planning has become a core aspect of global health, as rising rates of noncommunicable diseases in low-resource settings have fittingly propelled it into the spotlight. Comprehensive strategies for cancer control are needed to effectively manage the disease burden. As the most common cancer among women and the most likely reason a woman will die from cancer globally, breast cancer management is a necessary aspect of any comprehensive cancer control plan. Major improvements in breast cancer outcomes in high-income countries have not yet been mirrored in low-resource settings, making it a targeted priority for global health planning. Resource-stratified guidelines provide a framework and vehicle for designing programs to promote early detection, diagnosis, and treatment using existing infrastructure and renewable resources. Strategies for evaluating the current state and projecting future burden is a central aspect of developing national strategies for improving breast cancer outcomes at the national and international levels.

Mortality of major cancers in Guangxi, China: sex, age and geographical differences from 1971 and 2005

The incidence and mortality rates of liver and nasopharyngeal cancer in Guangxi province of China have always been among the highest in the world, and cancer is one of the major diseases that pose a threat to the health of residents in Guangxi. However, no systematic study has been performed to evaluate the time trends in the structure of cancer-related deaths and cancer mortality. In this study, we reveal sex, age and geography differences of cancers mortality between three death surveys (1971 to 1973, 1990 to 1992, and 2004 to 2005). The results show that the standardized mortality rate of cancer in Guangxi residents has risen from 43.3/100,000 to 84.2/100,000, the share of cancer deaths in all-cause deaths has increased from 13.3% to 20.7%, and cancer has become the second most common cause of death. The five major cancers, liver cancer, lung cancer, gastric cancer, nasopharyngeal cancer and colorectal cancer, account for 60% of all the cancer deaths. Cancers with growing mortality rates over the past 30 years include lung cancer, colorectal cancer, liver cancer and female breast cancer, of which lung cancer is associated with the sharpest rise in mortality, with a more than 600% rise in both men and women. Cancer death in Guangxi residents occurs mainly in the elderly population above 45 years of age, especially in people over the age of 65. The areas with the highest mortality rates for liver cancer and nasopharyngeal cancer, which feature regional high incidences, include Chongzuo and Wuzhou. Therefore, for major cancers such as liver cancer, lung cancer, gastric cancer, nasopharyngeal cancer and female breast cancer in Guangxi, we can select high-risk age groups as the target population for cancer prevention and control efforts in high-prevalence areas in a bid to achieve the ultimate goal of lowering cancer mortality in Guangxi.

Establishing of cancer units in low or middle income African countries: Angolan experience--a preliminary report

INTRODUCTION

The number of cancer cases and related deaths worldwide is expected to double over the next 20-30 years. African countries will be the most affected by the burden of cancer. The improving economic situation of Angola creates conditions for an increase in life expectancy which by itself is associated with an increased risk of oncological diseases. Because cancer therapy requires a multidisciplinary approach, trained health professionals, satisfactory infrastructure and appropriate facilities, the availability of effective cancer therapy is a difficult task that requires support. The aim of this article is to share our experience achieved in the establishment of cancer units in Angola and to validate our checklist for this action.

METHODS

The survey method was a questionnaire addressed to Angolan cancer units, in order to evaluate the usefulness and feasibility of a checklist developed by the authors--The Cancer Units Assessment Checklist for low or middle income African countries--which was used previously in the establishment of those units. Afterwards, the crucial steps taken for the establishing of the main sites of each cancer unit considering, facilities, resources and professionals, were also recorded.

RESULTS

All cancer units reported that the checklist was a useful tool in the development of the cancer program for the improvement of the unit or the establishing of cancer unit sites. This instrument helped identifying resources, defining the best practice and identifying barriers. Local experts, who know the best practices in oncology and who are recognized by the local heads, are also important and they proved to be the major facilitators.

CONCLUSION

The fight against cancer has just started in Angola. The training, education, advocacy and legislation are ongoing. According to our results, the assessment checklist for the establishment of cancer units is a useful instrument.

Implementation science in cancer prevention and control: a framework for research and programs in low- and middle-income countries

Implementation science is a set of tools, principles, and methodologies that can be used to bring scientific evidence into action, improve health care quality and delivery, and improve public health. As the burden of cancer increases in low- and middle-income countries, it is important to plan cancer control programs that are both evidence based and delivered in ways that are feasible, cost-effective, contextually appropriate, and sustainable. This review presents a framework for using implementation science for cancer control planning and implementation and discusses potential areas of focus for research and programs in low- and middle-income countries interested in integrating research into practice and policy.

Calponin-h2: a potential serum marker for the early detection of human breast cancer?

Early diagnosis is the key for the successful treatment of breast cancer. A serum marker for the early detection of breast cancer could significantly reduce breast cancer morbidity and mortality by bringing the time of diagnosis at an earlier and therefore still curable stage. So far, no biomarker for the early detection is available for the clinical routine. The aim of the present study was to evaluate the use of calponin-h2 as a blood-based biomarker for the early diagnosis of this disease. Using two monoclonal antibodies against calponin-h2, we developed a sandwich ELISA to analyze the serum levels of calponin-h2. In order to evaluate the diagnostic potential of this biomarker, patients with breast cancer (n = 76), benign diseases of the breast (n = 51) and healthy females (n = 24) were analyzed. Serum levels above 10 ng/ml were only observed in patients with breast cancer (n = 8; 10.5%). Further large-scale studies and preanalytic evaluations are necessary to clarify the definite role of calponin-h2 as a biomarker in breast cancer management.

International screening and early detection of breast cancer: resource-sensitive, age- and risk-specific guidelines

SUMMARY 

In this article we review the evidence and current controversies surrounding screening and early detection of breast cancer, from the initially positive age-specific randomized trials of the 1970s and 1980s, to the 2009 USPSTF recommendations, 2013 interpretation of SEER data, 2014 Canadian Study updates, and BHGI resource-sensitive guidelines, as well as the few reports available from emerging countries. We will also discuss the burden of breast cancer in low- and middle- income countries with rising incidence rates and advanced stages at presentation, the need for increasing awareness and downstaging of disease. We will discuss the data putting it in perspective for general guidelines for the international scene, and suggest adoption of evidence-based resource-sensitive and risk-specific guidelines, with less reliance on broad age-specific guidelines.

Pathogenesis, prevention, diagnosis and treatment of breast cancer

Breast cancer is the most common cancer affecting women worldwide. Prediction models stratify a woman's risk for developing cancer and can guide screening recommendations based on the presence of known and quantifiable hormonal, environmental, personal, or genetic risk factors. Mammography remains the mainstay breast cancer screening and detection but magnetic resonance imaging and ultrasound have become useful diagnostic adjuncts in select patient populations. The management of breast cancer has seen much refinement with increased specialization and collaboration with multidisciplinary teams that include surgeons, oncologists, radiation oncologists, nurses, geneticist, reconstructive surgeons and patients. Evidence supports a less invasive surgical approach to the staging and management of the axilla in select patients. In the era of patient/tumor specific management, the advent of molecular and genomic profiling is a paradigm shift in the treatment of a biologically heterogenous disease.

Why the time is right to tackle breast and cervical cancer in low-resource settings

The health concerns of women in their mid-adult years - when the prime age of reproduction has passed - have been traditionally given little or no attention by health systems and donors, despite the heavy burden that diseases such as breast and cervical cancer impose on women and their families. The risk of sexually transmitted infections that accompanies sexual relations and the risk of death and morbidity associated with pregnancy have long been recognized and have stimulated major control efforts that are finally yielding positive results. Much less attention has been focused, however, on how experiences in early life can affect women's health in adulthood. Breast and cervical cancers kill more women than any other types of cancer in all parts of the developing world. In most of Asia and Latin America and some African countries, deaths from these two forms of cancer now outnumber pregnancy-related deaths. There are five compelling reasons for focusing on these cancers now to try to reverse these epidemiologic trends: (i) the burden of breast and cervical cancer is large and is growing; (ii) effective screening and treatment are available; (iii) research is generating new knowledge; (iv) there are opportunities for synergy with other health programmes; and (v) noncommunicable diseases are the focus of much current interest.

Cervical and female breast cancers in the Americas: current situation and opportunities for action

OBJECTIVE

To understand better the current regional situation and public health response to cervical cancer and female breast cancer in the Americas.

METHODS

Data on cervical cancer and female breast cancers in 33 countries, for the period from 2000 to the last year with available data, were extracted from the Pan American Health Organization (PAHO) Regional Mortality Database and analysed. Changes in mortality rates over the study period - in all countries except those with small populations and large fluctuations in time-series mortality data - were calculated using Poisson regression models. Information from the PAHO Country Capacity Survey on noncommunicable diseases was also analysed.

FINDINGS

The Bahamas, Trinidad and Tobago and Uruguay showed relatively high rates of death from breast cancer, whereas the three highest rates of death from cervical cancer were observed in El Salvador, Nicaragua and Paraguay. Several countries - particularly Paraguay and Venezuela - have high rates of death from both types of cancer. Although mortality from cervical cancer has generally been decreasing in the Americas, decreases in mortality from breast cancer have only been observed in a few countries in the Region of the Americas. All but one of the 25 countries in the Americas included in the PAHO Country Capacity Survey reported having public health services for the screening and treatment of breast and cervical cancers.

CONCLUSION

Most countries in the Americas have the public health capacity needed to screen for - and treat - breast and cervical cancers and, therefore, the potential to reduce the burden posed by these cancers.

From the set-up of a screening program of breast cancer patients to the identification of the first BRCA mutation in the DR Congo

BACKGROUND

Breast cancer incidence in African population is low compared to western countries but the mortality rate is higher and the disease presents at a younger age and at a more advanced stage. The World Health Organisation and the Breast Health Global Initiative concluded that in low and middle income countries early breast cancer detection can be achieved by informing women on symptoms of breast cancer, on the practice of breast self-examination and clinical breast examination by trained health care workers. Based on these recommendations, we set up a breast cancer awareness campaign in Kinshasa, Democratic Republic of Congo (DRC). This paper describes the strategy that was established and the results that were achieved.

METHODS

A breast cancer awareness campaign was started in 2010 and data were collected until the end of 2012. Clinicians (expert group) trained nurses and health care workers (awareness groups) on clinical, technical and social aspects of breast cancer. Different channels were used to inform women about the campaign and clinical data (on medical and family history) were collected. The participating women were investigated with clinical breast examination by the awareness group. Women in whom a palpable mass was detected were referred to the hospital: they received a mammography and ultrasound and--in case of suspicious findings--additionally a core needle biopsy. In case of a positive family history, a blood sample was taken for genetic investigation.

RESULTS

In total, 4,315 women participated, resulting in 1,113 radiological breast examinations, performed in the General Hospital of Kinshasa of which 101 turned out to be malignant lesions. Fifty six percent of the women with breast cancer were less than 50 years old and 75% (65/87) were stage III tumors. A BRCA gene mutation was identified in a family with a severe history of breast cancer.

CONCLUSIONS

Even without financial support, it was possible to start an awareness campaign for breast cancer in Kinshasa. This campaign increased the awareness on cancer of the women in Kinshasa. The results demonstrate that this campaign had an immediate impact on patients and their families.

From the set-up of a screening program of breast cancer patients to the identification of the first BRCA mutation in the DR Congo

BACKGROUND

Breast cancer incidence in African population is low compared to western countries but the mortality rate is higher and the disease presents at a younger age and at a more advanced stage. The World Health Organisation and the Breast Health Global Initiative concluded that in low and middle income countries early breast cancer detection can be achieved by informing women on symptoms of breast cancer, on the practice of breast self-examination and clinical breast examination by trained health care workers. Based on these recommendations, we set up a breast cancer awareness campaign in Kinshasa, Democratic Republic of Congo (DRC). This paper describes the strategy that was established and the results that were achieved.

METHODS

A breast cancer awareness campaign was started in 2010 and data were collected until the end of 2012. Clinicians (expert group) trained nurses and health care workers (awareness groups) on clinical, technical and social aspects of breast cancer. Different channels were used to inform women about the campaign and clinical data (on medical and family history) were collected. The participating women were investigated with clinical breast examination by the awareness group. Women in whom a palpable mass was detected were referred to the hospital: they received a mammography and ultrasound and--in case of suspicious findings--additionally a core needle biopsy. In case of a positive family history, a blood sample was taken for genetic investigation.

RESULTS

In total, 4,315 women participated, resulting in 1,113 radiological breast examinations, performed in the General Hospital of Kinshasa of which 101 turned out to be malignant lesions. Fifty six percent of the women with breast cancer were less than 50 years old and 75% (65/87) were stage III tumors. A BRCA gene mutation was identified in a family with a severe history of breast cancer.

CONCLUSIONS

Even without financial support, it was possible to start an awareness campaign for breast cancer in Kinshasa. This campaign increased the awareness on cancer of the women in Kinshasa. The results demonstrate that this campaign had an immediate impact on patients and their families.

Breast cancer in young women in Latin America: an unmet, growing burden

BACKGROUND

Breast cancer (BC) is the leading cause of malignancy-related deaths among women aged ≤ 45 years. There are unexplored and uncertain issues for BC in this particular group in Latin America. The aim of this study is to evaluate BC incidence and mortality among young women and related clinicopathological and survivorship aspects in this region.

MATERIALS AND METHODS

Data were obtained from Globocan 2008 and the International Agency for Research on Cancer's Cancer Incidence in Five Continents series plus databases. We requested collaboration from the 12 different national cancer institutes in Latin America through SLACOM, the Latin American and Caribbean Society of Medical Oncology, and conducted a systematic literature review to obtain local data regarding the prevalence of BC among young women and their characteristics, outcomes, and survivorship-related issues.

RESULTS

BC incidence and mortality proportions for Latin American women aged <44 years were higher when compared with those of developed countries (20% vs. 12% and 14% vs. 7%, respectively). We found only a few Latin American series addressing this topic, and prevalence varied between 8% and 14%. Stage II and III disease, high histological grade, and triple-negative and HER2 BC were features frequently observed among young Latin American BC patients.

CONCLUSION

The rising incidence and mortality of BC in young Latin American women is a call to action in the region. It is necessary to monitor the epidemiological and clinical data through reliable cancer registries and to consider the implementation of protocols for education of patients and health professionals. This unmet, growing burden must be considered as a top priority of the national programs in the fight against BC, and models of specialized units should be implemented for this particular group of patients to provide better care for this emergent challenge.

Breast Cancer Risks and Effectiveness of BSE Training among Women Living in a District of İstanbul

OBJECTIVE

The purpose of this study to determine the risks associated with breast cancer in women who live in a neighborhood in Istanbul, and to evaluate the effectiveness of breast self-examination (BSE) training.

MATERIALS AND METHODS

This study was designed by using a half-experimental model, with women over the age of 18 who visited the community health center in a district of Istanbul, during March/April 2012. Sample selection was not implemented, and 169 women who voluntarily participated in the study were included. Data was collected by face-to-face interview technique with "Demographic Survey Form", "Breast Cancer Risk Assessment Form" and "BSE Training Assessment Scale". After risk assessment, women who wanted to learn BSE (n=109) were given a practical training program lasting approximately 20 minutes that was prepared together with expert consults.

RESULTS

32.1% of the participants regularly performed BSE. Out of those who do not use regular self-examination, 15.4% thought BSE was unnecessary, 44% was afraid to examine herself, and 40.7% did not know how to apply BSE. The mean breast cancer risk score was 135.64±61.33. There were statistically significant differences between breast cancer risk score and the educational status, marital status, and menstrual status. A statistically significant difference was found in pre- and post-training BSE Training Assessment Scale scores.

CONCLUSION

The breast cancer risk score was low among women included in this study. However, the vast majority of women did not perform BSE, and those who did were using either irregular or improper practice. It was detected that implementation of planned and in-person training programs were quite effective.

Development and application of a suite of 4-D virtual breast phantoms for optimization and evaluation of breast imaging systems

Mammography is currently the most widely utilized tool for detection and diagnosis of breast cancer. However, in women with dense breast tissue, tissue overlap may obscure lesions. Digital breast tomosynthesis can reduce tissue overlap. Furthermore, imaging with contrast enhancement can provide additional functional information about lesions, such as morphology and kinetics, which in turn may improve lesion identification and characterization. The performance of these imaging techniques is strongly dependent on the structural composition of the breast, which varies significantly among patients. Therefore, imaging system and imaging technique optimization should take patient variability into consideration. Furthermore, optimization of imaging techniques that employ contrast agents should include the temporally varying breast composition with respect to the contrast agent uptake kinetics. To these ends, we have developed a suite of 4-D virtual breast phantoms, which are incorporated with the kinetics of contrast agent propagation in different tissues and can realistically model normal breast parenchyma as well as benign and malignant lesions. This development presents a new approach in performing simulation studies using truly anthropomorphic models. To demonstrate the utility of the proposed 4-D phantoms, we present a simplified example study to compare the performance of 14 imaging paradigms qualitatively and quantitatively.

Relevance of health economics in breast cancer treatment: integration of economics in the management of breast cancer at the clinic level

Since the introduction of the diagnosis-related groups (DRG) system with cost-related and entity-specific flat-rate reimbursements for all in-patients in 2004 in Germany, economics have become an important focus in medical care, including breast centers. Since then, physicians and hospitals have had to gradually take on more and more financial responsibilities for their medical care to avoid losses for their institutions. Due to financial limitations of resources, most medical services have to be adjusted to correlating revenues, which results in the development of a variety of active measures to understand, steer, and optimize costs, resources and related processes for breast cancer treatment. In this review, the challenging task to implement microeconomic management at the clinic level for breast cancer treatment is analyzed from breast cancer-specific publications. The newly developed economic management perspective is identified for different stakeholders in the healthcare system, and successful microeconomic projects and future aspects are described.

Incidence and mortality of female breast cancer in the Asia-Pacific region

OBJECTIVE

To provide an overview of the incidence and mortality of female breast cancer for countries in the Asia-Pacific region.

METHODS

Statistical information about breast cancer was obtained from publicly available cancer registry and mortality databases (such as GLOBOCAN), and supplemented with data requested from individual cancer registries. Rates were directly age-standardised to the Segi World Standard population and trends were analysed using joinpoint models.

RESULTS

Breast cancer was the most common type of cancer among females in the region, accounting for 18% of all cases in 2012, and was the fourth most common cause of cancer-related deaths (9%). Although incidence rates remain much higher in New Zealand and Australia, rapid rises in recent years were observed in several Asian countries. Large increases in breast cancer mortality rates also occurred in many areas, particularly Malaysia and Thailand, in contrast to stabilising trends in Hong Kong and Singapore, while decreases have been recorded in Australia and New Zealand. Mortality trends tended to be more favourable for women aged under 50 compared to those who were 50 years or older.

CONCLUSION

It is anticipated that incidence rates of breast cancer in developing countries throughout the Asia-Pacific region will continue to increase. Early detection and access to optimal treatment are the keys to reducing breast cancer-related mortality, but cultural and economic obstacles persist. Consequently, the challenge is to customise breast cancer control initiatives to the particular needs of each country to ensure the best possible outcomes.

Differential diagnosis between malignant and benign breast lesions using single-voxel proton MRS: a meta-analysis

OBJECTIVES

We aim to investigate the diagnostic capability of single-voxel proton MR spectroscopy (MRS) for benign/malignant discrimination of focal breast lesions with a meta-analysis.

MATERIALS AND METHODS

The meta-analysis included a total of 750 malignant breast lesions and 419 benign breast lesions from eighteen studies.

RESULTS

The pooled sensitivity and specificity of MRS were 0.71 (95 % CI 0.68-0.74) and 0.85 (95 % CI 0.81-0.88), respectively. The positive likelihood ratio and negative LR were 4.11 (95 % CI 3.11-5.43) and 0.25 (95 % CI 0.17-0.36), respectively. The P value for χ(2) heterogeneity for all pooled estimates was <0.05. From the fitted summary receiver operating characteristics curve, AUC was 0.89 and Q* was 0.84. Asymmetrical in funnel plots indicated there may be publication bias (t = 2.85, P = 0.012). The meta-regression analysis indicated that neither threshold effect nor evaluated covariates that include strength of field, scanning technique (PRESS or STEAM), repetition time, NSA, and pre- or post-contrast agent were the sources of heterogeneity (all P value >0.05).

CONCLUSIONS

Single-voxel proton MRS was useful for differentiation between malignant and benign breast lesions. However, pooled diagnostic measures might be overestimated. The standardization of the acquisition protocol for MRS across the multicenter trials is recommended.

A semi-automated 3-D annotation method for breast ultrasound imaging: system development and feasibility study on phantoms

Spatial annotation is an essential step in breast ultrasound imaging, because the follow-up diagnosis and treatment are based on this annotation. However, the current method for annotation is manual and highly dependent on the operator's experience. Moreover, important spatial information, such as the probe tilt angle, cannot be indicated in the clinical 2-D annotations. To solve these problems, we developed a semi-automated 3-D annotation method for breast ultrasound imaging. A spatial sensor was fixed on an ultrasound probe to obtain the image spatial data. Three-dimensional virtual models of breast and probe were used to annotate image locations. After the reference points were recorded, this system displayed the image annotations automatically. Compared with the conventional manual annotation method, this new annotation system has higher accuracy as indicated by the phantom test results. In addition, this new annotation method has good repeatability, with intra-class correlation coefficients of 0.907 (average variation: ≤3.45%) and 0.937 (average variation: ≤2.85%) for the intra-rater and inter-rater tests, respectively. Breast phantom experiments simulating clinical breast scanning further indicated the feasibility of this system for clinical applications. This new annotation method is expected to facilitate more accurate, intuitive and rapid breast ultrasound diagnosis.

Qualitative assessment of breast cancer early detection services provided through well woman clinics in the district of Gampaha in Sri Lanka

BACKGROUND

Breast cancer is the most common cancer diagnosed among women in Sri Lanka. Early detection can lead to reduction in morbidity and mortality. The objective here was to identify perceptions of public health midwives (PHMs) on the importance of early detection of breast cancer and deficiencies of and suggestions on improving existing breast cancer early detection services provided through Well Woman Clinics.

MATERIALS AND METHODS

A qualitative study using four focus group discussions (FGDs) were conducted among 38 PHMs in the Gampaha district in Sri Lanka and the meetings were audio-recorded, transcribed and analyzed using constant comparison and identifying themes and categories.

RESULTS

All the PHMs had a firm realization on the need of breast cancer early detection. The four FGDs among PHMs revealed non-availability of guidelines, inadequacy of training, lack of skills and material to provide health education, inability to provide privacy during clinical examination, shortage of stationery, lack of community awareness and motivation. The suggestions for the improvements of the programme identified in FGDs were capacity building of PHMs, making availability of guidelines, rescheduling clinics, improving the supervision, strengthening the monitoring, improving coordination between clinical and preventive sectors, and improving community awareness.

CONCLUSIONS

Results of the FGDs can provide useful information on components to be improved in breast cancer early detection services. Study recommendations were training programmes at basic and post basic levels on a regular basis and supervision for the sustainance of the breast cancer early detection program.

Transcriptional regulation prediction of antiestrogen resistance in breast cancer based on RNA polymerase II binding data

Background

Although endocrine therapy impedes estrogen-ER signaling pathway and thus reduces breast cancer mortality, patients remain at continued risk of relapse after tamoxifen or other endocrine therapies. Understanding the mechanisms of endocrine resistance, particularly the role of transcriptional regulation is very important and necessary.

Methods

We propose a two-step workflow based on linear model to investigate the significant differences between MCF7 and OHT cells stimulated by 17β-estradiol (E2) respect to regulatory transcription factors (TFs) and their interactions. We additionally compared predicted regulatory TFs based on RNA polymerase II (PolII) binding quantity data and gene expression data, which were taken from MCF7/MCF7+E2 and OHT/OHT+E2 cell lines following the same analysis workflow. Enrichment analysis concerning diseases and cell functions and regulatory pattern analysis of different motifs of the same TF also were performed.

Results

The results showed PolII data could provide more information and predict more recognizably important regulatory TFs. Large differences in TF regulatory mode were found between two cell lines. Through verified through GO annotation, enrichment analysis and related literature regarding these TFs, we found some regulatory TFs such as AP-1, C/EBP, FoxA1, GATA1, Oct-1 and NF-κB, maintained OHT cells through molecular interactions or signaling pathways that were different from the surviving MCF7 cells. From TF regulatory interaction network, we identified E2F, E2F-1 and AP-2 as hub-TFs in MCF7 cells; whereas, in addition to E2F and E2F-1, we identified C/EBP and Oct-1 as hub-TFs in OHT cells. Notably, we found the regulatory patterns of different motifs of the same TF were very different from one another sometimes.

Conclusions

We inferred some regulatory TFs, such as AP-1 and NF-κB, cooperated with ER through both genomic action and non-genomic action. The TFs that were involved in both protein-protein interactions and signaling pathways could be one of the key resistant mechanisms of endocrine therapy and thus also could be new treatment targets for endocrine resistance. Our flexible workflow could be integrated into an existing analytical framework and guide biologists to further determine underlying mechanisms in human diseases.

Does a continuous local anaesthetic pain treatment after immediate tissue expander reconstruction in breast carcinoma patients more efficiently reduce acute postoperative pain--a prospective randomised study

Background

Immediate breast reconstruction with an expander is a reasonable option for properly selected patients. After reconstruction, patients have severe postoperative pain, which responds poorly to opioids. Our aim was to evaluate if continuous wound infusion of a local anaesthetic into the surgical wound reduces postoperative pain, consumption of opioids and incidence of chronic pain compared to standard intravenous piritramide after primary breast reconstruction in breast carcinoma patients.

Methods

Altogether, 60 patients were enrolled in our study; one half in the group with wound infusion of a local anaesthetic, and the other half in the standard (piritramide) group. Parameters measured included: pain intensity (visual analogue scale), drug requirements, alertness, hospitalisation, side-effects and late complications. A p-value of < 0.05 was considered statistically significant.

Results

In the recovery room, the test group reported less acute pain at rest (P = 0.03) and at activity (P = 0.01), and on the day of the surgical procedure they reported less pain at activity (P = 0.003). Consumption of piritramide and metoclopramide was lower in this group (P < 0.0001), but their alertness after the surgical procedure was higher compared to the standard group (P < 0.001). After three months, the test group reported less chronic pain (P = 0.01).

Conclusions

After primary tissue expander breast reconstruction, wound infusion of a local anaesthetic significantly reduces acute pain and enables reduced opioid consumption, resulting in less postoperative sedation and reduced need for antiemetic drugs. Wound infusion of a local anaesthetic reduces chronic pain.

Management of gastric cancer in Asia: resource-stratified guidelines

Gastric cancer is the fourth most common cancer globally, and is the second most common cause of death from cancer worldwide. About three-quarters of newly diagnosed cases in 2008 were from Asian countries. With a high mortality-to-incidence ratio, management of gastric cancer is challenging. We discuss evidence for optimum management of gastric cancer in aspects of screening and early detection, diagnosis, and staging; endoscopic and surgical intervention; and the concepts of perioperative, postoperative, and palliative chemotherapy and use of molecularly targeted therapy. Recommendations are formulated on the basis of the framework provided by the Breast Health Global Initiative, using the categories of basic, limited, enhanced, and maximum level. We aim to provide a stepwise strategy for management of gastric cancer applicable to different levels of health-care resources in Asian countries.

Management of B-cell non-Hodgkin lymphoma in Asia: resource-stratified guidelines

Treatment of B-cell non-Hodgkin lymphomas has undergone substantial developments in the past 10 years. The introduction of rituximab has greatly improved survival outcomes in patients. Clinical practice guidelines based on current evidence have been developed to provide recommendations for standard treatment approaches. However, guidelines do not take into account resource limitations in resource-poor countries. The huge disparities in economy, health-care infrastructure, and access to novel drugs between Asian countries can hinder the delivery of optimum care to patients with lymphoma in Asia. We outline guidelines appropriate to different levels of health-care resources and expertise, aiming to provide advice on diagnosis and treatment, unify interpretation of results, and allow the design of future studies in Asia. In this resource-adapted consensus, we summarise recommendations for diagnosis, staging, risk stratification, and treatment of common B-cell non-Hodgkin lymphomas in Asia.

Management of prostate cancer in Asia: resource-stratified guidelines from the Asian Oncology Summit 2013

Many local and systemic options for prostate cancer have emerged in recent years, but existing management guidelines do not account for diversity in health resources between different countries. We present recommendations for the management of prostate cancer, stratified according to the extent of resource availability-based on a four-tier system of basic, limited, enhanced, and maximum resources-to enable applicability to Asian countries with differing levels of health-care resources. This statement of recommendations was formulated by a multidisciplinary panel from Asia-Pacific countries, at a consensus session on prostate cancer that was held as part of the 2013 Asian Oncology Summit in Bangkok, Thailand.

Management of multiple myeloma in Asia: resource-stratified guidelines

Treatment of multiple myeloma has undergone substantial developments in the past 10 years. The introduction of novel drugs has changed the treatment of the disease and substantially improved survival outcomes. Clinical practice guidelines based on evidence have been developed to provide recommendations on standard treatment approaches. However, the guidelines do not take into account resource limitations encountered by developing countries. The huge disparities in economy, health-care infrastructure, and access to novel drugs in Asian countries hinder the delivery of optimum care to every patient with multiple myeloma in Asia. In this Review we outline the guidelines that correspond with different levels of health-care resources and expertise, with the aim to unify diagnostic and therapeutic guidelines and help with the design of future studies in Asia.

TNBC vs. Non-TNBC: A Five-Year Retrospective Review of Differences in Mean Age, Family History, Smoking History and Stage at Diagnosis at an Inner City University Program

BACKGROUND

In recent years, breast cancer has been classified on the basis of estrogen or progesterone receptor (ER/PR) status and whether the human epidermal growth factor 2 receptor (HER2/neu) protein is overexpressed. Based on this system, breast cancer is broadly divided into the triple negative breast cancer (TNBC) and the non-TNBC subtypes. TNBC is a subtype of breast cancer, notable for its propensity to metastasize early and display a comparatively more aggressive course than its non-TNBC counterpart. Certain clinico-pathologic and demographic risk factors have been associated with breast cancer. In this study, we aim to compare mean age, ethnicity, family history, tobacco use and stage at presentation between TNBC and non-TNBC subtypes at our inner city university program.

METHODS

We reviewed data in our tumor registry between January 2000 and December 2005 with particular attention to mean age, race, family history, tobacco use and stage at presentation. We found a total of 445 patients with various subtypes of breast cancers. We included only those patients in whom the status of both ER/PR and the status of Her2/neu protein overexpression were recorded. Our strict selection criteria lead to an exclusion of about 103 patients. Out of the remaining 342 patients, 39 were TNBC and 303 were non-TNBC.

RESULTS

Mean age of onset for TNBC vs. non-TNBC patients was 59.87 ± 15.67 years vs. 60.09 ± 13.98 years respectively (P = 0.9272). In terms of ethnicity, TNBC vs. non-TNBC patients had the following racial backgrounds: black, 58.97% vs. 39.27%; white, 35.90% vs. 57.76%; Chinese, 2.56% vs. 0.99%; others, 2.57% vs. 1.98% respectively (P = 0.004, OR = 2.755). Comparisons with respect to a history of tobacco abuse for TNBC vs. non-TNBC patients revealed a positive smoking history in 20.51% vs. 27.72% whereas there was no former or current smoking history in 71.79% vs. 61.72% respectively (P = 0.4385). Comparison of family history of a breast cancer in TNBC vs. non-TNBC patients showed that positive family history of breast cancer was seen in 30.77% vs. 33.33%, no family history of cancer was seen in 51.28% vs. 51.82% and unknown 17.95% vs. 14.85% (P = 0.8384). Pathologic stage at the time of diagnosis for TNBC vs. non-TNBC patients was as follows: stage 0, 15.79% vs. 11.37% (P = 0.4332); stage 1, 34.21% vs. 30.98% (P = 0.6890); stage 2, 28.98% vs. 37.25% (P = 0.3205); stage 3, 18.42% vs. 17.25% (P = 0.0.8591); and stage 4, 3.63% vs. 3.14% (P = 0.8651). Analysis using Chi-square test revealed χ2 value of 0.855.

CONCLUSION

Our results add to the growing body of evidence pertaining to the association of certain demographic and clinico-pathologic characteristics in women with breast cancer. We found that in our patient population, there is a significant ethnic predisposition for the two types of breast cancers that we studied. African Americans were more likely to have TNBC compared to the higher frequency of non-TNBC in white females. We did not find a significant difference in mean age, cigarette smoking, family history and stage at diagnosis between the TNBC and non-TNBC breast cancer patients. These findings are all consistent with the previously published research studies.

Breast cancer in young women in Latin America: an unmet, growing burden

Breast cancer (BC) is the leading cause of malignancy-related deaths among women aged ≤45 years. There are unexplored and uncertain issues for BC in this particular group in Latin America. The aim of this study is to evaluate BC incidence and mortality among young women and related clinicopathological and survivorship aspects in this region.

MATERIALS AND METHODS

Data were obtained from Globocan 2008 and the International Agency for Research on Cancer's Cancer Incidence in Five Continents series plus databases. We requested collaboration from the 12 different national cancer institutes in Latin America through SLACOM, the Latin American and Caribbean Society of Medical Oncology, and conducted a systematic literature review to obtain local data regarding the prevalence of BC among young women and their characteristics, outcomes, and survivorship-related issues.

RESULTS

BC incidence and mortality proportions for Latin American women aged <44 years were higher when compared with those of developed countries (20% vs. 12% and 14% vs. 7%, respectively). We found only a few Latin American series addressing this topic, and prevalence varied between 8% and 14%. Stage II and III disease, high histological grade, and triple-negative and HER2 BC were features frequently observed among young Latin American BC patients.

CONCLUSION

The rising incidence and mortality of BC in young Latin American women is a call to action in the region. It is necessary to monitor the epidemiological and clinical data through reliable cancer registries and to consider the implementation of protocols for education of patients and health professionals. This unmet, growing burden must be considered as a top priority of the national programs in the fight against BC, and models of specialized units should be implemented for this particular group of patients to provide better care for this emergent challenge.

Management of adult and paediatric acute lymphoblastic leukaemia in Asia: resource-stratified guidelines from the Asian Oncology Summit 2013

Survival for adults and children with acute lymphoblastic leukaemia has risen substantially in recent years because use of improved risk-directed treatments and supportive care has widened. In nearly all developed countries, multidisciplinary panels of leukaemia experts have formulated clinical practice guidelines in which standard treatment approaches are recommended on the basis of current evidence. However, those guidelines do not take into account resource limitations in low-income countries, including financial and technical challenges. In Asia, huge disparities in economy and infrastructure exist between countries, and even among different regions in some large countries. At a consensus session held as part of the 2013 Asian Oncology Summit in Bangkok, Thailand, a panel of experts summarised recommendations for management of adult and paediatric acute lymphoblastic leukaemia. Strategies were developed for Asian countries on the basis of available financial, skill, and logistical resources and were stratified in a four-tier system according to the resources available in a particular country or region (basic, limited, enhanced, and maximum).

The effectiveness of an abbreviated training program for health workers in breast cancer awareness: innovative strategies for resource constrained environments

Background

Breast cancer is characterized by late presentation and significant morbidity and mortality in developing countries. Breast screening aids in early detection of breast cancer. Nurses are uniquely placed to provide advocacy and screening in a resource limited environment.

Objectives

To assess the effectiveness of an abbreviated training program in breast cancer awareness on nurses at a tertiary hospital, in a resource constrained environment.

Methods

Using a statistical tool, the Solomon Model, 79 nurses were identified and divided into experimental and control groups. An abbreviated training intervention in breast cancer awareness was administered to the experimental group. Pre and post test questionnaires and objective structured clinical examinations were used to determine nurses’ knowledge and practice skills before and after the abbreviated training intervention.

Results

Initial scores of knowledge and practice skills related to clinical breast examination were low: Mean knowledge scores of 18 out of 25 [72%] and mean practice scores of 12.5 out of 30 [41.6%]. Significant improvement was observed following the abbreviated training intervention in both knowledge and practice skills. Knowledge scores of 22 out of 25 [88%, p = < 0.001] and practice scores of 26 out of 30 [86.6%, p=0.003]. Trained nurses were able to improve their knowledge of breast cancer from fair to good knowledge.

Conclusion

There is need to increase breast awareness, both in terms of knowledge and practice skills, in nurses as a means of improving awareness among the general population and early detection of breast cancer. An abbreviated training in breast cancer awareness can improve these skills in nurses.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-2-528) contains supplementary material, which is available to authorized users.

Supportive care during treatment for breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer patients may have unmet supportive care needs during treatment, including symptom management of treatment-related toxicities, and educational, psychosocial, and spiritual needs. Delivery of supportive care is often a low priority in low- and middle-income settings, and is also dependent on resources available. This consensus statement describes twelve key recommendations for supportive care during treatment in low- and middle-income countries, identified by an expert international panel as part of the 5th Breast Health Global Initiative (BHGI) Global Summit for Supportive Care, which was held in October 2012, in Vienna, Austria. Panel recommendations are presented in a 4-tier resource-stratified table to illustrate how health systems can provide supportive care services during treatment to breast cancer patients, starting at a basic level of resource allocation and incrementally adding program resources as they become available. These recommendations include: health professional and patient and family education; management of treatment related toxicities, management of treatment-related symptoms of fatigue, insomnia and non-specific pain, and management of psychosocial and spiritual issues related to breast cancer treatment. Establishing supportive care during breast cancer treatment will help ensure that breast cancer patients receive comprehensive care that can help 1) improve adherence to treatment recommendations, 2) manage treatment-related toxicities and other treatment related symptoms, and 3) address the psychosocial and spiritual aspects of breast cancer and breast cancer treatments.

'Suspect molecular signature' in blood as the indicator of undiagnosed breast cancer, cancer risk and targeted prevention

BACKGROUND

Breast cancer is a multifactorial disease with the highest incidence rates amongst all cancer types. Further, high levels of circulating tumour cells are a characteristic of breast cancer patients demonstrating a particular predisposition to the development of breast cancer metastatic disease. Actual diagnostic approaches are frequently unable to recognise early stages of tumour development which impairs individual outcomes. In contrast, predictive and preventive risk assessment and early diagnosis may lead to full recovery after surgical resection. Recently, the authors have reported about the construction of diagnostic windows, which could influence the molecular diagnostics of breast cancer.

MATERIAL AND METHODS

In a previous study, diagnostic windows for breast cancer risk assessment were analysed. Women with non-malignant breast diseases demonstrating molecular profiles similar to those of breast cancer patients were enrolled into this follow-up study. In the interviews, for patients identified as predisposed to cancer, a specialised questionnaire has been set up to characterise individual risk factors and estimate their potential impacts on cancer onset and progression.

RESULTS AND CONCLUSIONS

By utilising the technological tool of diagnostic windows, 13 individuals have been identified demonstrating molecular profiles typical for patients diagnosed with breast cancer. The current paper summarises the analytical results and makes statements to the application of the pathology-specific molecular profiles recognised as the technological tool for improved diagnostic approach, breast cancer risk assessment and preventive health care management. The necessity to create individual patient profiles and analyse the evolution of the molecular signature is justified for advanced medical services. Expert recommendations are provided to promote further developments in the field of advanced breast cancer management.

Alpha cyano-4-hydroxy-3-methoxycinnamic acid inhibits proliferation and induces apoptosis in human breast cancer cells

This study investigated the underlying mechanism of 4-hydroxy-3-methoxycinnamic acid (ACCA), on the growth of breast cancer cells and normal immortal epithelial cells, and compared their cytotoxic effects responses. Treatment of breast cancer cells (MCF-7, T47D, and MDA-231) with ACCA resulted in dose- and time-dependent decrease of cell proliferation, viability in colony formation assay, and programmed cell death (apoptosis) with minimal effects on non-tumoral cells. The ability of ACCA to suppress growth in cancer cells not expressing or containing defects in p53 gene indicates a lack of involvement of this critical tumor suppressor element in mediating ACCA-induced growth inhibition. Induction of apoptosis correlated with an increase in Bax protein, an established inducer of programmed cell death, and the ratio of Bax to Bcl-2, an established inhibitor of apoptosis. We also documented the ability of ACCA to inhibit the migration and invasion of MDA-231 cells with ACCA in vitro. Additionally, tumor growth of MDA-231 breast cancer cells in vivo was dramatically affected with ACCA. On the basis of its selective anticancer inhibitory activity on tumor cells, ACCA may represent a promising therapeutic drug that should be further evaluated as a chemotherapeutic agent for human breast cancer.

Planning cancer control in Latin America and the Caribbean

Non-communicable diseases, including cancer, are overtaking infectious disease as the leading health-care threat in middle-income and low-income countries. Latin American and Caribbean countries are struggling to respond to increasing morbidity and death from advanced disease. Health ministries and health-care systems in these countries face many challenges caring for patients with advanced cancer: inadequate funding; inequitable distribution of resources and services; inadequate numbers, training, and distribution of health-care personnel and equipment; lack of adequate care for many populations based on socioeconomic, geographic, ethnic, and other factors; and current systems geared toward the needs of wealthy, urban minorities at a cost to the entire population. This burgeoning cancer problem threatens to cause widespread suffering and economic peril to the countries of Latin America. Prompt and deliberate actions must be taken to avoid this scenario. Increasing efforts towards prevention of cancer and avoidance of advanced, stage IV disease will reduce suffering and mortality and will make overall cancer care more affordable. We hope the findings of our Commission and our recommendations will inspire Latin American stakeholders to redouble their efforts to address this increasing cancer burden and to prevent it from worsening and threatening their societies.

Challenges in the management of breast cancer in low- and middle-income countries

The incidence of breast cancer is rising in low- and middle-income countries (LMICs) due to 'westernization' of risk factors for developing breast cancer. However, survival remains low because of barriers in early detection and optimal access to treatment, which are the two main determinants of breast cancer outcome. A multidisciplinary approach to treatment gives the best results. An accurate diagnosis is dependent on a reliable pathology service, which will provide an adequate pathology report with prognostic and predictor information to allow optimal oncological treatment. Stratification of clinical practice guidelines based on resource level will ensure that women will have access to treatment even in a low-resource setting. Advocacy and civil society play a role in galvanizing the political will required to meet the challenge of providing opportunities for breast cancer control in LMICs. Collaboration between high-income countries and LMICs could be a strategy in facing these challenges.

Supportive, palliative, and end-of-life care for patients with cancer in Asia: resource-stratified guidelines from the Asian Oncology Summit 2012

The burden of cancer in Asia is high; 6·1 million new cases were diagnosed in the continent in 2008, which accounted for 48% of new cases worldwide. Deaths from cancer are expected to continue to rise because of ageing populations and modifiable risk factors such as tobacco and alcohol use, diet, and obesity. Most patients who are diagnosed with cancer in Asia have advanced disease that is not amenable to curative treatment, which means that they are likely to have pain and other symptoms and psychosocial concerns. These burdens vary with the economic and political situation of the different countries and are affected by such factors as an absence of screening programmes, insufficient cancer diagnostic and treatment services (especially in sparsely populated and rural areas), legal restrictions on access to drugs to relieve pain, and a medical culture in which quality-of-life considerations are undervalued in relation to imperatives to treat. These issues could be ameliorated by increased investment in cancer screening, removal of restrictions on prescription of opioids, and improvements in medical education to increase recognition of treatment futility. Supportive, palliative, and end-of-life care offer the potential to enhance quality of life, improve pain control, and reduce suffering for patients with cancer and their families, and to give patients a dignified death. All patients should have access to such care-in resource-rich regions these services should be integrated into oncology services, whereas in resource-poor regions they should be the main focus of treatment. The form of care should depend on the economic circumstances within and across countries, and recommendations are made across four resource classifications (basic to maximal) to take account of the diversity of settings in Asia.

Management of colon cancer: resource-stratified guidelines from the Asian Oncology Summit 2012

Colon cancer is seen with increasing frequency in the Asia-Pacific region, and it is one of the most important causes of cancer mortality worldwide. This article reviews the available evidence for optimum management of colon cancer-in particular, with respect to screening and early detection of colon cancer, laparoscopic surgical treatment, adjuvant treatment of individuals with high-risk stage II and stage III cancer, palliative treatment of patients with metastatic disease, and management of resectable and potentially resectable metastases-and how these strategies can be applied in Asian countries with different levels of health-care resources and economic development, stratified by basic, limited, enhanced, and maximum resource levels.