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

Sensors Based on Molecularly Imprinted Polymers in the Field of Cancer Biomarker Detection: A Review

Biomarkers play a pivotal role in the screening, diagnosis, prevention, and post-treatment follow-up of various malignant tumors. In certain instances, identifying these markers necessitates prior treatment due to the complex nature of the tumor microenvironment. Consequently, advancing techniques that exhibit selectivity, specificity, and enable streamlined analysis hold significant importance. Molecularly imprinted polymers (MIPs) are considered synthetic antibodies because they possess the property of molecular recognition with high selectivity and sensitivity. In recent years, there has been a notable surge in the investigation of these materials, primarily driven by their remarkable adaptability in terms of tailoring them for specific target molecules and integrating them into diverse analytical technologies. This review presents a comprehensive analysis of molecular imprinting techniques, highlighting their application in developing sensors and analytical methods for cancer detection, diagnosis, and monitoring. Therefore, MIPs offer great potential in oncology and show promise for improving the accuracy of cancer screening and diagnosis procedures.

Factors Influencing Time From Diagnosis to Treatment of Breast Cancer and the Impact of Longer Waiting Time on Survival in Kathmandu Valley, Nepal: A Population-Based Study

PURPOSE

Longer time between breast cancer (BC) diagnosis and treatment initiation is associated with poorer survival, and this may be a factor behind disparities in global survival rates. We assessed time to BC treatment in the Kathmandu Valley, Nepal, including factors associated with longer waiting times and their impact on survival.

METHODS

We conducted a retrospective population-based study of BC cases recorded in the Kathmandu Valley Population-Based Cancer Registry between 2018 and 2019. Fieldwork survey through telephone was undertaken to collect additional sociodemographic and clinical information. Logistic regression was performed to identify factors associated with longer time to treatment, and Kaplan-Meier and Cox proportional hazard regression was used to examine survival time and evaluate the association between longer time to treatment and survival.

RESULTS

Among the 385 patients with BC, one third waited >4 weeks from diagnosis to initial treatment. Lower education was associated with longer time to treatment (adjusted odds ratio, 1.63 [95% CI, 1.03 to 2.60]). The overall 3-year survival rate was 88.6% and survival was not associated with time to treatment (P = .50). However, advanced stage at diagnosis was associated with poorer survival (adjusted hazard ratio, 4.09 [95% CI, 1.27 to 13.23]). There was some indication that longer time to treatment was associated with poorer survival for advanced-stage patients, but data quality limited that analysis.

CONCLUSION

In the Kathmandu Valley, Nepal, women with a lower education tend to wait longer from BC diagnosis to treatment. Patients with advanced-stage BC had poorer survival, and longer waiting time may be associated with poorer survival for women diagnosed with advanced-stage disease.

Cancer Care Disparities: Overcoming Barriers to Cancer Control in Low- and Middle-Income Countries

The rising global burden of cancer disproportionately affects low- and middle-income countries (LMICs), which account for over half of new patients and cancer deaths worldwide. However, LMIC health systems face profound challenges in implementing comprehensive cancer control programs because of limited health care resources and infrastructure. This analytical review explores contemporary evidence on barriers undermining cancer control efforts in resource-constrained LMIC settings. We conducted a comprehensive literature review of peer-reviewed evidence on cancer control challenges and solutions tailored to resource-limited settings. We provide a conceptual framework categorizing these barriers across the cancer care continuum, from raising public awareness to palliative care. We also appraise evidence-based strategies proposed to overcome identified obstacles to cancer control in the published literature, including task-shifting to nonspecialist health workers, strategic prioritization of high-impact interventions, regional collaborations, patient navigation systems, and novel financing mechanisms. Developing strong primary care delivery platforms integrated with specialized oncology care, alongside flexible and resilient health system models tailored to local contexts, will be critical to curb the rising tide of cancer in resource-limited settings. Urgent global commitments and investments are needed to dismantle barriers and expand access to prevention, early detection, diagnosis, treatment, and palliation services for all patients with cancer residing in LMICs as an ethical imperative. The review elucidates priority areas for policy actions, health systems strengthening, and future research to guide international efforts toward more equitable cancer control globally.

Development of a model to predict the age at breast cancer diagnosis in a global population

Knowing the mean age at diagnosis of breast cancer (BC) in a country is important for setting up an efficient BC screening program. The aim of this study was to develop and validate a model to predict the mean age at diagnosis of BC at the country level. To develop the model, we used the CI5plus database from the IARC, which contains incidence data for 122 selected populations for a minimum of 15 consecutive years from 1993 to 2012 and data from the World Bank. The standard model was fitted with a generalized linear model with the age of the population, growth domestic product per capita (GDPPC) and fertility rate as fixed effects and continent as a random effect. The model was validated in registries of the Cancer Incidence in Five Continents that are not included in the CI5plus database (1st validation set: 1950-2012) and in the most recently released volume (2nd validation set: 2013-2017). The intercept of the model was 30.9 (27.8-34.1), and the regression coefficients for population age, GDPPC and fertility rate were 0.55 (95% CI: 0.53-0.58, p < 0.001), 0.46 (95% CI: 0.26-0.67, p < 0.001) and 1.62 (95% CI: 1.42-1.88, p < 0.001), respectively. The marginal R2 and conditional R2 were 0.22 and 0.81, respectively, suggesting that 81% percent of the variance in the mean age at diagnosis of BC was explained by the variance in population age, GDPPC and fertility rate through linear relationships. The model was highly accurate, as the correlations between the predicted age from the model and the observed mean age at diagnosis of BC were 0.64 and 0.89, respectively, and the mean relative error percentage errors were 5.2 and 3.1% for the 1st and 2nd validation sets, respectively. We developed a robust model based on population age and continent to predict the mean age at diagnosis of BC in populations. This tool could be used to implement BC screening in countries without prevention programs.

An analytical framework for breast cancer public policies in Sub-Saharan Africa: results from a comprehensive literature review and an adapted policy Delphi

BACKGROUND

Breast cancer is the leading cause of death from cancer in women and is a major public health problem worldwide. Despite the lower incidence rates of breast cancer in resource-limited settings, especially sub-Saharan Africa, there is a higher mortality rate compared to high-resource countries where the disease has a higher incidence. This makes breast cancer the second deadliest cancer in African women. These poor results reflect the weakness in public health policies. The aim of this paper is to contribute to the effective control of breast cancer by designing a framework for a comprehensive and systemic analysis of these policies in Sub-Saharan Africa.

METHODS

This research is based on a literature review that adopted a systematic approach followed by a modified policy Delphi involving breast cancer experts in Sub-Saharan Africa. We included narrative reviews and systematic reviews/meta-analyses published between 2015 and 2022 as well as official documents in the analysis. We integrated the World Health Organization's health system building blocks with Walt and Gilson's policy analysis triangle to analyse the information collected and develop our analytical framework.

RESULTS

A total of 22 reviews and documents were included in the study. Sixteen breast cancer experts from Sub-Saharan Africa participated in the first Delphi round, and nine participated in the second round. The different components identified for a comprehensive and systemic analysis of effective breast cancer policies can be classified into policy content divided according to the health system building blocks and related policy processes; individual, organized national and international policy stakeholders; and policy contexts.

CONCLUSION

This study enabled the design of a framework suitable for the comprehensive and systemic analysis of breast cancer control policies in Sub-Saharan Africa. This framework can be used as a checklist for stakeholders to guide the planning, implementation and evaluation of policies and specific breast cancer control programmes at the national and facility levels.

Current practices and challenges in genetic testing and counseling for women with breast and ovarian cancer in Asia

AIM

This study assesses current practices and challenges in genetic testing and counseling (GT and C) for breast cancer gene (BRCA)1/2 mutations in Asia, considering the increased risk of ovarian cancer (OC) and breast cancer (BC) in women carrying these mutations.

METHODS

Insights were gathered through a questionnaire from breast surgeons, gynecologists, oncologists, and genetic clinicians in 10 Asian countries: Thailand, Hong Kong, South Korea, India, Vietnam, Malaysia, the Philippines, Taiwan, Singapore, and Indonesia. The questionnaire covered their knowledge, attitudes, and practices in GT and C for BRCA1/2 mutations, along with information on perceived gaps and unmet needs in the region.

RESULTS

A total of 61 specialists participated in the survey. GT and C for BRCA1/2 mutations were less frequently offered in Asia compared to Western countries. Among the guidelines used, the National Comprehensive Cancer Network (NCCN) guidelines alone or in combination with other guidelines (American Society of Clinical Oncology [ASCO], National Institute for Health and Clinical Excellence [NICE], and European Society for Medical Oncology [ESMO]) were preferred for both BC and OC. Limited access to genetic counselors posed a significant challenge, resulting in delayed or no GT. Pretest genetic counseling was provided by the respondents themselves. Germline testing was preferred for BC, whereas both germline and somatic testing were preferred for OC, with the most preferred option being a multipanel germline test.

CONCLUSION

Disparities exist in GT and C practices between Asian and Western countries. To address this, steps, such as patient and doctor education, increased accessibility and affordability of GT and C services, and improved infrastructure for identifying gene mutations, should be taken.

Using Portuguese BRCA pathogenic variation as a model to study the impact of human admixture on human health

BACKGROUND

Admixture occurs between different ethnic human populations. The global colonization in recent centuries by Europeans led to the most significant admixture in human history. While admixture may enhance genetic diversity for better fitness, it may also impact on human health by transmitting genetic variants for disease susceptibility in the admixture population. The admixture by Portuguese global exploration initiated in the 15th century has reached over 20 million of Portuguese-heritage population worldwide. It provides a valuable model to study the impact of admixture on human health. BRCA1 and BRCA2 (BRCA) are two of the important tumor suppressor genes. The pathogenic variation (PV) in BRCA is well determined to cause high risk of hereditary breast and ovarian cancer. Tracing the distribution of Portuguese BRCA PV in Portuguese-heritage population will help to understand the impact of admixture on cancer susceptibility in modern humans. In this study, we analyzed the distribution of the Portuguese-originated BRCA variation in Brazilian population, which has high degree Portuguese-heritage.

METHODS

By comprehensive data mining, standardization and annotation, we generated a Portuguese-derived BRCA variation dataset and a Brazilian-derived BRCA variation dataset. We compared the two BRCA variation datasets to identify the BRCA variants shared between the two populations.

RESULTS

The Portuguese-derived BRCA variation dataset consists of 220 BRCA variants including 78 PVs from 11,482 Portuguese cancer patients, 93 (42.2%) in BRCA1 and 127 (57.7%) in BRCA2. Of the 556 Portuguese BRCA PV carriers carrying the 78 PVs, 331 (59.5%) carried the three Portuguese-BRCA founder PVs of BRCA1 c.2037delinsCC, BRCA1 c.3331_3334del and BRCA2 c.156_157insAlu. The Brazilian-derived BRCA variation dataset consists of 255 BRCA PVs from 7,711 cancer patients, 136 (53.3%) in BRCA1 and 119 (46.6%) in BRCA2. We developed an open database named dbBRCA-Portuguese ( https://genemutation.fhs.um.edu.mo/dbbrca-portuguese/ ) and an open database named dbBRCA-Brazilian ( https://genemutation.fhs.um.edu.mo/dbbrca-brazilian ) to host the BRCA variation data from Portuguese and Brazilian populations. We compared the BRCA PV datasets between Portuguese and Brazilian populations, and identified 29 Portuguese-specific BRCA PVs shared between Portuguese and Brazilian populations, 14 in BRCA1 including the Portuguese founder BRCA1 c.3331_3334del and BRCA1 c.2037delinsCC, and 15 in BRCA2 including the Portuguese founder BRCA2 c.156_157insAlu. Searching the 78 Portuguese BRCA PVs in over 5,000 ancient human genomes identified evolution origin for only 8 PVs in Europeans dated between 37,470 and 3,818 years before present, confirming the Portuguese-specificity of Portuguese BRCA PVs; comparing the 78 Portuguese BRCA PVs Portuguese, 255 Brazilian BRCA PVs, and 134 African BRCA PVs showed little overlapping, ruling out the possibility that the BRCA PVs shared between Portuguese and Brazilian may also be contributed by African.

CONCLUSION

Our study provides evidence that the admixture in recent human history contributed to cancer susceptibility in modern humans.

C. SP, Giri S, Dulal BP, Joshi D, Gautam G, Baral SC. Factors associated with uptake of breast and cervical cancer screening among Nepalese women: Evidence from Nepal Demographic and Health Survey 2022

Breast cancer screening (BCS) and cervical cancer screening (CCS) are integral parts of initiatives to reduce the burden associated with these diseases. In this context, we aimed to determine factors associated with BCS and CCS uptake among Nepalese women aged 30 to 49 years using data from the Nepal Demographic Health Survey (NDHS) 2022. We performed a weighted analysis to account complex survey design of the NDHS 2022. We employed univariable and multivariable logistic regression to determine factors associated with the uptake of BCS and CCS and results were presented as crude odds ratio and adjusted odds ratio (AOR) along with 95% confidence interval (CI). The uptake of BCS and CCS among Nepalese women aged 30 to 49 years were 6.5% and 11.4% respectively. Women from Terai compared to mountain region (AOR = 0.54, 95%CI: 0.31, 0.93) and those engaged in agriculture compared to non-working (AOR = 0.59, 95%CI: 0.42, 0.82) women had lower odds of BCS uptake. Conversely, Dalit women compared to Brahmin/Chhetri (AOR = 2.08, 95%CI: 1.37, 3.16), and women with basic (AOR = 1.49, 95%CI: 1.04, 2.13), secondary (AOR = 1.96, 95%CI: 1.33, 2.88), and higher education (AOR = 2.80, 95% CI: 1.51, 5.19) compared to those with no education had higher odds of BCS uptake. Women from rural areas (AOR = 0.76, 95%CI: 0.61, 0.96), and those living in Bagmati (AOR = 2.16, 95% CI: 1.44, 3.23) and Gandaki (AOR = 2.09, 95%CI: 1.40, 3.14) provinces had higher odds of CCS uptake compared to their urban counterparts and those living in Koshi province, respectively. The odds of CCS increased with age (AOR = 1.06, 95%CI: 1.04, 1.08). Women with secondary education (AOR = 1.47, 95%CI: 1.06, 2.04) had higher odds of CCS uptake compared to those without education. Similarly, married women (AOR = 8.24, 95%CI: 1.03, 66.21), and those with health insurance (AOR = 1.41, 95%CI: 1.08, 1.83) had higher odds of CCS. In conclusion, the uptake of both BCS and CCS was relatively poor among Nepalese women indicating a need for targeted and tailored intervention to increase BCS and CCS uptake.

Comprehensive Review of Breast Cancer Consequences for the Patients and Their Coping Strategies: A Systematic Review

BACKGROUND

Women with breast cancer usually face multiple short-term and long-term problems in dealing with their acute and chronic symptoms during and after cancer treatment. However, serious gaps remain in addressing these issues in clinical and public health practice.

METHODS

According to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we conducted a systematic literature search from 2000-2021 in electronic databases, including Medline, PubMed, Embase, Scopus, Web of Knowledge, and Google Scholar databases using predefined keywords.

RESULTS

The review identified several significant and interconnected problems in breast cancer patient's treatment and supportive care. The results revealed that these issues are very common among breast cancer patients, and specific attention and serious measures are needed to address these problems. Despite implementing different protocols and programs for covering and addressing these problems, serious gaps still exist in supporting breast cancer patients during clinical and follow-up care.

CONCLUSION

Developing innovative and holistic approaches and programs based on the multifactorial assessment of symptoms are suggested for addressing and covering the multidimensional requirements of this population. Consequently, thorough evaluation, education, treatment, and referrals should be provided for the most common sequelae of these patients by including appropriate medication, exercise, counselling, occupational therapy, and complementary therapies. The present study provides a more comprehensive source of information about breast cancer patient's medical and supportive needs in comparison with individual studies on symptom experiences.

Regional Collaboration and Trends in Clinical Management of Thyroid Cancer

OBJECTIVE

This study examines the trends in the management of thyroid cancer and clinical outcomes in the Southwestern region of The Netherlands from 2010 to 2021, where a regional collaborative network has been implemented in January 2016.

STUDY DESIGN

Retrospective cohort study.

SETTING

This study encompasses all patients diagnosed with thyroid cancer of any subtype between January 2010 and June 2021 in 10 collaborating hospitals in the Southwestern region of The Netherlands.

METHODS

The primary outcome of this study was the occurrence of postoperative complications. Secondary outcomes were trends in surgical management, centralization, and waiting times of patients with thyroid cancer.

RESULTS

This study included 1186 patients with thyroid cancer. Median follow-up was 58 [interquartile range: 24-95] months. Surgery was performed in 1027 (86.6%) patients. No differences in postoperative complications, such as long-term hypoparathyroidism, permanent recurrent nerve paresis, or reoperation due to bleeding were seen over time. The percentage of patients with low-risk papillary thyroid carcinoma referred to the academic hospital decreased from 85% (n = 120/142) in 2010 to 2013 to 70% (n = 120/171) in 2014 to 2017 and 62% (n = 100/162) in 2018 to 2021 (P < .01). The percentage of patients undergoing a hemithyroidectomy alone was 9% (n = 28/323) in 2010 to 2013 and increased to 20% (n = 63/317; P < .01) in 2018 to 2021.

CONCLUSION

The establishment of a regional oncological network coincided with a de-escalation of thyroid cancer treatment and centralization of complex patients and interventions. However, no differences in postoperative complications over time were observed. Determining the impact of regional oncological networks on quality of care is challenging in the absence of uniform quality indicators.

Liposomal Nano-Based Drug Delivery Systems for Breast Cancer Therapy: Recent Advances and Progresses

Breast cancer is a highly prevalent disease on a global scale, with a 30% incidence rate among women and a 14% mortality rate. Developing countries bear a disproportionate share of the disease burden, while countries with greater technological advancements exhibit a higher incidence. A mere 7% of women under the age of 40 are diagnosed with breast cancer, and the prevalence of this ailment is significantly diminished among those aged 35 and younger. Chemotherapy, radiation therapy, and surgical intervention comprise the treatment protocol. However, the ongoing quest for a definitive cure for breast cancer continues. The propensity for cancer stem cells to metastasize and resistance to treatment constitute their Achilles' heel. The advancement of drug delivery techniques that target cancer cells specifically holds significant promise in terms of facilitating timely detection and effective intervention. Novel approaches to pharmaceutical delivery, including nanostructures and liposomes, may bring about substantial changes in the way breast cancer is managed. These systems offer a multitude of advantages, such as heightened bioavailability, enhanced solubility, targeted tumor destruction, and diminished adverse effects. The application of nano-drug delivery systems to administer anti-breast cancer medications is a significant subject of research. This article delves into the domain of breast cancer, conventional treatment methods, the incorporation of nanotechnology into managerial tactics, and strategic approaches aimed at tackling the disease at its core.

Differences in breast and cervical cancer screening between West and East Germany: a secondary analysis of a german nationwide health survey

BACKGROUND

Breast cancer and cervical cancer are among the most common cancers in women in Germany. Early detection examinations such as mammography and the cervical smear test (Pap-test) have been shown to contribute to the reduction in the mortality and/or incidence of these cancers and can be utilised free of charge by women in certain age groups as part of national screening programmes. Analyses show that the use of health services varies regionally, especially when comparing the federal states of the former German Democratic Republic (GDR, Eastern Germany) and the Federal Republic of Germany (FRG, Western Germany). This study investigated to what extent the utilisation of mammography examinations and Pap-tests by women differs in federal states of former GDR and FRG.

METHODS

For this purpose, we analysed data from the nationwide health survey GEDA14/15 conducted by the Robert Koch Institute (RKI) in 2014 and 2015. We calculated weighted proportions and compared attendance between eastern and western German states by a Chi-Square-test. Additionally, we conducted regression analysis to adjust for socio-economic status, living environment and place of birth.

RESULTS

2,772 female participants aged 20-34 years were analysed for Pap-test attendance in the last two years and 4,323 female participants aged 50-69 years old were analysed for mammography screening attendance in the last two years. 50-69-year-old women in eastern German states were with 78.3% (95%-CI 75.3%, 81.2%) more likely to attend mammography screening than in western Germany with 73.4% (95%-CI 71.8%, 74.9%). Pap-test uptake was statistically significantly higher in the East of Germany with 83.3% (95%-CI 79.6%, 87.1%) compared to 77.5% (95%-CI 75.8%, 79.3%) in the West of Germany. This relationship was robust to adjusting for socio-economic status, living environment and place of birth.

CONCLUSIONS

Cultural influences and socialization in the GDR might explain the higher utilisation of these cancer screening examinations at least to some extent. This could have many reasons, for example a higher health awareness through education or a possible greater trust in medical structures and the associated higher compliance of women. These hypotheses should be further explored to increase the uptake of screening examinations by women in Germany.

Factors associated with diagnostic and pre-treatment intervals among breast cancer patients attending care at the Uganda Cancer Institute: A cross-sectional study

BACKGROUND

Most breast cancer (BC) patients in Uganda are diagnosed with advanced-stage disease and experience poor outcomes. This study examined the diagnostic and pre-treatment intervals and factors associated with these intervals among BC patients attending care at the Uganda Cancer Institute (UCI).

METHODS

This was a cross-sectional, facility-based study. Data were collected using structured questionnaire administered by trained research assistants and analyzed using STATA version 14.0. Modified Poisson regressions models were used to determine the strength of associations between independent variables and diagnostic and pre-treatment intervals.

RESULTS

The mean age (±SD) of the 401 participants was 47.1 ± 11.7 years. Four in 10 participants had stage III (41.9%; n = 168) and over a third (34.7%; n = 140) stage IV cancers. The median interval from first consultation to diagnosis, i.e. diagnostic interval (DI) was 5.6 months (IQR: 1.5-17.0), while the median interval from histological diagnosis to start of chemotherapy, i.e. pre-treatment interval (PTI) was 1.7 months (IQR: 0.7-4.5). Majority (85%, n = 341) of participants were diagnosed at ≥3 months from first consultation with clinicians. Participants with tertiary education and those who lived within 100-199 km from the UCI were about four times and twice more likely to be diagnosed early (DI <3 months from first consultation) ([aPR = 3.88; 95% CI: 1.15-13.0] and [aPR = 2.19; 95% CI: 1.06-4.55]), respectively. About half (48.3%; n = 176) of participants started chemotherapy within 1 month of cancer diagnosis. Patients who lived more than 300 km from the UCI were less likely to start chemotherapy within 1 month of histology diagnosis of cancer. [Correction added on October 17, 2023 after first online publication. The term ', i.e.' has been included in the results section in this version.] CONCLUSION: Majority of breast cancer patients are diagnosed late and in advanced stages. There is need to promote all efforts toward timely diagnosis when cancers are still in early stages by identifying factors responsible for prolonged diagnostic intervals among breast cancer patients.

Impact of multidisciplinary team on the pattern of care for brain metastasis from breast cancer

Purpose

The aim of this study was to explore how a multidisciplinary team (MDT) affects patterns of local or systematic treatment.

Methods

We retrospectively reviewed the data of consecutive patients in the breast cancer with brain metastases (BCBM) database at our institution from January 2011 to April 2021. The patients were divided into an MDT group and a non-MDT group.

Results

A total of 208 patients were analyzed, including 104 each in the MDT and non-MDT groups. After MDT, 56 patients (53.8%) were found to have intracranial "diagnosis upgrade". In the matched population, patients in the MDT group recorded a higher proportion of meningeal metastases (14.4% vs. 4.8%, p = 0.02), symptomatic tumor progression (11.5% vs. 5.8%, p = 0.04), and an increased number of occurrences of brain metastases (BM) progression (p < 0.05). Attending MDT was an independent factor associated with ≥2 courses of intracranial radiotherapy (RT) [odds ratio (OR) 5.4, 95% confidence interval (CI): 2.7-10.9, p < 0.001], novel RT technique use (7.0, 95% CI 3.5-14.0, p < 0.001), and prospective clinical research (OR 5.7, 95% CI 2.4-13.4, p < 0.001).

Conclusion

Patients with complex conditions are often referred for MDT discussions. An MDT may improve the qualities of intracranial RT and systemic therapy, resulting in benefits of overall survival for BC patients after BM. This encourages the idea that treatment recommendations for patients with BMBC should be discussed within an MDT.

Burden of breast cancer and attributable risk factors in the North Africa and Middle East region, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

Background

Breast cancer (BC) is the most common cancer in women globally. The North Africa and Middle East (NAME) region is coping hard with the burden of BC. We aimed to present the latest epidemiology of BC and its risk factors in this region.

Methods

We retrieved the data on BC burden and risk factors from the Global Burden of Disease Study 2019 to describe BC status in the 21 countries of the NAME region from 1990 to 2019. We explored BC incidence, prevalence, deaths, disability-adjusted life years (DALYs), and attributable burden to seven risk factors of female BC, namely, alcohol use, diet high in red meat, low physical activity, smoking, secondhand smoke, high body mass index, and high fasting plasma glucose. Decomposition analysis on BC incidence trend was done to find out the contributing factors to this cancer's growth.

Results

In 2019, there were 835,576 (95% uncertainty interval: 741,968 to 944,851) female and 10,938 (9,030 to 13,256) male prevalent cases of BC in the NAME region. This number leads to 35,405 (30,676 to 40,571) deaths among female patients and 809 (654 to 1,002) deaths in male patients this year. BC was responsible for 1,222,835 (1,053,073 to 1,411,009) DALYs among female patients in 2019, with a greater proportion (94.9%) of burden in years of life lost (YLLs). The major contributor to female BC incidence increase in the past three decades was found to be increase in age-specific incidence rates of BC (227.5%), compared to population growth (73.8%) and aging (81.8%). The behavioral risk factors were responsible for majority of attributable female BC burden (DALYs: 106,026 [66,614 to 144,247]). High fasting plasma glucose was found to be the risk factor with the largest effect (DALYs: 84,912 [17,377 to 192,838]) on female BC burden.

Conclusion

The increasing incidence and burden of BC in the NAME region is remarkable, especially when considering limited resources in the developing countries of this region. Proper policies like expanding screening programs and careful resource management are needed to effectively manage BC burden.

The link between relative stability constant of DNA- and BSA-chromenopyrimidine complexes and cytotoxicity towards human breast cancer cells (MCF-7)

In this study, we synthesized and characterized ten chromenopyrimidine derivatives using analytical and spectroscopic methods. Studies on DNA and albumin binding affinity, as well as cytotoxicity tests on human breast cancer (MCF-7) cells, of the chromenopyrimidines, were conducted. The natural logarithm of the relative stability constant of DNA- and BSA-chromenopyrimidine complexes [ln(K_DNA/K_BSA)] was used as a criterion for selecting compounds for cytotoxicity studies. We found that ln(K_DNA/K_BSA) was inversely related to IC₅₀ values of the compounds in MCF-7 cells. The antiproliferative effects of the compounds were found to induce apoptosis in MCF-7 cells, which is a desired mechanism of cell death. Correlations between the DNA and albumin binding affinities of chromenopyrimidines were established. We propose that this relationship approach can, for a given set of compounds, assist in predicting the cytotoxicity of potential drug candidates towards MCF-7 cells based on their experimentally determined CT-DNA and BSA binding affinities.

Predicting the relationship between pesticide genotoxicity and breast cancer risk in South Indian women in in vitro and in vivo experiments

Breast cancer is the third most common cancer in women after skin and lung cancer. Pesticides are of interest in etiologic studies of breast cancer because many pesticides mimic estrogen, a known breast cancer risk factor. In this study, we discerned the toxic role of the pesticides atrazine, dichlorvos, and endosulfan in inducing breast cancer. Various experimental studies, such as biochemical profiling of pesticide-exposed blood samples, comet assays, karyotyping analysis, pesticide and DNA interaction analysis by molecular docking, DNA cleavage, and cell viability assays, have been carried out. Biochemical profiling showed an increased level of blood sugar, WBC, hemoglobin, and blood urea in the patient exposed to pesticides for more than 15 years. The comet assay for DNA damage performed on patients exposed to pesticides and pesticide-treated blood samples revealed more DNA damage at the 50 ng concentration of all three pesticides. Karyotyping analysis showed enlargements in the heterochromatin region and 14pstk+, and 15pstk+in the exposed groups. In molecular docking analysis, atrazine had the highest glide score (- 5.936) and glide energy (- 28.690), which reveals relatively high binding capability with the DNA duplex. The DNA cleavage activity results showed that atrazine caused higher DNA cleavage than the other two pesticides. Cell viability was the lowest at 50 ng/ml (72 h). Statistical analysis performed using SPSS software unveiled a positive correlation (< 0.05) between pesticide exposure and breast cancer. Our findings support attempts to minimize pesticide exposure.

Deep Learning in Different Ultrasound Methods for Breast Cancer, from Diagnosis to Prognosis: Current Trends, Challenges, and an Analysis

Breast cancer is the second-leading cause of mortality among women around the world. Ultrasound (US) is one of the noninvasive imaging modalities used to diagnose breast lesions and monitor the prognosis of cancer patients. It has the highest sensitivity for diagnosing breast masses, but it shows increased false negativity due to its high operator dependency. Underserved areas do not have sufficient US expertise to diagnose breast lesions, resulting in delayed management of breast lesions. Deep learning neural networks may have the potential to facilitate early decision-making by physicians by rapidly yet accurately diagnosing and monitoring their prognosis. This article reviews the recent research trends on neural networks for breast mass ultrasound, including and beyond diagnosis. We discussed original research recently conducted to analyze which modes of ultrasound and which models have been used for which purposes, and where they show the best performance. Our analysis reveals that lesion classification showed the highest performance compared to those used for other purposes. We also found that fewer studies were performed for prognosis than diagnosis. We also discussed the limitations and future directions of ongoing research on neural networks for breast ultrasound.

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

Objective

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

Design

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

Main outcomes and measures

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

Results

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ultrasound for Breast Cancer Screening in Resource-Limited Settings: Current Practice and Future Directions

Breast cancer (BC) is the most prevalent cancer among women globally. Cancer screening can reduce mortality and improve women’s health. In developed countries, mammography (MAM) has been primarily utilized for population-based BC screening for several decades. However, it is usually unavailable in low-resource settings due to the lack of equipment, personnel, and time necessary to conduct and interpret the examinations. Ultrasound (US) with high detection sensitivity for women of younger ages and with dense breasts has become a supplement to MAM for breast examination. Some guidelines suggest using US as the primary screening tool in certain settings where MAM is unavailable and infeasible, but global recommendations have not yet reached a unanimous consensus. With the development of smart devices and artificial intelligence (AI) in medical imaging, clinical applications and preclinical studies have shown the potential of US combined with AI in BC screening. Nevertheless, there are few comprehensive reviews focused on the role of US in screening BC in underserved conditions, especially in technological, economical, and global perspectives. This work presents the benefits, limitations, advances, and future directions of BC screening with technology-assisted and resource-appropriate strategies, which may be helpful to implement screening initiatives in resource-limited countries.

A review of prognostic and predictive biomarkers in breast cancer

Breast cancer (BC) is a common cancer all over the world that affects women. BC is one of the leading causes of cancer mortality in women, which today has decreased with the advancement of technology and new diagnostic and therapeutic methods. BCs are histologically divided into in situ and invasive carcinoma, and both of them can be divided into ductal and lobular. The main function after the diagnosis of invasive breast cancer is which patient should use chemotherapy, which patient should receive adjuvant therapy, and which should not. If the decision is for adjuvant therapy, the next challenge is to identify the most appropriate treatment or combination of treatments for a particular patient. Addressing the first challenge can be helped by prognostic biomarkers, while addressing the second challenge can be done by predictive biomarkers. Among the molecular markers related to BC, ER, PR, HER2, and the Mib1/Ki-67 proliferation index are the most significant ones and are tightly confirmed in the standard care of all primary, recurrent, and metastatic BC patients. CEA and CA-15-3 antigens are the most valuable markers of serum tumors in BC patients. Determining the series of these markers helps monitor response to the treatment and early detection of recurrence or metastasis. miRNAs have been demonstrated to be intricate in mammary gland growth, proliferation, and formation of BC known to be incriminated in BC biology. By combining established prognostic factors with valid prognostic/predicted biomarkers, we can start the journey to personalized treatment for every recently diagnosed BC patient.

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

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

Establishing a Multicenter Network for Patients With Thyroid Nodules and Cancer: Effects on Referral Patterns

OBJECTIVE

To perform a qualitative evaluation of the Thyroid Network, with a quantitative analysis of second opinion referrals for patients in the southwestern part of the Netherlands who have thyroid nodules and cancer.

METHODS

This prospective observational study registered all patients with thyroid nodules and cancer who were referred to the academic hospital from 2 years before and 4 years after the foundation of the Thyroid Network. We implemented biweekly regional multidisciplinary tumor boards using video conference and a regional patient care pathway for patients with thyroid nodules and cancer. For qualitative evaluation, interviews were conducted with a broad selection of stakeholders via maximum variation sampling. The primary outcome was the change in second opinions after the foundation of the Thyroid Network.

RESULTS

Second opinions from Thyroid Network hospitals to the academic hospital decreased from 10 (30%) to 2 (7%) two years after the start of the Thyroid Network (P = .001), while patient referrals remained stable (n = 108 to 106). Qualitative evaluation indicated that the uniform care pathway and the regional multidisciplinary tumor board were valued high.

DISCUSSION

Establishing a regional network, including multidisciplinary tumor boards and a care pathway for patients with thyroid nodules and cancer, resulted in a decrease in second opinions of in-network hospitals and high satisfaction of participating specialists.

IMPLICATIONS FOR PRACTICE

The concept of the Thyroid Network could spread to other regions as well as to other specialties in health care. Future steps would be to assess the effect of regional collaboration on quality of care and patient satisfaction.

Is music intervention effective in reducing anxiety and pain during breast biopsy procedure? A systematic review and meta-analysis of randomized controlled trials

PURPOSE

To evaluate the evidence from randomized clinical trials (RCTs) about the effect of music intervention in reducing patients' anxiety during breast biopsy.

METHODS

Electronic databases including PubMed, Cochrane Library, Scopus, and Web of Science were searched using the relevant MeSH terms. The inclusion criteria were all RCTs assessing the effect of music therapy versus no music in reducing anxiety during breast biopsy. The extracted outcomes were anxiety and pain during breast biopsy. They were pooled as mean difference (MD) with a 95% confidence interval (CI) in a fixed-effects model, using Review Manager 5.3 software for windows. The quality of included studies was assessed with the Cochrane risk of bias assessment tool (RoB 1.0). Then, the outcomes of our meta-analyses were independently evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to know the grade of their evidence.

RESULTS

The final analysis included five RCTs. We found a positive effect of music therapy in reducing anxiety levels compared with control group (MD =  - 2.11; 95% CI (- 4.16 to - 0.06); p = 0.04). No difference between music and control groups regarding pain associated with breast biopsy (MD = 0.22; 95% CI (- 0.81 to 1.25); p = 0.68). The GRADE rating of our outcomes was low for anxiety levels and very low for pain during the biopsy.

CONCLUSIONS

Music therapy could be an effective, simple, non-pharmacological option in relieving anxiety during breast biopsy; however, it had no effect on procedure-associated pain. More large and high-quality studies are needed to confirm our results.

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.

Higher Expressions of SHH and AR Are Associated with a Positive Receptor Status and Have Impact on Survival in a Cohort of Croatian Breast Cancer Patients

Breast cancers (BC) are usually classified into four molecular subtypes according to the expression of estrogen (ER), progesterone (PR), and human epidermal growth factor 2 (HER2) receptors and proliferation marker Ki-67. Despite available anti-hormonal therapies and due to the inherent propensity of some subtypes to develop metastasis, there is a permanent need to discover new prognostic and predictive biomarkers, as well as therapeutic targets for BC. In this study, we used immunohistochemical staining to determine the expression of androgen receptor (AR) and sonic hedgehog protein (SHH), the main ligand of the Hedgehog-GLI (HH-GLI) signaling pathway, in 185 archival primary BC tissue samples and correlated it with clinicopathological characteristics, molecular subtypes, receptors statuses, and survival in a cohort of Croatian BC patients. Results showed that higher SHH and AR expressions were associated with positive receptor status, but increased SHH expression had a negative impact on survival in receptor-negative BCs. On the contrary, higher AR expression was mostly protective. However, multivariate analysis showed that only higher AR expression could be considered as an independent prognostic biomarker for poorer overall survival in triple-negative breast cancer patients (TNBC) (HR 10.9, 95% CI 1.43-83.67; p = 0.021), what could be Croatian population-related. SHH could be a potential target for treating TNBCs and HER2-enriched BCs, in cases where HH-GLI signaling is canonical (SHH-dependent).

Development, implementation and validation of resource-stratified guidelines in low-income and middle-income countries: a scoping review protocol

INTRODUCTION

Nearly every field of medicine has some form of clinical practice guidelines. However, only within the past 5-10 years has the medical community acknowledged the need for well-developed guidelines tailored to the local healthcare needs and the resources available. In most low-income and middle-income countries (LMICs), healthcare workers depend on guidelines developed in high-income countries (HICs), yet many interventions validated in a HIC are ineffective when implemented in an LMIC. The variation in infrastructure, medical personnel, technology and environmental conditions exhibited in LMICs relative to HICs necessitates a careful appraisal of the evidence base used in clinical guideline recommendations. This review aims to map the use of resource-stratified guidelines across all fields of medicine. The review seeks to answer three questions for the identified guidelines: (1) what was the method of development, (2) have they been implemented and, if so, (3) have they been validated.

METHODS

The search strategy will aim to locate studies from inception to November 2021. An initial limited search of PubMed and Scopus was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for PubMed and Scopus. This scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews. Data to be extracted from each study will include population characteristics of both developers and intended implementation population, medical specialty, validation status, method of guideline development, whether the study is consensus or evidence-based in addition to a summary of recommendations for practice.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. The plan for dissemination is to publish review findings in a peer-reviewed journal.

Participation in community-based healthcare interventions and non-communicable diseases early detection of general population in Indonesia

Background

Community-based Healthcare Interventions (CBHIs) are regarded as a critical component of healthcare task-sharing in LMICs and have the potential to address LMICs’ health system weaknesses to improve NCDs prevention care. This study aims to investigate the relationship between participation in CBHIs and NCDs early detection at medical facilities among Indonesians.

Methods

Data come from the fifth Indonesian Family Life Survey (2014–2015), a total of 27,692 individuals (14,820 female and 12,872 male individuals age 15 and older). Multiple ordered logistics and logistics regression was used to assess the association between individual participation in CBHI and early detection of NCDs at medical facilities.

Findings

Participation in CBHIs are associated with higher odds of having regular blood pressure test (adjusted odds ratio [OR], 3.09; 95% confidence interval [CI], 2.67–3.58), cholesterol test (adjusted OR, 1.88; 95% CI, 1.60–2.22), blood glucose test (adjusted OR, 1.88; 95% CI, 1.58–2.23), electrocardiogram (adjusted OR, 1.37; 95% CI, 1.06–1.76) and basic dental examination (adjusted OR, 1.32; 95% CI, 1.09–1.60) at medical facilities. The odds of having pap smears (adjusted OR, 2.20; 95% CI, 1.62–2.98) and breast self-examination (adjusted OR, 1.73; 95% CI, 1.37–2.19) among females who participated in CBHIs are substantially larger than those who did not participate in CBHIs. No significant association is shown for the basic vision examination (adjusted OR, 1.14; 95% CI, 0.95–1.37), while the association of participation in CBHIs on prostate cancer checkup (adjusted OR, 0.18; 95% CI, 0.04–0.76) was negative and significant. The results were controlled with a wide range of predisposing, enabling and need factors for NCDs early detection.

Conclusion

and recommendation: CBHIs may benefit NCDs early detection for the general population in Indonesia. Policymakers and health practitioners need to design CBHIs programs that are attractive to the population, especially men and younger people.

•

CBHIs are a distinct mode of healthcare delivery and are regarded as a critical component of healthcare task-sharing in LMICs.

•

CBHIs have the potential to address LMICs' health system weaknesses to improve NCDs prevention care.

•

Participation in CBHIs are associated with regular blood pressure, cholesterol, blood glucose, electrocardiogram, and dental tests.

Investigating the clinical significance of EGFR expression using machine learning in a series of Iraqi patients with triple-negative breast cancer

Breast cancer is a heterogeneous disease with a distinct profile of the expression of each tumor. Triple-negative breast cancer (TNBC) is a molecular subtype of breast cancer characterized by an aggressive clinical behavior linked to loss or reduced expression of estrogen, progesterone, and Her2/neu receptors. The study's main objective was to investigate the clinical significance of epidermal growth factor receptor (EGFR) overexpression in a series of Iraqi patients with TNBC. The sectional analytic study involved immunohistochemical analysis of EGFR expression in randomly selected 53 formalin fixed paraffin embedded tissue blocks of TNBC cases out of 127 Iraqi patients with TNBC and correlated expression data with clinicopathological parameters including survival time. Machine learning (statistical tests and principal component analysis (PCA)) was used to predict the outcome of the patients using EGFR expression data together with clinicopathological parameters. EGFR was expressed in approximately 28% of TNBC cases. We estimated the risk of mortality and distant metastasis based on EGFR expression and clinicopathologic factors using the principal component analysis (PCA) model. We found a substantial positive correlation between clinical stage and distant metastasis, clinical stage and death, death and distant metastasis, and death and positive EGFR expression. Overall, EGFR expression was linked to a poor prognosis and increased mortality. A higher risk of distant metastasis and death was associated with an advanced clinical stage of the tumor. Furthermore, the existence of distant metastases increased the risk of death. These findings raise the possibility of using EGFR expression data with other clinicopathological parameters to predict the outcome of patients with TNBC.

Barriers and challenges in providing standard breast cancer care in low resource settings

In this study, we investigated the barriers to the delivery of internationally accepted breast cancer care in low resource settings (LRS) as compared to well-endowed resource settings (WRS) via an online survey. The survey was completed by 199 surgeons from eleven countries: 51 from WRS and 148 from LRS, based on our definition. The two most common facilities lacking in LRS were sentinel lymph node biopsy and immune-histochemistry (67% and 60% respectively). Only 22% respondents from LRS confirmed that all their eligible patients received hormonal therapy and only 8% radiotherapy as compared to 98% and 75% from WRS. Widespread limitations exist in most LRS, making internationally accepted breast cancer treatment guidelines impossible to follow, and thus resulting in suboptimal cancer care.

Radiology volunteers to support a breast cancer screening program in Peru: Description of the project, preliminary results, and impressions

Breast cancer is the second most common cancer in Peruvian women. Due to limitations in national breast cancer screening programs, especially in rural areas, more than 50% of cases of breast cancer in Peru are diagnosed in advanced stages. In collaboration with a local clinic registered as a nongovernmental organization (CerviCusco), RAD-AID International aims to create a sustainable diagnostic structure to improve breast cancer screening in Cuzco. With the support of local, national, and international partners that have collaborated in analyzing radiological resources, raising awareness in the population, acquiring equipment, training clinical staff, and building referral networks, our teams of radiologists, included in the RAD-AID team, have participated in training CerviCusco staff in breast ultrasound, thus enabling additional training for radiology residents through a regulated international collaboration.

Association Between Adherence to Clinical Practice Guidelines for Adjuvant Therapy for Breast Cancer and Survival in a Resource-Limited Setting

PURPOSE

Addressing unwarranted clinical variation in oncology practices is expected to lead to improved cancer outcomes. Particularly, the application and impact of treatment guidelines on breast cancer outcomes are poorly studied in resource-limited settings. We measured adherence to a set of locally developed adjuvant treatment guidelines in a middle-income setting. Importantly, the impact of guidelines adherence on survival following breast cancer was determined.

METHODS

Data of 3,100 Malaysian women with nonmetastatic breast cancer diagnosed between 2010 and 2017 were analyzed. Adherence to the Malaysian Clinical Practice Guidelines for Management of Breast Cancer second Edition was measured. Outcomes comprised overall survival and event-free survival.

RESULTS

Guideline adherence for chemotherapy, radiotherapy, hormonal therapy, and targeted therapy were 61.7%, 79.2%, 85.1%, and 26.2%, respectively. Older age was generally associated with lower adherence to guidelines. Compared with patients who were treated according to treatment guidelines, overall survival and event-free survival were substantially lower in patients who were not treated accordingly; hazard ratios for all-cause mortality were 1.69 (95% CI, 1.29 to 2.22), 2.59 (95% CI, 1.76 to 3.81), 3.08 (95% CI, 1.94 to 4.88), and 4.48 (95% CI, 1.98 to 10.13) for chemotherapy, radiotherapy, hormone therapy, and targeted therapy, respectively. Study inferences remain unchanged following sensitivity analyses.

CONCLUSION

Our study findings appear to suggest that adherence to treatment guidelines that have been adapted for resource-limited settings may still provide effective guidance in improving breast cancer outcomes.

Non-adherence to local breast cancer CPG worsens survival in Malaysia.

Human BRCA pathogenic variants were originated during recent human history

BRCA1 and BRCA2 (BRCA) play essential roles in maintaining genome stability. BRCA germline pathogenic variants increase cancer risk. However, the evolutionary origin of human BRCA pathogenic variants remains largely elusive. We tested the 2,972 human BRCA1 and 3,652 human BRCA2 pathogenic variants from ClinVar database in 100 vertebrates across eight clades, but failed to find evidence to show cross-species evolution conservation as the origin; we searched the variants in 2,792 ancient human genome data, and identified 28 BRCA1 and 22 BRCA2 pathogenic variants in 44 cases dated from 45,000 to 300 yr ago; we analyzed the haplotype-dated human BRCA pathogenic founder variants, and observed that they were mostly arisen within the past 3,000 yr; we traced ethnic distribution of human BRCA pathogenic variants, and found that the majority were present in single or a few ethnic populations. Based on the data, we propose that human BRCA pathogenic variants were highly likely arisen in recent human history after the latest out-of-Africa migration, and the expansion of modern human population could largely increase the variation spectrum.

Implementation of a large-scale breast cancer early detection program in a resource-constrained setting: real-world experiences from 2 large states in India

Background

The Breast Health Initiative (BHI) was launched to demonstrate a scalable model to improve access to early diagnosis and treatment of breast cancer.

Methods

A package of evidence‐based interventions was codesigned and implemented with the stakeholders, as part of the national noncommunicable disease program, through the existing primary health care system. Data from the first 18 months of the BHI are presented.

Results

A total of 108,112 women received breast health education; 48% visited the health facilities for clinical breast examination (CBE), 3% had a positive CBE result, and 41% were referred to a diagnostic facility. The concordance of CBE findings between health care providers and adherence to follow‐up care improved considerably, with more women visiting the diagnostic facilities and completing diagnostic evaluation within 1 month from initial screening, and with only 9% lost to follow‐up. The authors observed a clinically meaningful decrease in time to complete diagnostic evaluation with biopsy, from 37 to 9 days.

Conclusions

The results demonstrate the feasibility and effectiveness of implementing a large‐scale, decentralized breast cancer early detection program delivered through the existing primary health care system in India.

This article presents the key strategies, interventions, and results from the first 18 months of the large‐scale, decentralized breast cancer early detection program in a real‐world setting in India.

Culture matters: adapting supportive programs for cancer patients in low- and middle-income countries

The global burden of cancer falls heavily on low- and middle-income countries (LMICs), where there are critical gaps in the provision of supportive care services, which leaves many cancer patients in these settings feeling overwhelmed and unable to manage the psychological effects associated with a cancer diagnosis and the ensuing treatment. In addressing these gaps, we adapted a widely replicated cancer peer mentoring model in the USA to the Viet Nam context. Using the Cultural Adaptation Framework, we examined cultural characteristics affecting three key domains-cognitive information processing, affective-motivational, and environmental-to inform the types of adaptations that are made to the program. We highlight here the major findings in the three domains and the adaptations made. This illustration can inform future efforts to adapt successful programs to different cultural contexts, ensuring that cancer psychosocial programs and activities are acceptable and appropriate to the culture, health system, and resources of the local community and setting.

OUP accepted manuscript

Introduction

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

Methods and Materials

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

Results

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

Conclusion

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

Breast Cancer Screening in Semi-Rural Malaysia: Utilisation and Barriers

Breast cancer (BC) is the commonest cancer in Malaysia. Delayed diagnosis is a significant cause of BC mortality in the country. Early diagnosis and screening are vital strategies in mortality reduction. This study assessed the level of utilisation and barriers for breast self-examination (BSE), clinical breast examination (CBE) and mammogram in a semi-rural population in Malaysia and compared these across the different ethnic groups. This cross-sectional study was conducted among women aged 40 years and above, embedded within a health and demographic surveillance site (HDSS) in Segamat, Malaysia. Trained data collectors collected data on screening and barriers during home visits. Study participants (n = 250) were aged 59.4 ± 10.9 years and represented Malaysia's three major ethnic groups. Practice of regular BSE, CBE uptake (ever) and mammogram (ever) was 23.2%, 36% and 22.4%, respectively. Regular BSE practice was highest in the Malay ethnic group and least among the Chinese. Regular CBE was very low in all ethnic groups (<5%). Mammogram uptake was highest among Chinese (34.4%), followed by Indians (30.4%) and Malays (16.6%). After adjusting for other socio-demographic variables, Malay ethnicity was positively associated with regular BSE (adjusted OR = 5.26, 95% CI 2.05, 13.50) and negatively associated with having had a mammogram (adjusted OR = 0.3, 95% CI 0.15, 0.57). Lower education was negatively associated (adjusted OR = 0.36, 95% CI 0.17, 0.74) with mammogram attendance (ever). Emotional and financial barriers were the most reported types of barriers, specifically, fear of diagnosis (74.8%), cost of diagnosis (69.6%) and fear of losing a breast (66.4%). Malay women more commonly reported most barriers compared to other ethnic groups. Screening uptake was low among semi-rural women in Malaysia. Implementing culturally appropriate interventions that consider ethnic differences is crucial to empowering women to engage in BC screening initiatives in these communities.

Improving knowledge about breast cancer and breast self examination in female Nigerian adolescents using peer education: a pre-post interventional study

Background

Prevention of BC of which the cornerstone is creating awareness and early detection is important in adolescents and young women because of their worse outcomes. Early detection strategies such as mammography are currently beyond the reach of most women in sub-Saharan Africa.. Lack of awareness and late presentation contribute to the poor outcomes. Awareness creation among adolescents may result in modification of some risk factors for BC with adoption of healthy life styles including accessing early detection activities. This study determined the effect of peer education as a strategy to create awareness on BC and breast self examination (BSE) among in-school female adolescents in Benin City.

Methods

This was a pre-post interventional study carried out in October –December 2016 on female students of four secondary schools in Benin City. Pre-peer training, using a pre-tested self-administered questionnaire, knowledge about BC and BSE was assessed in about 30% of each school population. This was followed by training of 124 students selected from the schools (one student per class) as peer trainers. The peer trainers provided training on BC and BSE (the intervention) for their classmates. Within two weeks of peer training knowledge about BC and BSE was reassessed in 30% of each school population. Selection of students for assessment pre and post intervention was by systematic sampling. Correct knowledge was scored and presented as percentages. Chi square test, student t test and ANOVA were used to assess associations and test differences with level of significance set at p < 0.05.

Results

There were 1337 and 1201 students who responded to the pre and post-training questionnaires respectively. The mean BC knowledge score (20.61 ± 13.4) prior to training was low and it statistically significantly improved to 55.93 ± 10.86 following training p < 0.0001 Following peer training, statistically significant improvement (p 0.037- < 0.001) occurred in most knowledge domains apart from symptomatology. Pre-peer training 906(67.8%) students knew about BSE but only 67(4.8%). Significantly more students 1134(94.7%) knew about BSE following peer training.

Conclusions

Peer education strategy can be used to improve BC and BSE knowledge in adolescents. This strategy is low cost and could be very useful in low resource settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01466-3.

The impact of scaling up access to treatment and imaging modalities on global disparities in breast cancer survival: a simulation-based analysis

BACKGROUND

Female breast cancer is the most commonly diagnosed cancer in the world, with wide variations in reported survival by country. Women in low-income and middle-income countries (LMICs) in particular face several barriers to breast cancer services, including diagnostics and treatment. We aimed to estimate the potential impact of scaling up the availability of treatment and imaging modalities on breast cancer survival globally, together with improvements in quality of care.

METHODS

For this simulation-based analysis, we used a microsimulation model of global cancer survival, which accounts for the availability and stage-specific survival impact of specific treatment modalities (chemotherapy, radiotherapy, surgery, and targeted therapy), imaging modalities (ultrasound, x-ray, CT, MRI, PET, and single-photon emission computed tomography [SPECT]), and quality of cancer care, to simulate 5-year net survival for women with newly diagnosed breast cancer in 200 countries and territories in 2018. We calibrated the model to empirical data on 5-year net breast cancer survival in 2010-14 from CONCORD-3. We evaluated the potential impact of scaling up specific imaging and treatment modalities and quality of care to the mean level of high-income countries, individually and in combination. We ran 1000 simulations for each policy intervention and report the means and 95% uncertainty intervals (UIs) for all model outcomes.

FINDINGS

We estimate that global 5-year net survival for women diagnosed with breast cancer in 2018 was 67·9% (95% UI 62·9-73·4) overall, with an almost 25-times difference between low-income (3·5% [0·4-10·0]) and high-income (87·0% [85·6-88·4]) countries. Among individual treatment modalities, scaling up access to surgery alone was estimated to yield the largest survival gains globally (2·7% [95% UI 0·4-8·3]), and scaling up CT alone would have the largest global impact among imaging modalities (0·5% [0·0-2·0]). Scaling up a package of traditional modalities (surgery, chemotherapy, radiotherapy, ultrasound, and x-ray) could improve global 5-year net survival to 75·6% (95% UI 70·6-79·4), with survival in low-income countries improving from 3·5% (0·4-10·0) to 28·6% (4·9-60·1). Adding concurrent improvements in quality of care could further improve global 5-year net survival to 78·2% (95% UI 74·9-80·4), with a substantial impact in low-income countries, improving net survival to 55·3% (42·2-67·8). Comprehensive scale-up of access to all modalities and improvements in quality of care could improve global 5-year net survival to 82·3% (95% UI 79·3-85·0).

INTERPRETATION

Comprehensive scale-up of treatment and imaging modalities, and improvements in quality of care could improve global 5-year net breast cancer survival by nearly 15 percentage points. Scale-up of traditional modalities and quality-of-care improvements could achieve 70% of these total potential gains, with substantial impact in LMICs, providing a more feasible pathway to improving breast cancer survival in these settings even without the benefits of future investments in targeted therapy and advanced imaging.

FUNDING

Harvard T H Chan School of Public Health, and National Cancer Institute P30 Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center.

Provider Barriers and Facilitators of Breast Cancer Guideline-Concordant Therapy Delivery in Botswana: A Consolidated Framework for Implementation Research Analysis

Introduction

Systemic treatment for breast cancer in sub‐Saharan Africa (SSA) is cost effective. However, there are limited real‐world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline‐concordant care at Princess Marina Hospital (PMH) in Botswana.

Materials and Methods

The Consolidated Framework for Implementation Research was used to conduct one‐on‐one semistructured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size was determined by thematic saturation. Transcribed interviews were double‐coded and analyzed in NVivo using an integrated analysis approach.

Results

Forty‐one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government‐funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention, lack of relative priority compared with HIV/AIDS, suboptimal interdepartmental communication, and lack of a clearly defined national cancer control policy. Community‐level barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy‐in, expansion of multidisciplinary tumor boards, leveraging nongovernmental and academic partnerships, and setting up monitoring, evaluation, and feedback processes.

Discussion

The study identified complex, multilevel factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes.

Implications for Practice

To address the increasing cancer burden in low‐ and middle‐income countries, resource‐stratified guidelines have been developed by multiple international organizations to promote high‐quality guideline‐concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they are intended to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource‐stratified guidelines in sub‐Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country‐level and facility‐level resources, cancer care accessibility, and community‐level barriers and facilitators.

To address an increasing mortality burden, resource‐stratified guidelines have been developed to ensure that breast cancer care is matched to specific resources in low‐ and middle‐income countries. This article identifies facilitators and barriers to the use of breast cancer guidelines by oncology providers at Princess Marina Hospital in Botswana using the Consolidated Framework for Implementation Research (CFIR).

Healthcare utilisation, cancer screening and potential barriers to accessing cancer care in rural South West Nigeria: a cross-sectional study

BACKGROUND/AIMS

Cancer burden is predicted to double by 2030 in sub-Saharan Africa; access to healthcare services for cancer management is a priority in the region. In Nigeria, National Cancer Control Plan aims to ensure >50% cancer screening of eligible populations by 2022 for all Nigerians. We describe healthcare utilisation, cancer screening activities and potential barriers to accessing cancer care within an understudied rural community-based adult population in South West Nigeria.

METHODS

In April 2018, we conducted a cross-sectional study of community-based adults (>18 years) ~130 km east of Ibadan, 250 km from Lagos in Osun State, South West Nigeria. Participants completed a face-to-face survey in local dialect. We used a questionnaire to assess demographics, health status, income, medical expenditures, doctor visits and cancer screening history.

RESULTS

We enrolled 346 individuals: with median age of 52 years and 75% women. Of the entire cohort, 4% had medical insurance. 46% reported a major medical cost in the last year. Cancer screening activities were infrequent in eligible participants: 1.5% reported having had cervical cancer screening, 3.3% mammogram and 5% colonoscopy screening. Cancer screening assessment was less frequent in those with less income and lower education levels. Using a multivariable logistic regression model including personal income, insurance status and education, higher personal income was associated with more cancer screening activity (OR 2.7, 95% CI 1.3 to 5.7, p<0.01). Despite this, most individuals had contact with a primary healthcare doctor (52% in the last year), and over 70% access to radio and TV suggesting the opportunity to expand community-based screening interventions and awareness exists.

CONCLUSIONS

Despite national increases in cancer cases, we highlight a deficiency in cancer screening and universal healthcare coverage within a community-based adult Nigerian population. Subject to availability of governmental resources, increasing financial risk protection, awareness and targeted resource allocation may help expand access in Nigeria.

Quality indicators for breast cancer care: A systematic review

Objectives

We evaluated breast cancer (BC) care quality indicators (QIs) in clinical pathways and integrated health care processes.

Methods

Following protocol registration (Prospero n^o: CRD42021228867), relevant documents were identified, without language restrictions, through a systematic search of bibliographic databases (EMBASE, Scopus, Web of Science, MEDLINE), health care valuable representatives and the World Wide Web in April 2021. Data concerning QIs, measurement tools and compliance standards were extracted from European and North American sources in duplicate with 98% reviewer agreement.

Results

There were 89 QIs found from 22 selected documents (QI per document mean 13.5 with standard deviation 11.9). The Belgian (38 QIs) and the EUSOMA (European Society of Breast Cancer Specialists) (34 QIs) documents were the ones that best reported the QIs. No identical QI was identified in all the documents analysed. There were 67/89 QIs covering processes (75.3%) and 11/89 (12.4%) for each structure and outcomes QIs. There were 21/89 QIs for diagnosis (30.3%), 43/89 for treatment (48.3%), and 19/89 for staging, counselling, follow-up and rehabilitation (21.4%). Of 67 process QIs and 11 outcome QIs, 20/78 (26%) did not report a minimum standard of care. Shared decision making was only included as a QI in the Italian document.

Conclusion

More than half of countries have not established a national clinical pathway or integrated breast cancer care process to achieve the excellence of BC care. There was heterogeneity in QIs for the evaluation of BC care quality. Over two-thirds of the clinical pathways and integrated health care processes did not provide a minimum auditable standard of care for compliance, leaving open the definition of best practice. There is a need for harmonisation of BC care QIs.

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The quality of breast cancer care has become a preference for health systems.

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There was no established set of quality indicators to harmonise BC quality management’s evaluation. A consensus is needed.

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Most of the integrated breast cancer care processes or clinical pathways did not indicate any standard for care compliance.

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No quality indicators specifically related to patient satisfaction or Primary care were found in our study.

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Shared decision making was only included as a QI in the Italian document.

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There is a vast space for improvement, and future studies should pay attention to this issue.

Opportunities for Improvement in the Administration of Neoadjuvant Chemotherapy for T4 Breast Cancer: A Comparison of the U.S. and Nigeria

BACKGROUND

Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions.

MATERIALS AND METHODS

Cross-sectional retrospective analysis included all patients with non-metastatic T4 BCa treated from 2010 to 2016 at Memorial Sloan Kettering Cancer Center (New York, New York) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated.

RESULTS

Three hundred and eight patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. Fifty-six out of ninety-three (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt. Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative versus 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five-year survival was significantly shorter in Nigeria versus the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5-year survival (67% vs. 72%) and 5-year recurrence-free survival (48% vs. 61%) did not significantly differ between countries.

CONCLUSION

Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria.

IMPLICATIONS FOR PRACTICE

This cross-sectional retrospective analysis of patients with T4 breast cancer in Nigeria and the U.S. found a significant difference in pathologic complete response to neoadjuvant chemotherapy (5% Nigeria vs. 27% U.S.). Five-year survival was shorter in Nigeria, but in patients receiving multimodality treatment, including neoadjuvant chemotherapy and surgery with curative intent, 5-year overall and recurrence-free survival did not differ between countries. Capacity-building efforts in Nigeria should focus on access to pathology services to direct systemic therapy and promoting receipt of complete chemotherapy to improve outcomes.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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