A study of patients who appear with far advanced cancer at Yaounde General Hospital, Cameroon, Africa

Meaningful engagement of people living with cancer: Leveraging breast cancer survivors in a stigma reduction intervention in Tanzania

INTRODUCTION

Cancer-related stigma is a key driver of advanced breast cancer stage in Sub-Saharan Africa (SSA). We developed and tested the impact of a breast cancer survivor-led Stigma reduction intervention (SRI) on stigma and treatment adherence of newly diagnosed patients with breast cancer in Tanzania.

METHODS

Breast cancer survivors were trained on breast cancer knowledge and motivational interviewing. A total of 4 trained survivors delivered a SRI (standardized flipchart breast education talk, personal testimony, and motivational interviewing) to 30 newly diagnosed patients with breast cancer before treatment. Pre- and post-intervention knowledge surveys and stigma scale surveys were analyzed via Fisher's exact test and Wilcoxon rank-sum tests. A discussion was held with a group of survivors after the intervention period to elicit feedback on their intervention experience.

RESULTS

Among the 30 patients, breast cancer knowledge (median overall percent correct) increased from 28% (IQR: 18%-45%) to 85% (IQR: 79%-88%) (p < 0.001) and stigma (median score) decreased from 75 (IQR: 57-81) to 53 (IQR: 44-66) (p < 0.01) following the intervention. All participants were willing to pursue hospital-based treatment after undergoing the intervention. Eighty-seven percent (n = 26) initiated treatment at 8-week follow-up after the intervention. All survivors endorsed feeling empowered and valued in their role in this intervention.

CONCLUSIONS

Breast cancer survivors are a powerful group to combat the lack of knowledge and stigma in community and healthcare settings. Expanding the scope and scale of this intervention holds promise for improving treatment-seeking behavior and ultimately breast cancer outcomes in SSA.

Feasibility of cancer genetic counselling and screening in Cameroon: perceived benefits and barriers

Because there was no genetic testing service in Cameroon, we assessed the acceptance, perceived benefits and barriers and willingness to pay for genetic cancer screening in Cameroon amongst patients with cancers. We carried out a hospital-based, cross-sectional study on adult cancer patients at the Yaoundé General Hospital and the non-Governmental Organisation Solidarity Chemotherapy between February 1, 2021, and December 31, 2021. This was a convenience sampling that included all consenting patients. Qualitative and quantitative data were analysed by Epi info version 7 and SPSS version 20. Our study included 160 (87.5% females) cancer patients, whose ages ranged from 20 to 82 years, with a mean of 49.9 ± 13.0 years. Only 11.9% had undergone some form of genetic counselling or information sessions, and most found this to be helpful in terms of increased knowledge and prevention strategies (13, 68.4%). Almost all participants (156, 97.5%) stated they will like their relatives to undergo genetic counselling. Of these, 151 (94.4%) expressed their desire for their relatives to discuss their cancer risk with a specialist. Perceived benefits of genetic testing included cancer prevention (108, 67.5%) and motivation of self-examination (81, 50.6%). Prominent possible barriers included the cost (129, 80.6%), unavailability of equipment (49, 30.6%) and anticipated anxiety (40, 25.0%). However, a majority of the participants (156, 97.5%) were willing to test for genetic mutations. One hundred and thirty-five (84.4%) participants were willing to pay for genetic testing, with the majority of them (71.8%) ready to pay between $16.7 and $100. Almost all of the participants expressed their willingness to receive cancer genetic counselling and testing but the cost became the main barrier. This pilot study will serve as a guide to the processes of establishing a cancer risk assessment clinic in Cameroon.

Perceived Barriers to Early Detection of Breast Cancer in Iranian Women: A Qualitative Content Analysis

Background: Breast cancer is one of the most common cancers among Iranian women. The early diagnosis of this disease can decrease the mortality rate and promote patient survival. Objectives: This study aimed at identifying the barriers to early detection of breast cancer in Iranian women. Methods: In this qualitative study, which was extracted from a large research project, an exploratory sequential mixed-methods design was used, and conventional content analysis was carried out. Twenty-one participants were selected by purposeful sampling (ten health professionals and 11 female patients with breast cancer). Data were collected through in-depth, semi-structured interviews from July 2018 to June 2019. Results: The content analysis revealed three major themes related to delay in presentation: individual barriers (limited/lack of knowledge, other life preferences, negative reactions to the disease, and belief in fate), environmental barriers (insufficient social support, inaccurate information sources, and alternative therapy recommendations), and organizational barriers (poor quality of health services, inadequate access to health services, and role of media in informing people). Conclusions: Various perceived barriers, at different levels, play influential roles in the patients’ early detection. Therefore, collaboration between public health professionals, healthcare providers, and policymakers seems necessary for reducing delays in presentation among women.

Cancer Control in Low- and Middle-Income Countries: Is It Time to Consider Screening?

The rising prevalence of noncommunicable diseases globally, with a strikingly disproportionate increase in prevalence and related mortality in low- and middle-income countries (LMICs), is a major threat to sustainable development. The epidemiologic trend of cancers in LMICs is of particular concern. Despite a lower incidence of cancer in LMICs compared with high-income countries, total cancer-related mortality is significantly higher in LMICs, especially in people younger than 65 years of age. The enormous economic impact of premature mortality and lost productive life years highlights the critical importance of galvanizing cancer prevention and management to achieve sustainable development. The rising burden of cancer in LMICs stresses an already weak health care and economic infrastructure and poses unique challenges. Although the WHO acknowledges that the effective management of cancer relies on early detection, accurate diagnosis, and access to appropriate multimodal therapy, the placement of priority on early detection cannot be assumed to be effective in LMICs, where limited downstream resources may be overwhelmed by the inevitable increases in number of diagnoses. This review discusses several factors and considerations that may compromise the success of cancer control programs in LMICs, particularly if the focus is only on early detection through screening and surveillance. It is intended to guide optimal implementation of cancer control programs by accentuating challenges common in LMICs and by emphasizing the importance of cancer prevention where relevant so that communities and stakeholders can work together to devise optimal means of combatting the growing burden of cancer.

Barriers to Management of Nontraumatic Neurosurgical Diseases at 2 Cameroonian Neurosurgical Centers: Cross-Sectional Study

BACKGROUND

Although nontraumatic diseases affect fewer people than traumatic neurosurgical diseases, they require expertise more often. The authors sought to understand the barriers to nontraumatic neurosurgical diseases (NTNSDs) in a country with limited access to neurosurgical care.

METHODS

This cross-sectional study with retrospective data collection was carried out in 2 Cameroonian reference hospitals for a year. Multiple imputations were used to generate data for the missing variables-death and discharge with sequelae. Bivariate relationships were evaluated using the chi-square and Mann-Whitney U tests. Odds ratios were equally calculated, and the results were considered significant for a P value <0.05.

RESULTS

NTNSDs represented 44.1% of neurosurgical activity. Our study included 177 patients with a mean age of 43.7 ± 21.2 years. More than half (53.1%) were female, 78% lived in a different region from that of the neurosurgical center, 18.1% had health insurance, 39.5% were referrals, and the mean symptom-to-admission delay was 409.0 ± 1301.7 days. Most (87%) of the patients had undergone at least 1 of the diagnostic examinations prescribed to them. Men (P = 0.029) and rural dwellers (P = 0.017) had shorter symptom-to-admission delays than women and urban dwellers, respectively. The mean length of stay was 18.2 ± 13.4, and 80.8% of patients were treated surgically. Thirty-one (17.5%) patients died in the hospital: 9 were treated surgically, and 22 were treated conservatively or expectantly.

CONCLUSIONS

Patients with NTNSD present at the definitive care facilities late. This delay is attributable to financial and geographic barriers.

Health beliefs and behaviours of families towards the health needs of children with intellectual and developmental disabilities (IDD) in Accra, Ghana

BACKGROUND

This paper explored the health beliefs and behaviours of families towards the health needs of children with intellectual and developmental disabilities (IDD) in Accra, Ghana. The aim was to inform health promotion strategies for the children and their families.

METHOD

Twenty-two parents of children with IDD participated in this study. Semi-structured interviews were the primary means of data collection. The interviews were analysed using constant comparison.

RESULTS

The signs that alerted the parents that the children might be ill included high temperature, vomiting and excessive sleep. The parents explained that some children expressed feelings of ill-health through verbal or non-verbal communication. Most of the parents self-prescribed medication for the children or waited for symptoms to persist for a while before accessing health care because they experienced difficulties managing the behavioural challenges associated with the IDD of the children in public and attitudinal barriers when accessing health care. The parents did not often patronise health facilities in their neighbourhoods due to private health insurance requirements for accessing care at designated facilities, poor confidence in neighbourhood facilities and long-term established relationships with facilities elsewhere. Further, many parents did not patronise religious interventions for the children. However, some parents explained that in addition to seeking medical care to address the physical symptoms of the children's disabilities and/or illnesses, they sought religious interventions because they believed that there could be a spiritual dimension to the situation.

CONCLUSION

The findings highlight key areas to address in health promotion for children with IDD and their families in Accra, Ghana.

Application of the rapid ethical assessment approach to enhance the ethical conduct of longitudinal population based female cancer research in an urban setting in Ethiopia

Background

Rapid Ethical Assessment (REA) is an approach used to design context tailored consent process for voluntary participation of participants in research including human subjects. There is, however, limited evidence on the design of ethical assessment in studies targeting cancer patients in Ethiopia. REA was conducted to explore factors that influence the informed consent process among female cancer patients recruited for longitudinal research from Addis Ababa Population-based Cancer Registry.

Methods

Qualitative study employing rapid ethnographic approach was conducted from May–July, 2017, at the Tikur Anbessa Specialized Referral Hospital. In-depth and key informants’ interviews were conducted among purposively selected 16 participants. Regular de-briefings among the study team helped to identify emerging themes and ensure saturation. Interviews and debriefings were tape recorded in Amharic, and transcribed and translated to English. Coding of the transcripts was facilitated by use of NVivo software. Thematic analysis was employed to respond to the initial questions and interpret findings.

Results

Perceived barriers to voluntary study participation included lack of reporting back study results of previous studies, the decision making status of women, hopelessness or fatigue in the patients, shyness of the women, data collectors approach to the patient, and patient’s time constraints. Most of the patients preferred oral over written consent and face-to-face interview over telephone interview. Provision of detail information about the study, using short and understandable tool, competent, compassionate and respectful enumerators of the same gender were suggested to assure participation. Due to the perceived severity, the use of the term “cancer” was associated with fear and anxiety. Alternatively, uses of phrases like “breast or cervical illness/disease” were suggested during patient interviews.

Conclusions

Voluntary participation is not straight forward but affected by different factors. Using competent, compassionate and respectful enumerators, short and precise questioning tools to limit the time of the interview could improve voluntary participation. Moreover, careful consideration of the patients and families concept of the disease such as wording and information has to be taken into account. This assessment helped in improving the consent process of the ongoing project on breast and cervical cancer patients.

Challenges in managing graft-versus-host disease in developing countries: a perspective

Hematopoietic cell transplant (HCT) activity is increasing worldwide due to safer techniques, widening indications, and more availability of donors. New HCT centers have recently been established in many developing countries including Asian and African countries. Due to limited resources, logistic, political, and social issues in developing countries, the treatment of orphan diseases like graft-versus-host disease (GVHD) can be challenging. We intended to delineate the current issues that institutions and clinicians face in managing GVHD. We conducted a comprehensive systematic electronic review of peer-reviewed published articles on GVHD management in developing countries. We used PubMed, Cochrane, and Embase databases as our primary source of data. Studies that were included described the treatments for both acute and chronic GVHD. Consensus on the use of high-dose methyl-prednisone and prednisolone as the initial therapy was widely accepted and used in practice. Socio-economic factors were found to be the major factor involved in GVHD management in lower income patients. Delayed diagnosis and treatment, lack of availability of healthcare professionals, lack of knowledge among cancer patients, and poverty are major concerns in the developing world. For optimal management, HCT programs should develop systems in place for long-term follow-up of HCT survivors and have a low threshold to initiate treatments for GVHD early. Awareness and health policy programs must be initiated at the grass-root level for long-term management of these survivors in developing countries.

Histo-epidemiological profile of breast cancers among women in the Central African Republic: about 174 cases

BACKGROUND

Breast cancer (BC) is the most common cancer in women worldwide and leading cause of cancer deaths indeveloping countries. There is very limited data on BC in the Central African Republic. The purpose of this study was to describe the epidemiological and histopathological characteristics of BC in Bangui.

METHODS

This retrospective study reviewed cancer data registries and medical records from the Pathology Unit of the National Laboratory in Bangui and the General Surgery and Gyneacology service from 2003 to 2015. A questionnaire was designed to collect information and data was analysed using descriptive and inferential statistical methods.

RESULTS

In total, 174 cases of BC were recorded, with an average annual frequency of13.4 cases per year. The age of the women at diagnosis varied from 16 to 90 years with a median of 45.5 years and InterQuartile range (IQR) 18 years. The age group of 45-54 years represented the majority of the study population (n = 51, 29.3%).About 25.9%ofthe patients were non-educated and 85.6% lived in cities. Over 48 % of the women were housewives with a moderate economic status (n = 99, 56.9%). Sixty nine percent of the specimens received at the pathology unit were pieces of breast tumour. Invasive ductal carcinoma (n = 113, 64.9%) was the main histological form and most of the tumours were of Grade III (n = 14, 46.7%). The only imaging assessment was ultrasound performed in (n = 53, 30.4%) women. Surgery was performed in (n = 166, 95.4%) patients, while (n = 159, 91.4%) received complementary chemotherapy. At the end of the study, 84.5%of the cases had died, 12.1% were alive and 3.4% were considered "lost to follow-up".

CONCLUSION

BC is an important public health problem and affected most of the younger Central African women. Epidemiological and histological characteristics are more or less common to those described other developing countries. It is imperative to improve the awareness of health care institutions and women on the burden of BC, to carry out early screening of BC, and to strengthen the capacity of women's health care system.

Delayed presentation and diagnosis of breast cancer in African women: a systematic review

PURPOSE

Africa has low breast cancer incidence rates but high mortality rates from this disease due to poor survival. Delays in presentation and diagnosis are major determinants of breast cancer survival, but these have not been comprehensively investigated in Africa.

METHODS

MEDLINE, Embase, and Global Health were searched to identify studies reporting on delays in presentation and/or diagnosis of breast cancer published between January 1, 2000 and May 31, 2016. Data were synthesized in narrative, tabular, and graphical forms. Meta-analyses were not possible due to between-study differences in the way delays were reported.

RESULTS

Twenty-one studies were included in the review. Study-specific average times between symptom recognition and presentation to a health care provider ranged from less than 1 to 4 months in North Africa and from less than 3 to greater than 6 months in sub-Saharan Africa. Study-specific average times from presentation to diagnosis were less than 1 month in North Africa but ranged from less than 3 to greater than 6 months in sub-Saharan Africa. Reported reasons for these delays included patient-mediated (e.g., socioeconomic factors) and health system-mediated factors (e.g., referral pathways).

CONCLUSIONS

This systematic review revealed marked delays in presentation and diagnosis of breast cancer in Africa. Identification of their drivers is crucial to the development of appropriate control strategies in the continent.

Functioning and disability in recent research from Cameroon: a narrative synthesis

Introduction

People living with disabilities in Cameroon face many barriers to daily functioning and social participation. However, there is limited research on disabilities and their impact. We sought to examine the research related to disability from Cameroon.

Methods

We conducted a systematic review, bibliometric analysis, and narrative synthesis of research related to disability, functioning, and social participation from Cameroon published during 2005-2014. The articles were screened in duplicate to identify articles addressing impacts of disability on functioning. Disability was contextualized using the International Classification of Functioning, Disability and Health (ICF) framework. Data were analyzed narratively per identified themes using an inductive data-driven approach.

Results

A total of 46 studies were included following full-text review of which 36 addressed non-communicable diseases and conditions, 7 addressed infectious diseases and 3 addressed neglected tropical diseases. Among ICF Activity and Participation Restrictions, work and employment was the highest reported category (19 studies), followed by intimate relationships (14 studies), and looking after one's health (8 studies). Among ICF Environmental Factors, societal attitudes were the highest reported category (21 studies), followed by health services, systems and policies (14 studies) and support and relationships (11 studies). Among other common themes, knowledge and awareness was the highest reported category (22 studies), closely followed by traditional beliefs (20 studies) and financial barriers (9 studies).

Conclusion

There is a small body of primary research from Cameroon on disability. The main themes related to disability are stigma, limited knowledge and awareness, poor quality of care and hindered employment opportunities. Further efforts are required to investigate the complexities of living with a disability in Cameroon and strategies to enhance adequate participation in activities of daily life.

Epidemiology of breast cancer: retrospective study in the Central African Republic

Background

Breast cancer is recognised as a major public health problem in developing countries; however, there is very limited evidence about its epidemiology in the Central African Republic. The aim of this study was to investigate the epidemiological and histopathological characteristics of breast cancer in Bangui.

Methods

This is a retrospective study based on the data collected from pathological anatomy records from 2003 to 2015 in Bangui. A questionnaire was designed to collect information and data was analysed using descriptive and inferential statistical methods.

Results

The mean age was 45.83 (SD = 13.5) years. The age group of 45–54 years represented the majority of the study population (29.3%). Over 69.5% of the women were housewives with a moderate economic status (56.9%). Less than 14% of the study population had a level of academic degree and 85.6% lived in cities. The breast cancer prevalence was 15.27%. The age-standardized incidence and death by world population (ASW) were 11.19/100,000 and 9.97/100,000 respectively. 50–54 years were most affected. Left breast cancer is mainly common and the time between first symptoms and consultation is more than 48 months. Most (69%) of the samples analysed were lumpectomy. The most common morphology of breast cancer was invasive ductal carcinoma (64.9%). Scarff Bloom Richardson III was the main grade in both common pathological types, but their proportion showed no significant increase along with time (χ2 = 7.06, p = 0.54). Invasion of regional lymph node differed significantly among the pathological type of breast cancer (χ2 = 24.6, p = 0.02). Surgery and chemotherapy were appropriate treatment yet 84.5% of the cases died.

Conclusion

The findings of this study showed that breast cancer is common and mostly affected women. Epidemiological trends are more or less common to those of developing countries with a predominance of invasive ductal carcinoma. However, most of the women studied live in an urban area and developed the disease in advanced stage. The establishment of an appropriate framework will effectively contribute to promoting the early detection and reducing the incidence of this disease in the population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3863-6) contains supplementary material, which is available to authorized users.

Mapping the Epidemiology of Kaposi Sarcoma and Non-Hodgkin Lymphoma Among Children in Sub-Saharan Africa: A Review

Children with human immunodeficiency virus (HIV) have an increased risk of developing Kaposi Sarcoma (KS) and non-Hodgkin lymphoma (NHL) compared to HIV-negative children. We compiled currently published epidemiologic data on KS and NHL among children in sub-Saharan Africa (SSA). Among countries with available data, the median incidence of KS was 2.05/100,000 in the general pediatric population and 67.35/100,000 among HIV-infected children. The median incidence of NHL was 1.98/100,000 among the general pediatric population, while data on NHL incidence among HIV-infected children were lacking. Larger regional studies are needed to better address the dearth of epidemiologic information on pediatric KS and NHL in SSA.

Transforming breast cancer control campaigns in low and middle-income settings: Tanzanian experience with 'Check It, Beat It'

Breast cancer incidence and mortality rates are similar in low resource settings like Tanzania. Structural and sociocultural barriers make late presentation typical in such settings where treatment options for advanced stage disease are limited. In the absence of national programmes, stand-alone screening campaigns tend to employ clinical models of delivery focused on individual behaviour and through a disease specific lens. This paper describes a case study of a 2010 stand-alone campaign in Tanzania to argue that exclusively clinical approaches can undermine screening efforts by premising that women will act outside their social and cultural domain when responding to screening services. A focus on sociocultural barriers dictated the approach and execution of the intervention. Our experience concurs with that in similar settings elsewhere, underscoring the importance of barriers situated within the sociocultural milieu of societies when considering prevention interventions. Culturally competent delivery could contribute to long-term reductions in late stage presentation and increases in treatment acceptance. We propose a paradigm shift in the approach to stand-alone prevention programmes.

Epidemiologic and Clinical Profiles of Breast Diseases in Niger

This study aimed at characterizing epidemiologic and clinical profiles of breast diseases in Niger during the period of 2010–2013 at the National Hospital of Niamey. Medical records were abstracted for demographic, reproductive, clinical, and treatment information. A process map of patient navigation and barriers to seeking medical care was developed after interviewing 26 local health professionals who encounter and/or manage breast diseases. We identified 245 breast cancers and 122 other breast diseases. Mean age of breast cancer patients was 45.4 (±13.26 years) and that of breast diseases was 31(±12.5 years) with 1/3 of cancers under age 44. Infection-related diseases represented 24% of non-cancers. Male breast diseases represented 4.75% of diseases and 2.05% of cancers. Only 37.1% of cancers had histopathologic confirmation and 90% of cancer patients presented at advanced stages and mastectomy was performed for 66% of breast cancers. Patient and system barriers to care were common in diagnosing and treating breast diseases. Women in Niger have double burden of infectious breast diseases and emerging breast cancer. Younger age and late diagnosis are common features. Reducing barriers to access to care, down-staging of cancer, implementation of clinical guidelines for managing advanced cases are important needs for reducing breast cancer morbidity and mortality in Niger.

Stage at breast cancer diagnosis and distance from diagnostic hospital in a periurban setting: a South African public hospital case series of over 1,000 women

Advanced stage at diagnosis contributes to low breast cancer survival rates in sub-Saharan Africa. Living far from health services is known to delay presentation, but the effect of residential distance to hospital, the radius at which this effect sets in and the women most affected have not been quantified. In a periurban South African setting, we examined the effect of a geographic information system (GIS)-measured straight-line distance, from a patient's residence to diagnostic hospital, on stage at diagnosis in 1,071 public-sector breast cancer patients diagnosed during 2006-2012. Generalized linear models were used to estimate risk ratios for late stage (stage III/IV vs. stage I/II) associated with distance, adjusting for year of diagnosis, age, race and socioeconomic indicators. Mean age of patients was 55 years, 90% were black African and diagnoses were at stages I (5%), II (41%), III (46%) and IV (8%). Sixty-two percent of patients with distances >20 km (n = 338) had a late stage at diagnosis compared to 50% with distances <20 km (n = 713, p = 0.02). Risk of late stage at diagnosis was 1.25-fold higher (95% CI: 1.09, 1.42) per 30 km. Effects were pronounced in an underrepresented group of patients over age 70. This positive stage-distance association held to 40 km, and plateaued or slightly reversed in patients (9%) living beyond this distance. Studies of woman and the societal and healthcare-level influences on these delays and on the late stage at diagnosis distribution are needed to inform interventions to improve diagnostic stage and breast cancer survival in this and similar settings.

Caring for a loved one with cancer: it is my job

This study investigated the experiences of caregivers of loved ones with cancer in Lomé, Togo. The authors developed a framework that captures the experiences of 17 caregivers. The framework explains the exploratory factors that influenced the lives of caregivers from the caregivers' own perspectives. Findings showed that even though the caregivers experienced significant challenges that affected their lives and the lives of their families, because of cultural norms and expectations, they tried their best to overcome the challenges. Although some reported positive impacts on their family functioning, others reported negative impacts such as fragmentation of the family unit. Implications for practice and policy are discussed.

Cancer care challenges in developing countries

BACKGROUND

Health systems in Sub-Saharan Africa are not prepared for the rapid rise in cancer rates projected in the region over the next decades. More must be understood about the current state of cancer care in this region to target improvement efforts. Yaounde General Hospital (YGH) currently is the only site in Cameroon (population: 18.8 million) where adults can receive chemotherapy from trained medical oncologists. The experiences of patients at this facility represent a useful paradigm for describing cancer care in this region.

METHODS

In July and August 2010, our multidisciplinary team conducted closed-end interviews with 79 consecutive patients who had confirmed breast cancer, Kaposi sarcoma, or lymphoma.

RESULTS

Thirty-five percent of patients waited >6 months to speak to a health care provider after the first sign of their cancer. The delay between first consultation with a health care provider and receipt of a cancer diagnosis was >3 months for 47% of patients. The total delay from the first sign of cancer to receipt of the correct diagnosis was >6 months for 63% of patients. Twenty-three percent of patients traveled for >7 hours to reach YGH, and 40% of patients interviewed spent >$200 on a single round of chemotherapy.

CONCLUSIONS

Cancer patients experienced numerous geographic and health care system challenges, resulting in significant delays in receiving diagnosis and treatment, even for cancers highly amenable to early intervention. This unacceptable and unethical situation is likely explained by limited knowledge about cancer among patients and health care professionals, government neglect, poverty, and reliance on traditional healers.

A nation-wide multicenter 10-year (1999-2008) retrospective clinical epidemiological study of female breast cancer in China

BACKGROUND

According to the very limited cancer registry, incidence and mortality rates for female breast cancer in China are regarded to be increasing especially in the metropolitan areas. Representative data on the breast cancer profile of Chinese women and its time trend over years are relatively rare. The aims of the current study are to illustrate the breast cancer profile of Chinese women in time span and to explore the current treatment approaches to female breast cancer.

METHODS

This was a hospital-based nation-wide and multi-center retrospective study of female primary breast cancer cases. China was divided into 7 regions according to the geographic distribution; from each region, one tertiary hospital was selected. With the exception of January and February, one month was randomly selected to represent each year from year 1999 to 2008 at every hospital. All inpatient cases within the selected month were reviewed and related information was collected based on the designed case report form (CRF). The Cancer Hospital/Institute, Chinese Academy of Medical Sciences (CICAMS) was the leading hospital in this study.

RESULTS

Four-thousand two-hundred and eleven cases were randomly selected from the total pool of 45,200 patients and were included in the analysis. The mean age at diagnosis was 48.7 years (s.d. = 10.5 yrs) and breast cancer peaked in age group 40-49 yrs (38.6%). The most common subtype was infiltrating ductal carcinoma (86.5%). Clinical stage I & II accounted for 60.6% of 4,211 patients. Three-thousand five-hundred and thirty-four cases had estrogen receptor (ER) and progestin receptor (PR) tests, among them, 47.9% were positive for both. Two-thousand eight-hundred and forty-nine cases had human epidermal growth factor receptor 2(HER-2) tests, 25.8% of them were HER-2 positive. Among all treatment options, surgery (96.9% (4,078/4,211)) was predominant, followed by chemotherapy (81.4% (3,428/4,211). Much less patients underwent radiotherapy (22.6% (952/4,211)) and endocrine therapy (38.0% (1,599/4,211)).

CONCLUSIONS

The younger age of breast cancer onset among Chinese women and more advanced tumor stages pose a great challenge. Adjuvant therapy, especially radiotherapy and endocrine therapy are of great unmet needs.

Breast Cancer Profile in a Group of Patients Followed up at the Radiation Therapy Unit of the Yaounde General Hospital, Cameroon

Objective. To describe the profile of breast cancer in the patients attending the radiation therapy unit of Yaounde General Hospital. Method. From 1989 to 2009, we conducted a descriptive retrospective study based on the register and medical records of patients. Results. During the study period, 531 breast cancer patients were recorded of which 0.75% were male. Age range was 18 to 82 years, with a mean of 45.17 years. Out of these, 66.1% were less than 50 years old and 31.9% less than 40. Self detection was the discovery method in most cases (95.34% of patients). Mean delay before presentation at hospital was 10.35 months, and 54.94% had used traditional medicine before medical evaluation. Metastasis and locally advanced breast cancer at diagnosis were present in 08.13% and 62.78%, respectively. Mastectomy was used in 88.08% of patients. Conclusion. The study reinforces the position occupied by late presentation and advanced stage at diagnosis of breast cancer profile in developing countries.

A mixed-method assessment of beliefs and practice around breast cancer in Ethiopia: implications for public health programming and cancer control

A large proportion of breast cancer patients in Ethiopia present for biomedical care too late, or not at all, resulting in high mortality. This study was conducted to better learn of beliefs and practices among patients accessing breast cancer services in a large referral centre in Ethiopia. Using a mixed-method design, we interviewed 69 breast cancer patients presenting for care at Tikur Anbessa Hospital in Addis Ababa, Ethiopia, about their beliefs, experiences and perspectives on breast cancer. Awareness of breast cancer is low in Ethiopia and even among those who are aware of the disease, a sense of hopelessness and fatalism is common. Early signs/symptoms are frequently ignored and patients often first present to traditional healers. Breast cancer is perceived as being caused typically from humoral anomalies or difficulties resulting from breast feeding, and study participants indicate that stigmatisation and social isolation complicate discussion and action around breast cancer. Consistent with other studies, this study shows that traditional beliefs and practices are common around breast cancer and that numerous barriers exist to identification and treatment in Ethiopia. Integrating health beliefs and practice into public health action in innovative ways may reduce stigma, increase awareness and promote survivability among breast cancer patients.

Patient-mediated factors predicting early- and late-stage presentation of breast cancer in Egypt

OBJECTIVE

Breast cancer fatality rates are high in low- and middle-income countries because of the late stage at diagnosis. We investigated patient-mediated determinants for late-stage presentation of breast cancer in Egypt.

METHODS

A case-case comparison was performed for 343 women with breast cancer, comparing those who had been initially diagnosed at Stage I or II with those diagnosed at Stage III or IV. Patients were recruited from the National Cancer Institute of Cairo University and Tanta Cancer Center in the Nile delta. Patients were either newly diagnosed or diagnosed within the year preceding the study. Interviews elicited information on disease history and diagnosis, beliefs and attitudes toward screening practices, distance to treatment facility, education, income, and reproductive history.

RESULTS

Forty-six per cent of the patients had presented at late stage. Women seen in Cairo were more likely to present at late stages than patients in Tanta (OR=5.05; 95% CI=1.30, 19.70). Women without any pain were more likely to present at later stage (OR=2.68; 95% CI=1.18, 6.08). Knowledge of breast self-examination increased the likelihood of women to present in early stages significantly (OR=0.24; 95% CI=0.06, 0.94).

CONCLUSIONS

Despite increasing numbers of cancer centers in Egypt during the past 20 years, additional regional facilities are needed for cancer management. In addition, increasing awareness about breast cancer will have significant long-term impact on breast cancer prevention.

Cancer control in developing countries: using health data and health services research to measure and improve access, quality and efficiency

Background

Cancer is a rapidly increasing problem in developing countries. Access, quality and efficiency of cancer services in developing countries must be understood to advance effective cancer control programs. Health services research can provide insights into these areas.

Discussion

This article provides an overview of oncology health services in developing countries. We use selected examples from peer-reviewed literature in health services research and relevant publicly available documents. In spite of significant limitations in the available data, it is clear there are substantial barriers to access to cancer control in developing countries. This includes prevention, early detection, diagnosis/treatment and palliation. There are also substantial limitations in the quality of cancer control and a great need to improve economic efficiency. We describe how the application of health data may assist in optimizing (1) Structure: strengthening planning, collaboration, transparency, research development, education and capacity building. (2) Process: enabling follow-up, knowledge translation, patient safety and quality assurance. (3) Outcome: facilitating evaluation, monitoring and improvement of national cancer control efforts. There is currently limited data and capacity to use this data in developing countries for these purposes.

Summary

There is an urgent need to improve health services for cancer control in developing countries. Current resources and much-needed investments must be optimally managed. To achieve this, we would recommend investment in four key priorities: (1) Capacity building in oncology health services research, policy and planning relevant to developing countries. (2) Development of high-quality health data sources. (3) More oncology-related economic evaluations in developing countries. (4) Exploration of high-quality models of cancer control in developing countries. Meeting these needs will require national, regional and international collaboration as well as political leadership. Horizontal integration with programs for other diseases will be important.

Clinical and epidemiologic profile of breast cancer in Tanzania

PURPOSE

breast cancer is a highly heterogeneous disease globally. Public health prevention measures require an understanding of the burden of breast cancer and its risk factors. The purpose of this study was to describe the clinical, pathologic, and epidemiologic characteristics of breast cancer patients in Tanzania.

METHODS

data was abstracted from the medical records of all breast cancer patients attending Ocean Road Cancer Institute (ORCI) over a 2-year period from July 2007 to June 2009. Tumor tissue paraffin blocks were collected for all patients with available tissues for the determination of estrogen receptor (ER) and progesterone receptor (PR). Data for all patients was analyzed descriptively and by using unconditional logistic regression, by comparing early stage (ES), defined as stages I and II and late stage (LS), defined as stages III and IV patients to obtain odds ratios (ORs), 95% confidence intervals (CIs), and P-values.

RESULTS

among the 488 patients, stage was determined for 356~patients, 90.7% of whom presented in LS. Of the 57 tumor tissues, 49.1% were ER-/PR-. Patients with ulceration (OR = 4.97; 95% CI= 1.07, 23.04; p=0.04) and peau d'orange (OR= 6.78; 95{\%} CI $=$ 1.48, 31.17; p=0.01) were more likely to present in LS rather than ES. Male breast cancer accounted for 2.9% of all breast cancers and inflammatory breast cancer (IBC) comprised 4.3-5.5% of cases based on registered t4d diagnosis or the criteria of IBC signs, if t4d was not reported in the medical records.

CONCLUSION

most breast cancer patients in Tanzania are diagnosed at advanced disease stages with about half of the tumors being ER-/PR-. These data strongly support that reducing barriers to care, down-staging of disease at diagnosis, implementation of clinical guidelines for management of advanced cases, and palliative care are the four most essential factors that need to be addressed to reduce morbidity and mortality from breast cancer in Tanzania. Further research is needed to quantify the magnitude and molecular features of two relatively rare forms of breast cancer that may account for a greater proportion of the burden of breast cancer in Tanzania compared to the USA and Western Europe: male breast cancer and IBC.

Guideline implementation for breast healthcare in low- and middle-income countries: breast healthcare program resource allocation

Breast cancer is serious public health problem in countries of all resource levels. Although major advances in the detection and treatment of the disease have occurred in higher income settings, similar progress has been slow or scarce in most low- and middle-income countries (LMCs). The poorer outcomes in LMCs may relate to the limited capability of their healthcare systems (HCS) to provide successful early detection, diagnosis, and treatment of breast cancer. Impediments to better outcomes include insufficient numbers of appropriately trained healthcare workers, limited access to screening/treatment facilities, inadequate supplies of necessary drugs, and timeliness of treatment after diagnosis. Clearly, these HCS deficiencies are broader than the scope of the Breast Health Global Initiative (BHGI) and are not unique to the issue of breast cancer. To address issues in HCS that hinder the delivery of breast health services, the BHGI Healthcare Systems and Public Policy Panel explored the HCS structures and function needed to operate a breast care program (BCP). Like with all BHGI guidelines, those proposed by this panel were expressed in terms of 4 strata of resource levels: basic, limited, enhanced, and maximal. The current report describes the issues and questions related to HCS that are important to consider when designing, implementing, and measuring the performance of a BCP. Health ministers, other policymakers, healthcare personnel, administrators, and anyone else involved in developing a BCP can use and adapt this framework to improve outcomes and ensure the more effective use of resources.

Pathological, clinical and prognostic characteristics of breast cancer in Central Sudan versus Northern Italy: implications for breast cancer in Africa

AIMS

In patients of Black African ethnicity, breast cancer is reportedly characterized by aggressive, poorly differentiated phenotype(s). To highlight possible differences between breast cancer in indigenous sub-Saharan African and European patients, two breast cancer case series, from Central Sudan (Khartoum) and Northern Italy (Milan), were compared for clinicopathological characteristics, expression of oestrogen receptor (ER), progesterone receptor (PR), Her-2/neu, basal cytokeratin (CK) 5/6 and CK17, and breast cancer subtypes.

METHODS AND RESULTS

After careful antigen retrieval, 114 and 138 consecutive formalin-fixed paraffin-embedded (FFPE) breast cancer cases from the Radiation and Isotope Centre (Khartoum) and from MultiMedica (Milan), respectively, were screened by immunohistochemistry for ER, PR, Her-2/neu, CK5/6 and CK17. Compared with the Italian patients, the Sudanese patients were younger (P < 0.0001) and their tumours were larger (P < 0.0001), more advanced in stage (P < 0.00001), higher grade (P < 0.00001) and more frequently positive for nodal metastases (P < 0.00001). ER expression varied between the two series (P < 0.0008), but no significant differences were found for PR (P < 0.32), combined hormone receptors (P < 0.12), Her-2/neu (P < 0.09), CK5/6 (P < 0.1), CK17 (P = 0.4), combined basal CK status (P = 1) or breast cancer subtypes (P = 0.12).

CONCLUSION

The differences between the Sudanese and Italian breast cancer series reflect stage at diagnosis rather than intrinsic biological characteristics. This may have relevant implications for breast cancer prevention and treatment in Africa.