Improving Outcomes in Breast Cancer for Low and Middle Income Countries

Cost of illness of breast cancer in low- and middle-income countries: a systematic review

This systematic review explores the cost of illness (COI) studies on breast cancer in low- to middle-income countries (LMICs). Studies in Cochrane, Proquest Thesis, PubMed and Scopus were considered. The reporting criteria were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 statement. Studies must (1) be peer-reviewed, (2) report cost data, and (3) be full-text articles. Non-English articles were excluded. Twelve studies were included. The identified costs were made constant to 2022 USD values for reporting and comparison across studies. Annual costs per patient varied from $195 to $11,866 direct medical costs, $201 to $2233 direct non-medical costs and $332 to $26,390 productivity losses were reported. Cost differences were due to the cost types and components in each study. Only three COI studies reported sensitivity analysis and discount rates. Hence, it is recommended that future COI studies include an analysis of correlation between cost components and other variables.

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.

Multi-level barriers to early detection of breast cancer among rural midlife women in Tanzania: A qualitative case study

BACKGROUND

Breast cancer is the second most common cause of cancer mortality among women in Tanzania and thus, early detection and treatment methods are central to improving breast cancer outcomes. However, in low- and middle-income countries in Sub-Saharan Africa, the survival rates remains low due to late presentation. Hence, a significant number of deaths could be prevented if barriers and facilitators to early detection are known.

PURPOSE

This qualitative case descriptive study explored the possible barriers to awareness and early breast cancer diagnostic services among midlife women in rural Tanzania.

METHODS

Ten key informant interviews with health systems managers and community health workers and eight focus group discussions with women aged 40-65 years and their spouses were conducted to elicit the study data conducted from July to August 2021.

RESULTS

The data revealed nine themes describing the barriers to early detection methods across five Socio-Ecological levels of influence, namely: 1) limited knowledge and 2) witchcraft beliefs (individual level); 3) limited male support (interpersonal level); 4) age and gender factors and 5) procrastination (community level) 6) limited availability of services 7) emphasis of curative over preventive care (institutional level); 8) poverty/inability to pay and 9) limitations of health insurance (societal/policy level).

CONCLUSIONS

The study findings suggest a need to further the design, implementation and evaluation of evidence-based community breast health awareness and education interventions to promote early detection of breast cancer in Tanzania. Specifically, the study highlights the need to address multiple level determinants of influence in breast cancer control as part of the country's Community Health Strategy.

Advancements in Biotechnology and Stem Cell Therapies for Breast Cancer Patients

This comprehensive review article examines the integration of biotechnology and stem cell therapy in breast cancer diagnosis and treatment. It discusses the use of biotechnological tools such as liquid biopsies, genomic profiling, and imaging technologies for accurate diagnosis and monitoring of treatment response. Stem cell-based approaches, their role in modeling breast cancer progression, and their potential for breast reconstruction post-mastectomy are explored. The review highlights the importance of personalized treatment strategies that combine biotechnological tools and stem cell therapies. Ethical considerations, challenges in clinical translation, and regulatory frameworks are also addressed. The article concludes by emphasizing the potential of integrating biotechnology and stem cell therapy to improve breast cancer outcomes, highlighting the need for continued research and collaboration in this field.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Decomposing socioeconomic disparity in the utilization of screening mammography: A cross-sectional analysis from the RaNCD cohort study

We aimed to examine the degree of socioeconomic inequality in screening mammography among Kurdish women of Iran. Data from the Ravansar Non-Communicable Diseases (RaNCD) Cohort Study were used. A total of 3,219 women aged 35-65 years were studied. The concentration index (CIn) was used to measure the magnitude of socioeconomic-related inequalities in screening mammography. Decomposition analysis was employed to calculate the contribution of each explanatory variable to the observed inequality. The participation rate for screening mammography was 19.7%. The CIn of screening mammography was 0.142 (95% CI: 0.0197, 0.0656), indicating that screening mammography is more concentrated among high-SES women. Socioeconomic status, education level and area of residence were the main contributors to the observed inequality, respectively. We found a pro-rich inequality in screening mammography among Iranian Kurdish women. For mitigating socioeconomic inequality in screening mammography policymakers should focus more on the poor and rural communities.

The anticancer mechanism of action of selected polyphenols in triple-negative breast cancer (TNBC)

Breast cancer is a leadingcause of cancer-related deaths in women globally, with triple-negative breast cancer (TNBC) being an aggressive subtype that lacks targeted therapies and is associated with a poor prognosis. Polyphenols, naturally occurring compounds in plants, have been investigated as a potential therapeutic strategy for TNBC. This review provides an overview of the anticancer effects of polyphenols in TNBC and their mechanisms of action. Several polyphenols, including resveratrol, quercetin, kaempferol, genistein, epigallocatechin-3-gallate, apigenin, fisetin, hesperetin and luteolin, have been shown to inhibit TNBC cell proliferation, induce cell cycle arrest, promote apoptosis, and suppress migration/invasion in preclinical models. The molecular mechanisms underlying their anticancer effects involve the modulation of several signalling pathways, such as PI3K/Akt, MAPK, STATT, and NF-κB pathways. Polyphenols also exhibit synergistic effects with chemotherapy drugs, making them promising candidates for combination therapy. The review also highlights clinical trials investigating the potential use of polyphenols, individually or in combination therapy, against breast cancer. This review deepens the under-standing of the mechanism of action of respective polyphenols and provides valuable insights into the potential use of polyphenols as a therapeutic strategy for TNBC, and lays the groundwork for future research in this area.

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.

More recent insights into the breast cancer burden across BRICS-Plus: Health consequences in key nations with emerging economies using the global burden of disease study 2019

Background

Brazil, Russia, India, China, South Africa, and 30 other Asian nations make up the BRICS-Plus, a group of developing countries that account for about half of the world's population and contribute significantly to the global illness burden. This study aimed to analyzed the epidemiological burden of female breast cancer (BC) across the BRICS-Plus from 1990 to 2019 and studied the associations with age, period, birth cohort and countries' sociodemographic index (SDI).

Methods

The BC mortality and incidence estimates came from the 2019 Global Burden of Disease Study. We estimated cohort and period effects in BC outcomes between 1990 and 2019 using age-period-cohort (APC) modeling. The maximum likelihood (ML) of the APC-model Poisson with log (Y) based on the natural-spline function was used to estimate the rate ratio (RR). We used annualized rate of change (AROC) to quantify change over the previous 30 years in BC across BRICS-Plus and compare it to the global.

Results

In 2019, there were about 1.98 million female BC cases (age-standardized rate of 45.86 [95% UI: 41.91, 49.76]) and 0.69 million deaths (age-standardized rate of 15.88 [95% UI: 14.66, 17.07]) around the globe. Among them, 45.4% of incident cases and 51.3% of deaths were attributed to the BRICS-Plus. China (41.1% cases and 26.5% deaths) and India (16.1% cases and 23.1% deaths) had the largest proportion of incident cases and deaths among the BRICS-Plus nations in 2019. Pakistan came in third with 5.6% cases and 8.8% deaths. Over the past three decades, from 1990 to 2019, the BRICS-Plus region's greatest AROC was seen in Lesotho (2.61%; 95%UI: 1.99-2.99). The birth cohort impacts on BC vary significantly among the BRICS-Plus nations. Overall, the risk of case-fatality rate tended to decline in all BRICS-Plus nations, notably in South Asian Association for Regional Cooperation (SAARC) and China-ASEAN Free Trade Area (China-ASEAN FTA) countries, and the drop in risk in the most recent cohort was lowest in China and the Maldives. Additionally, there was a substantial negative link between SDI and case fatality rate (r₁₉₉₀= -0.91, p<0.001; r₂₀₁₉= -0.89, p<0.001) in the BRICS-Plus in both 1990 and 2019, with the Eurasian Economic Union (EEU) nations having the highest case fatality rate.

Conclusions

The BC burden varies remarkably between different BRICS-Plus regions. Although the BRICS' efforts to regulate BC succeeded, the overall improvements lagged behind those in high-income Asia-Pacific nations. Every BRICS-Plus country should strengthen specific public health approaches and policies directed at different priority groups, according to BRIC-Plus and other high-burden nations.

Physicians' attitudes and perceived barriers to adherence to the national breast cancer clinical practice guidelines in Mexico: a survey study

BACKGROUND

Adherence to clinical practice guidelines improves outcomes for patients with breast cancer. However, their implementation may not be feasible in low- and middle-income countries. This study aimed to evaluate physicians' adherence, attitudes, and barriers towards the Colima Consensus, which is the Mexican national breast cancer clinical practice guideline.

METHODS

A cross-sectional, 31-item survey was e-mailed to Consensus attendees and members of the Mexican Society of Oncology and Mexican Mastology Association. Descriptive statistics, univariate, and multivariate analysis were used to analyze the associations between participants' characteristics, adherence, attitudes, and barriers.

RESULTS

Of 439 respondents, 78% percent adhered to Consensus recommendations and 94% believed it was applicable to their clinical practice. Forty percent reported using the Consensus as their sole breast cancer guideline. This was associated with being a surgical oncologist (OR 3.3, 95% CI 2.0-5.3) and practicing at a public hospital (OR 2.1, 95% CI 1.2-3.7). The most common barriers to adherence were lack of resources and logistical problems. Regarding attitudes towards the Consensus, 90% considered it a good educational tool, 89% considered it a reliable source of information, and 90% thought it improved quality of care.

CONCLUSIONS

We showed high levels of adherence and positive attitudes towards the Colima Consensus, with a significant proportion of physicians using it as their only guideline. Lack of resources and logistical issues were the main barriers to adherence. Our results highlight the relevance of local breast cancer guidelines and suggest a need for the creation of resource-stratified guidelines.

Breast ultrasound in Chinese hospitals: A cross-sectional study of the current status and influencing factors of BI-RADS utilization and diagnostic accuracy

BACKGROUND

With the growing demand for breast screening in public health services and clinical care, ultrasound departments in China are facing tremendous challenges.

METHODS

A cross-sectional nationwide survey was conducted in 5,460 departments providing ultrasound diagnoses in mainland China from 2020 to 2021. The survey included general information about the ultrasound department, the characteristics of sonologists, the use of Breast Imaging Reporting and Data System (BI-RADS) templates, and the diagnostic accuracy rate of breast cancer ultrasound.

FINDINGS

There were on average 2.25 sonologists per 10,000 patients in mainland China per year. The average utilization rate of BI-RADS in Chinese hospitals was 87.02%. The GDP per capita of the province (P = 0.008), whether the hospital was specialized (P = 0.002) or a Tier 3 facility (P < 0.001), the percentage of doctors with master's and doctoral degrees (P < 0.001) and doctors ≤35 years (P = 0.005) were significantly and independently associated with the utilization rate of BI-RADS. The average diagnostic accuracy rate of breast cancer ultrasound in Chinese hospitals was 73.64%, and we observed significant positive associations between GDP per capita (P = 0.02), BI-RADS utilization rate (P = 0.019), and breast cancer ultrasound diagnostic accuracy.

INTERPRETATION

The utilization of BI-RADS templates effectively improved the diagnostic accuracy of ultrasound. Moreover, the survey summarized the current situation of departments and sonologists providing breast ultrasound diagnosis in mainland China, which helped monitor the development of the discipline and provide information for administrators to meet the growing demand.

FUNDING

This work was supported by Natural Science Foundation of Beijing (7202156) and Foundation of ihecc (2019-C-0646-2).

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.

Comparison of female breast cancer between Russia and Germany: A population-based study on time trends and stage at diagnosis

OBJECTIVES

While a mammography-screening program (MSP) is being offered systematically in Germany since 2009, the dispanserizatsiya has been implemented in Russia since 2013. This study examined trends of stage at breast cancer diagnosis in two Russian regions and compared the results with the development in Germany. In addition, we aimed to gain further insights into the early detection of breast cancer in Russia.

METHODS

Incidence data from two cancer registries in Russia and 12 population-based cancer registries in Germany were used to analyse breast cancer incidence rates among women above age 30 over time. Further, we calculated rate ratios to compare the age group-specific incidence rates after the implementation of MSP in Germany (2010-2014) with the period before implementation (2003-2005) separately for each tumour stage and all stages combined.

RESULTS

During the study period from 2003 to 2014, age-standardised rates for breast cancer were 54.6 and 116.7 per 100,000 for Russia and Germany, respectively. The proportion of the T1 stage at diagnosis among Russian women aged 50 + is half than that in Germany. Nevertheless, we observed an increasing trend of early-stage alongside the reduction of advanced-stage incidence rates of breast cancer in Russia.

CONCLUSIONS

The observed trend in Russia may reflect overall positive changes in early detection of breast cancer, with actual proportion of T1 stage still far behind Germany. Advances in breast cancer screening efforts through the dispanserizatsiya may help to further reduce the breast cancer burden.

Zingiberene exerts chemopreventive activity against 7,12-dimethylbenz(a)anthracene-induced breast cancer in Sprague-Dawley rats

Breast cancer is the primary cause of cancer-related death in females, wherein increased mortality of breast cancer patients is recorded worldwide. Zingiberene is a monocyclic sesquiterpene from the ginger plant and has many pharmacological benefits. In this exploration, we assessed the anticancer actions of Zingiberene against the 7,12-dimethylbenz(a)anthracene (DMBA)-stimulated mammary carcinogenesis in rats and MDA-MB-231 cells. Breast cancer was induced in the Female Sprague-Dawley rats through the 25 mg/kg of DMBA in 0.5 ml of corn oil and then treated with 20 and 40 mg/kg of Zingiberene, respectively. The body weight of animals and tumor volume was measured. Hematological parameters, transaminases, lipid profile, lipid peroxidation, and antioxidants status were scrutinized using standard techniques. The estrogen receptor-α and inflammatory markers were inspected by using respective assay kits. Histological damage scores were determined. In vitro experiments were conducted to scrutinize Zingiberene's effect on cell viability and apoptotic cell death in MDA-MB-231 cells. Zingiberene substantially modulated the DMBA-stimulated physiological and hematological changes and decreased the transaminases, and lipid peroxidation in the DMBA-stimulated animals. Zingiberene also elevated the antioxidant level and suppressed the inflammatory markers. Histological study revealed the protective effects of Zingiberene. The viability of MDA-MB-231 cells was noticeably diminished by the Zingiberene, thus inducing apoptotic cell death. Overall, our findings reliably proved the anticancer potential of Zingiberene against the DMBA-stimulated mammary tumorigenesis, and it could be a promising chemotherapeutic agent.

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.

Adherence to the South African food based dietary guidelines may reduce breast cancer risk in black South African women: the South African Breast Cancer (SABC) study

OBJECTIVE

To determine the level of adherence and to assess the association between higher adherence to the South African food based dietary guidelines (SAFBDG) and breast cancer risk.

DESIGN

Population-based, case-control study (the South African Breast Cancer study) matched on age and demographic settings. Validated questionnaires were used to collect dietary and epidemiological data. To assess adherence to the SAFBDG, a nine-point adherence score (out of eleven guidelines) was developed, using suggested adherence cut-points for scoring each recommendation (0 and 1). When the association between higher adherence to the SAFBDG and breast cancer risk was assessed, data-driven tertiles among controls were used as cut-points for scoring each recommendation (0, 0·5 and 1). OR and 95 % CI were estimated using multivariate logistic regression models.

SETTING

Soweto, South Africa.

PARTICIPANTS

Black urban women, 396 breast cancer cases and 396 controls.

RESULTS

After adjusting for potential confounders, higher adherence (>5·0) to the SAFBDG v. lower adherence (<3·5) was statistically significantly inversely associated with breast cancer risk overall (OR = 0·56, 95 % CI 0·38, 0·85), among postmenopausal women (OR = 0·64, 95 % CI 0·40, 0·97) as well as for oestrogen-positive breast cancers (OR = 0·51, 95 % CI 0·32, 0·89). Only 32·3 % of cases and 39·1 % of controls adhered to at least half (a score >4·5) of the SAFBDG.

CONCLUSIONS

Higher adherence to the SAFBDG may reduce breast cancer risk in this population. The concerning low levels of adherence to the SAFBDG emphasise the need for education campaigns and to create healthy food environments in South Africa to increase adherence to the SAFBDG.

YY1-Induced Transcriptional Activation of FAM111B Contributes to the Malignancy of Breast Cancer

BACKGROUND

Family with sequence similarity 111 member B (FAM111B) is an oncoprotein associated with multiple malignancies. We investigated the potential mechanisms of FAM111B in breast cancer.

PATIENTS AND METHODS

We tested the expression of FAM111B in breast cancer tissues and the survival rate of breast cancer patients with high or low level of FAM111B through TCGA data. The expression of FAM111B in breast cancer tissues and adjacent tissues was detected using western blotting. Then we used siRNA to construct a low expression model of FAM111B in SKBR3 and MDA-MB-468. EdU, CCK-8, wound healing, and transwell assays were performed to monitor the proliferation, migration, and invasion of breast cancer cells. Western blotting was used to detect the expression of EMT-related indicators. Chromatin Immunoprecipitation (ChIP) and qPCR were used to evaluate the regulatory effect of Yin Yang 1 (YY1) on FAM111B.

RESULTS

The expression of FAM111B in breast cancer tissues was higher than that in normal tissues. Patients who had high FAM111B expression had a worse prognosis. Knockdown of FAM111B inhibited the proliferation, migration, and invasion of breast cancer cells. Knockdown of FAM111B resulted in increased expression of EMT-related protein E-cadherin and decreased expression of N-cadherin and Vimentin. ChIP-qPCR analysis demonstrated that YY1 could bind to the promoter of FAM111B gene and strengthen its transcription activity.

CONCLUSION

YY1-induced transcriptional activation of FAM111B accelerated the progression of breast cancer.

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.

Examination of incidence, mortality and disability-adjusted life years and risk factors of breast cancer in 49 Asian countries, 1990-2019: estimates from Global Burden of Disease Study 2019

BACKGROUND

This study presents an up-to-date, comprehensive and comparative examination of breast cancer's temporal patterns in females in Asia in last three decades.

METHODS

The estimates of incidence, mortality, disability-adjusted-life-years and risk factors of breast cancer in females in 49 Asian countries were retrieved from Global Burden of Disease 2019 study.

RESULTS

In Asia, female breast cancer incidence grew from 245 045[226 259-265 260] in 1990 to 914 878[815 789-1025 502] in 2019 with age-standardized incidence rate rising from 21.2/100 000[19.6-22.9] to 35.9/100 000[32.0-40.2] between 1990 and 2019. The death counts more than doubled from 136 665[126 094-148 380] to 337 822[301 454-375 251]. The age-standardized mortality rate rose marginally between 1990 and 2019 (1990: 12.1[11.0-13.1]; 2019: 13.4[12.0-14.9]). In 2019, age-standardized incidence rate varied from 17.2/100 000[13.95-21.4] in Mongolia to 122.5[92.1-160.7] in Lebanon and the age-standardized mortality rate varied 4-fold from 8.0/100 000 [7.2-8.8] in South Korea to 51.9[39.0-69.8] in Pakistan. High body mass index (5.6%), high fasting plasma glucose (5.6%) and secondhand smoke (3.5%) were the main contributory risk factors to all-age disability-adjusted-life-years due to breast cancer in Asia.

CONCLUSION

With growing incidence, escalating dietary and behavioural risk factors and lower survival rates due to late-disease presentation in low- and medium-income countries of Asia, breast cancer has become a significant public health threat. Its rising burden calls for increasing breast cancer awareness, preventive measures, early-stage detection and cost-effective therapeutics in Asia.

Limited access to care for persons with breast cancer in Africa: A systematic review

PURPOSE

To systematically review the available evidence and examine the factors that may limit patients' access to breast cancer care in Africa.

METHODS

We searched six databases (Google Scholar, Web of Science, PubMed, EMBASE, CINAHL, and Scopus) for studies conducted among breast cancer patients in Africa, highlighting patient challenges and barriers to care or treatment. The search was limited to studies published in the English language and from January 2000 until August 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. There were no limitations to the methodological design of the included studies.

RESULTS

In total, 18,154 articles were retrieved through electronic search; twenty-five were eligible for inclusion after quality appraisal. We analyzed the data using the deductive content analysis approach. Three categories emerged as barriers to breast cancer care: Socio-economic challenges, Institutional shortfalls, and Distinctiveness.

CONCLUSIONS

The findings support that economic hardships, fear, and scarcity of cancer treatments/equipment are critical in limiting access to breast cancer care. Sustainable strategies aimed at scaling-up breast cancer care in the region are necessary. The results also highlight the need for reduced treatment cost and aggressive educational campaigns across healthcare facilities and the local communities.

Quality indicators for the diagnosis and surgical management of breast cancer in South Africa

INTRODUCTION

Quality indicators (QIs) for breast cancer care have been developed and applied in high-income countries and contributed to improved quality of care and patient outcomes over time.

MATERIALS AND METHODS

A modified Delphi process was used to derive expert consensus. Potential QIs were rated by a panel of 17 breast cancer experts from various subspecialties and across South African provinces. Each QI was rated according to importance to measure, scientific acceptability and feasibility. Scoring ranged from 1 (no agreement) to 5 (strong agreement). Inclusion thresholds were set a priori at mean ratings ≥4 with a coefficient variation of ≥25%. Levels of evidence were determined for each indicator.

RESULTS

The literature review identified 790 potential QIs. After categorisation and removal of duplicates, 52 remained for panel review. There was strong consensus for 47 which were merged to 30 QIs by exclusion of similar indicators and indicator grouping. The final set included eight QIs with level I or II evidence and two QIs with level III evidence which were deemed "mandatory" due to clinical priority and impact on care. The remaining QIs with lower-level evidence were grouped as eight "recommended" QIs (regarded as standard of care) and twelve "optional" QIs (not regarded as standard of care).

CONCLUSION

A regional set of QIs was developed to facilitate standardised treatment and auditing of surgical care for breast cancer patients in South Africa. Routine monitoring of the ten mandatory QIs, which were selected to have the most substantial impact on patient outcome, is proposed.

Estimating the impact of treatment and imaging modalities on 5-year net survival of 11 cancers in 200 countries: a simulation-based analysis

BACKGROUND

Accurate survival estimates are important for cancer control planning. Although observed survival estimates are unavailable for many countries, where they are available, wide variations are reported. Understanding the impact of specific treatment and imaging modalities can help decision makers to effectively allocate resources to improve cancer survival in their local context.

METHODS

We developed a microsimulation model of stage-specific cancer survival in 200 countries and territories for 11 cancers (oesophagus, stomach, colon, rectum, anus, liver, pancreas, lung, breast, cervix uteri, and prostate) comprising 60% of global diagnosed cancer cases. The model accounts for country-specific availability of treatment (chemotherapy, surgery, radiotherapy, and targeted therapy) and imaging modalities (ultrasound, x-ray, CT, MRI, PET, single-photon emission CT), as well as quality of care. We calibrated the model to reported survival estimates from CONCORD-3 (which reports global trends in cancer survival in 2000-14). We estimated 5-year net survival for diagnosed cancers in each country or territory and estimated potential survival gains from increasing the availability of individual treatment and imaging modalities, and more comprehensive packages of scale-up of these interventions. We report the mean and 95% uncertainty intervals (UIs) for all outcomes, calculated as the 2·5 and 97·5 percentiles of the simulation results.

FINDINGS

The estimated global 5-year net survival for all 11 cancers combined is 42·6% (95% uncertainty interval 40·3-44·3), with survival in high-income countries being an average of 12 times (range 4-17) higher than that in low-income countries. Expanding availability of surgery or radiotherapy or improving quality of care would yield the largest survival gains in low-income (2·5-3·4 percentage point increase in survival) and lower-middle-income countries (2·4-6·1 percentage point increase), whereas upper-middle-income and high-income countries are more likely to benefit from improved availability of targeted therapy (0·7 percentage point increase for upper-middle income and 0·4 percentage point increase for high income). Investing in medical imaging will also be necessary to achieve substantial survival gains, with traditional modalities estimated to provide the largest gains in low-income settings, while MRI and PET would yield the largest gains in higher-income countries. Simultaneous expansion of treatment, imaging, and quality of care could improve 5-year net survival by more than ten times in low-income countries (3·8% [95% UI 0·5-9·2] to 45·2% [40·2-52·1]) and could more than double 5-year net survival in lower-middle-income countries (20·1% [7·2-31·7] to 47·1% [42·8-50·8]).

INTERPRETATION

Scaling up both treatment and imaging availability could yield synergistic survival gains for patients with cancer. Expanding traditional modalities in lower-income settings might be a feasible pathway to improve survival before scaling up more modern technologies.

FUNDING

Harvard T H Chan School of Public Health.

Vitex doniana Leaves Extract Ameliorates Alterations Associated with 7, 12-Dimethyl Benz[a]Anthracene-Induced Mammary Damage in Female Wistar Rats

Vitex doniana leaves are used traditionally in West Africa for the treatment of swellings and cancer. We investigated if Vitex doniana leaves extract could ameliorate 7, 12-dimethylbenz[a]anthracene (DMBA)-induced mammary damage. Female Wistar rats aged 52 ± 2 day were administered 80 mg/kg DMBA. After monitoring for 150 day, rats were administered 0, 50, 100, 200 mg/kg Vitex doniana and 20 mg/kg Tamoxifen for 14 day. Serum estrogen receptor-α, IL-1β and TNF -α levels were determined using ELISA kits. Oxidative stress markers in mammary tissue homogenates were determined using standard spectrophotometric methods. Histopathological examination was done using hematoxylin and eosin staining and cyclooxygenase-2 (COX-2) expression using immunohistochemistry. Liquid chromatography-mass spectrometry was used to determine components present in the extract. Although tumors were not observed, significantly (p < 0.05) lower estrogen receptor-α, malondialdehyde, IL-1β and TNF -α levels, significantly (p < 0.05) higher glutathione and catalase activity, attenuation of malignant epithelial hyperplasia and mild COX-2 expression were observed in rats administered Vitex doniana when compared to DMBA-induced untreated control. Liquid chromatography-mass spectrometry analysis of the V. doniana extract revealed the presence of 4,5-dihydroxy-7-methoxy-6-methylflavone and vanillylamine, which are compounds with reported antioxidant and anti-inflammatory effects. Collectively, treatment with Vitex doniana ameliorated some derangement observed in DMBA-induced rats.

Ultrasound for Breast Cancer Detection Globally: A Systematic Review and Meta-Analysis

PURPOSE

Mammography is not always available or feasible. The purpose of this systematic review and meta-analysis is to assess the diagnostic performance of ultrasound as a primary tool for early detection of breast cancer.

MATERIALS AND METHODS

For this systematic review and meta-analysis, we comprehensively searched PubMed and SCOPUS to identify articles from January 2000 to December 2018 that included data on the performance of ultrasound for detection of breast cancer. Studies evaluating portable, handheld ultrasound as an independent detection modality for breast cancer were included. Quality assessment and bias analysis were performed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Sensitivity analyses and meta-regression were used to explore heterogeneity. The study protocol has been registered with the international prospective register of systematic reviews (PROSPERO identifier: CRD42019127752).

RESULTS

Of the 526 identified studies, 26 were eligible for inclusion. Ultrasound had an overall pooled sensitivity and specificity of 80.1% (95% CI, 72.2% to 86.3%) and 88.4% (95% CI, 79.8% to 93.6%), respectively. When only low- and middle-income country data were considered, ultrasound maintained a diagnostic sensitivity of 89.2% and specificity of 99.1%. Meta-analysis of the included studies revealed heterogeneity. The high sensitivity of ultrasound for the detection of breast cancer was not statistically significantly different in subgroup analyses on the basis of mean age, risk, symptoms, study design, bias level, and study setting.

CONCLUSION

Given the increasing burden of breast cancer and infeasibility of mammography in certain settings, we believe these results support the potential use of ultrasound as an effective primary detection tool for breast cancer, which may be beneficial in low-resource settings where mammography is unavailable.

Assessment and Improvement Strategies for a Breast Cancer Early Detection Program in Rural South Africa

Purpose To assess and develop solutions for an ultrasound-based breast cancer early detection program in rural South Africa 1 year after implementation. Methods A WHO-endorsed RAD-AID Radiology Readiness Assessment was used to evaluate clinic resources. In addition, 5 weeks of observation identified resource deficiencies and reviewed existing documentation methods. On the basis of stakeholders' input and the BI-RADS, we developed new documentation systems. Training was followed by a survey that assessed feasibility and provider acceptance. Results Resource limitations included lack of computers, unpredictable electrical supply, and inconsistent Internet. The assessment revealed incomplete documentation of breast clinical examinations and history, breast lesions, and follow-up. Furthermore, limitations negatively affected communication among providers. Three solutions were developed: a paper patient history form, a paper clinical findings form, and a computerized patient-tracking data base compliant with BI-RADS. Three nurses, three nursing assistants, and one counselor completed the survey. Seventy-one percent indicated positive general attitudes, and 100% agreed that the documentation system is easy and useful and improves overall quality of care, follow-up, decision making; access to clinical information; and communication between clinicians and patients. Five of the seven providers reported that the system increased visit time, but three of those five believed that the process was valuable. Conclusion Implementation of a breast cancer early detection program in resource-limited regions is challenging, and continual assessment is essential. As a result of identified needs, we developed a documentation system that was broadly accepted. Future steps should focus on increasing efficiency, evaluation of provider attitudes long term, and clinical effect.

An educational intervention on based information, motivation and behavior skills model and predicting breast self-examination

Introduction

Breast self-examination recommend as a breast screening method in developing countries where there are limited access to other screening methods. Therefore promoting breast self-examination required to identify effective interventions and relevant factors.

Methods

This study was a quasi-experimental design carried out among 314 women 20-69 years in community cultural centers in Isfahan city, Iran. Sampling was conducted from April to 10 August, 2016. A structured questionnaire was used for data collection in before and after the educational intervention. Then participants were followed by phone call after one month for breast self-examination performance. We used descriptive statistical analysis (mean, standard division, frequency distribution), and also other statistical methods (Paired t-test, Pearson’s correlation and logistic regression).The data were analyzed using SPSS version 18 with considering a significant level less than 0.05.

Results

There was significant difference between mean scores of information, motivation and behavior skill before and after intervention (P < .0001). After one month following 205 of women (72.2%) reported to perform breast self-examination. Pearson’s correlation showed that breast self-examination significantly correlated with information (r = .305, p = .000), motivation (r = .128, p = .031) and behavior skills (r = .161, p = .006). Also the logistic regression results demonstrated that information (p < .001, OR = 1.071), motivation (p = .045, OR = .978) and behavior skills (p = .001, OR = 1.033) predicted breast self- examination.

Conclusions

Considering the results of this study, it appears that the use of educational interventions based on three constructs of information, motivation and behavior skills can be used to promote breast self-examination. Moreover these results can apply to improve breast self-examination among women by health care providers.

Barriers to early presentation of breast cancer among women in Soweto, South Africa

PURPOSE

Reported breast cancer incidence is rising in South Africa, where some women are diagnosed late and have poor outcomes. We studied patient and provider factors associated with clinical stage at diagnosis among women diagnosed at the Chris Hani Baragwanath Academic Hospital in Soweto, Johannesburg in 2015-2016.

METHODS

From face-to-face interviewer-administered questionnaires we compared self-reported socioeconomics, demographics, comorbidities, risk factors, personal and health system barriers, and from patient clinical records, clinical staging, receptor subtype, and tumor grade among 499 consecutive women newly diagnosed with advanced stage (III/IV) breast cancer versus those diagnosed early (stage 0/I/II). Logistic regression models were used to identify factors associated with advanced stage at diagnosis.

RESULTS

Among the women, 243 (49%) were diagnosed at early and 256 (51%) at advanced stages. In the multiple logistic regression adjusted model, completion of high school or beyond (odds ratio (OR) 0.59, and greater breast cancer knowledge and awareness (OR 0.86) were associated with lower stage of breast cancer at presentation. Advanced stage was associated with Luminal B (OR 2.25) and triple-negative subtypes (OR 3.17) compared to luminal A, with delays >3 months from first breast symptoms to accessing the health system (OR 2.79) and with having more than 1 visit within the referral health system (OR 3.19) for 2 visits; OR 2.73 for ≥3 visits).

CONCLUSIONS

Limited patient education, breast cancer knowledge and awareness, and health system inefficiencies were associated with advanced stage at diagnosis. Sustained community and healthcare worker education may down-stage disease and improve cancer outcomes.

Breast cancer survival in Soweto, Johannesburg, South Africa: A receptor-defined cohort of women diagnosed from 2009 to 11

BACKGROUND

South Africa's public healthcare system is better equipped to manage breast cancer than most other SSA countries, but survival rates are unknown.

METHODS

A historical cohort of 602 women newly diagnosed with invasive breast carcinoma during 2009-2011 at Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, was followed using health systems data to December 2014. 'Overall survival' time was defined from diagnosis to death or terminal illness. Cox regression was used to estimate hazard ratios (HR) associated with woman and tumour characteristics.

RESULTS

During a median 2.1 years follow-up (IQR 0.5-3.8), 149 women died or were classified terminally ill; 287 were lost-to-follow-up. 3-year survival was 84% for early stage (I/II) and 56% for late stage (III/IV) tumours (late v early: HR 2.8 (95% confidence interval (CI): 1.9-4.1), however the 42% cumulative losses to follow-up over this period were greater for late stage, half of which occurred within 6 months of diagnosis. After mutual adjustment for stage, grade, age, receptor subtype and HIV status, lower survival was also associated with triple negative (HR 3.1 (95% CI: 1.9-5.0)) and HER2-enriched (2.5 (95% CI: 1.4-4.5)) compared to ER/PR+ HER2- tumours, but not with age or HIV-infection (1.4 (95% CI: 0.8, 2.3)).

CONCLUSION

In this South African cohort, breast cancer survival is suboptimal, but was better for early stage and hormone receptor-positive tumours. Efforts to reduce clinic losses in the immediate post-diagnosis period, in addition to early presentation and accelerated diagnosis and treatment, are needed to prevent breast cancer deaths, and survival improvements need to be monitored using prospective studies with active follow-up.

An in silico comparative dosimetric study of postmastectomy locoregional irradiation using intensity-modulated vs 3-dimensional conventional radiotherapy

An in silico dosimetric evaluation of intensity-modulated radiation therapy (IMRT) vs 3-dimensional conventional radiation therapy (3D-CRT) treatment plans in postmastectomy radiation therapy (PMRT) to the chest wall and regional lymphatics was conducted. Twenty-five consecutive patients with breast cancer referred for locoregional PMRT, stages T_2-4 with N_1-3, were planned to receive 50 Gy in 25 fractions with IMRT. Additionally, a 3D-CRT plan was generated using identical contours for the clinical target volumes (CTV), planning target volumes (PTV), and organs at risk (OAR). Treatment plans were assessed using dose-volume histogram (DVH) parameters of D₉₈, D₉₅, D₅₀, D₂, and homogeneity index for individual CTVs and PTVs. OARs evaluated were ipsilateral and contralateral lungs, heart, spinal cord, and opposite breast. Most DVH parameters pertaining to CTVs and PTVs significantly favored IMRT. V₂₀ for ipsilateral and contralateral lungs, D₃₃ of heart and maximum dose to spinal cord favored IMRT (all p < 0.001). The mean dose to the opposite breast was significantly lesser with 3D-CRT (5.8 ± 1.8 Gy vs 2.0 ± 1.0 Gy, p < 0.001). Thus, except for the mean dose to the opposite breast, the compliance to DVH constraints applied to PTV and OARs were significantly better with IMRT. At a median follow-up of 76 months (7-91), none had locoregional failure or pulmonary or cardiac morbidity. For PMRT, requiring comprehensive irradiation to both chest wall and regional lymphatics, IMRT offers superior dosimetric advantages over 3D-CRT. This was also corroborated by long-term outcomes in these patients treated with IMRT.

Pilot Educational Intervention and Feasibility Assessment of Breast Ultrasound in Rural South Africa

PURPOSE

Breast cancer is the leading cause of cancer death in women worldwide, with high mortality in low- and middle-income countries because of a lack of detection, diagnosis, and treatment. With mammography unavailable, ultrasound offers an alternative for downstaging. The literature reports successful training in various domains, but a focus on the breast is novel. We assessed the feasibility (knowledge acquisition, perceived usefulness, and self-efficacy) of breast ultrasound training for nonphysician providers.

METHODS

Training was implemented for 12 providers at Hlokomela Clinic in Hoedspruit, South Africa, over 3 weeks. Didactic presentations and example cases were followed by a presurvey and test (n = 12). All providers received hands-on training with nurses as models; five providers trained with patients. A post-test (n = 12) assessed knowledge acquisition and a postsurvey (n = 10) assessed perceived program usefulness and provider self-efficacy.

RESULTS

The pre- to post-test averages improved by 68% in total and in four competencies (foundational knowledge, descriptive categories, benign v malignant, and lesion identification). On the postsurvey, providers expressed that ultrasound could significantly influence breast cancer detection (9.1 out of 10), treatment (7.9 out of 10), and survival (8.7 out of 10) in their community and endorsed moderate confidence in their scanning (6.3 out of 10) and interpreting abilities (5.6 out of 10).

CONCLUSION

Our research supports the feasibility of breast ultrasound training as part of a breast education program in low- and middle-income countries. Pre- and post-test results and observed proficiency indicate that training nonphysician providers is achievable; postsurvey responses indicate program acceptance, community-based ownership, and provider self-efficacy with ultrasound. Future work may show that breast ultrasound is viable for early detection where mammography is unavailable.

Leverage of an Existing Cervical Cancer Prevention Service Platform to Initiate Breast Cancer Control Services in Zambia: Experiences and Early Outcomes

PURPOSE

In 2005, the Cervical Cancer Prevention Program in Zambia (CCPPZ) was implemented and has since provided cervical cancer screen-and-treat services to more than 500,000 women. By leveraging the successes and experiences of the CCPPZ, we intended to build capacity for the early detection and surgical treatment of breast cancer.

METHODS

Our initiative sought to build capacity for breast cancer care through the (1) formation of a breast cancer advocacy alliance to raise awareness, (2) creation of resource-appropriate breast cancer care training curricula for mid- and high-level providers, and (3) implementation of early detection and treatment capacity within two major health care facilities.

RESULTS

Six months after the completion of the initiative, the following outcomes were documented: Breast health education and clinical breast examination (CBE) services were successfully integrated into the service platforms of four CCPPZ clinics. Two new breast diagnostic centers were opened, which provided access to breast ultrasound, ultrasound-guided core needle biopsy, and needle aspiration. Breast health education and CBE were provided to 1,955 clients, 167 of whom were evaluated at the two diagnostic centers; 55 of those evaluated underwent core-needle biopsy, of which 17 were diagnosed with invasive cancer. Newly trained surgeons performed six sentinel lymph node mappings, eight sentinel lymph node dissections, and 10 breast conservation surgeries (lumpectomies).

CONCLUSION

This initiative successfully established clinical services in Zambia that are critical for the early detection and surgical management of breast cancer.

Development and Validation of a Culturally-Tailored Breast Cancer Health Education Programme for Arab Women

OBJECTIVES

This study aimed to develop and validate a health education programme to encourage breast cancer awareness and early detection behaviours among Arab women.

METHODS

This study took place between December 2015 and March 2016. The Enabling Systems Raising Awareness model was used to develop a breast cancer health education programme which was subsequently implemented by trained health educators at three female-only fitness clubs in Muscat, Oman. Breast cancer knowledge among 53 women was assessed using the breast module of the Cancer Awareness Measure before and after each health education session. Overall pre- and post-session knowledge scores were then compared. Additionally, three focus group discussions were conducted with 10 participants from each location. Thematic analysis was used to analyse the transcribed discussions and collect feedback on the programme.

RESULTS

The health education sessions resulted in a statistically significant increase in overall mean knowledge scores (P <0.001). Participants also reported significantly improved intentions to undertake early detection practices (P <0.001). The focus group discussions yielded distinct themes and valuable feedback which can be utilised in the future to create an improved version of the programme.

CONCLUSION

While the health education programme significantly improved breast cancer and early detection knowledge among a cohort of Arab women, it still required critical improvements in terms of structure and administration. Additional studies are required in order to evaluate long-term behavioural outcomes resulting from the improved programme.

Breast cancer in Mongolia: an increasingly important health policy issue

Breast cancer is a leading cause of cancer-related death for women in both developed and developing countries. The incidence and mortality of breast cancer in Mongolia, while low compared with other counties, has been increasing on an annual basis. In addition, in Mongolia, approximately 90% of the patients are diagnosed at a late stage, resulting in high mortality, with the majority of individuals diagnosed with breast cancer dying within 5 years of diagnosis. Breast cancer screening plays an important role in reducing mortality in Western countries and has been adopted by a number of Asian countries; however, no such approach exists in Mongolia. In a country of limited resources, implementation of expensive health strategies such as screening requires effective allocations of resources and the identification of the most effective imaging methods. This requirement relies on recent accurate data; however, at this time, there is a paucity of information around breast cancer in Mongolia. Until data around features of the disease are available, effective strategies to diagnose breast cancer that recognize the economic climate in Mongolia cannot be implemented and the impact of breast cancer is likely to increase.