Breast cancer characteristics and HIV among 1,092 women in Soweto, South Africa

Breast cancer in women by HIV status: A report from the South African National Cancer Registry

BACKGROUND

Breast cancer (BC) is the leading cause of cancer-related morbidity and mortality in women living in South Africa, a country with a high HIV burden. However, characteristics of the double burden of HIV and BC in South Africa have not been properly investigated. We described characteristics of BC cases by HIV status in South Africa.

METHODS

In this nationwide South African study, we obtained BC records for women aged ≥15 years diagnosed in the public health sector between January 2004 and December 2014. We included records from the National Cancer Registry that had been linked to HIV-related laboratory records from the National Health Laboratory Service. We assessed the odds of being HIV positive versus HIV negative in relation to patient-, cancer-, and municipality-related characteristics.

RESULTS

From 2004-2014, 40 520 BC cases were diagnosed in women aged ≥15 years. Of these, 73.5% had unknown HIV status, 18.7% were HIV negative, and 7.7% were HIV positive. The median age at BC diagnosis was 43 years (interquartile range [IQR]: 37-52) in HIV positive and 57 years (IQR: 46-68) in HIV negative women, respectively. The odds of being HIV positive was higher for women who were aged 30-34 years compared to women aged 35-39 years at cancer diagnosis (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.10-1.71), Black versus non-Black (OR 6.41, 95% CI 5.68-7.23), diagnosed with cancer in rural versus urban areas (OR 1.59, 95% CI 1.40-1.82) and diagnosed in municipalities with low and middle (OR 3.46, 95% CI 2.48-4.82) versus high socioeconomic position (OR 2.69, 95% CI 2.11-3.42).

CONCLUSION

HIV status was unknown for the majority of BC patients. Among those with known HIV status, being HIV positive was associated with a younger age at cancer diagnosis, being Black and receiving care in municipalities of poor socioeconomic position. Future studies should examine opportunities to integrate HIV and BC control programs.

Gynaecologic and breast cancers in women living with HIV in South Africa: A record linkage study

Breast and gynaecologic cancers account for approximately half of all cancers diagnosed amongst women in South Africa, many of whom also live with HIV. We aimed to determine the incidence of and risk factors for developing breast and gynaecologic cancers in women living with HIV (WLHIV) in South Africa. This is a longitudinal analysis of the South African HIV Cancer Match study including women aged ≥15 years with two or more HIV-related laboratory tests. We used Cox proportional hazard models to determine the association of Human Papilloma Virus (HPV)-related and hormone-related gynaecologic cancer with patient- and municipal-level characteristics. From 3 447 908 women and 10.5 million years of follow-up, we identified 11 384 incident and 7612 prevalent gynaecologic and breast cancers. The overall crude incidence rate was 108/1 00 000 person-years (pyears) (95% confidence interval [CI]: 106-110), with the highest incidence observed for cervical cancer (70/1 00 000 pyears; 95% CI: 68.5-71.7). Low CD4 cell counts and high HIV RNA viral loads increased the risk of cervical and other HPV-related cancers. Age was associated with both HPV-related and hormone-related cancers. Women accessing health facilities in high socioeconomic position (SEP) municipalities were more likely to be diagnosed with HPV-related cancers and breast cancer than women accessing care in low SEP municipalities. It is important to improve the immunologic status of WLHIV as part of cancer prevention strategies in WLHIV. Cancer prevention and early detection programmes should be tailored to the needs of women ageing with HIV. In addition, SEP disparities in cancer diagnostic services have to be addressed.

Characterizing HIV status documentation among cancer patients at regional cancer centers in Malawi, Zimbabwe, and South Africa

INTRODUCTION

In East and Southern Africa, people with HIV (PWH) experience worse cancer-related outcomes and are at higher risk of developing certain cancers. Siloed care delivery pathways pose a substantial barrier to co-management of HIV and cancer care delivery.

METHODS

We conducted cross-sectional studies of adult cancer patients at public radiotherapy and oncology units in Malawi (Kamuzu Central Hospital), Zimbabwe (Parirenyatwa Group of Hospitals), and South Africa (Charlotte Maxeke Hospital) between 2018 and 2019. We abstracted cancer- and HIV-related data from new cancer patient records and used Poisson regression with robust variance to identify patient characteristics associated with HIV documentation.

RESULTS

We included 1,648 records from Malawi (median age 46 years), 1,044 records from South Africa (median age 55 years), and 1,135 records from Zimbabwe (median age 52 years). Records from all three sites were predominately from female patients; the most common cancers were cervical (Malawi [29%] and Zimbabwe [43%]) and breast (South Africa [87%]). HIV status was documented in 22% of cancer records from Malawi, 92% from South Africa, and 86% from Zimbabwe. Patients with infection-related cancers were more likely to have HIV status documented in Malawi (adjusted prevalence ratio [aPR]: 1.92, 95% confidence interval [CI]: 1.56-2.38) and Zimbabwe (aPR: 1.16, 95%CI: 1.10-1.22). Patients aged ≥ 60 years were less likely to have HIV status documented (Malawi: aPR: 0.66, 95% CI: 0.50-0.87; Zimbabwe: aPR: 0.76, 95%CI: 0.72-0.81) than patients under age 40 years. Patient age and cancer type were not associated with HIV status documentation in South Africa.

CONCLUSION

Different cancer centers have different gaps in HIV status documentation and will require tailored strategies to improve processes for ascertaining and recording HIV-related information in cancer records. Further research by our consortium to identify opportunities for integrating HIV and cancer care delivery is underway.

Validation of the Xpert Breast Cancer STRAT 4 Assay on the GeneXpert instrument to Assess Hormone Receptor, Ki67, and HER2 Gene Expression Status in Breast Cancer Tissue Samples

Breast cancer is the commonest cause of cancer-related mortality in African females where patients often present later and with advanced disease. Causes for delayed diagnosis include restricted diagnostic access and international controversy on interpretation of ancillary tests like immunohistochemistry (IHC). Fine needle aspirates (FNAC) are an attractive alternative although may have reduced sensitivity. The Xpert Breast Cancer STRAT4 (STRAT4) (CE-IVD*) assay (Cepheid, Sunnyvale) is a semi-quantitative reverse-transcription polymerase chain reaction assay which detects messenger RNA (mRNA) expression in breast samples for estrogen receptor ( ESR1 ), progesterone receptor ( PGR1 ), human epidermal growth factor receptor/Erb-B2 receptor tyrosine kinase 2 (HER2/ ERBB2 ) and the proliferation marker, MKi67 . We assessed the performance of this assay on both formalin-fixed paraffin-embedded (FFPE, n=31) and matched FNAC (n=20) samples from patients presenting with breast cancer to the Johannesburg academic hospitals. IHC and Fluorescent in situ hybridization analysis (performed on HER2-indeterminate samples) was compared with the mRNA expression of the corresponding target genes in FFPE samples, and mRNA expression on FNAC samples was compared with the FFPE results for both mRNA expression and IHC. Concordance between IHC/FISH and Xpert Breast Cancer STRAT4 in FFPE and FNAC samples using the Quick lysis (Q) method (a research-use-only modification of the validated FFPE-lysis method), showed an overall percentage agreement for ESR1 expression of 90.3% and 81.3%, and for PGR1 expression at 86.7% and 81.3% respectively in FFPE and FNAC samples. Concordance was lowest for Ki67 expression, using a binary IHC cutoff for Ki67 positivity at ≥20% staining) at 83.9% and 62.5%, for FFPE and FNAC samples, respectively. This suggests that the STRAT4 assay may be a useful ancillary test in determining HR and Ki67 status in FFPE samples and that use on FNAC samples may be feasible. Future studies should expand the sample numbers and establish locally relevant cutoffs.

Characterizing HIV status documentation among cancer patients at regional cancer centers in Malawi, Zimbabwe, and South Africa

Introduction

In East and Southern Africa, people with HIV (PWH) experience worse cancer-related outcomes and are at higher risk of developing certain cancers. Siloed care delivery pathways pose a substantial barrier to co-management of HIV and cancer care delivery.

Methods

We conducted cross-sectional studies of adult cancer patients at public radiotherapy and oncology units in Malawi (Kamuzu Central Hospital), Zimbabwe (Parirenyatwa Group of Hospitals), and South Africa (Charlotte Maxeke Hospital) between 2018-2019. We abstracted cancer- and HIV-related data from new cancer patient records and used Poisson regression with robust variance to identify patient characteristics associated with HIV documentation.

Results

We included 1,648 records from Malawi (median age 46 years), 1,044 records from South Africa (median age 55 years), and 1,135 records from Zimbabwe (median age 52 years). Records from all three sites were predominately from female patients; the most common cancers were cervical (Malawi [29%] and Zimbabwe [43%]) and breast (South Africa [87%]). HIV status was documented in 22% of cancer records from Malawi, 92% from South Africa, and 86% from Zimbabwe. Patients with infection-related cancers were more likely to have HIV status documented in Malawi (adjusted prevalence ratio [aPR]: 1.92, 95% confidence interval [CI]: 1.56-2.38) and Zimbabwe (aPR: 1.16, 95%CI: 1.10-1.22). Patients aged ≥60 years were less likely to have HIV status documented (Malawi: aPR: 0.66, 95% CI: 0.50-0.87; Zimbabwe: aPR: 0.76, 95%CI: 0.72-0.81) than patients under age 40 years. Patient age and cancer type were not associated with HIV status documentation in South Africa.

Conclusion

Different cancer centers have different gaps in HIV status documentation and will require tailored strategies to improve processes for ascertaining and recording HIV-related information in cancer records. Further research by our consortium to identify opportunities for integrating HIV and cancer care delivery is underway.

Risk factors for breast cancer among women in Ekurhuleni Metropolitan Municipality, Gauteng province of South Africa, 2017‒2020: a case-control study

Introduction

Breast cancer (BC) is the most common cancer among women in South Africa (SA), with an age-standardised incidence rate of 52.6 and an age-standardised mortality rate of 16.0 per 100,000 population. There is a paucity of evidence on the risk factors for BC among women of all races in SA. Given the rising prevalence of BC in SA, literature-based evidence is critical for the appropriate dissemination of preventative measures. This study aimed to identify the risk factors associated with the development of BC among women in Ekhuruleni Metropolitan Municipality.

Methods

An unmatched case-control study was conducted from 1 January 2017 to 31 December 2020 using secondary data extracted from the Ekurhuleni Population-Based Cancer Registry. Unconditional multivariable logistic regression analysis was carried out using the adjusted odds ratio (aOR). The variables race, employment, human immunodeficiency virus (HIV), smoking and alcohol status were included in the multivariable logistic regression model while the model was adjusted for age.

Results

A total of 2,217 cases and 851 controls were enrolled in the study. The mean age (±SD) in years was 55.7 (±15.2). The White population group, being self-employed and being HIV positive was significantly associated with reduced odds of BC development. HIV-positive women were 61% less likely to have BC than women who were HIV-negative (aOR 0.39; 95% confidence interval (CI): 0.27‒0.57). White women were 65% less likely to have BC than women of other races (aOR 0.35; 95% CI: 0.29‒0.43). Self-employed women were 59% less likely to have BC than women who were formally employed (aOR 0.41; 95% CI: 0.18‒0.97). No evidence of association was observed between tobacco smoking and BC as well as alcohol consumption and BC.

Conclusion

There was a 65% reduction in BC risk among White women compared to other races. HIV-positive women demonstrated a 61% lower likelihood of BC while self-employed women showed a 59% reduced risk of developing BC. These findings suggest that being White, self-employed or HIV-positive may provide some protection against BC. However, additional research is needed to validate these results and establish the underlying reasons behind these associations.

Preoperative Biomarkers and Survival in Chinese Breast Cancer Patients with HIV: A Propensity-Score-Matched-Cohort Study

BACKGROUND

China initiated its national free antiretroviral therapy program in 2004 and saw a dramatic decline in mortality among the population with HIV. However, the morbidity of non-AIDS-defining cancers such as breast cancer is steadily growing as life expectancy improves. The aim of this study was to investigate the clinical characteristics and prognosis of breast cancer patients with HIV in China.

MATERIALS AND METHODS

Data from 21 breast cancer patients with HIV and 396 breast cancer patients without HIV treated at the Shanghai public health clinical center from 2014-2022 was collected. After propensity score matching, 21 paired patients in the two groups were obtained and compared. The optimal cut-off value of preoperative biomarkers for recurrence was determined via maximally selected log-rank statistics. Preoperative biomarkers were categorized into high and low groups, based on the best cut-off values and compared using Kaplan-Meier survival curves and the log-rank test. The Cox proportional hazards regression model was used to perform univariate and multivariate analyses.

RESULTS

The median follow-up time was 38 months (IQR: 20-68 months) for the propensity-score-matching cohort. The progression-free survival at 1, 2 and 3 years for patients with and without HIV were 74.51%, 67.74%, and 37.63% and 95.24%, 95.24%, and 90.48%, respectively. The overall survival for patients with HIV at 1, 2 and 3 years were 94.44%, 76.74%, and 42.63%. After multivariate analysis, Only HIV status (hazard ratios (HRs) = 6.83, 95% [confidence intervals (CI)] 1.22-38.12) were associated with progression-free survival. Based on the best cut-off value, CD8 showed discriminative value for overall survival (p = 0.04), whereas four variables, the lymphocyte-to-monocyte ratio (p = 0.02), platelet-to-lymphocyte ratio (p = 0.03), CD3 (p = 0.01) and CD8 (p < 0.01) were suggested be significant for progression-free survival. The univariate analysis suggested that CD3 (HRs = 0.10, 95% [CI] 0.01-0.90) and lymphocyte-to-monocyte ratio (HRs = 0.22, 95% [CI] 0.05-0.93) were identified as significant predictors for progression-free survival.

CONCLUSION

In this study, breast cancer in patients with HIV in China reflected a more aggressive nature with a more advanced diagnostic stage and worse prognosis. Moreover, preoperative immune and inflammatory biomarkers might play a role in the prognosis of breast cancer patients with HIV.

HIV Prevalence and Characteristics Among Patients With AIDS-Defining and Non-AIDS-Defining Cancers in a Tertiary Hospital in Kenya

PURPOSE

Antiretroviral therapy (ART) has resulted in a higher life expectancy of persons living with HIV. This has led to an aging population at risk for both non-AIDS-defining cancers (NADCs) and AIDS-defining cancers (ADCs). HIV testing among patients with cancer in Kenya is not routinely performed, making its prevalence undefined. The aim of our study was to determine the prevalence of HIV and the spectrum of malignancies among HIV-positive and HIV-negative patients with cancer attending a tertiary hospital in Nairobi, Kenya.

MATERIALS AND METHODS

We conducted a cross-sectional study between February 2021 and September 2021. Patients with a histologic cancer diagnosis were enrolled. Demographic data and HIV- and cancer-related clinical variables were obtained. HIV pretest counseling and consent were done, and testing was performed using a fourth-generation assay. Positive results were confirmed using a third-generation assay.

RESULTS

We enrolled 301 patients with cancer; 67.8% (204 of 301) were female; the mean age was 50.7 ± 12.5 years. From our cohort, 10.6% (95% CI, 7.4 to 14.7, n = 32 of 301) of patients were HIV-positive with the prevalence of a new HIV diagnosis of 0.7% (n = 2 of 301). Of the HIV-positive patients, 59.4% (19 of 32) had a NADC. The commonest NADC was breast cancer (18.8%; 6 of 32), whereas non-Hodgkin lymphoma (18.8%; 6 of 32) and cervical cancer (18.8%; 6 of 32) were the most prevalent ADCs among HIV-positive patients.

CONCLUSION

The prevalence of HIV infection among patients with cancer was twice the Kenya national HIV prevalence. NADCs comprised a larger percentage of the cancer burden. Universal opt-out HIV testing of patients attending for cancer care regardless of cancer type may facilitate early recognition of HIV-infected patients and aid in appropriate selection of ART and cancer therapies and preventive strategies.

Virologic Nonsuppression Among Patients With HIV Newly Diagnosed With Cancer at Uganda Cancer Institute: A Cross-Sectional Study

PURPOSE

AIDS-related mortality declined markedly since the introduction of antiretroviral therapy (ART); however, cancer mortality in Africa was higher than its incidence in 2020. People living with HIV (PLWHIV) are at an increased risk of malignancy and death from malignancy compared with the general population. In Uganda, AIDS-defining malignancies (ADMs), including cervical cancer, Kaposi sarcoma, and non-Hodgkin lymphoma, are among the commonest malignancies. Virologic nonsuppression has been identified as an important predictor of mortality among PLWHIV diagnosed with cancer. This study aimed to determine the prevalence and to identify factors associated with virologic nonsuppression among PLWHIV newly diagnosed with cancer.

METHODS

This was a cross-sectional study that was carried out between December 2018 and April 2019 at the Uganda Cancer Institute. PLWHIV who had been on ART for at least 6 months and were newly diagnosed with cancer were enrolled.

RESULTS

A total of 167 participants were enrolled. Cervical cancer was the commonest ADM (n = 45; 50.6%) of all ADMs, while esophageal and breast cancers were the commonest non-ADMs, accounting for 17.5% (n = 14) each of all non-ADMs. The prevalence of virologic nonsuppression was 15%. Having Kaposi sarcoma (odds ratio [OR], 8.15; P = .003), being poorly adherent to ART (OR, 4.1; P = .045), and being on second-line ART (OR, 5.68; P = .011) were associated with virologic nonsuppression.

CONCLUSION

The prevalence of virologic nonsuppression is high among patients with HIV newly diagnosed with cancer. These findings emphasize the need for strengthening of adherence strategies, optimizing ART regimens, and prioritization of viral load testing among PLWHIV with newly diagnosed malignancy.

Epidemiology of Breast Cancer Presentation in Botswana, South Africa, and the United States

INTRODUCTION

This study sought to compare the clinicopathologic features of women with breast cancer presenting in South Africa, Botswana, and the United States (US).

METHODS

Breast cancer samples from Botswana (n = 384, 2011-2015), South Africa (n = 475, 2016-2017), and the US (n = 361,353, 2011-2012) were retrospectively reviewed.

RESULTS

The median age of sub-Saharan African women presenting with breast cancer (age 54 in Botswana and South Africa) was younger than that of those in the US (age 61) (P < 0.001). Sub-Saharan women were more likely to present with advanced stage disease than US counterparts (64.7% in Botswana, 63.3% in South Africa, 13% in the US, P < 0.001). Triple negative disease was highest in Botswana (21.3%) compared to South Africa (11.4%) and the US (12.94%) (P < 0.001). Differences in receptor status at presentation among the three cohorts (P < 0.001) were not observed when the cohorts were stratified by ethnicity. Black/multiracial patients in Botswana and the US were the most likely subsets to present with the adverse characteristic of triple negative disease (21.3% and 23.2%, respectively). No correlation was found between HIV and receptor status in the Botswana (P = 0.513) or South African (P = 0.352) cohorts.

CONCLUSIONS

Here we report receptor status patterns at presentation in Botswana and South Africa. This study reveals important similarities and differences which may inform policy and provide context for future epidemiologic trends of breast cancer in low- and-middle-income countries particularly in sub-Saharan Africa.

Pharmacogenetics of Breast Cancer Treatments: A Sub-Saharan Africa Perspective

Breast cancer is the most frequent cause of cancer death in low- and middle-income countries, in particular among sub-Saharan African women, where response to available anticancer treatment therapy is often limited by the recurrent breast tumours and metastasis, ultimately resulting in decreased overall survival rate. This can also be attributed to African genomes that contain more variation than those from other parts of the world. The purpose of this review is to summarize published evidence on pharmacogenetic and pharmacokinetic aspects related to specific available treatments and the known genetic variabilities associated with metabolism and/or transport of breast cancer drugs, and treatment outcomes when possible. The emphasis is on the African genetic variation and focuses on the genes with the highest strength of evidence, with a close look on CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP3A4/5, CYP19A1, UGT1A4, UGT2B7, UGT2B15, SLC22A16, SLC38A7, FcγR, DPYD, ABCB1, and SULT1A1, which are the genes known to play major roles in the metabolism and/or elimination of the respective anti-breast cancer drugs given to the patients. The genetic variability of their metabolism could be associated with different metabolic phenotypes that may cause reduced patients' adherence because of toxicity or sub-therapeutic doses. Finally, this knowledge enhances possible personalized treatment approaches, with the possibility of improving survival outcomes in patients with breast cancer.

Disparities in breast cancer survival between women with and without HIV across sub-Saharan Africa (ABC-DO): a prospective, cohort study

BACKGROUND

Studies have shown increased mortality among women living with HIV diagnosed with breast cancer compared with HIV-negative women with breast cancer. We aimed to examine how this HIV differential varies by patient or breast tumour characteristics.

METHODS

The African Breast Cancer-Disparities in Outcomes (ABC-DO) study is a prospective cohort of women (aged ≥18 years) with incident breast cancer recruited consecutively at diagnosis (2014-17) from hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. Detailed clinical and epidemiological data, including self-reported or tested HIV status, were collected at baseline. Participants were actively followed up via telephone calls every 3 months. The primary outcome was all-cause mortality, assessed in all women who had at least one updated vital status after baseline interview. Using Cox regression, we examined differences in overall survival by HIV status in the cohort, and across country and patient subgroups, adjusted for age, tumour grade, and tumour stage at cancer diagnosis.

FINDINGS

Between Sept 8, 2014, and Dec 31, 2017, we recruited 2154 women with primary breast cancer, 519 of whom were excluded due to their countries having small numbers of women with HIV for comparison. Among the remaining 1635 women, 313 (19%) were living with HIV, 1184 (72%) were HIV negative, and 138 (9%) had unknown HIV status. At breast cancer diagnosis, women with HIV were younger and had lower body-mass index (BMI) than their HIV-negative counterparts, but had similar tumour stage, grade, and receptor subtypes. At the end of the follow-up (Jan 1, 2019), a higher proportion of women with HIV (137 [44%] of 313) had died than had HIV-negative women (432 [37%] of 1184). Crude 3-year survival was 9% lower for women with HIV (46% [95% CI 40-53]) than for HIV-negative women (55% [52-59]; hazard ratio (HR) 1·41 [1·15-1·74]). The HIV survival differential did not differ by age, BMI, tumour subtype, or tumour grade, but was stronger in women with non-metastatic disease (3-year survival 52% HIV-positive vs 63% HIV-negative women, adjusted HR 1·65 [1·30-2·10]), whereas women with metastatic cancer had low survival, regardless of HIV status.

INTERPRETATION

The larger survival deficit among women with HIV with non-metastatic breast cancer calls for a better understanding of the reasons underlying this differential (eg, biological mechanisms, health behaviours, detrimental HIV-breast cancer treatment interactions, or higher HIV background mortality) to inform strategies for reducing mortality among this patient group.

FUNDING

Susan G Komen, International Agency for Research on Cancer, National Cancer Institute, and UK-Commonwealth Scholarships.

Impact of HIV infection on overall survival among women with stage IV breast cancer in South Africa

PURPOSE

Advanced breast cancer (BC) at diagnosis is common in sub-Saharan Africa (SSA), including among women living with HIV (WLWH). In public hospitals across South Africa (SA), 10-15% of women present with stage IV BC, compared to < 5% in the United States (US); 20% of new BC diagnoses in SA are in WLWH. We evaluated the impact of HIV on overall survival (OS) among women with stage IV BC.

METHODS

We conducted a prospective cohort study of women diagnosed with stage IV BC between February 2, 2015 and September 18, 2019 at six public hospitals in SA. Multivariate Cox regression models were used to estimate the association between HIV status and OS.

RESULTS

Among 550 eligible women, 147 (26.7%) were WLWH. Compared to HIV-negative BC patients, WLWH were younger (median age 45 vs. 60 years, p < 0.001), predominantly black (95.9% vs. 77.9%, p < 0.001), and more likely to have hormone receptor-negative (hormone-negative) BC (32.7% vs. 22.6%, p = 0.016). Most women received systemic cancer-directed therapy (80.1%). HIV status was not associated with treatment or OS (Hazard Ratio (HR) 1.13 [95%CI 0.89-1.44]). On exploratory subgroup analysis, WLWH and hormone-negative BC had shorter OS compared to HIV-uninfected women (1-year OS: 27.1% vs. 48.8%, p = 0.003; HR 1.94 [95%CI 1.27-2.94]; p = 0.002), which was not observed for hormone receptor-positive BC.

CONCLUSION

HIV status was not associated with worse OS in women with stage IV BC in SA and cannot account for the poor survival in this cohort. Subgroup analysis revealed that WLWH with hormone-negative BC had worse OS, which warrants further investigation.

Risk Factors for Breast Cancer, Overall and by Tumor Subtype, among Women from Mozambique, Sub-Saharan Africa

BACKGROUND

Breast cancer incidence is rising in Africa, but there are scare data regarding risk factors in this region. We assessed the relation between risk factors and the occurrence of breast cancer, overall and by tumor subtype in women from Mozambique.

METHODS

The associations between education, number of births, height, weight, body mass index (BMI), and breast cancer risk among 138 cases (participants from the Moza-BC cohort) and 638 controls from the general population (from a World Health Organization stepwise approach to surveillance survey), recruited during 2014 to 2017, were investigated. Adjusted ORs (aOR) and 95% confidence intervals (CI) were estimated using multivariable logistic regression.

RESULTS

Multiparity (≥6 vs. 0-1 live births) was a protective factor for the development of hormone receptor (HR)-positive (aOR = 0.22; 95% CI, 0.08-0.64) and HR-positive/HER2-negative tumors (aOR = 0.20; 95% CI, 0.06-0.68), whereas a higher educational level (≥8 vs. 0 schooling years) increased breast cancer risk across all subtypes (overall aOR = 1.98; 95% CI, 1.04-3.80). Higher weight and BMI were associated with a higher breast cancer risk among postmenopausal women (per 1-kg increase: aOR = 1.05; 95% CI, 1.02-1.08; per 1-kg/m² increase: aOR = 1.11; 95% CI, 1.04-1.18, respectively), but were protective in premenopausal women (aOR = 0.98; 95% CI, 0.96-0.99; aOR = 0.95; 95% CI, 0.91-0.99, respectively), regardless of subtype. Higher height increased the risk of HR-negative tumors in postmenopause (per 10-cm increase: aOR = 2.81; 95% CI, 1.41-6.03).

CONCLUSION

These results demonstrate the etiological heterogeneity of breast cancer among native African women, namely regarding the differential effect of multiparity, education, and body parameters in breast cancer risk.

IMPACT

As the prevalence of obesity grows, these findings are important to inform public health policies on cancer prevention, by highlighting obesity as a modifiable risk factor for breast cancer among African women.

Impact of HIV infection on baseline characteristics and survival of women with breast cancer

BACKGROUND

As women living with HIV (WLWH) become older, their risk of developing breast cancer increases. Nonetheless, literature is conflicting regarding tumor stage, distribution of subtypes and overall survival among WLWH vs. HIV-negative women with breast cancer. We assessed differences in clinicopathological characteristics and overall survival between these two groups.

METHODS

Systematic review and meta-analysis using MEDLINE, Scopus, ISI Web of Knowledge, LILACS, SciELO and conference abstracts up to 1 January 2020. Cross-sectional/cohort studies comparing baseline characteristics (stage and/or subtypes) and/or overall survival of WLWH vs. HIV-negative women with breast cancer were included. We performed random-effects meta-analyses to estimate summary statistics and subgroup analyses according to region of the world.

RESULTS

Eighteen studies [4 from North America, 14 from sub-Saharan Africa (SSA)] were included, with 3174 WLWH and 2 394 598 HIV-negative women. WLWH from North America and SSA were more likely to present with stage III/IV disease compared with HIV-negative women - pooled odds ratio (pOR) 1.76 [95% confidence interval (CI):1.58-1.95] and pOR 1.23 (95% CI: 1.06-1.42), respectively. WLWH from SSA were also less likely to have estrogen receptor-positive/HER2-negative tumors (pOR 0.81; 95% CI: 0.66-0.99). After adjustment, WLWH had worse overall survival compared with HIV-negative women, both in North America [pooled adjusted hazard ratio (aHR) 2.45; 95% CI: 1.11-5.41] and SSA (aHR 1.43; 95% CI: 1.06-1.92).

CONCLUSION

Compared with HIV-negative women, WLWH are diagnosed with breast cancer at a more advanced stage and have a worse overall survival. These results should raise awareness regarding the detection and survival gap among WLWH with breast cancer and further studies are needed to decipher the reasons behind these disparities.

Health system experiences of breast cancer survivors in urban South Africa

BACKGROUND

Breast cancer is the most common cancer globally and among South African women. Women from socioeconomically disadvantaged South African communities more often present later and receive total mastectomy compared to those from more affluent communities who have more breast conserving surgery (which is less invasive but requires mandatory radiation treatment post-operatively). Standard chemotherapy and total mastectomy treatments are known to cause traumatizing side effects and emotional suffering among South African women; moreover, many women face limited communication with physicians and psychological support.

OBJECTIVE

This article investigates the experiences of women seeking breast cancer treatment at the largest public hospital in South Africa.

METHODS

We interviewed 50 Black women enrolled in the South African Breast Cancer Study to learn more about their health system experiences with detection, diagnosis, treatment, and follow-up care for breast cancer. Each interview was between 2-3 hours, addressing perceptions, experiences, and concerns associated with breast cancer and comorbidities such as HIV and hypertension.

RESULTS

We found most women feared diagnosis, in part, because of the experience of chemotherapy and physical mutilation related to mastectomy. The importance of social support from family, religion, and clinical staff was fundamental for women coping with their condition and adhering to treatment and medication.

CONCLUSIONS

These findings exemplify how interventions might promote early detection of breast cancer and better adherence to treatment. Addressing community perceptions of breast cancer, patient needs and desires for treatment, structural barriers to intensive therapies, and the burden of invasive treatments are imperative next steps for delivering better breast cancer care in Soweto and other resource-constrained settings.

CytoPAN-Portable cellular analyses for rapid point-of-care cancer diagnosis

Rapid, automated, point-of-care cellular diagnosis of cancer remains difficult in remote settings due to lack of specialists and medical infrastructure. To address the need for same-day diagnosis, we developed an automated image cytometry system (CytoPAN) that allows rapid breast cancer diagnosis of scant cellular specimens obtained by fine needle aspiration (FNA) of palpable mass lesions. The system is devoid of moving parts for stable operations, harnesses optimized antibody kits for multiplexed analysis, and offers a user-friendly interface with automated analysis for rapid diagnoses. Through extensive optimization and validation using cell lines and mouse models, we established breast cancer diagnosis and receptor subtyping in 1 hour using as few as 50 harvested cells. In a prospective patient cohort study (n = 68), we showed that the diagnostic accuracy was 100% for cancer detection and the receptor subtyping accuracy was 96% for human epidermal growth factor receptor 2 and 93% for hormonal receptors (ER/PR), two key biomarkers associated with breast cancer. A combination of FNA and CytoPAN offers faster, less invasive cancer diagnoses than the current standard (core biopsy and histopathology). This approach should enable the ability to more rapidly diagnose breast cancer in global and remote settings.

Epidemiological, clinical and diagnostic profile of breast cancer patients treated at Potchefstroom regional hospital, South Africa, 2012-2018: an open-cohort study

Introduction

Breast cancer is the second most diagnosed cancer worldwide. We aimed to depict the diagnostic approach as well as the epidemiological and clinical profile of patients with breast cancer at Potchefstroom regional hospital, South Africa.

Methods

This descriptive open-cohort study included patients with primary invasive breast cancer, confirmed by histology results and treated at the hospital from 01 January 2012 to 31 December 2018. Data such as demographics, patient history, histology, breast clinical findings, physical mass description and diagnostic investigations were captured from hospital registries and patient files.

Result

One-hundred thirty-eight patients (mean age 56.2 (SD: 14.4) (95% CI 54.6-59.7) years) met inclusion criteria. Most patients were female (98.6%), from African (67.4%) or Caucasian (23.9%) descent. Findings included mostly left-sided breast involvement (51.8%), lesions in the upper-outer quadrant (43.1%), extensions to the skin (25.6%, N = 39), and tumour size of 2 ≤ 5 cm (49.3%), or > 5 cm (39.1%). Most patients (57.9%, N = 135) were categorised as BIRADS-5, with a ductal pattern (89.6%) (p < 0.01). Patients mostly presented in stages II to IV of disease (89.1%; p < 0.05). Late-stage (stages III-IV) at time of diagnosis (n = 84) was significantly associated with mass location (p = 0.006; Cramér's V = 0.280), tumour size (p < 0.001, Cramér's V = 0.239), and skin changes (p = 0.027, Cramér's V = 0.492).

Conclusion

Most patients consulted at a late-stage of the disease, indicating a need for the promotion of breast awareness campaigns, early detection, and timeous referral.

Cancer spectrum in HIV-infected patients: A zonal hospital experience in Tanzania

BACKGROUND

Although the burden of human immunodeficiency virus (HIV) infection in Tanzania is high, limited data are available on cancers in HIV-infected patients. We aimed to determine the spectrum and prevalence of cancers in HIV-infected patients attending care at a zonal hospital in Tanzania.

MATERIALS AND METHODS

Clinical records of HIV-infected patients from 2009 to 2019 were identified and retrospectively reviewed.

RESULTS

A total of 3398 HIV-infected patients were recruited with median age of 37 years. Cancer was diagnosed in 9% of the patients after enrollment into HIV clinical care, with an increasing prevalence from 7.2% between years 2009 and 2013 to 8.6% between years 2017 and 2019 (p-value <0.0001). Majority (89.2%) were on antiretroviral therapy (ART) during the time of cancer diagnosis. The proportions of acquired immunodeficiency syndrome (AIDS)-defining cancers and non-AIDS defining cancers were 28% and 72% respectively. Kaposi's sarcoma was the most common (13.2%) AIDS-defining cancer while esophageal cancer was the most common (11.1%) non-AIDS defining cancer. The median duration of time from HIV infection to cancer diagnosis was 715 days (IQR: 98-2570). The median CD4⁺T-cell count was 318(IQR 159-690) cells/µl at the time of cancer diagnosis and 40.7% of the patients had advanced immunosuppression with CD4 count less than 200 cells/µl at the time of cancer diagnosis.

CONCLUSION

Non-AIDS defining cancers were much more common than AIDS-defining cancers suggesting increased longevity due to ART access. The prevalence of cancer among HIV-infected patients was 9% with an increasing trend over time; highlighting the importance of promoting cancer screening in this vulnerable population and implementation of vaccinations programs for liver and cervical cancers as well as tobacco control policies for smoking-related cancers.

Association between HIV infection and outcomes of care among medicare enrollees with breast cancer

BACKGROUND

To assess the interaction of breast cancer, HIV infection, Medicare disability status, cancer stage and its implications for outcomes, after accounting for competing risks among female, fee-for-service Medicare enrollees.

METHODS

We used data from Surveillance, Epidemiology and End Results (SEER) -Medicare (2000-2013). From primary female breast cancer cases diagnosed between 2001 and 2011, we identified those with HIV infection. We used Generalized Linear Model for phase-specific incremental cost of HIV, Cox regression for association between HIV and all-cause mortality, and Fine and Gray competing risk models to assess hazard of breast cancer-specific mortality by HIV status. We also studied this association for subgroups of cancer stage and disability status.

FINDINGS

Of 164,080 eligible cases of breast cancer, 176 had HIV infection. Compared to HIV-uninfected patients, HIV infected patients had 16% higher cost in initial phase, and 80% higher cost in interim stage of care, and at least two times higher mortality (all-cause and breast cancer-specific), after accounting for competing risk. Among disabled enrollees, HIV-infected patients had higher risk of all-cause and breast cancer-specific mortality, compared to HIV-uninfected patients.

INTERPRETATION

Female fee-for-service Medicare enrollees with breast cancer experience higher initial and interim phase cost and worse survival in the presence of HIV. This association was also significant among disabled Medicare enrollees. Medicare is the single largest source of federal financing for HIV care. Burden on Medicare will grow exponentially due to higher proportion of disabled among HIV-infected enrollees, longer survival among HIV- infected persons, increased HIV incidence in older adults, and increased age related risk of breast cancer. Future research can identify the pathways via which HIV infection affects cost and mortality, and develop integrated strategies for effective management of concomitant breast cancer and HIV and inform survivorship guidelines.

FUNDING

National Institute on Aging, National Institutes of Health, Grant # R21AG34870-1A1.

Report of clinico-pathological features of breast cancer in HIV-infected and uninfected women in Botswana

BACKGROUND

To characterize the clinico-pathological features including estrogen receptor (ER), progesterone receptor (PR) and Her-2/neu (HER2) expression in breast cancers in Botswana, and to compare them by HIV status.

METHODS

This was a retrospective study using data from the National Health Laboratory and Diagnofirm Medical Laboratory in Gaborone from January 1, 2011 to December 31, 2015. Clinico-pathological details of patients were abstracted from electronic medical records.

RESULTS

A total of 384 unique breast cancer reports met our inclusion criteria. Of the patients with known HIV status, 42.7% (50/117) were HIV-infected. Median age at the time of breast cancer diagnosis was 54 years (IQR 44-66 years). HIV-infected individuals were more likely to be diagnosed before age 50 years compared to HIV-uninfected individuals (68.2% vs 23.8%, p < 0.001). The majority of patients (68.6%, 35/51) presented with stage III at diagnosis. Stage IV disease was not presented because of the lack of data in pathology records surveyed, and additionally these patients may not present to clinic if the disease is advanced. Overall, 68.9% (151/219) of tumors were ER+ or PR+ and 16.0% (35/219) were HER2+. ER+ or PR+ or both, and HER2- was the most prevalent profile (62.6%, 132/211), followed by triple negative (ER-/PR-/HER2-, 21.3%, 45/211), ER+ or PR+ or both, and HER2+, (9.0%, 19/211) and ER-/PR-/HER2+ (7.1%, 15/211). There was no significant difference in receptor status noted between HIV-infected and HIV-uninfected individuals.

CONCLUSIONS

Majority of breast cancer patients in Botswana present with advanced disease (stage III) at diagnosis and hormone receptor positive disease. HIV-infected breast cancer patients tended to present at a younger age compared to HIV-uninfected patients. HIV status does not appear to be associated with the distribution of receptor status in breast cancers in Botswana.

Idioms of resilience among cancer patients in urban South Africa: An anthropological heuristic for the study of culture and resilience

Despite the large body of research on idioms of distress in anthropology and transcultural psychiatry, few scholars have examined the concepts that people use to describe social and psychological resilience. The experience of social and psychological resilience is embedded in and shaped by social, political, and economic contexts-much like the factors that shape idioms of distress. As resilience literature more broadly has adopted a socio-ecological rather than trait-based approach, anthropology has much to contribute. This article investigates what idioms of resilience and cultural scripts emerge among low-income patients with cancer residing in Soweto, a peri-urban neighborhood in Johannesburg, South Africa. We conducted 80 life history interviews to better understand what social and psychological factors led some people to thrive more than others despite extraordinary adversity. We describe one idiom of resilience, acceptance (ukwamukela in isiZulu), and three broader themes of resilience that emerged from life history narrative interviews (social support, religious support, and receiving medical care). We also present two examples from study participants that weave these concepts together. Our findings suggest that rarely is one form of resilience experienced in isolation. A focus on idioms of resilience can help chart the complex dimensions of acceptance and the dynamic social, religious, political, and temporal factors that mediate both suffering and resilience within individuals and communities.

Cancer, chemotherapy, and HIV: Living with cancer amidst comorbidity in a South African township

Cancer is on the rise in Sub-Saharan Africa. In South Africa, where cancer detection, intervention, and care are available for many citizens, cancer is poorly detected and understood among politically and economically marginalized communities in rural and urban centers. These trends are reflected in a history of systematic marginalization of such contexts from public resources, including education and health care, stemming from racism and wealth inequity. This article investigates how Black South Africans residing in Soweto, a township of Johannesburg, perceive and experience breast and prostate cancers amidst multiple, concurrent medical conditions. We used convenience sampling to recruit 80 study participants already enrolled in longitudinal studies of breast and prostate cancers at a tertiary hospital in Soweto between June and August 2017. This included 50 women diagnosed with breast cancer and 30 men diagnosed with prostate cancer; three-quarters of the sample had two or more comorbidities, including HIV, hypertension, diabetes, anxiety, and others. Many described sickness in terms of any physical ill-health that affected daily routines, but rarely was it associated exclusively with a specific disease. Men and women described more fear associated with cancer than HIV or hypertension-two of the most common diseases. We found that this may be in part a reflection of how people feared and demonized their cancer diagnoses, calling it "a demon!", and framing cancer through the trauma of aggressive treatments like chemotherapy ("the red devil!") and physical disfiguration from mastectomy. In contrast, men's prostate cancer treatments were often hormonal therapy and men associated cancer to a normal side effect of aging. Intervening in how people think about cancer may improve how people live well with the condition amidst other cascading social and health problems they face.

Clinico-pathological characteristics among South African women with breast cancer receiving anti-retroviral therapy for HIV

PURPOSE

Breast cancer is the most common cancer in women and a leading cause of cancer-related mortality worldwide. South Africa has the largest global burden of HIV infection and the largest anti-retroviral treatment (ART) program. This study aimed to analyse the association of HIV and ART use with breast cancer clinico-pathological characteristics.

METHODS

Study participants were females, newly diagnosed from May 2015 through September 2017 with invasive breast cancer at two academic Surgical Breast Units in Johannesburg, South Africa at the Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital. We compared HIV-positive and HIV negative patients' demographic and clinical-pathological characteristics at the time of breast cancer diagnosis.

RESULTS

Of 1050 patients enrolled, 1016 (96.8%) had known HIV status, with 226 (22.2%) being HIV positive. HIV positive patients were younger (median (IQR) age 45 (40-52) years), than HIV-negative patients (median (IQR) age 57 (46-67)) (p < 0.001). HIV positive patients were more likely to be diagnosed with late stage breast cancer (p = 0.01). However, HIV positive patients receiving ART at the time of breast cancer diagnosis were less likely to present with metastatic disease than those not on ART (p = 0.05).

CONCLUSION

HIV-positive patients present with breast cancer at a younger age and later stage disease than HIV-negative patients. Neither the duration of HIV infection nor ART use was associated with clinico-pathological characteristics of breast cancer.

Breast cancer, human immunodeficiency virus and highly active antiretroviral treatment; implications for a high-rate seropositive region

Sub-Saharan Africa is the region in the world with the most people infected with the human immunodeficiency virus (HIV). The incidence of breast cancer is also rising in the region. This transcript focusses on the burden of these two diseases when they converge in the same populace. This comprehensive literature review of the topic suggests a trend towards an increasing incidence of breast cancer in the HIV-infected population, and the rationale for such a tendency is hypothesized, especially in the context of the availability of highly active antiretroviral therapy. Besides the age at diagnosis, all other clinical characteristics appear to be similar in HIV-positive and HIV-negative breast cancer populations. Outcomes of the different treatment modalities for breast cancer in HIV-positive patients are also appraised and finally innovative areas of future research are suggested along with plausible recommendations.

Neoadjuvant Chemotherapy Use for Nonmetastatic Breast Cancer at Five Public South African Hospitals and Impact on Time to Initial Cancer Therapy

In sub‐Saharan Africa, clinical decisions can be affected by resource constraints. This article analyzes the clinical and sociodemographic factors associated with receiving neoadjuvant chemotherapy among patients from a previously existing cohort: women enrolled in the prospective South African Breast Cancer and HIV Outcomes study.

Background.

In the U.S., neoadjuvant chemotherapy (NAC) for nonmetastatic breast cancer (BC) is used with extensive disease and aggressive molecular subtypes. Little is known about the influence of demographic characteristics, clinical factors, and resource constraints on NAC use in Africa.

Materials and Methods.

We studied NAC use in a cohort of women with stage I–III BC enrolled in the South African Breast Cancer and HIV Outcomes study at five hospitals. We analyzed associations between NAC receipt and sociodemographic and clinical factors, and we developed Cox regression models for predictors of time to first treatment with NAC versus surgery.

Results.

Of 810 patients, 505 (62.3%) received NAC. Multivariate analysis found associations between NAC use and black race (odds ratio [OR] 0.49; 95% confidence limit [CI], 0.25–0.96), younger age (OR 0.95; 95% CI, 0.92–0.97 for each year), T‐stage (T4 versus T1: OR 136.29; 95% CI, 41.80–444.44), N‐stage (N2 versus N0: OR 35.64; 95% CI, 16.56–76.73), and subtype (triple‐negative versus luminal A: OR 5.16; 95% CI, 1.88–14.12). Sites differed in NAC use (Site D versus Site A: OR 5.73; 95% CI, 2.72–12.08; Site B versus Site A: OR 0.37; 95% CI, 0.16–0.86) and time to first treatment: Site A, 50 days to NAC versus 30 days to primary surgery (hazard ratio [HR] 1.84; 95% CI, 1.25–2.71); Site D, 101 days to NAC versus 126 days to primary surgery (HR 0.49; 95% CI, 0.27–0.89).

Conclusion.

NAC use for BC at these South African hospitals was associated with both tumor characteristics and heterogenous resource constraints.

Implications for Practice.

Using data from a large breast cancer cohort treated in South Africa's public healthcare system, the authors looked at determinants of neoadjuvant chemotherapy use and time to initiate treatment. It was found that neoadjuvant chemotherapy was associated with increasing tumor burden and aggressive molecular subtypes, demonstrating clinically appropriate care in a lower resource setting. Results of this study also showed that time to treatment differences between chemotherapy and surgery varied by hospital, suggesting that differences in resource limitations were influencing clinical decision making. Practice guidelines and care quality metrics designed for low‐ and middle‐income countries should accommodate heterogeneity of available resources.

Breast cancer in women living with HIV: A first global estimate

There is a growing population of older women living with HIV/AIDS (WLWHA). Breast cancer is a common cancer in women worldwide, but the global number of breast cancers in WLWHA is not known. We estimated, for each UN sub-region, the number and age distribution of WLWHA who were diagnosed with breast cancer in 2012, by combining IARC-GLOBOCAN estimates of age-country specific breast cancer incidence with corresponding UNAIDS HIV prevalence. Primary analyses assumed no HIV-breast cancer association, and a breast cancer risk reduction scenario was also considered. Among 16.0 million WLWHA aged 15+ years, an estimated 6,325 WLWHA were diagnosed with breast cancer in 2012, 74% of whom were in sub-Saharan Africa, equally distributed between Eastern, Southern and Western Africa. In most areas, 70% of HIV-positive breast cancers were diagnosed under age 50. Among all breast cancers (regardless of HIV status), HIV-positive women constituted less than 1% of the clinical burden, except in Eastern, Western and Middle Africa where they comprised 4-6% of under age 50 year old breast cancer patients, and in Southern Africa where this patient subgroup constituted 26 and 8% of breast cancers diagnosed under and over age 50 respectively. If a deficit of breast cancer occurs in WLWHA, the global estimate would reduce to 3,600. In conclusion, worldwide, the number of HIV-positive women diagnosed with breast cancer was already substantial in 2012 and with an expected increase within the next decade, early detection and treatment research targeted to this population are needed.

Enacted HIV-related stigma and breast-health beliefs and practices among African American women living with HIV: The mediating roles of internalized HIV-related stigma and depressive symptoms

Reducing HIV-related stigma among African American women living with HIV is a priority to improve HIV-specific health outcomes, but may also impact other health beliefs and practices. Testing this hypothesis is important because African American women experience worse health outcomes, including for breast cancer. This study examines the relationship between enacted HIV-related stigma and breast health beliefs and practices and the mediating effects of depressive symptoms and internalized HIV-related stigma. We use baseline data from a stigma reduction intervention trial for adult African American women living with HIV in Chicago, IL and Birmingham, AL (n = 237). Data were collected using computer-assisted self-interviewing software. After adjusting for covariates, enacted HIV-related stigma was associated with greater perceived threat of breast cancer, specifically in terms of breast cancer fear (p <0.0001), but not regular breast healthcare engagement (p = .17). Internalized HIV-related stigma and depressive symptoms were associated with enacted HIV-related stigma, perceived threat of breast cancer, and regular breast healthcare engagement (all p <.05). Internalized HIV-related stigma mediated the relationship between enacted HIV-related stigma and perceived threat of breast cancer (p = .001); depressive symptoms did not (p = .84). We provide evidence concerning broader influences of internalized HIV-related stigma for the health of African American women living with HIV. Future studies should consider the impact of HIV stigma on other health beliefs and behaviors.

Unraveling the South African Breast Cancer Story: The Relationship of Patients, Delay to Diagnosis, and Tumor Biology With Stage at Presentation in an Urban Setting

BACKGROUND

Adverse outcomes from breast cancer disproportionately affect women in sub-Saharan Africa, with delay the most studied contribution to advanced stage at presentation. However, tumor molecular biology and its contribution to advanced stage are yet to be explored.

MATERIALS AND METHODS

Patients newly diagnosed with breast cancer in a South African tertiary breast center completed a questionnaire and file review concerning socioeconomics, delay to care, stage at presentation, and molecular characteristics. Logistic regression was done to determine the relative risk of advanced stage presentation.

RESULTS

Advanced stage was present in 70.1% (n = 162) of the 231 participants, with 55.8% stage III (n = 129) and 32% (n = 72) having a T4 tumor. The median age was 56 y with 21.6% (n = 47) aged <45 y. Most common subtype was luminal B (57.7%, n = 128) followed by luminal A (21.6%, n = 48), triple negative (13.9%, n = 31), and HER2 positive (6.7%, n = 15). Lobular cancer (incidence risk ratio [IRR], 1.29; 95% confidence interval [CI], 1.03-1.62), high grade and intermediate grade tumors (IRR, 1.90; 95% CI, 1.15-3.13 and IRR, 1.95; 95% CI, 1.18-3.22, respectively), high Ki67 proliferation index (IRR, 1.30; 95% CI, 1.02-1.66), and HER2 overexpression (IRR, 1.32; 95% CI, 1.12-1.55) were more likely to present with advanced disease, as were luminal B (HER2+) cancers (adjusted IRR [aIRR], 1.46; 95% CI, 1.10-1.95). Although on univariate analysis Black and young participants were both more likely to have advanced stage (IRR, 1.23; 95% CI, 1.01-1.49 and IRR, 1.25; 95% CI, 1.04-1.51, respectively), in multivariate analysis controlling for tumor biology and delay, these were no longer significant (aIRR, 1.12; 95% CI, 0.91-1.37 and aIRR, 1.17; 95% CI, 0.94-1.48, respectively).

CONCLUSIONS

Tumor biology has a compelling role in the etiology of advanced-stage disease irrespective of socioeconomic factors. Accurate pathologic assessment is important in planning breast cancer care in Africa.

Human immunodeficiency virus infection in breast cancer patients: The prevalence thereof and its effect on breast cancer characteristics at Dr. George Mukhari Academic Hospital Breast Clinic, Ga-Rankuwa, South Africa

BACKGROUND

Since the advent of highly active anti-retroviral therapy, improved immune functioning and prolonged survival of Human immunodeficiency virus (HIV)-positive patients has been accompanied by an increased incidence of non-AIDS-defining cancers (NADC). Breast cancer is the most prevalent NADC among HIV-positive women. However, data regarding the interaction between these two diagnoses remain limited.

OBJECTIVES

To determine the effect of HIV status on the presentation of breast cancer patients at Dr. George Mukhari Academic Hospital (DGMAH).

METHODS

The age, gender, HIV status, CD4 count and tumour node metastases stage at presentation were recorded from the files of patients with histologically proven breast carcinoma, who had presented to the breast clinic at DGMAH from 01 January 2013 to 30 November 2017. Histological subtypes and molecular markers were retrieved from the National Health Laboratory Service. Prevalence of HIV among breast cancer patients was calculated. Cross-tabulations compared the variables between HIV-positive and HIV-negative groups. Statistical significance was assessed using Fisher's Exact Test.

RESULTS

HIV status was determined in 129 breast cancer patients. Eighty (62.02%) were HIV-negative and 49 (37.98%) were HIV-positive. All patients were female. The mean age at presentation with breast cancer in the HIV-positive group was approximately 10 years younger, compared to the entire population and to the HIV-negative group (p < 0.0001). No further statistically significant associations were observed concerning HIV status and other variables.

CONCLUSION

HIV-positive women present with breast cancer at a significantly younger mean age. Breast cancer screening protocols may need to be adjusted accordingly in such patients.

The association of human immunodeficiency virus and skeletal metastases in breast cancer using Tc-99m methyl diphosphonate bone scan

Skeletal involvement occurs in 30%–70% of all cancer patients, with breast cancer (BC) being the leading cause for bone metastases in women and prostate cancer in men followed by lung cancer. Human immunodeficiency virus (HIV) is a lentivirus (a member of the retrovirus family) that causes acquired immunodeficiency syndrome. It is yet unknown what is the impact of HIV to the onset and progression of bone disease in BC. The purpose of the study was to determine the association of HIV infection and skeletal metastases in BC using skeletal scintigraphy. A retrospective analysis of 25 female BC patients' bone scans was performed. The 25 bone scans of 12 patients known HIV positive and 13 patients who were known HIV negative, of similar age and histology, were compared. All 13 HIV negative patients had a positive bone scan. Of the 12 HIV-positive patients, 4 patients on highly active antiretroviral therapy (HAART) had positive bone scans for skeletal metastases. The remaining eight HIV-positive patients had negative bone scans, of which six were on HAART and two were not on HAART. In our study, HIV infection was not found to be a contributing risk factor for skeletal metastases. From our small series, it appears that HIV patients and on HAART have a delay in the onset of skeletal metastases in BC.

Rising global burden of breast cancer: the case of sub-Saharan Africa (with emphasis on Nigeria) and implications for regional development: a review

BACKGROUND

Despite mortality from breast cancer in Africa being higher than in high income countries, breast cancer has not been extensively studied in the region. The aim of this paper was to highlight the rising burden of breast cancer with an emphasis on sub-Saharan Africa as well as trends, characteristics, controversies and their implications for regional development.

METHODOLOGY

A review of published studies and documents was conducted in Medline, Scopus, Pubmed and Google using combinations of key words-breast neoplasm, breast cancer, cancer, incidence, mortality, Africa, Nigeria. Graphical and frequency analyses were carried out on some of the incidence and mortality figures retrieved from published papers and the GLOBOCAN website.

FINDINGS

Globally, about 25% and 15% of all new cancer cases and cancer deaths respectively among females were due to breast cancer. Africa currently had the highest age-standardized breast cancer mortality rate globally, with the highest incidence rates being recorded within the sub-Saharan African sub-region. Incidence trends such as inherently aggressive tumour and younger age profile had been subject to controversies. Certain factors such as westernized diet, urbanization and possibly increasing awareness had been implicated, though their specific contributions were yet to be fully established.

CONCLUSION

Unless urgent action is taken, breast cancer will compound sub-Saharan Africa's disease burden, increase poverty and gender inequality as well as reverse the current global gains against maternal and neonatal mortality.

Breast Cancer in Low- and Middle-Income Countries: Why We Need Pathology Capability to Solve This Challenge

Breast cancer is the leading cause of cancer mortality among women in developing countries. Timely and accurate histopathological diagnosis of breast cancer is critical to delivering high-quality breast cancer care to patients in low- and middle-income countries (LMIC). The most important prognostic factors in breast cancer along with tumor size and nodal status are tumor grade, estrogen receptor status, as well as HER2 status in countries where specific targeted therapies are available. In addition, detailed and complete cancer registry data are needed to assess a country's disease burden and guide disease prioritization and allocation of resources for breast cancer treatment. Innovations in leapfrog technology and low-cost point-of-care tests for molecular evaluations are needed to provide accurate and timely pathology, with the ultimate goal of improving survival outcomes for patients with breast cancer in LMIC.

Neoadjuvant chemotherapy among patients treated for nonmetastatic breast cancer in a population with a high HIV prevalence in Johannesburg, South Africa

Background

Neoadjuvant (primary) chemotherapy (NACT) is the standard of care for locally advanced breast cancer. It also allows for the short-term assessment of chemotherapy response; a pathological complete responses correspond to improved long-term breast cancer outcomes. In sub-Saharan Africa, many patients are diagnosed with large nonresectable tumors. We examined NACT use in breast cancer patients who visited public hospitals in Johannesburg, South Africa.

Methods

We assessed demographic characteristics, tumor stage and grade, hormone receptor status, and human immunodeficiency virus (HIV) status of female patients diagnosed with nonmetastatic invasive carcinoma of the breast at Chris Hani Baragwanath Academic Hospital between January 1, 2009, and December 31, 2011. The patients received neoadjuvant, adjuvant, or no chemotherapy. Trastuzumab was unavailable. We developed logistic regression models to analyze the factors associated with NACT receipt in these patients.

Results

Of 554 women with nonmetastatic breast cancer, the median age at diagnosis was 52 years (range: 28–88 years). Only 5.8% of patients were diagnosed with stage I disease; 49.3% and 44.9% were diagnosed with stages II and III, respectively. Most patients had hormone-responsive tumors: luminal A, 38.1%; luminal B₁ (human epidermal growth factor receptor 2 [HER2]-negative and high grade), 12.5%, and luminal B₂ (HER2-positive any grade), 11.6%; 11.6% had a HER2-enriched tumor and 20.6% a triple-negative tumor. Eighty (14.4%) patients were HIV-positive. In total, 195 patients (35.2%) received NACT, 264 (47.7%) patients received adjuvant chemotherapy, and 95 patients (17.1%) received no chemotherapy, including 62 (11.2%) patients who received only hormonal therapy. Of patients receiving NACT, 125 (64.1%) were evaluable for clinical response. Eighty (64.0%) patients had a clinically significant response; 19 (15.2%) patients had a stable disease, and 26 (20.8%) patients had a progressive disease. Multivariate analysis showed age <40 years and disease stage to be independently associated with the receipt of NACT.

Conclusion

Most women receiving NACT with available response data showed a clinical benefit. Stage III disease at diagnosis and age <40 years were predictors of neoadjuvant versus adjuvant chemotherapy treatment.

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.

Hybrid 2D/3D-quantitative structure-activity relationship and modeling studies perspectives of pepstatin A analogs as cathepsin D inhibitors

AIM

Cathepsin D, one of the attractive targets in the treatment of breast cancer, has been implicated in HIV neuropathogenesis with potential proteolytic effects on chemokines. Methodology/result: Diverse modeling tools were used to reveal the key structural features affecting the inhibitory activities of 78 pepstatin A analogs. Analyses were performed to investigate the stability, rationality and fluctuation of the analogs. Results showed a clear correlation between the experimental and predicted activities of the analogs as well as the variation in their activities relative to structural modifications.

CONCLUSION

The insight gained from this study offers theoretical references for understanding the mechanism of action of cathepsin D and will aid in the design of more potent and clinically-relevant drugs. Graphical abstract [Formula: see text].

HIV-1 matrix protein p17 and its variants promote human triple negative breast cancer cell aggressiveness

Background

The introduction of cART has changed the morbidity and mortality patterns affecting HIV-infected (HIV⁺) individuals. The risk of breast cancer in HIV⁺ patients has now approached the general population risk. However, breast cancer has a more aggressive clinical course and poorer outcome in HIV⁺ patients than in general population, without correlation with the CD4 or virus particles count. These findings suggest a likely influence of HIV-1 proteins on breast cancer aggressiveness and progression. The HIV-1 matrix protein (p17) is expressed in different tissues and organs of successfully cART-treated patients and promotes migration of different cells. Variants of p17 (vp17s), characterized by mutations and amino acid insertions, differently from the prototype p17 (refp17), also promote B-cell proliferation and transformation.

Methods

Wound-healing assay, matrigel-based invasion assay, and anchorage-independent proliferation assay were employed to compare the biological activity exerted by refp17 and three different vp17s on the triple-negative human breast cancer cell line MDA-MB 231. Intracellular signaling was investigated by western blot analysis.

Results

Motility and invasiveness increased in cells treated with both refp17 and vp17s compared to untreated cells. The effects of the viral proteins were mediated by binding to the chemokine receptor CXCR2 and activation of the ERK1/2 signaling pathway. However, vp17s promoted MDA-MB 231 cell growth and proliferation in contrast to refp17-treated or not treated cells.

Conclusions

In the context of the emerging role of the microenvironment in promoting and supporting cancer cell growth and metastatic spreading, here we provide the first evidence that exogenous p17 may play a crucial role in sustaining breast cancer cell migration and invasiveness, whereas some p17 variants may also be involved in cancer cell growth and proliferation.

Malignancies and infection due to the human immunodeficiency virus. Are these emerging diseases?

Since the start of the human immunodeficiency virus (HIV) epidemic, tumour disease among patients has been significant. The collection of malignancies can be divided primarily into 2 groups: those associated with HIV (all of which are related to viral diseases) and those not associated with HIV (only some of which are associated with viral diseases). The origin of these malignancies is multifactorial, and the main causes that have led to an increase in tumour disease are immunosuppression, coinfection with oncogenic viruses and life prolongation secondary to the use of antiretroviral therapy. Establishing the general characteristics of the undiagnosed AIDS tumours is difficult, mainly because they are a highly heterogeneous group formed by malignancies of a diverse nature. The treatments do not differ from those used in the general population, although the management can be more difficult due to the late diagnosis, drug interactions and associated comorbidities.

Breast conservation surgery versus total mastectomy among women with localized breast cancer in Soweto, South Africa

PURPOSE

Breast conserving surgery (BCS) has become the preferred surgical option for the management of patients with nonmetastatic breast cancer in high-income countries. However, little is known about the distribution and determinants of BCS in low-and middle-income countries, especially those with high HIV prevalence.

METHODS

We compared demographic and clinical characteristics of female patients who received BCS and those who received total mastectomy (TM) for nonmetastatic invasive carcinoma of the breast in Soweto, South Africa, 2009-2011. We also developed a multivariable logistic regression model of predictors of type of surgery.

RESULTS

Of 445 patients, 354 (80%) underwent TM and 91 (20%) BCS. Of 373 patients screened for HIV, 59 (15.8%) tested positive. Eighty-two of 294 patients with stage I/II disease (28%), but just 9 of 151 (6%) with stage III disease had BCS (p<0.001). All women who received BCS (except for seven who received completion mastectomy within 6 weeks of BCS) and 235 (66.4%) women who received TM were referred for radiation therapy (RT). In our multivariable analysis, age group 50-59 years (OR = 2.28, 95% CI = 1.1-4.8) and ≥70 years (OR = 9.55, 95% CI = 2.9-31.2) vs. age group <40 years, stage at diagnosis (stage II (OR = 3.79, 95% CI = 1.6-8.2) and stage III (OR = 27.8, 95% CI = 9.0-78.8) vs. stage 1, HIV (HIV positive (OR = 3.19, 95% CI = 1.3-7.9) vs. HIV negative) and HER2-enriched subtype (OR = 3.50, 95% CI = 1.2-10.1) vs. triple negative were independently associated with TM.

CONCLUSION

TM was more common than BCS among patients with nonmetastatic breast cancer in Soweto, not only among patients with locally advanced disease at diagnosis, but also among women with stage I and II disease.

South African Breast Cancer and HIV Outcomes Study: Methods and Baseline Assessment

Purpose

In low- and middle-income, HIV-endemic regions of sub-Saharan Africa, morbidity and mortality from the common epithelial cancers of the developed world are rising. Even among HIV-infected individuals, access to antiretroviral therapy has enhanced life expectancy, shifting the distribution of cancer diagnoses toward non–AIDS-defining malignancies, including breast cancer. Building on our prior research, we recently initiated the South African Breast Cancer and HIV Outcomes study.

Methods

We will recruit a cohort of 3,000 women newly diagnosed with breast cancer at hospitals in high (average, 20%) HIV prevalence areas, in Johannesburg, Durban, Pietermaritzburg, and Empangeni. At baseline, we will collect information on demographic, behavioral, clinical, and other factors related to access to health care. Every 3 months in year 1 and every 6 months thereafter, we will collect interview and chart data on treatment, symptoms, cancer progression, comorbidities, and other factors.

We will compare survival rates of HIV-infected and uninfected women with newly diagnosed breast cancer and their likelihood of receiving suboptimal anticancer therapy. We will identify determinants of suboptimal therapy and context-specific modifiable factors that future interventions can target to improve outcomes. We will explore molecular mechanisms underlying potentially aggressive breast cancer in both HIV-infected and uninfected patients, as well as the roles of pathogens, states of immune activation, and inflammation in disease progression.

Conclusion

Our goals are to contribute to development of evidence-based guidelines for the management of breast cancer in HIV-positive women and to improve outcomes for all patients with breast cancer in resource-constrained settings.

An update on the management of breast cancer in Africa

Background

There is limited information about the challenges of cancer management and attempts at improving outcomes in Africa. Even though South and North Africa are better resourceds to tackle the burden of breast cancer, similar poor prognostic factors are common to all countries. The five-year overall Survival rate for breast cancer patients does not exceed 60% for any low and middle-income country (LMIC) in Africa. In spite of the gains achieved over the past decade, certain characteristics remain the same such as limited availability of breast conservation therapies, inadequate access to drugs, few oncology specialists and adherence to harmful socio-cultural practices. This review on managing breast cancer in Africa is authored by African oncologists who practice or collaborate in Africa and with hands-on experience with the realities.

Methods

A search was performed via electronic databases from 1999 to 2016. (PubMed/Medline, African Journals Online) for all literature in English or translated into English, covering the terms “breast cancer in Africa and developing countries”. One hundred ninety were deemed appropriate.

Results

Breast tumors are diagnosed at earlier ages and later stages than in highincome countries. There is a higher prevalence of triple-negative cancers. The limitations of poor nursing care and surgery, inadequate access to radiotherapy, poor availability of basic and modern systemic therapies translate into lower survival rate. Positive strides in breast cancer management in Africa include increased adaptation of treatment guidelines, improved pathology services including immuno-histochemistry, expansion and upgrading of radiotherapy equipment across the continent in addition to more research opportunities.

Conclusion

This review is an update of the management of breast cancer in Africa, taking a look at the epidemiology, pathology, management resources, outcomes, research and limitations in Africa from the perspective of oncologists with local experience.

Breast Cancer and HIV in Sub-Saharan Africa: A Complex Relationship

Introduction

The number and lifespan of individuals living with HIV have increased significantly with the scale-up of antiretroviral therapy. Furthermore, the incidence of breast cancer in women with HIV is growing, especially in sub-Saharan Africa (SSA). However, the association between HIV infection and breast cancer is not well understood.

Methods

A literature search was performed to identify articles published in journals pertaining to breast cancer and HIV, with an emphasis on SSA. Selected US-based studies were also identified for comparison.

Results

Among the 56 studies reviewed, the largest study examined 314 patients with breast cancer and HIV in the United States. There is no consensus on whether HIV infection acts as a pro-oncogenic or antioncogenic factor in breast cancer, and it may have no relation to breast cancer. A higher incidence of breast cancer is reported in high-income countries than in SSA, although breast cancer in SSA presents at a younger age and at a more advanced stage. Some studies show that patients with breast cancer and HIV experience worse chemotherapy toxicity than do patients without HIV. Data on treatment outcomes are limited. The largest study showed worse treatment outcomes in patients with HIV, compared with their counterparts without HIV.

Conclusion

HIV infection has not been associated with different clinical presentation of breast cancer. However, some evidence suggests that concurrent diagnosis of HIV with breast cancer is associated with increased therapy-related toxicity and worse outcomes. Systematic prospective studies are needed to establish whether there is a specific association between breast cancer and HIV.

The effect of HIV infection on the surgical, chemo- and radiotherapy management of breast cancer. A prospective cohort study

INTRODUCTION

Breast cancer is the most common cancer of women in the world. Twenty-five percent of people living with the human immunodeficiency virus (HIV) reside in South Africa. The coincidence of breast cancer and HIV infection is therefore common in South Africa. There is a perception that systemic and local surgical complications are more common in HIV-infected patients, and that these patients tolerate chemo- and radiotherapy poorly.

AIM

The aim of the study was to determine the effect of HIV infection on the management of breast cancer by comparing HIV-infected to -noninfected patients. The outcomes of surgery and adjuvant/neoadjuvant therapy were examined in these groups.

METHOD

The study was performed at the Steve Biko Academic Hospital, Pretoria, South Africa, during 2009-2014. Patients scheduled for surgery for breast cancer were recruited prospectively and their HIV status was determined. All patients were managed according to standard guidelines for breast cancer. Patients were followed up for 30 days and local and systemic surgical complications documented. Completion or non-completion of courses of chemo- and radiotherapy, and reasons for non-completion were documented. HIV-infected and -noninfected patients respectively were grouped, and compared statistically.

RESULTS

One hundred and sixty patients (31 HIV-infected) were included. The frequency of surgical complications did not differ significantly between HIV-noninfected and infected patients (p = 0.08), more occurring in the HIV-noninfected patients. The risk ratio of HIV infection for surgical complications was 0.20 and the odds ratio 0.23. The completion of courses of chemo- and radiotherapy did not differ between the HIV-infected and -noninfected patients. Twenty-five of 27 HIV-infected patients (93%) and 100 of 113 HIV-noninfected patients (94%) completed their courses of chemotherapy (p = 0.68). Twelve of 14 HIV-infected patients (86%) and 40 of 41 HIV-noninfected patients (98%) completed their courses of radiotherapy (p = 0.16).

CONCLUSION

These results suggest that HIV-infected patients with breast cancer do not experience more treatment-related complications and can be treated according to standard guidelines.

African Breast Cancer-Disparities in Outcomes (ABC-DO): protocol of a multicountry mobile health prospective study of breast cancer survival in sub-Saharan Africa

INTRODUCTION

Sub-Saharan African (SSA) women with breast cancer (BC) have low survival rates from this potentially treatable disease. An understanding of context-specific societal, health-systems and woman-level barriers to BC early detection, diagnosis and treatment are needed.

METHODS

The African Breast Cancer-Disparities in Outcomes (ABC-DO) is a prospective hospital-based study of overall survival, impact on quality of life (QOL) and delays along the journey to diagnosis and treatment of BC in SSA. ABC-DO is currently recruiting in Namibia, Nigeria, South Africa, Uganda and Zambia. Women aged 18 years or older who present at participating secondary and tertiary hospitals with a new clinical or histocytological diagnosis of primary BC are invited to participate. For consented women, tumour characteristics, specimen and treatment data are obtained. Over a 2-year enrolment period, we aim to recruit 2000 women who, in the first instance, will be followed for between 1 and 3 years. A face-to-face baseline interview obtains information on socioeconomic, cultural and demographic factors, QOL, health and BC attitudes/knowledge, and timing of all prediagnostic contacts with caregivers in orthodox health, traditional and spiritual systems. Responses are immediately captured on mobile devices that are fed into a tailored mobile health (mHealth) study management system. This system implements the study protocol, by prompting study researchers to phone women on her mobile phone every 3 months and, failing to reach her, prompts contact with her next-of-kin. At follow-up calls, women provide updated information on QOL, care received and disease impacts on family and working life; date of death is asked of her next-of-kin when relevant.

ETHICS AND DISSEMINATION

The study was approved by ethics committees of all involved institutions. All participants provide written informed consent. The findings from the study will be published in peer-reviewed scientific journals, presented to funders and relevant local organisations and at scientific conferences.

Phenotype and Treatment of Breast Cancer in HIV-Positive and -Negative Women in Cape Town, South Africa

Purpose

An estimated 5.9 million people in South Africa are infected with HIV. Because antiretroviral therapy has made infection with HIV a treatable, chronic condition, HIV-infected individuals are now surviving to middle and older age. We investigated the implications of HIV status for breast cancer in South Africa.

Methods

We compared clinical and demographic characteristics of women newly diagnosed with a first primary breast cancer at Tygerberg Hospital, Cape Town, South Africa, from January 2010 to December 2011 by HIV status. We then compared HIV-positive patients with HIV-negative controls, matched 2:1 on age and ethnicity, with respect to chemotherapy regimens, toxicities, completion of systemic chemotherapy, and changes in CD4 cell count.

Results

Of 586 women with breast cancer, 31 (5.3%) were HIV positive, 420 (71.7%) were HIV negative, and 135 (23%) were untested for HIV. Women with HIV were younger than other women (P < .001). The groups did not differ in regard to stage at presentation, histologic subtype, tumor grade, nodal involvement, or hormone receptor positivity. More than 84% of patients who initiated systemic chemotherapy, regardless of HIV status, completed it without serious toxicity. Among HIV-positive patients receiving chemotherapy, the mean baseline CD4 cell count was 477 cells/µL (standard deviation, 160 cells/µL), and the mean nadir was 333 cells/µL (standard deviation, 166 cells/µL).

Conclusion

HIV-infected women were younger at breast cancer diagnosis than HIV-negative women but otherwise similar in phenotype and completion of chemotherapy. Longer term follow-up is needed to evaluate the effects of HIV, antiretroviral therapy, and chemotherapy on the survival and quality of life of patients with breast cancer.