Factors Contributing to Late-Stage Breast Cancer Presentation in sub-Saharan Africa

Clinical Utility of a Hand-Held Scanner for Breast Cancer Early Detection and Patient Triage

PURPOSE

Globally, breast cancer represents the most common cause of cancer death among women. Early cancer diagnosis is difficult in low- and middle-income countries, most of which are unable to support population-based mammographic screening. Triage on the basis of clinical breast examination (CBE) alone can be difficult to implement. In contrast, piezo-electric palpation (intelligent Breast Exam [iBE]) may improve triage because it is portable, low cost, has a short learning curve, and provides electronic documentation for additional diagnostic workup. We compared iBE and CBE performance in a screening patient cohort from a Western mammography center.

METHODS

Women presenting for screening or diagnostic workup were enrolled and underwent iBE then CBE, followed by mammography. Mammography was classified as negative (BI-RADS 1 or 2) or positive (BI-RADS 3, 4, or 5). Measures of accuracy and κ score were calculated.

RESULTS

Between April 2015 and May 2017, 516 women were enrolled. Of these patients, 486 completed iBE, CBE, and mammography. There were 101 positive iBE results, 66 positive CBE results, and 35 positive mammograms. iBE and CBE demonstrated moderate agreement on categorization (κ = 0.53), but minimal agreement with mammography (κ = 0.08). iBE had a specificity of 80.3% and a negative predictive value of 94%. In this cohort, only five of 486 patients had a malignancy; iBE and CBE identified three of these five. The two cancers missed by both modalities were small—a 3-mm retro-areolar and a 1-cm axillary tail.

CONCLUSION

iBE performs comparably to CBE as a triage tool. Only minimal cancers detected through mammographic screening were missed on iBE. Ultimately, our data suggest that iBE and CBE can synergize as triage tools to significantly reduce the numbers of patients who need additional diagnostic imaging in resource-limited areas.

Geospatial barriers to healthcare access for breast cancer diagnosis in sub-Saharan African settings: The African Breast Cancer-Disparities in Outcomes Cohort Study

We examined the geospatial dimension of delays to diagnosis of breast cancer in a prospective study of 1541 women newly diagnosed in the African Breast Cancer-Disparities in Outcomes (ABC-DO) Study. Women were recruited at cancer treatment facilities in Namibia, Nigeria, Uganda and Zambia. The baseline interview included information used to generate the geospatial features: urban/rural residence, travel mode to treatment facility and straight-line distances from home to first-care provider and to diagnostic/treatment facility, categorized into country/ethnicity (population)-specific quartiles. These factors were investigated in relation to delay in diagnosis (≥3 months since first symptom) and late stage at diagnosis (TNM: III, IV) using logistic regression, adjusted for population group and sociodemographic characteristics. The median (interquartile range) distances to first provider and diagnostic and treatment facilities were 5 (1-37), 17 (3-105) and 62 (5-289) km, respectively. The majority had a delay in diagnosis (74%) and diagnosis at late stage (64%). Distance to first provider was not associated with delay in diagnosis or late stage at diagnosis. Rural residence was associated with delay, but the association did not persist after adjustment for sociodemographic characteristics. Distance to the diagnostic/treatment facility was associated with delay (highest vs lowest quartile: odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.08-2.27) and late stage (overall: OR = 1.47, CI = 1.05-2.06; without Nigerian hospitals where mostly local residents were treated: OR = 1.73, CI = 1.18-2.54). These findings underscore the need for measures addressing the geospatial barriers to early diagnosis in sub-Saharan African settings, including providing transport or travel allowance and decentralizing diagnostic services.

Better Reporting and Awareness Campaigns Needed for Breast Cancer in Pakistani Women

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer deaths in women globally. In 2018, 2.1 million new cases were reported, with 627,000 deaths. Pakistan has the highest incidence rate of breast cancer among Asian countries: one in every nine women has a lifetime risk of being diagnosed with breast cancer. By reason of many misconceptions about the etiology of the disease and socioeconomic factors, Pakistani women have very low rates of early detection and diagnose breast cancer at advance stages with fewer chances of survival. The key to cure the breast cancer is early diagnosis. The aim of current review is to highlight the factors leading to the delays in early presentation of breast cancer in Pakistani women and to summarize possible recommendations for educating women about early diagnosis along with palliative care facilities for patients suffering from breast cancer. Furthermore, this study appeals to both the general public and government in the belief that better reporting and awareness campaigns may bring more women to clinics for early diagnosis.

A Global Perspective on Screening

Breast cancer is emerging as a major global public health problem. Incidence and mortality continues to rise in low- and middle-income countries (LMICs). A significant and growing disparity exists between high-income countries and LMICs in the availability of screening services and associated preventable mortality. However, population imaging-based screening programs are not appropriate for all settings. Planners should perform a thorough assessment of the target setting prior to implementing any breast cancer detection program, as appropriate guidelines vary according to the resources available. Financial, social, and cultural barriers to breast cancer care need to be addressed to sustainably improve the morbidity and mortality of the populations and make efficient use of available services. Creative approaches, such as mobile and portable imaging and bundling of services, can facilitate the installation of early breast cancer detection programs in LMICs. While image-based screening programs are not initially resource-appropriate in many LMICs, planners can work towards this goal as part of their comprehensive breast cancer detection strategy.

A phased approach to implementing the Breast Imaging Reporting and Data System (BI-RADS) in low-income and middle-income countries

BACKGROUND

Successful breast cancer detection programs rely on standardized reporting and interpreting systems, such as the Breast Imaging Reporting and Data System (BI-RADS), to improve system performance. In low-income and middle-income countries, evolving diagnostic programs have insufficient resources to either fully implement BI-RADS or to periodically evaluate the program's performance, which is a necessary component of BI-RADS. This leads to inconsistent breast ultrasound interpretation and a failure to improve performance.

METHODS

The authors applied the Breast Health Global Initiative's phased implementation strategy to implement diagnostic ultrasound and BI-RADS within the context of a limited-resource setting.

RESULTS

The authors recommended starting with triage ultrasound to distinguish suspicious masses from normal breast tissue and benign masses such as cysts because the majority of health workers performing ultrasounds at this level have minimal breast imaging experience. Transitioning to full diagnostic ultrasound with condensed or full BI-RADS should occur after performance and quality metrics have been met.

CONCLUSIONS

Transitioning through these phases across facilities likely will occur at different times, particularly in rural versus urban settings.

Educational Opportunities for Down-Staging Breast Cancer in Low-Income Countries: an Example from Tanzania

While more than 90% of breast cancer patients in western countries survive for at least 5 years, the survival rate in Tanzania is less than 45% because of late stage at presentation. The aim of this study was to identify patient and health system factors related to early or late stages of a breast cancer diagnosis. The study was conducted at the Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania, and included interviews with 196 breast cancer patients diagnosed with early (stage I/II, n = 44) or late (stage III/IV, n = 152) stage who were referred to ORCI from January 2016 to August 2018. The questionnaire elicited information regarding disease history, sociodemographics, barriers to navigating the health system, and patient attitudes towards breast cancer. More early-stage patients (54.5%) stated history of previous breast examinations before their initial diagnosis compared to late-stage patients (19.7%) (p = < 0.001). Financial restraints were cited more often as barriers to diagnosis among late-stage presentation patients (55.7%) compared to early-stage patients (35.5%) (p = 0.047). Patients who were diagnosed at late-stage (47.5%) were also more likely to state time restraints as significant barriers to their diagnosis than early-stage patients (25.8%) (p = 0.041). Although the late diagnosis of breast cancer will take immense efforts of policy workers to resolve, this study offers significant opportunities for making immediate health system changes through patient and physician education that can aid in reducing diagnosis delay in Tanzania other low-income developing countries, and low-income communities within the USA.