Supportive care during treatment for breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Subjective well-being among Iranian breast cancer patients: Exploring the influential role of psychological capital

PURPOSE

Breast cancer is a prevalent and emotionally challenging condition that profoundly affects women worldwide. Effectively managing the mental and emotional dimensions of this disease is crucial for the holistic well-being of patients. Psychological capital (PsyCap) has emerged as a pivotal psychological construct with the potential to effectively address these challenges. This study aims to explore the influential role of PsyCap and its constructs on the subjective well-being (SWB) of Iranian breast cancer patients.

METHODS

A total of 173 breast cancer patients participated in this study, selected through a random sampling approach. Face-to-face interview data on socio-demographics, PsyCap, and SWB were collected using a structured questionnaire. The analytical procedures encompassed independent sample t-tests, ANOVA tests, Pearson correlation tests, and stepwise multiple regression.

RESULTS

The findings revealed that the majority of participants fell within the 41-50 age group (38.7%), with an average age of 46.50 ± 11.76 years, and 35.8% had tumor growth in the upper left lobe. The average PsyCap score was 107.93 ± 1.52 (out of a possible score of 144), whereas SWB scored 196.51 ± 1.90 (out of 291). Notably, PsyCap showed a positive correlation with SWB (r = 0.119), accounting for approximately 8% of the variance in SWB. The final regression model showed the substantial predictive roles of PsyCap (1.667), self-efficacy (-3.692), age (-2.977), and education (-3.939) in shaping SWB.

CONCLUSIONS

Focusing on understanding and addressing factors like PsyCap, self-efficacy, and educational support could improve SWB, offering a potential avenue for comprehensive and individualized psychosocial care for women with breast cancer.

The Impact of Cancer on Mental Health and the Importance of Supportive Services

Cancer is a complex disease that affects the physical and psychological well-being of the patient, their families, and caregivers. Indeed, cancer-related mental health disorders could impact treatment adherence, quality of life, and overall health outcomes. In addition, approximately 30% of patients may experience cancer-related psychological disorders, including anxiety, depression, and post-traumatic stress. Also, caregivers of patients with cancer can experience significant emotional, physical, and financial stress, which can have a negative impact on their health. Therefore, to address these issues, mental health resources should be integrated into cancer care settings to identify and intervene early for individuals with psychological distress. Hence, providing psychological support, counseling, and education about coping strategies could create a safe and supportive environment where individuals can express their emotions, reducing feelings of isolation and depression. However, there are some important barriers to accessing mental health support for individuals with cancer, including stigma, cultural attitudes, and financial and logistical challenges. Hence, strategies to overcome these barriers include increasing awareness and education about the importance of mental health care, providing integrated care that addresses both physical and mental health needs, and utilizing telehealth services. So, healthcare providers should continue to develop and implement innovative approaches to mental health care that are tailored to the essential requirements of individuals with cancer and to enhance knowledge regarding the key roles of mental health care for individuals with cancer.

"In My Mind, It Was Just Temporary": A Qualitative Study of the Impacts of Cancer on Men and Their Strategies to Cope

Individuals who are diagnosed and treated for cancer use a variety of strategies to manage its impacts. However, there is currently a lack of research on men's experience with managing cancer impacts, which is necessary to better support them throughout the cancer care continuum. This study explored the experience of men diagnosed with cancer, focusing on the impacts of the illness and its treatment and men's strategies to cope. A qualitative descriptive design was used. Thirty-one men (Mage = 52.7 [26-82] years) diagnosed with various cancer types were recruited to take part in individual telephone interviews (n = 14) or online focus groups (n = 17) addressing the impacts of cancer and strategies they used to cope with these impacts. Directed content analysis was performed, using Fitch's (2008) supportive care framework to guide the analysis. Cancer impacts and strategies used to cope were classified into six categories: physical, psychological, interpersonal, informational, practical, and spiritual. Results indicate that the cancer experience is diverse and multifaceted rather than homogeneous. Medical and supportive care services could be more effectively personalized to meet the diversity of men's needs by adopting a comprehensive and holistic approach to supportive care. Working in partnership with patients, it appears promising to recognize and identify men's needs and match them to appropriate resources to provide truly supportive care.

Cancer incidence estimates in adults aged 60 years and older living in low-and-middle-income countries for the years 2020 and 2040

Previous studies have shown a disproportionate rise in cancer incidence in low-and-middle-income countries (LMICs) due to rapid population ageing. This study aims to describe the cancer incidence in adults aged 60 years and older in LMICs to inform cancer control planning. Using the latest GLOBOCAN estimates for 2020, we describe the cancer incidence and the top five cancer sites among adults aged 60 years and older living in LMICs. We also project the incidence in 2040 by applying population projections, assuming no changes in incidence rates and risk profiles over time. In 2020, 6.3 million new cancer cases were diagnosed in older adults in LMICs, constituting over half of the global incidence burden (55%). In females aged 60 years and older living in LMICs, breast, lung, colon, stomach, and cervix uteri were the most frequent cancer types representing 51% of the total number of new cancer cases in older females. In males aged 60 years and older living in LMICs, lung, prostate, stomach, liver and colon were the most frequent cancer types representing 58% of the total number of new cancer cases in this subgroup. Variations were observed between income categories. The number of new cancer diagnoses in adults aged 60 years and older living in LMICs will almost double by 2040, reaching 11.5 million new cancer cases. The greatest increase is expected to happen in lower-income countries (+158% in lower-middle-income countries (excluding India) and +99% in low-income countries versus +38% in upper-middle-income countries). In conclusion, our findings call for an urgent adaptation of healthcare systems in LMICs by developing geriatric oncology and by including older adults in research, clinical guidelines, insurance schemes and cancer prevention policies.

Predictors of Decreased Quality of Life in Breast Cancer Survivors Five Years After Diagnosis

PURPOSE

Due to improved therapy, early diagnosis, and growing incidence rates, the number of long-term breast cancer survivors is increasing. Survivors can still be affected by aftercare, resulting in reduced quality of life (QoL). Thus, in this study, we investigated possible predictors of decreased physical and social functioning in breast cancer survivors.

METHODS

In a German multicenter prospective study, we enrolled 759 female patients with breast cancer before surgery (t1), and contacted them again 5 years after surgery (t4). Data on QoL were assessed at t4 using the European Organization for Research and Treatment of Cancer QoL Core Questionnaire (EORTC QLQ-C30) and its breast cancer module EORTC QLQ-BR23. Predictors of decreased physical and social functioning were analyzed using logistic regression with odds ratios as effect estimates and 95% confidence intervals. Thresholds for the clinical importance of detrimental effects on QoL were defined according to Giesinger.

RESULTS

Questionnaires from 759 patients were retrieved at t1. Of these, 456 participated in the study at t4. Poor QoL 5 years after diagnosis was reported by 20%-50% of the participants. Age, mastectomy, chemotherapy, education, employment, cohabitation, psychiatric comorbidities at t1, anxiety, depression, and intensity of physical activity emerged as predictors of decreased physical and social functioning 5 years after diagnosis.

CONCLUSION

Relief of symptoms and improvement in the QoL should be priorities in aftercare. Detecting patients with a decreased QoL is a rising challenge. Healthcare providers should take special care of patients aged 50-59 years, patients with psychiatric comorbidities and depression, and patients who have undergone mastectomy.

Silver sulfide coated alginate radioenhancer for enhanced X-ray radiation therapy of breast cancer

A wide range of high-Z nanomaterials are fabricated to decrease radiation dose by sensitizing cells to irradiation through various mechanisms such as ROS generation enhancement. Alginate-coated silver sulfide nanoparticles (Ag₂S@Alg) were synthesized and characterized by SEM, TEM, DLS, XRD, EPS, FT-IR, and UV-vis analysis techniques. Cytotoxicity of nanoparticles was tested against HFF-2, MCF-7, and 4 T1 cell lines for biocompatibility and radio enhancement ability evaluation, respectively. Moreover, the hemolysis assay demonstrated that the nanoparticles were biocompatible and nontoxic. In vitro intracellular ROS generation and calcein AM/PI co-staining unveiled cancerous cell death induction by nanoradiosensitizer, Ag₂S@Alg. Further, histopathology results emphasized the tumor ablation capability of Ag₂S@Alg. Silver anticancer properties were also recognized and combined with its radiosensitizing effect under X-ray irradiation.

Effect of a social network-based supportive program (WhatsApp) on the sexual self-concept of women with breast cancer: A single-blind-randomized controlled trial

OBJECTIVES

Sexual self-concept has an influence on the sexual behaviors of women with breast cancer. Supportive programs for these women have demonstrable empirical efficacy; however, their effectiveness has not been examined. The aim of this study was to investigate the effect of a supportive program based on social networks on the sexual self-concept of women with breast cancer.

METHODS

In this randomized controlled single-blind trial, 60 women were assigned to the intervention (n = 30) and control (n = 30) groups using permuted block randomization. Overall, eight 45-min intervention sessions were held (twice a week). The primary outcome was sexual self-concept, and the secondary outcomes were women's sexual quality of life and participants' satisfaction. The questionnaires were completed by patients before the intervention and immediately and 1 month after the intervention.

RESULTS

The generalized equation estimation test showed that the positive sexual self-concept score of the intervention group versus the control group had increased by 15.67 points (P < 0.001, effect size = 2.00) 1 month after the intervention. The negative sexual self-concept score had decreased by 2.65 points (P < 0.001, effect size = 0.74), and the situational sexual self-concept score had upturned by 6.82 points (P < 0.001, effect size = 2.08) in the intervention group at the same period. Also, the sexual quality of life score in the intervention group compared to the control group generally increased by 13.82 points (P < 0.001, Effect size = 2.08) 1 month following the intervention.

SIGNIFICANCE OF THE RESULTS

A social networking support program can be a promising approach to improve the sexual self-concept of women with breast cancer.

CLINICAL TRIALS.GOV IDENTIFIER

Iranian Clinical Trial Register, IRCT20150608022609N8. Registered on 2 July 2020.

Prevalence of radiotherapy, chemotherapy and access to supportive care in cancer in Brazil, China, France, Russia and the USA

OBJECTIVES

The objective of this study is to assess the prevalence of treatment with radiotherapy and/or chemotherapy in the general adult population of five countries (Brazil, China, France, Russia and the USA) and to evaluate the use of different Supportive Care in Cancer (SCC) services.

METHODS

A total of 11,100 individuals representing the general population over 18 years of age were recruited from the five countries via a rigorous quota sampling method.

RESULTS

There are between 4.1% and 8.78% of respondents reported having undergone medical cancer treatment. Among these subpopulations, the use of at least one SCC was reported by 63% to 86% of respondents. The most commonly used SCC was psychological counselling in France, dietary counselling in Brazil and China, participating in a focus group in the USA and using alternative medicine in Russia. Alternative medicines were chosen by 50% to 61% of patients in every country.

CONCLUSION

This study provides information on the prevalence of patients treated by chemotherapy and/or radiotherapy in representative populations from five countries. Among them, SCC was widely used. However, these uses varied both in proportion and choice, given the cultural differences in patients' and families' health beliefs and values, differences among organisations, in available resources and in ethics and policies among countries.

Patients’ Experiences of Care With or Without the Support of an Interactive App During Neoadjuvant Chemotherapy for Breast Cancer: Interview Study

Background

Neoadjuvant chemotherapy (NACT) is often recommended for patients with breast cancer with more aggressive tumor characteristics. As with all chemotherapies, they can cause substantially disturbing symptoms. Most patients receive their treatment as outpatients, which means that they must take responsibility for self-care and management of symptoms at home for a long period. Patients with breast cancer undergoing chemotherapy may not receive sufficient support for management of treatment-related symptoms. For patients undergoing NACT, it has been concluded that information and supportive needs are not always met. In our previous study, the use of mobile health to support patients with breast cancer undergoing NACT reduced symptoms during treatment with the support of an interactive app. Therefore, it is important to investigate how patients experience their care and explore any specific contribution that the app may have brought in care.

Objective

This study aims to explore patients’ experiences of care with or without the support of an interactive app during NACT for breast cancer.

Methods

This qualitative study was part of a larger randomized controlled trial and included 40 individual face-to-face interviews conducted with patients in both intervention and control groups after the end of NACT. The interviews were audio recorded, and the data were analyzed inductively using thematic analysis.

Results

No major differences in experience of care were observed between the groups. A total of 4 overarching themes emerged. In the first theme, The health care context, patients described care as assessible, although sometimes there was a lack of time and continuity with nurses. In the second theme, Being a recipient of care, it emerged that the patients experienced a warm and positive atmosphere at the clinics. In the third theme, Taking an active role as a patient, patients described being active in searching for information and various ways of participation in their own care. In the fourth theme, The value of the app, patients who had used the app experienced it as a complementary source of information, creating a sense of security. Using the app provided patients with the support of being contacted by a nurse if needed, enabled self-care, and facilitated the planning of daily activities.

Conclusions

Overall, patients’ experiences of care were similar and mostly positive. However, for patients using the app, it provided additional support for information and self-care and enhanced participation in their own care. The easy access to a nurse gave patients a sense of security. The findings suggest integrating an interactive app as a complement to standard care to support patients with breast cancer during treatment.

International Registered Report Identifier (IRRID)

RR2-DOI: 10.1186/s12885-017-3450-y

Predictors of the relationship between the duration of cancer and care time with the supportive care needs of patients and the quality of life of their caregivers: a path analysis

BACKGROUND

Breast cancer (BC) patients face various physical and psychological challenges. The mutual impacts of patients and caregivers on each other show the need for further supportive care from the community and family. This study aimed to identify the predictors of the direct and indirect relationships of the duration of cancer (CANCERT) and care time (CARET) with the supportive care needs (SCN) of the patients and the quality of life (QOL) of their family caregivers.

METHODS

This descriptive study included 150 patients and their caregivers in Iran. Data were collected using the Supportive Care Needs Survey-Short Form (SCNS-SF34), the Caregiver Quality of Life Index-Cancer (CQOLC) scale, and a socio-demographic checklist. The data were then analyzed in SPSS-24 and Lisrel-8.8 software using descriptive statistics and path analysis.

RESULTS

The mean age of the patients and caregivers was 45.76 ± 10.44 and 43.46 ± 9.5, respectively. The majority of patients (96%) were in stages II and III of the disease. There was no statistically significant relationship between cancer stages with SCN of the patients and also caregivers' QOL (P > 0.05). Based on the test results, the CANCERT was positively correlated with the patients' care and support needs (SN) in total effect (β = 0.24). The patients' sexuality needs had the highest negative correlation with their CANCERT in the direct path (β =  - 0.27) and had the highest negative correlation with psychological needs in the indirect path (β =  - 0.174). The CARET (hours per day) had positive correlation with health systems and information needs in both the direct (β = 0.26) and indirect paths (β = 0.15). The highest positive correlation with physical needs was in the direct path (β = 0.34). The caregivers' QOL had a negative and direct relationship with the CANCERT (β =  - 0.19), and there was a positive and direct relationship between CARET and the caregivers' QOL (β = 0.18).

CONCLUSIONS

The correlations obtained from this study are not necessarily strong, yet they are important and should be noticed and tested in the future studies. The present findings reveal the need to provide comprehensive care, planning to provide supportive care, and counseling to both BC patients and their family caregivers, especially when the duration of the disease is prolonged.

Blended Oncology Nursing Training: A Quality Initiative in East Africa

PURPOSE

Lack of education and awareness about cancer treatment may result in suboptimal care of patients with cancer. Unlike high-income countries, resource-limited countries lack the standardized training and scope of practice in oncology nursing. This quality improvement project was conducted to assess nurses' knowledge gain, retention of knowledge and clinical skill set, and feasibility of a blended learning approach in the care of adult oncology patients across four hospitals in Kenya and Tanzania.

METHOD

We used a combination of computer-led eLearning sessions and face-to-face interactions over 12 months for cancer education to oncology nurses. Pre- and posttests with each training session were combined with face-to-face clinical skills training at beginning and completion of the course. A comprehensive postassessment was conducted immediately after the training, and at 6, 9, and 12 months to evaluate knowledge gain and retention.

CONCLUSION

Of 21 participants across four sites, there was a statistically significant improvement in knowledge scores for 12 participants (P value < .05). The mean pre- and posttest results found significant differences across 10 sessions individually and cumulatively (P value < .01). Results from a one-way repeated measures analysis of variance (ANOVA) test on comprehensive test results suggested that there was no significant difference in knowledge retention across 9 months (F(2, 30) = 1.648412, P > .05).

IMPLICATIONS FOR NURSING PRACTICE

Blended learning is an effective tool in improving knowledge, skills, and self-efficacy for clinicians practicing in resource-limited countries. Developing a structured oncology training program has implications for bridging knowledge gaps among clinicians in resource-limited countries and promoting international knowledge exchange.

Boys Don't Cry: Examining Sex Disparities in Behavioral Oncology Referral Rates for AYA Cancer Patients

Psychosocial distress is highly prevalent in cancer patients, approaching rates around 40% across various cancer sites according to multicenter studies. As such, distress screening procedures have been developed and implemented to identify and respond to cancer patients' psychosocial distress and concerns. However, many cancer patients continue to report unmet psychosocial needs suggesting gaps in connecting patients with psychosocial services. Presently, there is a paucity of research examining sex-based disparities in referral rates to behavioral oncology services, particularly for adolescent and young adult (AYA) cancer patients. Informed by gender role conflict and empirical literature documenting disparities in cancer care and treatment based on a variety of sociocultural variables, this study aimed to examine the presence of sex disparities in referral rates to behavioral oncology services for AYA cancer patients. Data for this study consisted of 1,700 AYA cancer patients (age 18–39) who completed a distress screening at a large cancer center of a teaching hospital in the Midwestern United. Results indicated that patient sex significantly predicted the odds of behavioral oncology referral (γ₅₀ = −0.95, Odds ratio = 2.60, p < 0.001). This finding indicates that female AYA cancer patients are 2.5 times more likely to be referred to behavioral oncology services compared to male AYA cancer patients after controlling for psychosocial distress and emotional, family, and practical problems. Additionally, we found that emotional problems significantly moderated the odds of referral for males and females (γ₆₀ = 0.37, Odds ratio = 1.44, p < 0.001), however the odds of referral for males who endorsed emotional problems were lower than males who did not endorse emotional problems. This contrasted with female AYA cancer patients where the endorsement of emotional problems increased the odds of referral to behavioral oncology services. Findings are discussed with particular focus on how to enhance equitable care and reduce sex and other sociocultural-based disparities in AYA psychosocial oncology.

Self-reported arm and shoulder problems in breast cancer survivors in Sub-Saharan Africa: the African Breast Cancer-Disparities in Outcomes cohort study

Background

Arm and shoulder problems (ASP), including lymphedema, were common among women with breast cancer in high-income countries before sentinel lymph node biopsy became the standard of care. Although ASP impair quality of life, as they affect daily life activities, their frequency and determinants in Sub-Saharan Africa remain unclear.

Methods

All women newly diagnosed with breast cancer at the Namibian, Ugandan, Nigerian, and Zambian sites of the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort study were included. At each 3-month follow-up interview, women answered the EORTC-QLQ-Br23 questionnaire, including three ASP items: shoulder/arm pain, arm stiffness, and arm/hand swelling. We estimated the cumulative incidence of first self-reported ASP, overall and stratified by study and treatment status, with deaths treated as competing events. To identify determinants of ASP, we estimated cause-specific hazard ratios using Cox models stratified by study site.

Results

Among 1476 women, up to 4 years after diagnosis, 43% (95% CI 40–46), 36% (33–38) and 23% (20–25), respectively, self-reported having experienced arm/shoulder pain, stiffness and arm/hand swelling at least once. Although risks of self-reported ASP differed between sites, a more advanced breast cancer stage at diagnosis, having a lower socioeconomic position and receiving treatment increased the risk of reporting an ASP.

Conclusion

ASP are very common in breast cancer survivors in Sub-Saharan Africa. They are influenced by different factors than those observed in high-income countries. There is a need to raise awareness and improve management of ASP within the African setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01486-9.

Health-Related Suffering and Palliative Care in Breast Cancer

Purpose of Review

Breast cancer continues to be the most frequently diagnosed cancer in women and the leading cause of cancer death worldwide. By the suffering that it causes in various domains of life, breast cancer seriously impacts the quality of life of affected individuals and causes a major burden of suffering in the community. The objectives of the review were to understand the health-related suffering in patients with breast cancer and to identify the scope of palliative care in improving the quality of life of patients with breast cancer.

Recent Findings

Breast cancer causes suffering in physical, psychological, social, financial, and spiritual domains of the lives of the patient and family. Management of breast cancer with surgery, chemotherapy, and radiation could have adverse effects, such as pain, nausea and vomiting, fatigue, shortness of breath, depression, and constipation. Both cancer and its treatment can impact the psychosocial and spiritual well-being of the patient and family members. Integrating palliative care into existing breast cancer treatment programs seems to be the best approach to diminish these sufferings.

Summary

In addition to pain and other physical symptoms, breast cancer can cause major psychological, social, and spiritual suffering. In the context of developing countries, out-of-pocket expenditure can cause major financial destruction which can impact generations. Integration of palliative care to breast cancer treatment is essential.

Breast cancer treatment: A phased approach to implementation

Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low- and middle-income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited-resource settings by creating roadmaps that are individualized and adapted to the baseline environment. This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late-stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements. A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1-stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana.

The effect of a supportive program on coping strategies and stress in women diagnosed with breast cancer: A randomized controlled clinical trial

AIM

To investigate the effect of a supportive program on coping strategies and stress in women with breast cancer.

DESIGN

A randomized, two-armed, controlled trial.

METHODS

Sixty women were randomly allocated to intervention group (N = 30) and control group (N = 30). The interventions were held in six sessions, weekly from August 2018-March 2019 It was consisting of education regarding breast cancer; progressive muscle relaxation; stress management; emotional coping; and problem-solving strategies.

RESULTS

At baseline, there was no difference between the two groups regarding the mean score of coping strategies and stress. Supportive program group participants experienced a significantly higher increase on their problem-oriented coping strategies score in comparison with the control group. At the same time, scores in emotion-oriented coping strategies and stress decreased significantly in the intervention group compared with the control group. Result of this study can be used to develop relevant interventions targeting coping strategies to reduce stress among women with breast cancer.

Insights on emotional distress following cancer, sources of support and the unmet needs in a setting with limited supportive care services for people living with cancer

INTRODUCTION

Delivery of supportive cancer care is often deemed a low priority in resource-limited settings. We aimed to explore the sources of emotional distress, the related support and the unmet needs of cancer survivors in Malaysia, where cancer survivorship services are presently limited.

METHOD

Twenty focus group discussions were conducted with 102 cancer patients from diverse ethnic and socioeconomic backgrounds. Thematic analyses were performed.

RESULTS

Patient narratives suggested that emotional distress arose from direct and indirect stressors. Direct stressors comprised physical and cognitive side effects of cancer surgery and therapies, and fear of recurrence. Indirect stressors included worry over dependent family members, financial distress following cancer, working with cancer and lack of practical support at home. Distress from altered physical appearances, fear of recurrence and lack of practical support were mainly raised by women, implying that men and women may have disproportionate emotional needs. Emotional support largely came from informal sources including self, family, friends and religion. While formal emotional support from professional counsellors and cancer support groups was acknowledged as important, it appeared to be largely lacking. Unmet needs in coping with fear of recurrence, financial distress, workplace discrimination and household chores were particularly highlighted.

CONCLUSION

The unmet needs revealed in this study provide insights to initiate actionable changes to improve the emotional wellbeing of people living with cancer in settings where cancer survivorship services are still in its infancy.

Multicentre prospective cohort study of unmet supportive care needs among patients with breast cancer throughout their cancer treatment trajectory in Penang: a PenBCNeeds Study protocol

INTRODUCTION

Proper assessment of unmet supportive care needs of patients with breast cancer and its influencing factors at different treatment intervals will improve the rehabilitation of patients with breast cancer. Therefore, this study aims to determine the prevalence of unmet supportive care needs, changes of needs over time and associated factors during the treatment period.

METHODS AND ANALYSIS

This multicentre, prospective cohort study will be conducted in three governmental hospitals and one tertiary cancer institute in Penang, Malaysia. Adult women diagnosed with primary or recurrent tumour, node, metastases stage I-IV breast cancer based on pathological biopsy will be eligible for this study. At least 281 samples are required for this study. Participants will undergo follow-up at three time intervals: T1 at breast cancer diagnosis; T2 at 3 months after diagnosis and T3 at 6 months after diagnosis. Patients will complete a set of questionnaires at each time. The primary outcome of this study includes the changes in supportive care needs over three time points, followed by the secondary outcome examining patients' characteristics, coping behaviours and positive psychological components as they affect changes in unmet supportive care needs over time.

ETHICS AND DISSEMINATION

The study has received ethics approval from the Medical Research and Ethics Committee, Ministry of Health Malaysia (NMRR-19-268-45809 IIR) and the Human Research Ethics Committee of Universiti Sains Malaysia (USM/JEPeM/17100443). The results of the prospective study will be submitted for publication in a peer-reviewed journal.

Factors influencing quality of life of Asian breast cancer patients and their caregivers at diagnosis: perceived medical and psychosocial needs

INTRODUCTION

We aimed to examine the relative importance of medical and psychosocial needs of Asian breast cancer patients and their caregivers, and to identify the determinants of quality of life (QoL) at the time of diagnosis.

METHODS

This is a prospective observational study of the perceived needs and QoL of 99 dyads of breast cancer patients and their caregivers at diagnosis. A self-administered questionnaire was used to measure the perceived importance of medical and psychosocial support needs. Short Form-36 health survey (SF-36) version 2 was used to measure QoL. We also collected patient and caregiver demographic profiles and disease-specific information. Descriptive analysis of perceived needs was performed. SF-36 scores for eight domains and composite scores were calculated. Bivariate analysis and linear regression were performed to identify significant independent predictors of QoL of patients and caregivers.

RESULTS

The mean ages of the patients and caregivers were 56.5 years and 51.7 years, respectively. To have family around (73%), prompt information about treatment and treatment options, including side effects (71%), and prompt treatment for side effects (71%) were the top three needs among patients and their caregivers. Supportive nurses and prompt treatment for side effects positively improved patients' social functioning and bodily pain scores. Stage of disease, age, education and ethnicity also influenced QoL. Only the presence of chronic disease influenced caregivers' physical functioning and role-physical scores.

CONCLUSION

Patients and caregivers have similar perceptions of needs at diagnosis. A supportive healthcare team can positively influence patients' QoL, highlighting the importance of tailoring support according to needs.

Close2U: An App for Monitoring Cancer Patients with Enriched Information from Interaction Patterns

The management of cancer patients' symptoms in doctor consultations is a cornerstone in clinical care, this process being fundamental for the follow-up of the evolution of these. This article presents an application that allows collecting periodically and systematically the data of cancer patients and their visualization by the medical team. In this article, we made the analysis, design, implementation, and final evaluation by analyzing the correlation of this data collection with interaction patterns to determine how the user information can be enriched with information from the interaction patterns. We have followed an agile methodology based on the iterative and incremental development of successive prototypes with increased fidelity, where the requirements and solutions have evolved over time according to the need and assessments made. The comprehensive analysis of the patient's condition allowed us to perform a first analysis of the correlation of the states of patients concerning mood, sleeping quality, and pain with the interaction patterns. A future goal of this project is to optimize the process of data collection and the analysis of information. Another future goal is to reduce the time dedicated to reporting the evolution of symptoms in face-to-face consultations and to help professionals in analyzing the patient's evolution even in the period that has not been attended in person.

Psychological and physical effects of breast cancer diagnosis and treatment on young Ghanaian women: a qualitative study

BACKGROUND

Young women diagnosed with breast cancer face challenges that interfere with their entire life with psychological and physical effects.

METHOD

We employed a qualitative exploratory descriptive design, and recruited twelve participants through purposive and snowball sampling methods to conduct 12 face to face individual interviews. A reputable review board in Ghana; Noguchi Memorial Institute for Medical Research, gave ethical clearance for data collection. Data were transcribed verbatim and analysed using thematic content analysis.

RESULTS

Three themes emerged from the data; physical effects of breast cancer, effects of treatment on body image, and emotional effects of breast cancer diagnosis and treatment. The negative effects of treatment incapacitated most of the women and limited their activities of daily living. Some experienced severe bodily weakness and stayed indoors for days. Most participants felt they looked unattractive because they have had a mastectomy done, and used pieces of rags and handkerchiefs as breast prostheses. Those who had hair loss through chemotherapy used different kinds of wigs to cover their baldness. Almost all the participants cried, felt depressed, and became emotionally unstable when they were told their diagnosis. Some denied their diagnoses and displaced their anger on healthcare personnel. A few of them felt they had brought disgrace to their families because breast cancer is perceived, a disgraceful disease.

CONCLUSION

Young women diagnosed with breast cancer require psychological interventions and physical support from healthcare personnel and their families.

The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation: Methods and overview

BACKGROUND

The Breast Health Global Initiative (BHGI) established a series of resource-stratified, evidence-based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice.

METHODS

In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation) for guiding the translation of resource-appropriate breast cancer control guidelines into real-world practice. Three expert consensus panels developed stepwise, resource-appropriate recommendations for implementing these guidelines in low-income and middle-income countries as well as underserved communities in high-income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening.

RESULTS

Key findings from the summit and subsequent article preparation included the identification of phased-implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real-world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits.

CONCLUSIONS

Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.

Reduced symptom burden with the support of an interactive app during neoadjuvant chemotherapy for breast cancer - A randomized controlled trial

Objectives

Neoadjuvant chemotherapy causes distressing symptoms, which have to be managed by patients at home. Assessing and acting upon relevant patient-reported symptoms regularly with the support of mHealth such as apps, has shown to decrease symptom burden and improve health-related quality of life (HRQoL). There is a lack of apps for patients with breast cancer which are tested in rigorous trials and only a few include interactive components for immediate clinical management. The aim of this study was to evaluate whether the use of the interactive app Interaktor improves patients’ levels of symptom burden and HRQoL during neoadjuvant chemotherapy for breast cancer.

Materials and methods

This randomized controlled trial included patients in an intervention group (n = 74) and a control group (n = 75), recruited at two university hospitals in Stockholm, Sweden. The intervention group used Interaktor for symptom reporting, self-care advice and support from health-care professionals during treatment, and the control group received standard care alone. Self-reported symptoms and HRQoL were assessed at two time points to determine differences between the groups.

Results

The intervention group rated statistically significant less symptom prevalence in nausea, vomiting, feeling sad, appetite loss and constipation. Overall symptom distress and physical symptom distress were rated statistically significant lower in the intervention group. Further, emotional functioning was rated statistically significant higher in the intervention group.

Conclusions

By using the Interaktor app in clinical practice, patients get individual support when managing treatment-related symptoms during neoadjuvant chemotherapy for breast cancer, leading to decreased symptom burden and improved emotional functioning.

•

Using the app Interaktor reduced symptom burden in patients with breast cancer.

•

The use of Interaktor enhanced emotional functioning during treatment.

•

Interaktor provided individual support during neoadjuvant chemotherapy.

•

Use of Interaktor allowed breast cancer patients for daily reflection over symptoms.

Update Breast Cancer 2019 Part 5 - Diagnostic and Therapeutic Challenges of New, Personalised Therapies in Patients with Advanced Breast Cancer

Significant advancements have been made in recent years in advanced breast cancer and nearly all of them have been in the field of targeted therapy. Pertuzumab and trastuzumab-emtansine (T-DM1) have been able to be introduced in HER2-positive breast cancer. Now other anti-HER2 therapies are being developed (e.g. margetuximab, DS-8201a, pyrotinib) which can overcome other resistance mechanisms in the HER2 signalling pathway. In the field of hormone-receptor-positive breast cancer, an mTOR inhibitor and CDK4/6 inhibitors were introduced in the past. Now the introduction of the first PI3K inhibitor is forthcoming and this inhibitor will involve genetic testing of the tumour for a mutation in the PIK3CA gene. There are also significant advancements in triple-negative breast cancer: By combining chemotherapy and immunotherapy, an advantage for overall survival was able to be demonstrated in a subgroup (immune cells PD-L1-positive). The PARP inhibitor therapy for HER2-negative patients with a germ line mutation in BRCA1 or BRCA2 was also associated with an improved overall survival in a subgroup. These promising new study results are summarised in this review.

The effect of informational-emotional support program on illness perceptions and emotional coping of cancer patients undergoing chemotherapy

PURPOSE

The present study aims to assess the effect of a nurse-led informational-emotional support program on illness perceptions and emotional coping of cancer patients undergoing chemotherapy.

METHODS

We used a quasi-experimental design, pre- and post-test. A total of 80 cancer patients undergoing chemotherapy were selected by convenience sampling method and assigned to experimental (n = 40) and control groups (n = 40). The nurse-led informational-emotional support program included five face-to-face sessions, educational booklet, and five phone follow-ups, and was conducted for the experimental group over 10 weeks. The control group received routine cares. The outcomes were assessed at baseline and end of intervention and included illness perceptions, which were assessed using the Illness Perception Questionnaire-Revised (IPQ-R), and emotional coping as the secondary outcome using the Coping Through Emotional Approach Scale. Data were analyzed in SPSS using multivariate analysis of covariance (MANCOVA) models, t test, paired t test, and chi-square.

RESULTS

Between group analysis showed that the mean scores of global illness perceptions and subscales including timeline, consequences, controllability, and coherence significantly increased in the experimental group compared to the control (P < 0.001), but no significant change was observed in two groups in the subscale of emotional representation (P < 0.571) and in the secondary outcome including emotional coping (P < 0.08).

CONCLUSIONS

A 10-week nurse-led informational-emotional support program can lead to changed illness perceptions without changing emotional coping. The effect of this support program should be studied on the coping and illness perceptions over the trajectory of cancer, especially in end stages in the future.

Update Breast Cancer 2019 Part 2 - Implementation of Novel Diagnostics and Therapeutics in Advanced Breast Cancer Patients in Clinical Practice

The treatment of patients with advanced breast cancer has developed further in recent years. In addition to therapeutic progress in the established subgroups (hormone receptor and HER2 status), there are now therapies which are geared to individual molecular characteristics, such as PARP inhibitor therapy in BRCA-mutated patients. In addition to this, tests are being developed which are intended to establish additional markers within subgroups in order to predict the efficacy of a therapy. PI3K mutation testing in HER2-negative, hormone-receptor-positive tumours and PD-L1 testing of immune cells in triple-negative tumours are expected to become established in clinical practice in order to select patients for the respective therapies. With new therapeutic approaches, new adverse effects also appear. The management of these adverse effects, just as those of classical therapy (supportive therapy), is essential with the introduction of new treatments in order to preserve patients' quality of life. Knowledge regarding measures to preserve and improve quality of life has significantly increased in recent years. Lifestyle factors should be taken into account, as should modern therapeutic methods. This review summarises the latest studies and publications and evaluates them in regard to the relevance for clinical practice.

Course and predictors of supportive care needs among Mexican breast cancer patients: A longitudinal study

OBJECTIVE

This study examined the course and predictors of supportive care needs among Mexican breast cancer patients for different cancer treatment trajectories.

METHODS

Data from 172 (66.4% response rate) patients were considered in this observational longitudinal study. Participants were measured after diagnosis, neoadjuvant treatment, surgery, adjuvant treatment, and the first post-treatment follow-up visit. Psychological, Health System and Information, Physical and Daily Living, Patient Care and Support, Sexual, and Additional care needs were measured with the Supportive Care Needs Survey (SCNS-SF34). Linear mixed models with maximum-likelihood estimation were computed.

RESULTS

The course of supportive care needs was similar across the different cancer treatment trajectories. Supportive care needs declined significantly from diagnosis to the first post-treatment follow-up visit. Health System and Information care needs were the highest needs over time. Depressive symptoms and time since diagnosis were the most consistent predictors of changes in course of supportive care needs of these patients.

CONCLUSIONS

Health system and information care needs of Mexican breast cancer patients need to be addressed with priority because these needs are the least met. Furthermore, patients with high depressive symptoms at the start of the disease trajectory have greater needs for supportive care throughout the disease trajectory.

An integrative Tai Chi program for patients with breast cancer undergoing cancer therapy: study protocol for a randomized controlled feasibility study

BACKGROUND

Breast cancer patients experience various side effects during cancer therapy, often resulting in reduced quality of life and poor adherence to treatment. A limited range of proven interventions has been developed to target such side effects. While Tai Chi offers benefits for the health and well-being of breast cancer survivors, the effectiveness of Tai Chi across the treatment continuum has not been evaluated. Improved patient education and support has been suggested as a priority for breast cancer care. This pilot study assesses the feasibility of a randomized controlled trial (RCT) to evaluate the effectiveness of "an integrative Tai Chi" (ANITA) program for breast cancer patients undergoing cancer therapy.

METHODS/DESIGN

This is a single-centre, two-arm feasibility RCT. Twenty-four patients with breast cancer who have undergone surgical treatment will be recruited from the Dunedin Hospital (New Zealand) over a 12-month period (from August 2017 to July 2018). Subject to informed consent, patients will be randomized to receive standard cancer treatment alone or standard cancer treatment plus the ANITA program, consisting of peer support, health education, and Tai Chi Ruler exercise. The program runs alongside the patient's adjuvant cancer therapy, which may include chemotherapy, radiation therapy, antibody treatment, and/or antihormonal therapy. Analysis in this study will focus on process evaluation of participant recruitment, retention, treatment fidelity, acceptability of the program, and occurrence of adverse events. Clinical outcomes (i.e., fatigue, sleep quality, anxiety and depression and quality of life) will be assessed at baseline, and at 12 weeks and 24 weeks post-randomization.

DISCUSSION

Outcomes from this study will inform the feasibility and methodology for a future fully-powered RCT.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry with the identifier ACTRN12617000975392.

2016 President's Plenary International Psycho-Oncology Society: challenges and opportunities for growing and developing psychosocial oncology programmes worldwide

Consistent with the International Psycho-Oncology Society's (IPOS) vision and goals, we are committed to improving quality cancer care and cancer policies through psychosocial care globally. As part of IPOS's mission, upon entering "Official Relations" for a second term with the World Health Organization (WHO), IPOS has dedicated much attention to reaching out to countries, which lack formalized psychosocial care programmes. One of IPOS's strategies to accomplish this goal has been to bring psycho-oncology training programmes to low- and middle-income countries and regions. To this end, the IPOS Board approved a new position on the Board of Directors for a member from a low- to middle-income country (LMIC). The IPOS 2016 President's Plenary focused on challenges and opportunities that exist in growing and developing psychosocial oncology programmes worldwide. The plenary presentations highlight how IPOS and WHO have aligned their goals to help LMICs support cancer patients as an essential element of cancer and palliative care. IPOS country representatives are strongly supported in liaising with national health authorities and with WHO Country Representatives in LMICs. The plenary speakers discussed the role IPOS Federation has taken in building a global network of psychosocial leaders and the impact this had in assisting LMICs in meeting IPOS's psychosocial care objectives. The plenary highlighted the challenges of expanding psychosocial reach into these countries. One significant question remains: Can psychosocial guidelines be adapted to LMICs and regions?

Specialized programs to support young women with breast cancer

PURPOSE OF REVIEW

Because of the recognized impact of breast cancer and its treatment on a young woman's life, initiatives are being established worldwide. The main aim of this review was to describe existing specialized programs that support young women with breast cancer (YWBC), advances to date, current challenges and future actions.

RECENT FINDINGS

Current programs for YWBC are now educating professionals, patients, and communities on their specific needs. Also, support groups have helped break isolation and connect YWBC together. Research on biology, treatment, adverse effects, risk factors, genetics, and social aspects on YWBC is now being actively conducted. In low- and middle-income countries, the particular issues of young women are, however, still not systematically addressed, because of scarce funding, lack of awareness of YWBC needs, and deficient provider training.

SUMMARY

Practice guidelines and algorithms should be disseminated and available for their widespread use to allow standard clinical and supportive care for YWBC even in oncologic centers where no specific programs exist. Also, cancer centers should formally commit to financing, at least partially, dedicated services, and existing programs for YWBC, guaranteeing their continuity. Finally, interinstitutional and international collaborations should be encouraged to facilitate adequately powered research, to avoid repetitive efforts, and to promote knowledge sharing and translation.

Management of locally advanced and metastatic breast cancer: guidelines, infrastructures and low resource settings

Breast cancer incidence is rising and it accounts for over 1.6 million cases per year worldwide. It represents about one-third of female cancers and is a significant health issue in countries at all economic levels. In this article, we review global cancer statistics, breast cancer staging including late-stage presentation in limited resource settings, disparities in the breast cancer outcomes and requirements for optimal management, including infrastructure needs for optimal surgery, radiation treatment and systemic therapy. We will discuss controversies related to drug pricing and availability, process and delays in registration of new drugs as well as resource stratification and resource-stratified guidelines for locally advanced breast cancer and metastatic breast cancer.

Management of fatigue following breast cancer treatment

Cancer-related fatigue (CRF) is a very distressing symptom experienced by most cancer patients. CRF is a complex symptom and there is no agreement regarding the exact definition, the best measurement instrument or even the optimal treatment. CRF is an important problem especially in breast cancer patients, during and after treatment, in long-term survivors. In the last few decades survival rates have dramatically improved. Thus, the number of breast cancer survivors has increased and preservation of quality of life has become very important. This paper is a literature review of the studies published in the last 5 years on management of CRF and breast cancer patients. We distinguished CRF during and after oncological therapy and examined both pharmacological and nonpharmacological interventions.

Global health from a cancer care perspective

Cancer is now recognized as one of the four leading causes of morbidity and mortality worldwide, and incidence is expected to rise significantly in the next two decades. Unfortunately, low- and middle-income countries (LMIC) suffer disproportionately from the world's cancer cases. The growing burden of cancer and maldistribution of cancer care resources in LMIC warrant a massive re-evaluation of the structural inequalities that produce global oncological disparities and a worldwide commitment to improve both prevention and treatment strategies. Efforts to improve cancer care capacity should focus on horizontal strengthening of healthcare systems that provide safe, affordable, effective and sustainable care. In response to current deficiencies, many international organizations have started to partner with LMIC to create solutions. Telemedicine and international collaboration are also promising ways to effect change and improve global oncological care.

Complementary and alternative medicine use and its association with quality of life among Lebanese breast cancer patients: a cross-sectional study

BACKGROUND

Breast cancer patients are increasingly seeking Complementary and Alternative Medicine (CAM) therapies with the hope of alleviating the burden of the disease and improving their quality of life (QOL). The objective of this study was to assess the prevalence, types, socio-demographic and disease-related correlates as well as characteristics of CAM use (including disclosure to treating physicians) among breast cancer patients in Beirut, Lebanon. A secondary objective was to evaluate the association between CAM use and QOL.

METHODS

A cross-sectional survey was conducted on breast cancer patients recruited from two major referral centers in Beirut: a philanthropic hospital and a private academic medical center. In face-to-face interviews, participants completed a questionnaire of three sections: socio-demographic and lifestyle characteristics, breast cancer condition, and CAM use. Three to four weeks following these interviews, the secondary QOL assessment was carried out via telephone using the Arabic version of the Functional Assessment of Cancer Therapy-Breast questionnaire. The main outcome in this study, CAM use, was defined as using CAM at least once after breast cancer diagnosis.

RESULTS

A total of 180 breast cancer patients completed the survey (response rate: 94.6 %). Prevalence of CAM use was 40 %. Using multivariate logistic regression, CAM use was negatively associated with age (OR: 0.96, CI: 0.92-0.99), treatment at the philanthropic hospital (OR: 0.13, CI: 0.05-0.35) and was positively associated with an advanced stage of the disease (OR: 4.20, CI: 1.65-10.69). Among study participants recruited from both sites, the most commonly used CAM was 'special food' followed by 'herbal teas', 'diet supplements' and 'Spiritual healing'. Only 4 % of CAM users cited health professionals as influencing their choice of CAM and only one in four patients disclosed CAM use to their treating physician. There was no significant association between CAM use and QOL.

CONCLUSIONS

The findings of this study revealed a prevalent CAM use among Lebanese breast cancer patients. Furthermore, physicians' role in orienting CAM use was found to be marginal as patients relied mainly on family and media for their choice of CAM and were less likely to disclose CAM use to their treating physicians.

Developing the Evidence Base to Inform Best Practice: A Scoping Study of Breast and Cervical Cancer Reviews in Low- and Middle-Income Countries

BACKGROUND

Breast and cervical cancers have emerged as major global health challenges and disproportionately lead to excess morbidity and mortality in low- and middle-income countries (LMICs) when compared to high-income countries. The objective of this paper was to highlight key findings, recommendations, and gaps in research and practice identified through a scoping study of recent reviews in breast and cervical cancer in LMICs.

METHODS

We conducted a scoping study based on the six-stage framework of Arskey and O'Malley. We searched PubMed, Cochrane Reviews, and CINAHL with the following inclusion criteria: 1) published between 2005-February 2015, 2) focused on breast or cervical cancer 3) focused on LMIC, 4) review article, and 5) published in English.

RESULTS

Through our systematic search, 63 out of the 94 identified cervical cancer reviews met our selection criteria and 36 of the 54 in breast cancer. Cervical cancer reviews were more likely to focus upon prevention and screening, while breast cancer reviews were more likely to focus upon treatment and survivorship. Few of the breast cancer reviews referenced research and data from LMICs themselves; cervical cancer reviews were more likely to do so. Most reviews did not include elements of the PRISMA checklist.

CONCLUSION

Overall, a limited evidence base supports breast and cervical cancer control in LMICs. Further breast and cervical cancer prevention and control studies are necessary in LMICs.

Optimisation of the continuum of supportive and palliative care for patients with breast cancer in low-income and middle-income countries: executive summary of the Breast Health Global Initiative, 2014

Supportive care and palliative care are now recognised as critical components of global cancer control programmes. Many aspects of supportive and palliative care services are already available in some low-income and middle-income countries. Full integration of supportive and palliative care into breast cancer programmes requires a systematic, resource-stratified approach. The Breast Health Global Initiative convened three expert panels to develop resource allocation recommendations for supportive and palliative care programmes in low-income and middle-income countries. Each panel focused on a specific phase of breast cancer care: during treatment, after treatment with curative intent (survivorship), and after diagnosis with metastatic disease. The panel consensus statements were published in October, 2013. This Executive Summary combines the three panels' recommendations into a single comprehensive document covering breast cancer care from diagnosis through curative treatment into survivorship, and metastatic disease and end-of-life care. The recommendations cover physical symptom management, pain management, monitoring and documentation, psychosocial and spiritual aspects of care, health professional education, and patient, family, and caregiver education.

Breast cancer in low and middle income countries (LMICs): a shifting tide in global health

Cancer control planning has become a core aspect of global health, as rising rates of noncommunicable diseases in low-resource settings have fittingly propelled it into the spotlight. Comprehensive strategies for cancer control are needed to effectively manage the disease burden. As the most common cancer among women and the most likely reason a woman will die from cancer globally, breast cancer management is a necessary aspect of any comprehensive cancer control plan. Major improvements in breast cancer outcomes in high-income countries have not yet been mirrored in low-resource settings, making it a targeted priority for global health planning. Resource-stratified guidelines provide a framework and vehicle for designing programs to promote early detection, diagnosis, and treatment using existing infrastructure and renewable resources. Strategies for evaluating the current state and projecting future burden is a central aspect of developing national strategies for improving breast cancer outcomes at the national and international levels.

Supportive and palliative care for metastatic breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Many women diagnosed with breast cancer in low- and middle-income countries (LMICs) present with advanced-stage disease. While cure is not a realistic outcome, site-specific interventions, supportive care, and palliative care can achieve meaningful outcomes and improve quality of life. As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert international panel identified thirteen key resource recommendations for supportive and palliative care for metastatic breast cancer. The recommendations are presented in three resource-stratified tables: health system resource allocations, resource allocations for organ-based metastatic breast cancer, and resource allocations for palliative care. These tables illustrate how health systems can provide supportive and palliative care services for patients at a basic level of available resources, and incrementally add services as more resources become available. The health systems table includes health professional education, patient and family education, palliative care models, and diagnostic testing. The metastatic disease management table provides recommendations for supportive care for bone, brain, liver, lung, and skin metastases as well as bowel obstruction. The third table includes the palliative care recommendations: pain management, and psychosocial and spiritual aspects of care. The panel considered pain management a priority at a basic level of resource allocation and emphasized the need for morphine to be easily available in LMICs. Regular pain assessments and the proper use of pharmacologic and non-pharmacologic interventions are recommended. Basic-level resources for psychosocial and spiritual aspects of care include health professional and patient and family education, as well as patient support, including community-based peer support.