Predictive Factors of the Survival of Women With Invasive Breast Cancer in French Guiana: The Burden of Health Inequalities

The Epidemiological Particularities of Malignant Hemopathies in French Guiana: 2005-2014

French Guiana is a French Overseas territory with singular features: it has a high prevalence of HIV and HTLV-1, its population is ethnically mixed, with widespread poverty, and up to 20% of the population lives in geographic isolation. In this context, we used registry data to estimate incidence and mortality due to hematological malignancies and to compare them with France and tropical Latin America. ICD codes C90 and C88 were compiled between 2005 and 2014. The direct standardization of age structure was performed using the world population. Survival analysis was performed, and Kaplan-Meier curves were drawn. The overall standardized incidence rate was 32.9 per 100,000 male years and 24.5 per 100,000 female years. Between 2005 and 2009, the standardized incidence rate was 29.6 per 100,000 among men and 23.6 per 100,000 among women, and between 2010 and 2014, it was 35.6 per 100,000 among men and 25.2 per 100,000 among women. Multiple myeloma/plasmocytoma and mature t/NK cell lymphomas, notably adult t-cell lymphoma/leukemia due to HTLV-1 infection, were the two most common hematologic malignancies and causes of death. Non-Hodgkin's lymphoma incidence estimates were greater than global estimates. After adjusting for age, sex, and type of malignancy, people born in a foreign country independently had a poorer case-fatality rate, presumably reflecting difficulties in accessing care. The epidemiology of hematological malignancies in French Guiana has features that distinguish it from mainland France or from Latin America. The incidence of multiple myeloma and adult t-cell lymphoma/leukemia was significantly greater in French Guiana than in France or other Latin American countries.

Contrasted life trajectories: reconstituting the main population exposomes in French Guiana

In French Guiana, life expectancy is between 2 and 3 years below that of France, reflecting differences in mortality rates that are largely sensitive to primary healthcare and thus preventable. However, because poverty affects half of the population in French Guiana, global measurements of life expectancy presumably conflate at least two distinct situations: persons who have similar life expectancies as in mainland France and persons living in precariousness who have far greater mortality rates than their wealthier counterparts. We thus aimed to synthesize what is known about statistical regularities regarding exposures and sketch typical French Guiana exposomes in relation to health outcomes. We conducted a narrative review on common exposures in French Guiana and made comparisons between French Guiana and mainland France, between rich and poor in French Guiana, and between urban and rural areas within French Guiana. The most striking fact this panorama shows is that being a fetus or a young child in French Guiana is fraught with multiple threats. In French Guiana, poverty and poor pregnancy follow-up; renouncing healthcare; wide variety of infectious diseases; very high prevalence of food insecurity; psychosocial stress; micronutrient deficiencies; obesity and metabolic problems; and frequent exposure to lead and mercury in rural areas constitute a stunningly challenging exposome for a new human being to develop into. A substantial part of the population's health is hence affected by poverty and its sources of nutrition.

The Singular Epidemiology of Plasmacytoma and Multiple Myeloma in French Guiana

BACKGROUND

The objective was to review a decade of plasmacytoma (PC) and multiple myeloma (MM) data from French Guiana, and to study its spatial and temporal trends.

METHODS

This was a retrospective study of MM and PC between January 2005 and December 2014 using cancer registry data, including age-standardized incidence and mortality rates.

RESULTS

There were 110 cases of PC and MM (62 women and 48 men), representing the eighth most frequent malignancy in French Guiana. PC and MM were much more common in females. In men, 79% of cases occurred at ≥55 years, and in women, 90% of cases occurred at ≥50 years. The median age at diagnosis was 60 years for men and 66 years for women, while it was 72 years for men and 75 years for women in mainland France. The incidence rate standardized to the world population was 5.9 patients of PC and MM per 100,000 men/year and 7.8 per 100,000 women/year.

CONCLUSIONS

In our territory, the incidence of PC and MM was higher and patients were diagnosed at a substantially younger age than in mainland France. Women had a greater incidence than men, and there was an increasing temporal trend of incidence among women. African ancestry and the frequency of obesity, notably among women, could have contributed to this observation.

Pathological Significance of GLUT-1 Expression in Breast Cancer Cells in Diabetic and Obese Patients: The French Guiana Study

Simple Summary

This study describes the clinical, histological, and molecular features of breast cancer in French Guiana, and characterizes the expression of the tumor metabolic marker GLUT-1 in breast cancers cells in diabetic and obese patients compared to a control group. This study reveals an overall overexpression of GLUT-1 in 60% of invasive breast carcinomas and in all medullary pattern and carcinoma in situ lesions. Our results highlight the potential role of GLUT-1 as a tumor metabolic prognostic marker and also as an interesting target therapy, independently of patient metabolic disorder.

Abstract

The prevalence of obesity and type 2 diabetes is higher in French Guiana compared to mainland France. These metabolic disorders are associated with an increased risk of cancer. One of the factors involved is hyperinsulinemia that promotes the action of glucose transporter 1 (GLUT-1). The objective of this study is to characterize the expression of GLUT-1 in breast cancers cells in diabetic and obese patients compared to those who are not and to describe the clinical and histological prognostic factors of breast cancer in this population. We conducted a monocentric study including patients with breast cancer diagnosed between 2014 and 2020. Patients were classified into three groups: diabetes, obesity, and control group. The GLUT-1 expression was assessed by immunohistochemistry. In total, 199 patients were included in this study. The median age was 53.5 years, and the median tumor size was 2.8 cm. Luminal A was the most frequent molecular type (58.1%), followed by the triple-negative type (19.9%). The breast cancer in our population was characterized by a younger age at diagnosis, more aggressive molecular types, and larger tumor size. Thus, we suggest the advancement of the age of breast cancer screening in this territory. A total of 144 patients (31 diabetes, 22 obese, and 91 control group) were included for the study of GLUT-1 expression. Overexpression of GLUT-1 was observed in 60.4% of cases and in all carcinoma in situ lesions. GLUT-1 overexpression was associated with more aggressive cancers. This overexpression is correlated with high histological grade, high proliferation index, and aggressive molecular types. Our study found no difference in GLUT-1 expression between the diabetic or obese patients and the control group. These results highlight the potential role of GLUT-1 as a tumor metabolic prognostic marker and also as an interesting target therapy, independently of patient metabolic disorder.

The comparison of censored quantile regression methods in prognosis factors of breast cancer survival

The Cox proportional hazards model is a widely used statistical method for the censored data that model the hazard rate rather than survival time. To overcome complexity of interpreting hazard ratio, quantile regression was introduced for censored data with more straightforward interpretation. Different methods for analyzing censored data using quantile regression model, have been introduced. The quantile regression approach models the quantile function of failure time and investigates the covariate effects in different quantiles. In this model, the covariate effects can be changed for patients with different risk and is a flexible model for controlling the heterogeneity of covariate effects. We illustrated and compared five methods in quantile regression for right censored data included Portnoy, Wang and Wang, Bottai and Zhang, Yang and De Backer methods. The comparison was made through the use of these methods in modeling the survival time of breast cancer. According to the results of quantile regression models, tumor grade and stage of the disease were identified as significant factors affecting 20th percentile of survival time. In Bottai and Zhang method, 20th percentile of survival time for a case with higher unit of stage decreased about 14 months and 20th percentile of survival time for a case with higher grade decreased about 13 months. The quantile regression models acted the same to determine prognostic factors of breast cancer survival in most of the time. The estimated coefficients of five methods were close to each other for quantiles lower than 0.1 and they were different from quantiles upper than 0.1.

Diabetes in French Guiana, adapting national standards of therapeutic education and care to the amazonian challenge

French Guiana is a territory located more than 7000 km from France. It is also the largest French territory, with almost 84000 km² and 90% of it is covered by forest. Some municipalities are isolated due to the scarcity of transportation and the poor road infrastructure. The population is extremely diverse ethnically and culturally, and includes more than thirty ethnic groups. Immigration is high because it is one of the richest countries in the area bordering northern Brazil, Suriname, Guyana, and as a result of socio-economic crises in some other countries such as Haiti, and it has permeable natural borders. Diabetes and obesity, are emerging issues, with double the prevalence of Mainland France, whereas infectious diseases, such as HIV, take second place. Therapeutic and educational management are challenging because they require the adaptation of tools and treatments to the mul-ticulturalism and precariousness often encountered in these populations. The French and European recommendations are unsuited to the needs of the territory and must take into account the epidemiological, sociological and cultural parameters of these populations in order to provide appropriate and graded management of diabetes in the French Amazon.

Gynaecological cancer in Caribbean women: data from the French population-based cancer registries of Martinique, Guadeloupe and French Guiana (2007-2014)

BACKGROUND

For the first time, we present regional-level cancer incidence and world-standardized mortality rates for cancers for Martinique, Guadeloupe and French Guiana.

METHODS

For Martinique, Guadeloupe and French Guiana, incidence data come from population-based cancer registries, and cover the periods 2007-2014, 2008-2014 and 2010-2014 respectively. Standardized incidence and mortality rates were calculated using the world population.

RESULTS

In the 3 regions, all cancers combined represent 3567 new cases per year, of which 39.8% occur in women, and 1517 deaths per year (43.4% in women). Guadeloupe and Martinique present similar world-standardized incidence rates. Among gynaecological cancers, breast cancer, the second most common cancer type in the 3 regions, has an incidence rate 35 to 46% lower than in mainland France. On the other hand, cervical cancer has a higher incidence rate, particularly in French Guiana. For both endometrial cancer and ovarian cancer, no significant differences in incidence rates are found compared to mainland France. Regarding mortality, world-standardized mortality rates are similar between Guadeloupe and Martinique, and higher than in French Guiana. This situation compares favourably with mainland France (all cancers). Among gynaecological cancers, the mortality rate is lower for breast cancer in all regions compared to mainland France, and also lower for ovarian cancer in Martinique and Guadeloupe, but higher (albeit non-significantly) in French Guiana.

CONCLUSION

The ethno-geographic and socio-demographic characteristics in this population of mainly Afro-Caribbean origin could partially explain these disparities. Major disparities exist for certain cancer sites: excess incidence and excess mortality for cervical cancer; lower, but increasing incidence of breast cancer.

[The interplay between isolation and precariousness, and hospitalization duration in French Guiana]

BACKGROUND

French Guiana faces singular health challenges: poverty, isolation, structural lag, difficulties in attracting health professionals. Hospital stays exceed the recommended durations. The present study aimed to model the impact of precariousness and geographic isolation on the hospital duration performance indicator and to recalculate the indicator after incrementing severity by 1 unit when patients were socially precarious.

METHODS

Cayenne hospital data for 2017 were used to model the hospital duration performance indicator (IP-DMS) using quantile regression to study the impact of geographic and social explanatory variables. This indicator was computed hypothesizing a 1 unit increment of severity for precarious patients and by excluding patients from isolated regions.

RESULTS

Most excess hospitalization days were linked to precariousness: the sojourns of precarious patients represented 47% of activity but generated 71% of excess days in hospital. Quantile regression models showed that after adjustment for potential confounders, patients from western French Guiana and Eastern French Guiana, precarious patients and the interactions terms between residence location and precariousness were significantly associated with IP-DMS increases. Recalculating the IP-DMSafter exclusion of patients from the interior and after increasing severity by 1 notch if the patient was precarious led to IP-DMS levels close to 1.

CONCLUSION

The results show the nonlinear relationship between the IP-DMS and geographical isolation, poverty, and their interaction. These contextual variables must be taken into account when choosing the target IP-DMS value for French Guiana, which conditions funding and number of hospital beds allowed in a context of rapid demographic growth.

Investigation of Prognostic Factors of Survival in Breast Cancer Using a Frailty Model: A Multicenter Study

Background

Using data from different health centers can provide more accurate knowledge of the survival prognostic factors and their effect on the patient's survival. In this multicenter study, we aimed to investigate the role of prognostic factors on breast cancer survival with large data set.

Methods

This historical cohort study was carried out using data from 1785 participants with breast cancer. Data were gathered from medical records of patients referring to 4 breast cancer research centers in Tehran, Iran, between 1997 and 2013. Age at diagnosis (year), size of the tumor, involve lymph nodes, tumor grade, type of surgery, auxiliary treatment of chemotherapy, radiotherapy, recurrence, and metastasis were the prognosis factors considered in this study. A shared frailty model with a gamma distribution for frailty term was used.

Results

The median follow-up period was 29.71 months with the interquartile range of 19 to 61 months. During the follow-up period, 337 (18.9%) patients died from breast cancer and 1448 (81.1%) survived. The 1-, 3-, 5-, and 10-year survival rates were 96%, 84%, 76%, and 58%, respectively. In the Cox model by centers, in Center A, the type of surgery, number of nodes involved, and the grade 3 tumor; in center B, age, radiotherapy, metastasis, and between 1 and 3 involved nodes; in center C, age, radiotherapy, recurrence, metastasis, tumor size, and grade 3 tumor; and in center D, chemotherapy, metastasis, and lymph nodes involved were significant. Shared frailty model showed that type of surgery, number of lymph nodes involved, metastasis, radiotherapy, and the tumor grade are the prognostic factors survival in breast cancer. The frailty variance was significant, and it affirmed there was significant variability between centers.

Conclusions

This study showed it is necessary to consider the frailty term in modeling multicenter survival studies and confirmed the importance of early diagnosis of cancer before the involvement of lymph nodes and the onset of metastasis and timely treatment could lead to longer life and increased quality of life for patients.

Renouncing care in French Guiana: the national health barometer survey

Background

In French Guiana, health inequalities are patent for a broad range of pathologies for all age groups. The objective of the present study was to quantify the proportion of the population that had renounced care in the past year, to study predictive factors, and to compare results with other French territories.

Methods

A two-stage random sample of 2015 individuals aged 15 to 75 years was surveyed by telephone. A descriptive analysis of variables relative to renouncing care, use of health care, screening, and vaccination was initially performed. Multivariate analysis was then used to determine variables associated with renouncing care for financial reasons and renouncing for reasons linked to time were directly estimated using a Poisson model on weighted data. Variables with a significance level < 0.2 in the bivariate analysis were included in the full multivariate model.

Results

In French Guiana, during the past 12 months, 30.9% of surveyed persons renounced care whatever the type for financial reasons. Results of the multivariate analysis showed that gender, perceived financial situation, perceived health and complementary insurance status were independent predictive factors of care renouncement for financial reasons. Overall, 24% of the surveyed population declared having renounced to care for time-related motives. The independent predictors for time-related renouncing were different than those for renouncing care for financial reasons: a higher education level and a poor perceived health were independently associated with time-related renouncement; retired persons and students were found to renounce care less frequently than persons with a job.

Conclusions

Renouncing for financial reasons, a major target of the 2016 health law, represented a public health problem in French Guiana. Renouncing for lack of time was an important motive for renouncing, which is aggravated by the insufficient number of health professionals, but may benefit from organizational solutions. There are avenues for improvement of health for the most vulnerable: promote health, act on risk factors, and facilitate the readability and accessibility of the health system. Recent reforms to stabilize health insurance may however have some adverse consequences for migrants.

Factors predicting local relapse and survival in patients treated with surgery for breast cancer

BACKGROUND

Assessment of local relapse in patients treated with surgery for breast cancer.

MATERIALS AND METHODS

This observational study included 673 patients treated with surgery for breast cancer between 2005 and 2010, who were monitored for a 7-year minimum follow-up period. The study was concluded on 2017 and yielded a total of 31 cases of local relapse.

RESULTS

4.6% of patients presented local relapse, most of them during the first 3 years of follow-up; 45% of patients with local relapse subsequently presented the disease at distant points. The association between the occurrence of local relapse and later onset of the disease at distant points was significant. The Kaplan-Meier survival analysis revealed that negative results for the presence of progesterone receptors, the use of neoadjuvant chemotherapy and the presence of the disease at distant points were factors that significantly influenced patient survival.

CONCLUSIONS

Almost half of the patients suffering relapse subsequently present the disease at distant points. Certain factors increase the aggressiveness of the disease, predict higher risk of relapse and determine its prognosis.

Breast Cancer Research in the Caribbean: Analysis of Reports From 1975 to 2017

PURPOSE

Breast cancer is among the leading causes of death resulting from cancer in Caribbean women. Studies examining exogenous and genetically predetermined endogenous risk factors are critical to define breast cancer susceptibility in Caribbean women. The purpose of this systematic review is to assess the existing scientific literature in the last 42 years (1975 to 2017) to describe the body of research generated for the population of this region and determine future research directions.

METHODS

We selected published research articles using a combination of definite keyword searches in PubMed. Only articles presenting the Caribbean population as the focus of their research objectives were included in this analysis.

RESULTS

Studies on breast cancer in the Caribbean are limited. A majority of publications on Caribbean populations were descriptive, focusing on cancer trends and clinicopathologic factors. High incidence and mortality rates for breast cancer are reported for the region, and there seem to be some differences between countries in the frequency of cases according to age at presentation. A limited number of epidemiologic, behavioral, and genetic and molecular studies were conducted in more recent years.

CONCLUSION

A regional strategy for cancer registration is needed for the Caribbean to address possible underestimates of breast cancer incidence. Furthermore, behavioral, molecular, genetic, and epidemiologic investigations of breast cancer are critical to address the concerns related to currently described high incidence and mortality rates in the Caribbean.

Cancer patterns and trends in Central and South America

RATIONALE AND OBJECTIVE

Cancer burden is increasing in Central and South America (CSA). We describe the current burden of cancer in CSA.

METHODS

We obtained regional and national-level cancer incidence data from 48 population-based registries (13 countries) and nation-wide cancer mortality data from the WHO (18 countries). We estimated world population age-standardized incidence and mortality rates per 100,000 person-years.

RESULTS

The leading cancers diagnosed were prostate, lung, breast, cervix, colorectal, and stomach, which were also the primary causes of cancer mortality. Countries of high/very high human development index (HDI) in the region experienced a high burden of prostate and breast cancer while medium HDI countries had a high burden of stomach and cervical cancers. Between countries, incidence and mortality from all cancers combined varied by 2-3-fold. French Guyana, Brazil, Uruguay, and Argentina had the highest incidence of all cancers while Uruguay, Cuba, Argentina, and Chile had the highest mortality. Incidence of colorectum, prostate and thyroid cancers increased in Argentina, Brazil, Chile and Costa Rica from 1997 to 2008, while lung, stomach and cervical cancers decreased.

CONCLUSION

CSA carries a double-burden of cancer, with elevated rates of infection- and lifestyle-related cancers. Encountered variation in cancer rates between countries may reflect differences in registration practices, healthcare access, and public awareness. Resource-dependent interventions to prevent, early diagnose, and treat cancer remain an urgent priority. There is an overwhelming need to improve the quality and coverage of cancer registration to guide and evaluate future cancer control policies and programs.