Breast cancer in Brazil: present status and future goals

Spheroid Model of Mammary Tumor Cells: Epithelial-Mesenchymal Transition and Doxorubicin Response

Breast cancer is the most prevalent cancer among women worldwide. Therapeutic strategies to control tumors and metastasis are still challenging. Three-dimensional (3D) spheroid-type systems more accurately replicate the features of tumors in vivo, working as a better platform for performing therapeutic response analysis. This work aimed to characterize the epithelial-mesenchymal transition and doxorubicin (dox) response in a mammary tumor spheroid (MTS) model. We evaluated the doxorubicin treatment effect on MCF-7 spheroid diameter, cell viability, death, migration and proteins involved in the epithelial-mesenchymal transition (EMT) process. Spheroids were also produced from tumors formed from 4T1 and 67NR cell lines. MTSs mimicked avascular tumor characteristics, exhibited adherens junction proteins and independently produced their own extracellular matrix. Our spheroid model supports the 3D culturing of cells isolated from mice mammary tumors. Through the migration assay, we verified a reduction in E-cadherin expression and an increase in vimentin expression as the cells became more distant from spheroids. Dox promoted cytotoxicity in MTSs and inhibited cell migration and the EMT process. These results suggest, for the first time, that this model reproduces aspects of the EMT process and describes the potential of dox in inhibiting the metastatic process, which can be further explored.

Racial disparities in breast cancer survival after treatment initiation in Brazil: a nationwide cohort study

BACKGROUND

Breast cancer is a public health priority in Brazil and ensuring equity in health care is one of the cancer control plan goals. Our aim was to present the first assessment on the influence of race or skin colour on breast cancer survival at the national level.

METHODS

In this nationwide cohort study, data on women who initiated treatment for breast cancer in the public health-care system (Sistema Unico de Saúde), Brazil, were assembled through record linkage of administrative and mortality information systems. The administrative information systems were the Outpatient Information System (data from high complexity procedure authorisations) and the Hospital Information System (data from hospitalisation authorisations). We included women aged 19 years or older who started treatment between Jan 1, 2008, and Nov 30, 2010; self-identified as having White, Black, or Brown race or skin colour; had tumour stage I-IV; and were treated with chemotherapy or radiotherapy, or both. Patients were followed up until Dec 31, 2015. Patients with only hormone therapy records or who underwent only surgery were excluded. The Kaplan-Meier method was used to estimate crude overall survival for race or skin colour by time since treatment initiation, and Cox regression to estimate all-cause mortality hazard ratios (HRs) before and after adjustment for other covariates.

FINDINGS

We identified 59 811 women treated for stage I-IV breast cancer. 37 318 (62·4%) women identified themselves as White, 18 779 (31·4%) as Brown, and 3714 (6·2%) as Black. 5-year overall survival probability was higher for White women (74% [95% CI 73-74]) than Black women (64% [62-65]; p<0·0001). In adjusted regression models stratified by the absence of hormone therapy, Black women had a 24% (HR 1·24 [95% CI 1·16-1·34]; p<0·0001) higher risk of all-cause death than White women, and in the presence of hormone therapy Black women had a 25% (1·25 [1·14-1·38]; p<0·0001) higher risk of all-cause death than White women.

INTERPRETATION

Black skin colour was identified as a statistically significant risk marker for lower 5-year survival probability and higher risk of all-cause death among women treated for breast cancer by the Sistema Unico de Saúde. Actions to understand and mitigate this unfair difference in health results are urgently needed.

FUNDING

Conselho Nacional de Desenvolvimento Científico e Tecnológico and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior and Pró-Reitoria de Pesquisa da Universidade Federal de Minas Gerais.

State of Cancer Control in South America: Challenges and Advancement Strategies

Cancer is a major public health problem in South America. The cancer mortality burden is increasing in the region due to its presentation at later stages, which is related to limited access to cancer care. This results in a noticeable inequity in provisions of cancer care including specialized screening programs, as well as cancer-related treatments such as personalized medicine, radiation therapy, palliative care, and survivorship services. Consequently, South America faces many challenges for cancer control, most of them deriving from a lack of funding and unequal distribution of resources and cancer services, affecting mostly the underserved populations in the region.

Comprehensive Review of Breast Cancer Consequences for the Patients and Their Coping Strategies: A Systematic Review

BACKGROUND

Women with breast cancer usually face multiple short-term and long-term problems in dealing with their acute and chronic symptoms during and after cancer treatment. However, serious gaps remain in addressing these issues in clinical and public health practice.

METHODS

According to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we conducted a systematic literature search from 2000-2021 in electronic databases, including Medline, PubMed, Embase, Scopus, Web of Knowledge, and Google Scholar databases using predefined keywords.

RESULTS

The review identified several significant and interconnected problems in breast cancer patient's treatment and supportive care. The results revealed that these issues are very common among breast cancer patients, and specific attention and serious measures are needed to address these problems. Despite implementing different protocols and programs for covering and addressing these problems, serious gaps still exist in supporting breast cancer patients during clinical and follow-up care.

CONCLUSION

Developing innovative and holistic approaches and programs based on the multifactorial assessment of symptoms are suggested for addressing and covering the multidimensional requirements of this population. Consequently, thorough evaluation, education, treatment, and referrals should be provided for the most common sequelae of these patients by including appropriate medication, exercise, counselling, occupational therapy, and complementary therapies. The present study provides a more comprehensive source of information about breast cancer patient's medical and supportive needs in comparison with individual studies on symptom experiences.

Impacts of Sociodemographic Factors, Screening, and Organization of Health Services on Breast Cancer Mortality in Brazil: An Ecological Study of 20 Years

Background

Breast cancer mortality is increasing in Brazil. This study examines the impact of sociodemographic factors, screening procedures, and primary healthcare (PHC) on breast cancer mortality.

Methods

An ecological study analyzed secondary data of women diagnosed with breast cancer who died between 2000 and 2019. Sociodemographic factors, screening procedures, and PHC were examined in relation to breast cancer mortality. Statistical analyses included normality tests, Kruskal-Wallis and one-way ANOVA tests with post hoc comparisons, Pearson and Spearman correlation tests, age-period-cohort analysis, Kaplan-Meier analysis, and Cox regression analysis. Significance was set at p < 0.05.

Results

Mortality rates were higher in the southeast (15.77) and south (15.97) regions compared to the north (5.07) (p < 0.0001). Survival rates were longer in the southeast (70.3 ± 0.05) and south (70.6 ± 0.09) than in the north (63.98 ± 0.053) (p ≤ 0.001). Mortality increased with age after 32 years (p ≤ 0.001). Brown and indigenous women had lower mortality and survival rates. Increased coverage of PHC, ultrasound, and biopsy did not reduce mortality. However, improved cytopathologic analysis led to a decrease in mortality.

Conclusions

Sociodemographic factors, screening procedures, and PHC are specific predictors of breast cancer mortality in Brazil.

How well are Brazilian mastologists (breast surgeons) trained in breast reconstruction and oncoplastic surgery? A study of the impact of a breast reconstruction and oncoplastic surgery improvement course

Introduction

The breasts are a female symbol, impacts self-image and self-esteem. Breast reconstructive and oncoplastic surgeries have an important role in minimizing injuries. In Brazil less than a third of public health system (SUS) users have access to immediate reconstructive surgery. The low rate of breast reconstructions has multiple causes and the deficiency in availability and surgeons' technical qualification play a role. In 2010, the Breast Reconstruction and Oncoplastic Surgery Improvement Course was created by professors of the Mastology Department of Santa Casa de São Paulo and State University of Campinas (UNICAMP). The objectives of this study were to evaluate the impact of the techniques learned on patients' management by the surgeons enrolled in the Course, as well as to characterize their profile.

Methods

All students enrolled in the Improvement Course between 2010 and 2018 were invited to answer an online questionnaire. Students who did not agree to answer the questionnaire or answered them incompletely were excluded.

Results

Total students included: 59. The mean age: 48.9 years, male (72%) with more than 5 years of Mastology practice (82.2%), from all regions of Brazil, 1.7% from the North, 33.9% from the Northeast, 44.1% from the Southeast, and 12% from the South. Most of the students considered they had little or no knowledge of breast reconstruction (74.6%) and 91,5% did not consider they had enough aptitude to perform breast reconstructions after finishing residency. After the Course, 96.6% considered themselves apt to perform such surgeries. Over 90% of the students considered the Course had impacted their practice and changed their surgical strategy view. Before the Course, 84.8% of the students stated that less than half of their patients who were operated on for breast cancer had breast reconstruction, compared to 30.5% after the Course.

Conclusion

The Breast Reconstruction and Oncoplastic Surgery Improvement Course studied here positively impacted the mastologists' management of patients. New training centers worldwide can help a lot of women with breast cancer.

Time interval between diagnosis to treatment of breast cancer and the impact of health insurance coverage: a sub analysis of the AMAZONA III Study (GBECAM 0115)

PURPOSE

Breast cancer (BC) is the most common type of cancer among women in Brazil. Evidence shows that delayed treatment onset is associated with increased mortality. This study aimed to evaluate median days between diagnosis and treatment and factors associated with delayed start of treatment (> 60 days after diagnosis): stage, treatment received, subtype, epidemiological characteristics, and type of healthcare coverage.

METHODS

This analysis included 1709 stage I-III BC patients from AMAZONA III, a prospective, observational study, diagnosed from January 2016 to March 2018 in 22 centers in Brazil.

RESULTS

The median number of days from diagnosis to beginning of first oncologic treatment was 46 days (IQR 28-75) overall, 43 days (IQR 25-75) for stage I disease, 49 days (IQR 28-81) for stage II, and 44 days (IQR 30-68) for stage III, (p = 0.1180). According to first treatment received, diagnosis-to-treatment interval was 43 days (IQR 29-65) for neoadjuvant chemotherapy and 48 days (IQR 26-81) for surgery. Diagnosis-to-treatment interval was higher in women treated in the public system versus the private system (56 vs. 34 days, p < 0.0001). Patients in the public system had an increased odds of delayed treatment initiation (OR 4.74 95% CI 3.09-7.26, p < .0001). The longer interval from diagnosis to treatment in the public system was independent of clinical stage, type of treatment (systemic vs surgery first), subtype and region of the country.

CONCLUSION

By characterizing the delays in care delivery, our study will aid stakeholders to better design interventions and allocate resource to improve timely treatment for breast cancer in Brazil.

CLINICALTRIALS

gov Identifier: NCT02663973, registered on January, 26th, 2016.

Oligometastatic breast cancer to parotid gland with complete response

Breast cancer metastatic to parotid gland is a very rare condition which tend to confer poor prognosis and challenging approaches. Oligometastatic breast cancer is usually defined as advanced breast cancer with less or equal than 5 metastatic lesions. We report a case of oligometastatic HER-2 breast cancer to parotid gland and lymph nodes which presented with left hemifacial swelling with erythema and enlargement of cervical and axillary lymph nodes. After 6 cycles of Docetaxel plus Trastuzumab the patient had complete response that was complemented with posterior surgical removal of primary tumor followed by radiotherapy directed to plastron, left supraclavicular and cervical drainage. The patient is still on Trastuzumab therapy and is free of disease in the last two years. We discuss the presentation and approach of a patient with metastatic breast cancer to parotid gland in the oligometastatic scenario.

Surgical Treatment of the Five Most Common Types of Cancer in Brazil: 7 Years Analysis Overview

Background

Surgery is the main treatment for the majority of solid cancers. Studies investigating surgical interventions are a critical asset in improving patient health outcomes. We aim to analyze the temporal and spatial distribution of the surgical treatment of Brazil’s 5 most common types of cancer.

Methods

The selected cancers were stomach, colorectal and rectosigmoid junction, bronchial and lung, breast, and prostatic. Surgical data were collected from the DATASUS database from 2013 to 2019. Statistical analyses included linear regression tests with a significance level of .05.

Results

From 2013 to 2019, 19.72% of the diagnoses of all cancers were treated surgically. Only breast cancer didn’t have a significant linear increase in surgeries ( P = .702). Prostatic cancer had the highest annual increase rate and breast the lowest. Analyzing the Brazilian regions, the Southeast had the highest incidence of oncological surgeries, and the Midwest had the lowest.

Discussion

Brazil’s surgical oncology scenario is progressing positively through the analyzed period. The analysis of the 5 most common types of cancer in Brazil and their progression over the years provides an idea of the cancer surgery capacity in Brazil. There were disparities between the Brazilian regions in all types of cancer. Our study is the first step to better comprehending cancer care in Brazil and the access issues that some areas have. With that, it will be possible to provide better care to cancer patients needing surgical treatment.

Relapse-free survival in Sudanese women with non-metastatic breast cancer

Background

Breast cancer (BC) is the most frequently diagnosed cancer and a major cause of cancer mortality in Sudan. However, there is lack of data related to BC relapse. Therefore, this study was undertaken to estimate the 5-year relapse free survival (RFS) rate and factors related to BC relapse in Sudanese women with non-metastatic BC.

Methods

Data of BC women with BC diagnosed and treated at the National Cancer Institute-University of Gezira during 2012 were retrieved from medical records. The cases were followed-up through hospital records and telephone contact. Survival functions were calculated using Kaplan-Meier method and compared by log-rank test. The prognostic factors were tested using univariate and multivariable Cox regression analyses.

Results

We included 168 women with median age of 45 years (range, 22-83 years). 53.5%of women had stage III at time of diagnosis, whereas 4.2% and 42.3% of women presented with stage I and stage II, respectively. At the end of 5 years follow-up, with median follow-up period of 64 months, 94 (56.0%) women were alive in remission, 11 (6.5%) were alive with BC relapse, 49 (29.2%) were dead, and survival status was unknown in 14 (8.3%) women. Most of the occurred relapses were distant relapses. The 5-year RFS was 59%. The independent predictors of relapse were: larger primary tumor size (HR:1.84, 95% CI: 1.54-5.48, p=0.018); involved axillary lymph nodes with tumour (HR:  2.91, 95% CI:  1.53-7.91, p=0.001); not receiving adjuvant radiotherapy (HR: 2.2, 95% CI: 1.22-3.95, p=0.009); and not receiving hormone therapy (HR: 1.67, 95% CI: 1.01-2.76, p= 0.046).

Conclusion

We found a high risk of BC relapse in our resource-constrained settings. Advanced stages, not receiving adjuvant radiotherapy, and not receiving adjuvant hormone therapy were independent predictors associated with worse 5-year RFS. Therefore, enhancing the early diagnosis of BC and improving timely access to appropriate treatments represent key approaches to achieving better treatment outcomes.

Overall survival analyses of female malignancies in Southern Brazil during 2008-2017: A closer look at breast, cervical and ovarian cancer

Background

The aim of this study was to report the overall survival and baseline factors associated with OS for breast, cervical and ovarian cancer in Florianópolis, Southern Brazil, a region with quality-of-life indicators comparable to high-income countries.

Methods

Cohort study was performed from probabilistic record linkage of the Mortality Information System and the Population-based cancer registry of Florianópolis. It was included breasts, cervical and ovarian cancer diagnosis during the period of 2008-2012 with a follow up of 60 months. Cox regression and Kaplan-Meier method were used for associations with overall survival and risk factors.

Findings

1857 cases of the three malignancies were included in the analysis. We identified 202 deaths in breast cancer subjects, 53 for cervical cancer and 51 for ovarian cancer. Metastatic disease at diagnosis was present in 31%, 9.6%, and 55% of the cases, respectively. Overall survival was statistically correlated with age, educational level and stage for breast cancer; age and stage for cervical cancer; age and stage for ovarian cancer.

Interpretation

Metastatic disease and age are the main prognostic factors for the malignancies studied, as they were associated with both overall survival and risk of death. Better screening and preventive tests for early diagnosis are needed.

Funding

Support of Research and Innovation in the State of Santa Catarina, Research Program for the Unified Health System (FAPESC/MS-DECIT/CNPQ/SES-SC-PPSUS); the Brazilian National Research Council (CNPq); and the Coordination for the Improvement of Higher Education Personnel (CAPES).

Optimizing pathological assessment of breast cancer in Brazil: recommendations from a multidisciplinary working group on the tumor-tissue journey

Timely and correct assessment of histopathological, immunohistochemical and molecular features of biopsy and surgical specimens is of paramount importance in the provision of care to patients with breast cancer, particularly in the current era of precision oncology. In order to ensure that tissue samples are obtained, processed, analyzed and reported in an optimal way, a concerted effort is required by institutions and individuals, taking into account state-of-the-art scientific and technical knowledge and circumventing logistic and operational constraints. This may be particularly challenging in some settings due to several sources of economic, structural, organizational and communication inefficiencies. In the current article, we present a brief review of breast cancer epidemiology and challenges in the disease diagnosis, especially in Brazil, and report the results of a multidisciplinary working group convened in May 2020 in an expert panel to identify and discuss the barriers and challenges related to the journey of breast cancer samples in Brazil. Following the identification of the issues, the working group also discussed and proposed recommendations for improving the journey and quality of breast cancer samples based on their professional experience and the current scientific literature, including guidelines of national and international health organizations (e.g. World Health Organization), consensus of medical societies and other published literature on the topic. We outline the most salient issues related to that journey in Brazilian public and private medical institutions, based on the experts’ clinical experience, since all of them are actively working at both sectors, and discuss current recommendations to address these issues aiming at mitigating and preventing preanalytical and analytical issues affecting diagnostic and therapeutic decisions. Such issues are grouped under four headings pertaining to education, communication, procedures in the operating room and sample transportation, and procedures in the pathology laboratory. Selected recommendations based on the current literature and discussed by the group of Brazilian experts are reviewed, which may mitigate the issues identified and optimize diagnostic and therapeutic decisions for patients with breast cancer, currently the most frequent malignant tumor worldwide and in Brazil. This paper has been submitted and published jointly, upon invitation and consent, in both the Surgical and Experimental Pathology and the Mastology journals.

Public procurement of antineoplastic agents used for treating breast cancer in Brazil between 2013 and 2019

Background

Breast cancer is the most common cancer among women in Brazil and the country’s public health care system is the main care provider. Timely treatment can increase the chance of cure, prevent metastasis and improve quality of life. Effective public procurement of antineoplastic agents can therefore improve access to drug therapy. This study investigates patterns in the procurement of selected antineoplastic agents used for treating breast cancer by public bodies and avoidable expenditure on these drugs between January 2013 and December 2019.

Methods

We selected antineoplastic agents used for adjuvant or preoperative chemotherapy listed in the 2018 Breast Cancer Diagnosis and Treatment Guidelines and included in category L of the WHO Anatomical Therapeutic Chemical classification system. We analyzed regular purchases of antineoplastic agents registered in the Integrated General Services Administration System (SIASG), considering purchased quantity, unit price, date of purchase and procuring entity. Prices were inflation-adjusted to July 2019 based on the National Consumer Price Index.

Results

A total of 10 antineoplastic agents were selected. Trastuzumab and tamoxifen accounted for the largest share of total spending and largest volume of purchases, respectively. The Ministry of Education was the largest purchaser in volume terms of all the drugs studied, except trastuzumab 440 mg, where the category “Other Institutions” accounted for most purchases, and vinorelbine 20 mg, where the Ministry of Health made most purchases. The category “Other Institutions” accounted for the largest share of total spending. Total avoidable expenditure was R$99,130,645. Prices paid for medicines and avoidable expenditure were highest in the Ministry of Defense.

Conclusions

The differences observed in the performance of different categories of buyers as to amounts purchased and prices practiced for antineoplastic agents could be reduced by employing strategies to expand the centralization of purchases, resulting in expanded access to breast cancer medicines in the public sector.

Integrative oncology: Addressing the global challenges of cancer prevention and treatment

The increase in cancer incidence and mortality is challenging current cancer care delivery globally, disproportionally affecting low- and middle-income countries (LMICs) when it comes to receiving evidence-based cancer prevention, treatment, and palliative and survivorship care. Patients in LMICs often rely on traditional, complementary, and integrative medicine (TCIM) that is more familiar, less costly, and widely available. However, spheres of influence and tensions between conventional medicine and TCIM can further disrupt efforts in evidence-based cancer care. Integrative oncology provides a framework to research and integrate safe, effective TCIM alongside conventional cancer treatment and can help bridge health care gaps in delivering evidence-informed, patient-centered care. This growing field uses lifestyle modifications, mind and body therapies (eg, acupuncture, massage, meditation, and yoga), and natural products to improve symptom management and quality of life among patients with cancer. On the basis of this review of the global challenges of cancer control and the current status of integrative oncology, the authors recommend: 1) educating and integrating TCIM providers into the cancer control workforce to promote risk reduction and culturally salient healthy life styles; 2) developing and testing TCIM interventions to address cancer symptoms or treatment-related adverse effects (eg, pain, insomnia, fatigue); and 3) disseminating and implementing evidence-based TCIM interventions as part of comprehensive palliative and survivorship care so patients from all cultures can live with or beyond cancer with respect, dignity, and vitality. With conventional medicine and TCIM united under a cohesive framework, integrative oncology may provide citizens of the world with access to safe, effective, evidence-informed, and culturally sensitive cancer care.

Prevalência e fatores associados ao diagnóstico de câncer de mama em estágio avançado

Resumo Este estudo transversal investigou a prevalência e os fatores associados ao diagnóstico de câncer de mama em estágio avançado entre 18.890 mulheres assistidas em hospital especializado da capital do Rio de Janeiro, Brasil, entre os anos 1999 e 2016. Utilizou-se regressão de Poisson com variância robusta para estimar razões de prevalência e respectivos intervalos de 95% de confiança. Apresentaram maiores prevalências de diagnóstico nessa condição mulheres com idade entre 20-39 e 40-49 anos, de raça/cor da pele preta e parda, que viviam sem companheiro(a), procedentes de outros municípios do estado do Rio de Janeiro, que tiveram o Sistema Único de Saúde como origem do encaminhamento e que foram diagnosticadas nos sexênios 1999-2004 e 2005-2010. Em contrapartida, mulheres com idade entre 60-69 e 70-99 anos, que cursaram algum nível de escolaridade, com histórico familiar de câncer e que chegaram ao hospital com diagnóstico e sem tratamento apresentaram menores prevalências de diagnóstico em estágio avançado. Esses resultados podem ser considerados no planejamento de ações de prevenção secundária, a fim de antecipar o diagnóstico de câncer de mama dos grupos mais vulneráveis e assim colaborar para a redução da prevalência do diagnóstico em estágio avançado.

Identification of Crucial lncRNAs for Luminal A Breast Cancer through RNA Sequencing

BACKGROUND

The growing body of evidence indicates aberrant expression of long noncoding RNAs (lncRNAs) in breast cancer. Nevertheless, a few studies have focused on identifying key lncRNAs for patients with luminal A breast cancer. In our study, we tried to find key lncRNAs and mRNAs in luminal A breast cancer.

METHODS

RNA sequencing was performed to identify differentially expressed mRNAs (DEmRNAs) and differentially expressed lncRNAs (DElncRNAs) in luminal A breast cancer. The protein-protein interaction (PPI), DElncRNA-DEmRNA coexpression, DElncRNA-nearby DEmRNA interaction networks, and functional annotation were performed to uncover the function of DEmRNAs. Online databases were used to validate the RNA sequencing result. The diagnostic value of candidate mRNAs was evaluated by receiver operating characteristic (ROC) curve analysis.

RESULTS

A total number of 1451 DEmRNAs and 272 DElncRNAs were identified. Several hub proteins were identified in the PPI network, including TUBB3, HIST2H3C, MCM2, MYOC, NEK2, LIPE, FN1, FOXJ1, S100A7, and DLK1. In the DElncRNA-DEmRNA coexpression, some hub lncRNAs were identified, including AP001528.2, LINC00968, LINC02202, TRHDE-AS1, LINC01140, AL354707.1, AC097534.1, MIR222HG, and AL662844.4. The mRNA expression result of TFF1, COL10A1, LEP, PLIN1, PGM5-AS1, and TRHDE-AD1 in the GSE98793 was consistent with the RNA sequencing result. The protein expression results of TUBB3, MCM2, MYOC, FN1, S100A7, and TFF1 were consistent with the mRNA expression result COL10A1, LEP, PLIN1, PGM5-AS1, and TRHDE-AD1 were capable of discriminating luminal A breast cancer and normal controls. Four lncRNA-nearby and coexpressed mRNA pairs of HOXC-AS3-HOXC10, AC020907.2-FXYD1, AC026461.1-MT1X, and AC132217.1-IGF2 were identified. AMPK (involved LIPE and LEP) and PPAR (involved PLIN1) were two significantly enriched pathways in luminal A breast cancer.

CONCLUSION

This study could be helpful in unraveling the pathogenesis and providing novel therapeutic strategies for luminal A breast cancer.

Practical considerations for expediting breast cancer treatment in Brazil

Patients in Brazil continue to present with late-stage breast cancer. Notwithstanding these figures, policies and programs to overcome this long-lasting scenario have had limited results. We enlist the main barriers for advancing breast cancer diagnosis in Brazil, based on the available evidence, and we propose feasible strategies that may serve as a platform to address this major public health challenge.

Internet of Things in active cancer Treatment: A systematic review

The Internet of Things (IoT) applied to the treatment of cancer patients has been explored and the results are promising. This review aims to identify the applications and benefits of using IoT techniques, especially wearable devices, on the management of the adverse effects and symptoms, quality of life, and survival in cancer patients undergoing active treatment. The work also presents the architecture and taxonomy of the use of IoT, the challenges and the relevant results, as well as the association of the collected information with the type of treatment and the type of cancer. This study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and considered articles from the last 10 years. Specific and general research questions and the PICOS approach were used to define the search string and to guide the selection of articles. The search retrieved 1678 publications, of which 121 were included for a full review. 67% of selected studies addressed the monitoring and follow-up of physical activities and their associations with the adverse effects and symptoms related to cancer treatment. Besides, 53% evaluated sleep patterns, heart rate, and oxygen saturation levels. One-third of the studies assessed patients with the indication for surgery and about one-half evaluated patients undergoing chemotherapy. Furthermore, the IoT allowed verifying associations of human behaviors with adverse effects and quality of life. IoT was observed to contribute to monitoring cancer patients, improve their quality of life and manage adverse effects related to cancer treatment. 53% were pilot studies and 93% were published in the last 5 years, which demonstrates to be a recent issue and therefore still has a lot to be explored.

Healthy lifestyle behaviors and the periodicity of mammography screening in Brazilian women

Introduction:

Certain behaviors have been associated with health promotion, including mammography screening, in women worldwide.

Objective:

The objective of this study was to determine whether there is an association between the periodicity of mammography screening and healthy lifestyle behaviors in Brazilian women employed at a public university in Bahia, Brazil.

Methods:

A total of 635 women of 50–69 years of age at the time of the interview, from the Brazilian Longitudinal Study of Adult Health cohort who were resident in Bahia, participated in the study. Data were collected using a multidimensional questionnaire that included questions on participants’ sociodemographic characteristics and health-related behaviors (smoking, alcohol consumption, leisure-time physical activity and diet) and another questionnaire that dealt with risk factors and breast cancer screening. Measures of association were calculated using simple and multivariate logistic regression.

Results:

The practice of physical activity, not smoking, moderate alcohol consumption and a healthy diet were the health behaviors most adopted by the women who had last had a mammogram ⩽2 years previously (which is in line with the interval recommended by the Brazilian Ministry of Health). A statistically significant association was found between a lapse of ⩾3 years since last undergoing mammography screening and excessive alcohol consumption, while a borderline association was found between the same screening interval and leisure-time physical inactivity.

Conclusion:

There was an association between lifestyle risk behaviors and a longer time interval between mammography screenings. The present results contribute to the debate on the use of mammography, lifestyle behaviors and health promotion among women.

Factors related to mammography adherence among women in Brazil: A scoping review

AIM

To explore and synthesize the literature on factors related to mammography screening adherence among women in Brazil.

DESIGN

A scoping review.

METHODS

We searched 11 databases for studies published between 2006-January 2020. All identified articles were screened, and data were extracted from eligible studies. We used the UK Government Social Research Service weight of evidence appraisal tool to appraise the quality of the included study.

RESULTS

From a total of 1,384 identified articles, 22 were retained. All included studies used quantitative, non-experimental methods and all but two studies used cross-sectional data. Quality of evidence varied across studies. We identified 41 factors that were investigated across the set of studies. Demographic and socio-economic factors were the most commonly investigated, with older age, urban residence, living in the southeast of Brazil, higher level of education, higher income and private health insurance most consistently associated with mammography adherence.

Inequalities in the burden of female breast cancer in Brazil, 1990-2017

Background

Breast cancer is the most frequently diagnosed cancer in women and the leading cause of cancer death among females worldwide. In recent decades, breast cancer death rates have been stable or decreasing in more developed regions; however, this has not been observed in less developed regions. This study aims to evaluate inequalities in the burden of female breast cancer in Brazil including an analysis of interregional and interstate patterns in incidence, mortality and disability-adjusted life years (DALYs) rates from 1990 to 2017, and mortality-to-incidence ratio (MIR), and their association with the Socio-demographic Index (SDI).

Methods

Using estimates from the global burden of disease (GBD) study, we applied a spatial exploratory analysis technique to obtain measurements of global and local spatial correlation. Percentage changes of breast cancer incidence, mortality, and DALYs rates between 1990 and 2017 were calculated, and maps were developed to show the spatial distribution of the variables. Spatial panel models were adjusted to investigate the association between rates and SDI in Brazilian states.

Results

In Brazil, while breast cancer mortality rate have had modest reduction (−4.45%; 95% UI: −6.97; −1.76) between 1990 and 2017, the incidence rate increased substantially (+39.99%; 95% UI: 34.90; 45.39). Breast cancer incidence and mortality rates in 1990 and 2017 were higher in regions with higher SDI, i.e., the most developed ones. While SDI increased in all Brazilian states between 1990 and 2017, notably in less developed regions, MIR decreased, more notably in more developed regions. The SDI had a positive association with incidence rate and a negative association with MIR.

Conclusion

Such findings suggest an improvement in breast cancer survival in the period, which may be related to a broader access to diagnostic methods and treatment. This study also revealed the inequality in breast cancer outcomes among Brazilian states and may guide public policy priorities for disease control in the country.

Clinical outcomes of patients with breast cancer relapsing after (neo)adjuvant trastuzumab and receiving trastuzumab rechallenge or lapatinib-based therapy: a multicentre retrospective cohort study

Background

In the prepertuzumab era, we evaluated the clinical outcomes of patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer who underwent first-line trastuzumab-based or lapatinib-based therapy according to prior exposure to (neo)adjuvant trastuzumab.

Materials and methods

In this multicentre retrospective cohort study conducted in 14 Italian centres of the Gruppo Italiano Mammella, consecutive patients undergoing first-line trastuzumab or lapatinib-based therapy were included. Analyses were performed according to the type of first-line therapy for metastatic disease (trastuzumab or lapatinib). Dichotomous clinical outcomes were analysed using logistic regression and time-to-event outcomes using Cox proportional hazard models controlling for relevant demographic, clinicopathological and therapy characteristics.

Results

Out of 450 patients included in the study, 416 (92%) received trastuzumab and 34 (7.5%) lapatinib. As compared with the trastuzumab cohort, more patients in the lapatinib cohort had a trastuzumab-free interval <1 month (37% vs 13.9%; p=0.017) and brain metastasis as first site of relapse (38.2% vs 9.4%; p<0.001). Among the 128 patients who relapsed after prior (neo)adjuvant trastuzumab, 101 (78.9%) received first-line trastuzumab and 27 (21.1%) first-line lapatinib. The following outcomes were observed with first-line lapatinib or trastuzumab, respectively: overall response rate 45.5% vs 61.3% (p=0.184), clinical benefit rate 68.2% vs 72.5% (p=0.691), median progression-free survival (PFS) 11.4 vs 12.0 months (p=0.814) and median overall survival (OS) 34.7 vs 48.2 months (p=0.722). In patients with brain metastasis as first site of relapse, median PFS was 12.2 vs 9.9 months (p=0.093) and median OS 33.7 vs 28.5 months (p=0.280), respectively.

Conclusions

In patients with HER2-positive breast cancer relapsing after prior (neo)adjuvant trastuzumab, first-line treatment with trastuzumab or lapatinib was not associated with a significant difference in the clinical outcomes. A non-significant trend favouring the use of lapatinib was observed in patients with brain metastasis as the first site of relapse.

Have Health Reforms in Brazil Reduced Inequities in Access to Cancer Screenings for Women?

We measured asset-based and education-based inequity in utilization of 2 cancer screening tests, Pap tests and mammograms, using nationally representative surveys conducted in 2003, 2008, and 2013. Utilization of Pap tests (ages 25-59 years) and mammograms (ages 50-69 years) increased over time. Asset-based and education-based inequities declined significantly for both screening tests, particularly among women who reported a doctor visit in the previous year. This decline coincided with increases in the coverage of primary health care in Brazil. However, barriers persisted; in 2013, college-educated women were still 2.27 times more likely to have a mammogram than those who were illiterate.

Advanced Stage at Diagnosis and Worse Clinicopathologic Features in Young Women with Breast Cancer in Brazil: A Subanalysis of the AMAZONA III Study (GBECAM 0115)

PURPOSE

Breast cancer (BC) in young women is uncommon and tends to present with more aggressive characteristics. To better understand and characterize this scenario in Brazil through real-world data, we performed a subanalysis of AMAZONA III study (ClinicalTrials.gov identifier: NCT02663973).

METHODS

The AMAZONA III study (GBECAM 0115) is a prospective registry that included 2,950 women newly diagnosed with invasive BC in Brazil from January 2016 until March 2018 at 22 sites. Valid data were obtained from 2,888 patients regarding age at diagnosis and complete baseline information. To compare epidemiologic and clinicopathological features at the time of diagnosis, patients with BC were divided into two groups according to age: ≤ 40 years and > 40 years. Quantitative variables were described as means, and categorical variables were described as frequencies and percentages and compared using the Pearson’s χ² test.

RESULTS

Of 2,888 women diagnosed with BC, 486 (17%) were ≤ 40 years old. Young women had higher educational level, most were employed and a significant number were married (P < .001 for all associations). Younger patients were more symptomatic at BC diagnosis (P < .001), and they also presented more frequently with stage III, T3/T4, grade 3 tumors, HER-2–positive, luminal B, and triple-negative subtypes.

CONCLUSION

Brazilian women younger than age 40 years have unfavorable clinicopathological features of BC at diagnosis, with more aggressive subtypes and advanced stage when compared with older women. These differences are not explained by socioeconomic or ethnic imbalances. The causes of a higher prevalence of BC among young women in Brazil deserve additional investigation.

Does Tai Chi Chuan improve psychological well-being and quality of life in patients with breast cancer? Protocol for a systematic review of randomized controlled trials: A Protocol for Systematic Review and Meta-Analysis

BACKGROUND

Breast cancer is the most prevalent cancer in women worldwide. Treatment for breast cancer can be expensive, painful and can significantly affect the quality of life, leading to various side effects such as depression and anxiety, fatigue, sleep disorders, and cognitive impairment. Tai Chi Chuan (TCC) is the most prominent manifestation of tai chi in Chinese martial arts. TCC has been reported to be potentially effective for health and well-being of both the sick and the healthy. However, it is still controversial whether TCC benefits breast cancer patients. It is therefore of great value to evaluate the effectiveness of TCC on the psychological well-being and quality of life in people with breast cancer.

METHODS

This review will summarize and meta-analyze all relevant randomized controlled trials on TCC in patients with breast cancer in the light of their anxiety, depression and fatigue level, inflammatory cytokine as well as quality of life, sleep quality, and cognitive function. The following electronic databases will be searched: PubMed, Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure Database, Chinese Biomedical Literature Database, VIP Chinese Science and Technology Periodical Database, and Wan Fang Data. The methodologic quality of randomized controlled trials has been assessed using the Cochrane risk assessment tool. All trials included are analyzed according to the criteria of the Cochrane Handbook. Review Manager 5.3, R-3.5.1 software and grading of recommendations assessment, development, and evaluation pro-GDT online software are used for data synthesis and analysis.

RESULTS

The results of this systematic review will be used to summarize and evaluate the evidence available from randomized controlled clinical trials of TCC as supportive and adjuvant therapy for breast cancer.

CONCLUSION

This review will provide a detailed summary of the evidence to assess the effectiveness of TCC for breast cancer.

OSF REGISTRATION

DOI 10.17605/OSF.IO/Z2FSA.

Obstructive sleep apnea syndrome and causal relationship with female breast cancer: a mendelian randomization study

Although observational studies have reported a positive association between obstructive sleep apnea syndrome (OSAS) and breast cancer (BC) risk, causality remains inconclusive. We aim to explore whether OSAS is associated with etiology of BC by conducting a two-sample Mendelian randomization (MR) study in a Chinese population and Asian population from the Breast Cancer Association Consortium (BCAC). We found a detrimental causal effect of OSAS on BC risk in the primary analysis of our samples (IVW OR, 2.47 for BC risk per log-odds increment in OSAS risk, 95% CI = 1.86-3.27; P = 3.6×10^-10). This was very similar to results of the direct observational case-control study between OSAS and BC risk (OR = 2.80; 95% CI = 2.24-3.50; P =1.4×10^-19). Replication in the Asian population of the BCAC study also supported our results (IVW OR, 1.33 for BC risk per log-odds increment in OSAS risk, 95% CI = 1.13-1.56; P = 0.0006). Sensitivity analyses confirmed the robustness of our findings. We provide novel evidence that genetically determined higher risk of OSAS has a causal effect on higher risk of BC. Further studies focused on the mechanisms of the relationship between OSAS and breast carcinogenesis are needed.

Assessing trends of breast cancer and carcinoma in situ to monitor screening policies in developing settings

There have been arguments about the role of breast cancer screening at the population level, and some points of controversy have arisen, such the establishment of organized screening policies and the age at which to begin screening. The real benefit of screening has been questioned because the results of this practice may increase the diagnosis of indolent lesions without decreasing mortality due to breast cancer. The authors have proposed a study of incidence and mortality trends for breast cancer in a developing setting in Brazil to monitor the effectiveness of the official recommendations that prioritize the age group from 50 to 69 years. The database of the Cancer Registry and the Mortality Information System was used to calculate age-standardized and age-specific rates, which were then used to calculate incidence and mortality trends using the Joinpoint Regression Program. The results showed stability in trends across all ages and age-specific groups in both incidence and mortality. In conclusion, we found that incidence and mortality rates are compatible with those in regions with similar human development indexes, and trends have demonstrated stabilization. Thus, we do not endorse changes in the official recommendations to conduct screening for ages other than 50 to 69 years, nor should policy makers implement organized screening strategies.

Temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service between 2008 and 2017

BACKGROUND

In Brazil, 70% of the population depends on the public healthcare system. Since early detection is considered crucial, this study aimed to evaluate temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service (SUS) according to the different regions of the country between 2008 and 2017.

METHODS

This ecological study analyzed data on breast cancer screening within the SUS for women aged 50-69 years. Coverage was calculated from the ratio between the number of screening tests conducted and the expected number for the target population. Joinpoint regression analysis was used to calculate annual percent changes (APC) in coverage.

RESULTS

Around 19 million mammograms were performed in 50-69-year old women within the SUS between 2008 and 2016. The estimated APC indicates that breast cancer screening coverage increased by 14.5% annually in Brazil between 2008 and 2012 (p < 0.01), with figures stabilizing between 2012 and 2017 as shown by an APC of - 0.4% (p = 0.3). In the five geographic regions of the country, the APC initially increased, then stabilized in the north, northeast and southeast and decreased in the south and Midwest. Of the 26 states, coverage increased in seven and remained stable in six. In the other 13, there was an initial increase followed by stabilization in 11, and a reduction in coverage in two. In the Federal District, coverage remained stable throughout the study period.

CONCLUSION

Evaluation of the temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service revealed an initial increase, confirming that public policies were effective, although insufficient to ensure organized screening. There appears to be a lack of uniformity between the different regions and states and this situation is highlighted in the final 5-year period, with the APC reflecting stabilization of breast cancer screening coverage.

Access to high-cost drugs for advanced breast cancer in Latin America, particularly trastuzumab

Provision of high-level healthcare is a challenge for all low- to middle-income countries (LMICs) since healthcare systems are heterogeneous, face many challenges such as inadequate funding, inequitable distribution of resources and services and usually are not adequately equipped to deal with a huge problem such as breast cancer. The development of anti-HER2 therapies can be considered one of the most important examples of the translation of molecular biology knowledge into clinical benefits for cancer patients. While a variety of novel therapeutic strategies are emerging, current treatment regimens remain focussed on targeted therapy with monoclonal antibodies, mainly trastuzumab, the first agent developed in this field. While these results have revolutionised the outcome of HER2+ patients in clinical trials and in high-income countries where they are widely available, results have not impacted the natural history of this aggressive disease in most of the world. Unfortunately, the availability of these drugs is far from universal in many LMICs, and in Latin America, in particular, patients with HER2+ breast cancer are treated exclusively with standard chemotherapy, a more toxic and less efficient therapy. While the complexity of the situation and the multiple factors that have an impact in this scenario are recognised, we need to map the future and develop feasible strategies to address possible solutions to the problem of drug access. A clear and unbiased diagnosis of the situation is a good starting point. Defining healthcare priorities and a clear strategy for the allocation of resources is difficult but mandatory. In this article, we will discuss current and future challenges regarding access (and lack of access) to high-cost cancer drugs in Latin America, with a focus on anti-HER2 therapies.

Locally advanced breast cancer in Brazil: current status and future perspectives

Breast cancer (BC) is the most frequent cancer and the main cause of cancer deaths among women worldwide and in Brazil. A high proportion of patients are diagnosed with locally advanced breast cancer (LABC) in Brazil, mainly due to limited coverage of screening programmes. A disparity in the access to optimal treatment is evident between the public and private health systems which impact patient outcomes. Clinical research is an opportunity for patients, institutions and investigators and therefore should be facilitated through a better regulatory environment. In a country facing a trend of increasing BC incidence for the next years, it is critical to improve BC screening and incorporate new medicines and devices into the public health system to control the burden of LABC.

Patients With Breast Cancer: Report From a National Hospital-Based Cancer Registry in Argentina, 2012 to 2016

Purpose

To describe sociodemographic, epidemiologic, and clinical characteristics of patients who were diagnosed with breast cancer and registered in the Institutional Tumor Registry of Argentina (RITA) as of April 2016.

Methods

This was an observational, descriptive case study in patients who were diagnosed with breast cancer between April 2012 and April 2016 and registered in RITA. Quantitative and qualitative analyses were done, including delay from symptoms to first consultation, delay from diagnosis to treatment (opportunities), as well as patients’ survival (Kaplan-Meier and log-rank tests).

Results

There were 4,883 identified patients and 4,950 tumors. The mean age of patients was 57.6 years (median, 56 years); 60% of patients had completed elementary studies, 46.8% had some health coverage, and 85.4% of diagnoses were made by tumor histology (TNM stage: T2 19%, N0 20%, M0 29.1%; clinical stages II and III: 34.7%). In terms of morphology, 89.6% of primary tumors had malignant behavior (76% ductal, 8% lobular); and for immunohistochemistry, 34.3% were estrogen receptor positive/progesterone receptor positive/human epidermal growth factor receptor 2 negative. The longest delays analyzed were from diagnosis date to the beginning of first treatment. Survival rates were 96% for up to 24 months and 84.7% for up to 36 months.

Conclusion

For the first time in Argentina, there is systematized information on the care of oncology patients at public health institutions, which is useful for improving patients’ care. We found that RITA collects important information for the identification of groups with similar sociodemographic and clinical characteristics that could show different vulnerabilities along the disease process.

Delay in breast cancer diagnosis: a Brazilian cohort study

OBJECTIVES

To evaluate the delay in breast cancer (BC) diagnosis and its risk factors.

STUDY DESIGN

A cohort study of BC patients referred to treatment at oncological reference hospital, Brazil. Delay in BC diagnosis was defined as a time interval ≥90 days between the first contact with a care provider and a BC diagnosis.

METHODS

The association between independent variables and delay was performed by univariate analysis and multiple logistic regression.

RESULTS

Five hundred and twenty-six women were included in the study. Delay was observed in 68.8% and was associated with performing histopathological examination at oncological reference hospital (odds ratio [OR]: 3.96, 95% confidence interval [CI]: 1.91-8.20) or at another public health service (OR: 2.31; 95% CI: 1.50-3.56) and attending gynecological consultations annually (OR: 3.24; 95% CI: 1.97-5.33) or every 2-3 years (OR: 2.86; 95% CI: 1.55-5.28). Patients who presented a lump as the first sign or symptom had a lower chance of delay (OR: 0.43; 95% CI: 0.29-0.65).

CONCLUSIONS

Improvements in the structure and access to health services are needed to reduce the time to diagnosis.

Global Breast Cancer Research: Moving Forward

Breast cancer is a major global health problem and major cause of mortality. Although mortality trends are declining in high-income countries, trends are increasing in low- and middle-income countries (LMICs). Addressing global breast cancer research is a challenging endeavor, as notable disparities and extremely heterogeneous realities exist in different regions across the world. Basic global cancer health care needs have been addressed by the World Health Organization's (WHO) proposed list of essential medicines and by resource-stratified guidelines for screening and treatment. However, specific strategies are needed to address disparities in access to health care, particularly access to new therapies. Discussions about global research in breast cancer should take into account the ongoing globalization of clinical trials. Collaboration fostered by well-established research organizations in North America and Europe is essential for the development of infrastructure and human resources in LMICs so that researchers in these countries can begin to address regional questions. Specific challenges that impact the future of global breast cancer research include increasing the availability of trials in LMICs, developing strategies to increase patient participation in clinical trials, and creation of clear guidelines for the development of real-world evidence-based research. The main objective of this review is to encourage the discussion of challenges in global breast cancer research with the hope that collectively we will be able to generate workable proposals to advance the field.

Spatial distribution of breast cancer mortality: Socioeconomic disparities and access to treatment in the state of Parana, Brazil

INTRODUCTION

Breast cancer remains an important public health problem that is responsible for high morbidity and mortality rates, especially in developing countries.

OBJECTIVE

To analyze the socioeconomic and access disparities related to breast cancer mortality in 399 cities in the state of Parana, Brazil.

METHODS

Ecological, descriptive and analytical cross-sectional study based on secondary data from the Mortality Information System from 2009 to 2012 in the state of Parana. Breast cancer mortality rate was calculated considering the mortality cases and women population of each municipality, both based on women older than 20 years old. Moran global and local analyses were used to verify the presence of spatial autocorrelation and spatial regression modeling (Spatial Lag-SAR) with the purpose of analyzing the association between socioeconomic indicators, access and mortality rates for breast cancer.

RESULTS

Significant positive spatial autocorrelation was found for breast cancer mortality rates (I = 0.5432, p = 0.001). In the spatial regression analysis, the model explained 61% of the variance of the mortality rates for breast cancer. The mortality rate for breast cancer was negatively associated with the illiteracy rate (Coefficient = -0.0279) and positively associated with the access index (Coefficient = 12.9525).

CONCLUSION

The lower illiteracy rate has not been sufficient to reduce the specific mortality rate by breast cancer, and the higher the score of accessibility to cancer services, the higher the specific mortality due to breast cancer. The results show that in the state of Parana, the problem is not related to a lack of education of the patients or the distance walked, but rather with the organization of services. These conclusions have important political implications on the organization and quality of the services provided for the diagnosis and treatment of breast cancer in the state of Parana.

Evolution of accesses to information on breast cancer and screening on the Brazilian National Cancer Institute website: an exploratory study

Delays in diagnosis due to low Breast Cancer awareness are widespread in Brazil maybe owing to ineffective strategies to raise attention on early diagnosis. As a proxy of collective interest in BC screanning (BCS) we studied the monthly accesses to BC and BCS webpages in INCA's website along 48 months. A log analyzer built a time serie (2006-2009) of BC and BCS monthly means, which oscilations were studied by analysis of variance (ANOVA). We found significant increasing accesses to BC and transient "attention peaks". Enlargement in BC/BCS differences along all period were caused by increasing accesses to BC and decreasing/minor/stable oscillations to SBC pages. These results are consistent with previous reports on increasing interest to BC contrasting with indifference on BCS. In the context of an exploratory study, we discussed some aspects: weakness of a "prevention culture"; lack of confidence in health system and screening programs; "celebrity effect" in the context of media framing; collective perception of risks heightened by perception of social vulnerability. Findings suggest that culture-tailored communication strategies would be necessary to inform Brazilian people about BCS. Future research is needed to study social perceptions and constructions on BC topics.

Outcome of Patients With Breast Cancer Treated in a Private Health Care Institution in Brazil

PURPOSE

Middle-income countries like Brazil often have a dichotomous health care system in which patients may be treated in either public or private institutions that differ substantially in terms of level of access to diagnostic and therapeutic procedures.

PATIENTS AND METHODS

This was a prospective, observational study to assess real-world data in 1,230 female patients with breast cancer who were treated in a private health care institution between 2012 and 2016 in Brazil.

RESULTS

Breast cancer in these patients mostly was diagnosed at early (79.0% stages I or II) or locally advanced (16.1% stage III) stages. The primary tumor was resected in 89.0% of cases, most often through breast-conserving surgery (55.1%). Patients with locally advanced disease received more aggressive therapy (eg, higher rates of mastectomy, axillary dissection and chemotherapy use) than patients with early-stage disease. The estimated 2-year overall survival (OS) was 95.3%. Survival was significantly longer among patients with stage I or II disease (2-year OS, 97.9% and 97.5%, respectively) than those with stage III or IV disease (89.4% and 69.5%, respectively; P < .01). Tumor grade was also correlated with OS in the overall cohort ( P = .05); triple-negative status was only prognostic for patients with stage III disease ( P < .01).

CONCLUSION

The data provided aid understanding of the current scenario of breast cancer presentation and treatment in the Brazilian private health care system and may serve as a foundation to guide resource allocation. Our results reinforce the need to pursue adequate access to cancer care in low- and middle-income countries to optimize patient outcome.

A combined approach with gene-wise normalization improves the analysis of RNA-seq data in human breast cancer subtypes

Breast cancer (BC) is increasing in incidence and resistance to treatment worldwide. The challenges in limited therapeutic options and poor survival outcomes in BC subtypes persist because of its molecular heterogeneity and resistance to standard endocrine therapy. Recently, high throughput RNA sequencing (RNA-seq) has been used to identify biomarkers of disease progression and signaling pathways that could be amenable to specific therapies according to the BC subtype. However, there is no single generally accepted pipeline for the analysis of RNA-seq data in biomarker discovery due, in part, to the needs of simultaneously satisfying constraints of sensitivity and specificity. We proposed a combined approach using gene-wise normalization, UQ-pgQ2, followed by a Wald test from DESeq2. Our approach improved the analysis based on within-group comparisons in terms of the specificity when applied to publicly available RNA-seq BC datasets. In terms of identifying differentially expressed genes (DEGs), we combined an optimized log2 fold change cutoff with a nominal false discovery rate of 0.05 to further minimize false positives. Using this method in the analysis of two GEO BC datasets, we identified 797 DEGs uniquely expressed in triple negative BC (TNBC) and significantly associated with T cell and immune-related signaling, contributing to the immunotherapeutic efficacy in TNBC patients. In contrast, we identified 1403 DEGs uniquely expressed in estrogen positive and HER2 negative BC (ER+HER2-BC) and significantly associated with eicosanoid, notching and FAK signaling while a common set of genes was associated with cellular growth and proliferation. Thus, our approach to control for false positives identified two distinct gene expression profiles associated with these two subtypes of BC which are distinguishable by their molecular and functional attributes.

Association between primary care coverage and breast cancer mortality in Brazil

Breast cancer early detection is the major strategy for mortality rates reduction. In Brazil, Primary Health Care is an important strategy for public health promotion. To analyse the association between breast cancer mortality and primary health care indicators in Brazilian municipalities, data on breast cancer mortality and primary healthcare coverage of the 5,700 Brazilian municipalities were collected from the Department of Informatics of the Brazilian Unified Health System. We collected data on the deaths of women living in Brazil in 2010 with breast cancer. Breast cancer mortality was calculated by 100,000 women and age-standardised from the World Health Organisation population. We studied the coverage of primary health care, family health team and community health agents. We found that increase of both primary care indexes was related to increasing of the breast cancer mortality. Additionally, improving the scholarly and reducing the income inequality was related to reducing the breast cancer mortality. Strategies to improve the quality of primary care, reduce the income inequality and improve elementary scholarly should be taken into account in the development of public policies in the Brazilian municipalities to reduce breast cancer in Brazilian municipalities.

Current Status of Neoadjuvant Endocrine Therapy in Early Stage Breast Cancer

OPINION STATEMENT

Neoadjuvant endocrine therapy (NET) with Ki67-based response monitoring is a practical, cost-effective approach to the management of clinical stage II and III estrogen receptor-positive (ER+) breast cancer. In addition to marked improvements in rates of breast conservation, the identification of extreme responders on the basis of the preoperative endocrine prognostic index (PEPI) provides a rationale to avoid chemotherapy on the basis of highly favorable prognosis in some patients. Finally, samples accrued from patients treated with neoadjuvant therapy are providing valuable insights into the molecular basis for intrinsic resistance to endocrine therapy and promise a more rational basis and precise approach to the systemic treatment of ER+ breast cancer.

Developmental Origins of Breast Cancer: A Paternal Perspective

The developmental origins of breast cancer have been considered predominantly from a maternal perspective. Although accumulating evidence suggests a paternal programming effect on metabolic diseases, the potential impact of fathers' experiences on their daughters' breast cancer risk has received less attention. In this chapter, we focus on the developmental origins of breast cancer and examine the emerging evidence for a role of fathers' experiences.

G2/M inhibitors as pharmacotherapeutic opportunities for glioblastoma: the old, the new, and the future

Glioblastoma (GBM) is one of the deadliest tumors and has a median survival of 3 months if left untreated. Despite advances in rationally targeted pharmacological approaches, the clinical care of GBM remains palliative in intent. Since the majority of altered signaling cascades involved in cancer establishment and progression eventually affect cell cycle progression, an alternative approach for cancer therapy is to develop innovative compounds that block the activity of crucial molecules needed by tumor cells to complete cell division. In this context, we review promising ongoing and future strategies for GBM therapeutics aimed towards G2/M inhibition such as anti-microtubule agents and targeted therapy against G2/M regulators like cyclin-dependent kinases, Aurora inhibitors, PLK1, BUB, 1, and BUBR1, and survivin. Moreover, we also include investigational agents in the preclinical and early clinical settings. Although several drugs were shown to be gliotoxic, most of them have not yet entered therapeutic trials. The use of either single exposure or a combination with novel compounds may lead to treatment alternatives for GBM patients in the near future.

The performance of mobile screening units in a breast cancer screening program in Brazil

PURPOSE

In Brazil, access to breast cancer screening outside of urban centers is limited. This study aims to describe the coverage and performance of a breast cancer screening program implemented with Mobile Screening Units (MSU) in northern São Paulo state.

METHODS

This is a retrospective cohort study of a population-based mammography program targeting women ages 40-69 in 108 municipalities from 12/2010 to 07/2015. Screening coverage rates were estimated using the Brazil 2010 census data. We calculated performance measures for the number of exams, recalls, and detected cases of cancer. Screen-detected cases were compared to clinically detected cases using hospital cancer registry data and a propensity-score matching method. The down-staging of screen-detected cases relative to clinically detected cases was assessed using logistic regression to calculate risk ratios (RRs) with 95% confidence intervals.

RESULTS

122,634 women were screened through the MSU program, representing a cumulative coverage rate of 54.8% in the target population. For initial and subsequent rounds, recall rates were 12.25 and 6.10% and cancer detection rates were 3.63 (95% CI 3.23-4.10) and 1.94 (95% CI 1.59-2.41), respectively. 92.51% of referrals were successful. Screen-detected cases had more favorable prognoses than clinically detected cases, including smaller tumor size and a decreased risk of late-stage detection (RR 0.14 95% CI 0.074-0.25).

CONCLUSIONS

MSUs are a feasible method for the delivery of mammography services in this setting. Patients who had breast cancer detected on an MSU had favorable prognostic factors when compared with clinically detected cases arising from the same target population.

Spatially balanced provision of health equipment: a cross-sectional study oriented to the identification of challenges to access promotion

BACKGROUND

Access to health services is in part defined by the spatial distribution of healthcare equipment. To ensure equity in the provision of health services, it is important to examine availability across different health care providers taking into account population demand. Given the importance of the equitable provision of health equipment, we evaluate its spatial distribution in Brazil.

METHODS

This study is classified as cross-sectional with an ecological design. We evaluate Brazilian data on distance to available health equipment considering: dialysis machines (385), magnetic resonance imaging (MRI) (257), hospital beds (3675) and bone densitometers (429). We define two distance thresholds (50 km and 200 km) from a municipality to the center of services provision. The balance between infrastructure capacity and potential demand was evaluated to identify a lack or surplus of health services.

RESULTS

The distribution of dialysis equipment and bone densitometers is not balanced across Brazilian states, and unmet demand is high. With respect to MRIs, the large capacity of this equipment results in a large excess of supply. However, this characteristic alone cannot account for excesses of supply of over 700%, as is the case of the Federal District when the range is limited to 50 km. At the same time, four states in the Northeastern region of Brazil show a net excess of demand. Some regions do not meet the standard amount of supply defined by Brazilian Ministry of Health. The quantity and distribution of hospital beds are not sufficient to provide full coverage to the population.

CONCLUSION

Our main focus was to evaluate the network of the provision of health equipment in Brazil, considering both private and public sectors conjointly. We take into account two main aspects of a spatially balanced health system: the regional availability of health equipment and the geographic distance between its demand and supply at the municipality level. Some regions do not meet the minimum requirement defined by the Brazilian Ministry of Health regarding the supply of health services.

The role of health policy in the burden of breast cancer in Brazil

Background

Breast cancer affects millions of women worldwide, particularly in Brazil, where public healthcare system is an important model in health organization and the cost of chronic disease has affected the economy in the first decade of the twenty-first century. The aim was to evaluate the role of health policy in the burden of breast cancer in Brazil between 2004 and 2014.

Methods

Secondary analysis was performed in 2017 with Brazilian Health Ministry official data, extracted from the Department of Informatics of the National Health System. Age-standardized mortality and the age-standardized incidence of hospital admission by breast cancer were calculated per 100,000 people. Public healthcare costs were converted to US dollars. Regression analysis was performed to estimate the trend of breast cancer rates and healthcare costs, and principal component analysis was performed to estimate a cost factor. Stata® 11.0 was utilized.

Results

Between 2004 to 2014, the age-standardized rates of breast cancer mortality and the incidence of hospital admission and public healthcare costs increased. There was a positive correlation between breast cancer and healthcare public costs, mainly influenced by governmental strategies.

Conclusions

Governmental strategies are effective against the burden of breast cancer in Brazil.

Income Inequality and Mortality Owing to Breast Cancer: Evidence From Brazil

BACKGROUND

The relationship between breast cancer and inequality income is unclear. This study analyzed the correlation between income inequality and mortality standardized by age and proportional mortality owing to breast cancer among Brazilian women.

PATIENTS AND METHODS

This is an ecological study using data of the federative units and Federal District of Brazil in 2010. The age-standardized mortality owing to breast cancer was estimated using data from the Department of Informatics of Brazil's Unified Health System. Income inequality indicators used included the Gini index, Theil-L index, Palma index, and the ratio of income distribution quintiles obtained from the United Nations Development Program. We used Pearson correlation and linear regression adjusted for income per capita and other variables.

RESULTS

An increase of 0.1 in the Gini index was associated with increases of 9.8 deaths per 100,000 women (95% confidence interval [CI], 1.7-17.9); an increase in the Palma index was associated with increases in mortality of 0.7 deaths per 100,000 women (95% CI, 0.1-1.4), an increase in the Theil-L index was associated with increases in mortality of 4.9 deaths per 100,000 women (95% CI, 1.9-7.9), and of 0.8 (95% CI, 0.2-1.5) in the proportional mortality.

CONCLUSION

Income inequality, as assessed by the Gini, Palma, and Theil-L indexes, is positively associated with an increase in breast cancer mortality in Brazil.

Short-term combined exercise training improves cardiorespiratory fitness and autonomic modulation in cancer patients receiving adjuvant therapy

The present study aimed to investigate the impact of a short-term exercise training (ET) on the cardiorespiratory fitness and autonomic modulation of women with breast cancer who were receiving adjuvant radiotherapy, chemotherapy or hormonotherapy. Eighteen women previously diagnosed with breast cancer receiving adjuvant radiotherapy, chemotherapy or hormone therapy were randomly allocated into breast cancer nonexercise (BC) and exercise groups (BC+Ex). Moreover, nine healthy physically inactive volunteers were recruited to compose the noncancer control group (CG). The BC+Ex group was underwent to a combined ET program, which was based on resistance, aerobic and flexibility exercises. ET was performed 3 times a week, on nonconsecutive days, for 4 weeks at the hospital room under the professional supervision. In turn, BC and CG remained without be engaged in physical exercise programs. Volunteers were evaluated regarding their cardiorespiratory fitness and autonomic modulation (i.e., time, frequency domains, and nonlinear [symbolic analysis]) before and after the end of the ET program. A priori, data indicate that women patients with breast cancer showed impaired exercise tolerance, as well as autonomic dysfunction in comparison with age-matched healthy control subjects. However, a 1-month combined ET program could reverse such impairments, so that after the intervention, BC+Ex and CG showing similar results in the cardiorespiratory test and heart rate variability analysis. In conclusion, data of the current study indicate that 1 month of ET is able to reverse impaired cardiorespiratory fitness and autonomic modulation in women with breast cancer receiving adjuvant therapy.