Breast cancer in Mexico: a growing challenge to health and the health system

Addressing the unmet needs of women with breast cancer in Mexico: a non-randomised pilot study of the digital ePRO intervention

OBJECTIVES

This study aimed to explore the acceptability, feasibility, usability, and preliminary effect of an electronic patient-reported outcome (ePRO) intervention for patients with breast cancer in Mexico.

DESIGN

We conducted a multimethod non-randomised pilot study. We used a pre-test/post-test design for quantitative assessment of the intervention's effect on patients' supportive care needs and quality of life. We conducted in-depth interviews (IDIs) with participants and healthcare workers to explore the intervention's benefits and barriers and understand its feasibility.

PARTICIPANTS

50 women aged 20-75 diagnosed with stage I-III breast cancer were enrolled within 2 weeks of starting neoadjuvant or adjuvant treatment with chemotherapy or radiotherapy. We excluded illiterate women and those with visual impairment, cognitive disability or severe depression. IDIs were conducted with 18 participants and 10 healthcare providers.

SETTING

Oncology services in three public hospitals of the Mexican Social Security Institute.

INTERVENTION

The ePRO intervention consisted of a responsive web application for weekly symptom reporting combined with proactive follow-up by nurses guided by predefined clinical algorithms for 6 weeks.

RESULTS

50 women were enrolled out of 66 eligible patients approached (75.8%). All 50 completed the 4-week follow-up assessment (100% retention). Completion of the symptom registry declined from 100% in week 1 to 66% in week 6. Participants experienced decreases in supportive care needs and increased quality of life. The ePRO application was rated highly usable. Participants and health professionals both perceived intervention benefits. Drawbacks included poor fit for women receiving radiotherapy and challenges using the application for women with low digital literacy or experiencing severe symptoms.

CONCLUSIONS

This pilot study provided evidence of the high usability and potential efficacy of a web-based ePRO intervention. We revised recruitment during the pilot to include multiple facilities, and we will further revise for the randomised trial to address barriers to successful ePRO implementation.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID: NCT05925257.

Uptake of Risk-Reducing Measures, Cascade Testing, and Related Challenges Among Carriers of Breast Cancer-Associated Germline Pathogenic Variants in Mexico

PURPOSE

Genetic cancer risk assessment (GCRA) provides pathogenic variant (PV) carriers with the invaluable opportunity to undertake timely cancer risk-reducing (RR) measures and initiate cascade testing (CT). This study describes the uptake of these strategies and the related barriers among breast cancer-associated germline PV carriers in Mexico.

METHODS

Carriers who were at least 6 months after disclosure of genetic test results at two GCRA referral centers were invited to answer a survey assessing sociodemographic characteristics, awareness of their carrier status and its implications, uptake of RR measures according to international guidelines by PV, CT initiation, and associated challenges.

RESULTS

Of the eligible carriers, 246/384 (64%) answered the survey (median age: 44 years). Most were female (88%), married/in domestic partnership (66%), and had personal breast/ovarian cancer history (61%). PVs included BRCA1/2 (75%), CHEK2 (10%), PALB2 (5%), ATM (5%), NF1 (2%), RAD51C (2%), PTEN (1%), and TP53 (1%). Most (87%) participants were aware of their carrier status. When recommended, 37% underwent RR bilateral mastectomy, 48% RR oophorectomy, 70% annual mammogram, and 20% breast magnetic resonance imaging. Challenges hindering the uptake of RR measures included financial limitations (67%), lack of recommendation by their physician (35%), and fear (24%). Nearly all (98%) claimed sharing their results with their relatives. CT was initiated in 63% of families and was associated with carriers being married/in domestic partnership (P = .04) and believing GCRA was useful (P < .001).

CONCLUSION

Despite the resource-constrained setting, relevant rates of RR measures and CT were observed. Targeted interventions to reduce out-of-pocket expenses and improve patient-physician communication and patients' understanding on carrier status are warranted to enhance the overall benefit of GCRA and ultimately improve the provision of patient-centered care to both carriers and their at-risk relatives.

Disparities in Cancer Control in Central America and the Caribbean

Central America and the Caribbean is a highly heterogeneous region comprising more than 30 countries and territories with more than 200 million inhabitants. Although recent advances in the region have improved access to cancer care, there are still many disparities and barriers for obtaining high-quality cancer treatments, particularly for those from disadvantaged populations, immigrants, and rural areas. In this article, we provide an overview of cancer care in Central America and the Caribbean, with selected examples of issues related to disparities in access to care and suggest solutions and strategies to move forward.

Survival Outcomes of Patients With Breast Cancer in a Mexican Population

PURPOSE

The Instituto Mexicano del Seguro Social is a tripartite contribution providing care to more than 74 million beneficiaries, representing more than 50% of the country's general population. This study aims to describe the survival outcomes and clinicopathologic characteristics of patients with breast cancer at our Center.

METHODS

A retrospective cohort of patients with breast cancer treated between January 2012 and December 2020 was conducted. Survival outcomes were assessed using the Kaplan-Meier method. Univariate and multivariate analyses were performed using a Cox proportional hazards model.

RESULTS

There were 5,264 patients included with a median follow-up of 54.9 months. Forty-three percent (n = 2,274) were diagnosed in stage I-IIA, 43.1% (n = 2,269) in stage IIB-III, and 7% (n = 383) in stage IV. At 5 years, disease-free survival was 74.9% (95% CI, 73.5 to 76.3) and overall survival (OS) 90.4% (95% CI, 89.4 to 91.3). For stage IV, it was 22.7% (95% CI, 17.3 to 28.5). High histologic grade (hazard ratio, 1.51 [95% CI, 1.34 to 1.7]; P < .001) and lymphovascular invasion (LVI; hazard ratio, 1.85 [95% CI, 1.62 to 2.1]; P < .001) were associated with a higher risk of recurrence.

CONCLUSION

Histologic grade and LVI should be considered in the decision to treat with adjuvant chemotherapy in sites where genomic signatures are not available. Our OS data are comparable with other Mexican series; however, it is lower in stage IV. Much remains to be done at the national level, mainly regarding access to additional therapies for each breast cancer subtype. This work contributes to the evaluation of areas for improvement in outcomes in our population.

Automated Computer-Assisted Medical Decision-Making System Based on Morphological Shape and Skin Thickness Analysis for Asymmetry Detection in Mammographic Images

Breast cancer is a significant health concern for women, emphasizing the need for early detection. This research focuses on developing a computer system for asymmetry detection in mammographic images, employing two critical approaches: Dynamic Time Warping (DTW) for shape analysis and the Growing Seed Region (GSR) method for breast skin segmentation. The methodology involves processing mammograms in DICOM format. In the morphological study, a centroid-based mask is computed using extracted images from DICOM files. Distances between the centroid and the breast perimeter are then calculated to assess similarity through Dynamic Time Warping analysis. For skin thickness asymmetry identification, a seed is initially set on skin pixels and expanded based on intensity and depth similarities. The DTW analysis achieves an accuracy of 83%, correctly identifying 23 possible asymmetry cases out of 20 ground truth cases. The GRS method is validated using Average Symmetric Surface Distance and Relative Volumetric metrics, yielding similarities of 90.47% and 66.66%, respectively, for asymmetry cases compared to 182 ground truth segmented images, successfully identifying 35 patients with potential skin asymmetry. Additionally, a Graphical User Interface is designed to facilitate the insertion of DICOM files and provide visual representations of asymmetrical findings for validation and accessibility by physicians.

Physicians' attitudes and perceived barriers to adherence to the national breast cancer clinical practice guidelines in Mexico: a survey study

BACKGROUND

Adherence to clinical practice guidelines improves outcomes for patients with breast cancer. However, their implementation may not be feasible in low- and middle-income countries. This study aimed to evaluate physicians' adherence, attitudes, and barriers towards the Colima Consensus, which is the Mexican national breast cancer clinical practice guideline.

METHODS

A cross-sectional, 31-item survey was e-mailed to Consensus attendees and members of the Mexican Society of Oncology and Mexican Mastology Association. Descriptive statistics, univariate, and multivariate analysis were used to analyze the associations between participants' characteristics, adherence, attitudes, and barriers.

RESULTS

Of 439 respondents, 78% percent adhered to Consensus recommendations and 94% believed it was applicable to their clinical practice. Forty percent reported using the Consensus as their sole breast cancer guideline. This was associated with being a surgical oncologist (OR 3.3, 95% CI 2.0-5.3) and practicing at a public hospital (OR 2.1, 95% CI 1.2-3.7). The most common barriers to adherence were lack of resources and logistical problems. Regarding attitudes towards the Consensus, 90% considered it a good educational tool, 89% considered it a reliable source of information, and 90% thought it improved quality of care.

CONCLUSIONS

We showed high levels of adherence and positive attitudes towards the Colima Consensus, with a significant proportion of physicians using it as their only guideline. Lack of resources and logistical issues were the main barriers to adherence. Our results highlight the relevance of local breast cancer guidelines and suggest a need for the creation of resource-stratified guidelines.

Psychological suppressive profile and autoantibodies variability in women living with breast cancer: A prospective cross-sectional study

Breast cancer (BC) is a leading cause of women's morbimortality worldwide. Unfortunately, attempts to predict women's susceptibility to developing BC well before it becomes symptomatic, based on their genetic, family, and reproductive background have proved unsatisfactory. Here we analyze the matching of personality traits and protein serum profiles to predict women's susceptibility to developing cancer. We conducted a prospective study among 150 women (aged 18-70 years), who were distributed into three groups (n = 50): women without breast pathology and women diagnosed with BC or benign breast pathology. Psychological data were obtained through standardized psychological tests and serum protein samples were analyzed through semiquantitative protein immunoblotting. The matching for psychological and immunological profiles was constructed from these data using a mathematical generalized linear model.The model predicted that women who have stronger associations between high-intensity stress responses, emotional containment, and an increased number and reduced variability of serum proteins (detected by IgG autoantibodies) have the greatest susceptibility to develop BC before the disease has manifested clinically. Hence, the present study endorses the possibility of using psychological and biochemical tests in combination to increase the possibility of identifying women at risk of developing BC before the disease shows clinical manifestations. A longitudinal study must be instrumented to test the prediction ability of the instrument in real scenarios.

Trial registration

Committee of Ethical Research of the Hospital General de México "Dr. Eduardo Liceaga," Ministry of Health (DI/12/111/03/064).

Knowledge, Attitudes, Behavior, and Practices of Self-Breast Examination in Jalisco, Mexico

The importance of self-breast examination to identify early signs of breast cancer has been widely discussed in scientific literature. We conducted a cross-sectional survey of women aged 18 years and over (n = 547) living in urban and rural areas in the State of Jalisco, Mexico. Survey questions included measures on knowledge, attitudes, behaviors, and practices related to self-breast examination. We compared these measures between women living in urban and rural areas and women aged 18-39 years and 40+ years. Using t-test, we tested the significance of these differentials. Our results indicate that there is no significant difference in knowledge, attitudes, behavior, and practices regarding self-breast examination between women living in urban and in rural areas of Jalisco. However, we found some difference in these measures between women in 18-39 years and 40+ years. While the State of Jalisco has taken significant steps toward promoting significance of cancer prevention, further attention to women in the older cohort is recommended.

Utility values and its time to deterioration in breast cancer patients after diagnosis and during treatments

BACKGROUND

The potential effects of breast cancer (BC) on health-related quality of life (HRQoL) should be considered in clinical and policy decision-making, as the economic burden of BC management is currently assessed. In the last decades, time-to-HRQoL score deterioration (TTD) has been proposed as an approach to the analysis of longitudinal HRQoL in oncology. The main objectives of the current study were to investigate the evolution of the utility values in BC patients after diagnosis and during follow-ups and to evaluate the TTD in utility values among women in all stages of BC.

METHODS

Health-state utility values (HSUV) were assessed using the EuroQol 5-Dimension 3-Level at diagnosis, at the end of the first hospitalization and 3 and 6 months after the first hospitalization. For a given baseline score, HSUV was considered to have deteriorated if this score decreased by ≥ 0.08 points of the EQ-5D utility index score and ≥ 7 points of the EQ visual analogue scale. TTD curves were calculated using the Kaplan-Meier estimation method.

RESULTS

Overall 381 patients were enrolled between February 2006 and February 2008. The highest proportions of respondents at the baseline and all follow-ups reporting some and extreme problems were in pain discomfort and anxiety/depression dimensions; more than 80% of patients experienced a deterioration in EQ-5D utility index score and EQ VAS score with a median TTD of 3.15 months and 6.24 Months, respectively.

CONCLUSIONS

BC patients undergoing therapy need psychological support to cope with their discomfort, pain, depression, anxiety, and fear during the process of diagnosis and treatment to improve their QoL.

Adipocytokines and Insulin Resistance: Their Role as Benign Breast Disease and Breast Cancer Risk Factors in a High-Prevalence Overweight-Obesity Group of Women over 40 Years Old

Insulin levels, adipocytokines, and inflammatory mediators trigger benign breast disease (BBD) and breast cancer (BC). The relationship between serum adipocytokines levels, overweight-obesity, metabolic disturbs, and BC is unclear. Methods: To analyze the serum levels of the adipocytokines, insulin, and the HOMA IR in women without breast disease, with BBD or BC, and the role of these as risk factors for benign breast disease or breast cancer. Results: Adipsin values > 0.91 and visfatin levels > 1.18 ng/mL represent a risk factor to develop BBD in NBD lean women (OR = 18; and OR = 12). Data in overweight-obese women groups confirm the observation due to insulin levels > 2.6 mU/mL and HOMA IR > 0.78, with OR = 60.2 and 18, respectively; adipsin OR = 26.4, visfatin OR = 12. Breast cancer risk showed a similar behavior: Adipsin risk, adjusted by insulin and visfatin OR = 56 or HOMA IR and visfatin OR = 22.7. Conclusion: Adipose tissue is crucial for premalignant and malignant tissue transformation in women with overweight-obesity. The adipocyte−breast epithelium interaction could trigger a malignant transformation in a continuum, starting with BBD as premalignant disease, especially in overweight-obese women.

ESR2 gene variants (rs1256049, rs4986938, and rs1256030) and their association with breast cancer risk

Background

Variants of the estrogen receptor b (ESR2) gene have been associated with different types of cancer. However, these associations have been inconsistent. We genotyped the ESR2 variants (rs1256049, rs4986938, and rs1256030) in breast cancer (BC) patients and in healthy women.

Results

The variants rs1256049 and rs4986938 in the ESR2 gene were not associated with risk susceptibility in BC patients. However, the rs1256030 variant had an association as a risk factor for BC patients when compared with controls and BC patients for the TT genotype (odds ratio (OR) 1.86, 95% confidence intervals (CI) [1.05-3.28], p = 0.042). In addition, differences were observed in patients and controls carrying the TT genotype under 50 years of age (OR 1.85, 95% CI [1.05-3.27], p = 0.043). Thus, evident differences showed the rs1256030 variant in patients with TT, TC, and TC+TT genotypes with: (1) Stage IV (OR 1.60, 95% CI [1.06-2.54], p = 0.033), and (2) Luminal A (OR 1.60, 95% CI [0.47-0.21], p = 0.041), as well as in BC carriers of the TT genotype with indices of cellular proliferative (Ki-67) elevated (>20%) and overweight (OR 1.67, 95% CI [0.85-3.28], p = 0.041), respectively. In BC HER2 with lymph node metastasis, the TT genotype was a protective factor (OR 0.38, 95% CI [0.18-0.78], p = 0.005). The identification of haplotypes included two common GAT as risk factors (OR 3.1, 95% CI [1.31-7.72], p = 0.011) and GGC as a protective factor (OR 0.7, 95% CI [0.60-0.97], p = 0.034). The haplogenotype GGGATC was a risk factor (OR 2.5, 95% CI [1.28-5.0], p = 0.008).

Conclusion

The variant rs1256030 (TT) of the ESR2 gene and haplotype GAT were associated with susceptibility to BC as risk factors in this sample from the Mexican population.

Risk Factors Associated to Residual Tumor in Re-excision for Positive Margins in Breast Conservative Surgery

BACKGROUND

Breast conservative surgery (BCS) is an adequate treatment for patients with early breast cancer. Local recurrence is associated with diverse factors. Our objective was to evaluate risk factors associated with finding residual tumor in patients with positive margins in BCS.

METHODS

Observational retrospective study, including patients diagnosed with breast cancer undergoing BCS between 2000 and 2016. Clinicopathological and treatment variables were collected. Main outcome was the finding of residual tumor on re-excision. Positive margins were defined as tumor present on ink.

RESULTS

Three hundred and six patients underwent BCS. Mean age was 57 ± 12.2 years. Positive margins were found in 84 (27.4%) patients, 15 (4.9%) had unknown margin status, and 207 (67.6%) had negative margins. Seventy-eight patients from the positive margin group and 23 patients from the unknown/negative margin group were reintervened. Residual tumor was present in 41% of patients with positive margins and in 45% of patients with negative margins (P = .192). In univariate analysis, overweight (P = .04) and positive axillary lymph nodes (P = .02) were associated with residual tumor on re-excision. In multivariate analysis, postmenopausal status was a protective factor (HR .047, P = .30). Mean follow-up was 58.4 months and mean local recurrence-free survival (LRFS) was 56.4 months (.1-203.2), with no difference regarding margin status or residual tumor.

DISCUSSION

Postmenopausal status was associated with a decreased rate of residual tumor in patients with positive margins. The presence of residual tumor on re-excision was not associated with a lower LRFS. These factors must be considered when positive margins are present in BCS.

Comprehensive omic characterization of breast cancer in Mexican-Hispanic women

Breast cancer is a heterogeneous pathology, but the genomic basis of its variability remains poorly understood in populations other than Caucasians. Here, through DNA and RNA portraits we explored the molecular features of breast cancers in a set of Hispanic-Mexican (HM) women and compared them to public multi-ancestry datasets. HM patients present an earlier onset of the disease, particularly in aggressive clinical subtypes, compared to non-Hispanic women. The age-related COSMIC signature 1 was more frequent in HM women than in those from other ancestries. We found the AKT1^E17K hotspot mutation in 8% of the HM women and identify the AKT1/PIK3CA axis as a potentially druggable target. Also, HM luminal breast tumors present an enhanced immunogenic phenotype compared to Asiatic and Caucasian tumors. This study is an initial effort to include patients from Hispanic populations in the research of breast cancer etiology and biology to further understand breast cancer disparities.

Cancers in different populations have been shown to be genetically distinct. Here, the authors sequence breast cancers from Mexican-Hispanic patients and find that these patients have a higher percentage of Akt1 mutations compared to Caucasian and Asian populations, suggesting these are clinically actionable.

Coexpression of Smac/DIABLO and Estrogen Receptor in breast cancer

BACKGROUND

Smac/DIABLO is a proapoptotic protein deregulated in breast cancer, with a controversial role as a tumor marker, possibly due to a lack of correlative mRNA and protein analyses.

OBJECTIVE

To investigate the association of Smac/DIABLO gene and protein levels with clinical variables in breast cancer patients.

METHODS

Smac/DIABLO mRNA expression was analyzed by qPCR in 57 frozen tissues, whereas protein levels were assessed by immunohistochemistry in 82 paraffin-embedded tissues. Survivin mRNA levels were also measured. In vitro assays were performed to investigate possible regulators of Smac/DIABLO.

RESULTS

Higher levels of Smac/DIABLO mRNA and protein were found in estrogen receptor (ER)-positive samples (p= 0.0054 and p= 0.0043, respectively) in comparison to ER-negative tumors. A negligible positive association was found between Smac/DIABLO and survivin expression. In vitro assays showed that Smac/DIABLO is not regulated by ER and, conversely, it does not participate in ER expression modulation.

CONCLUSIONS

mRNA and protein levels of Smac/DIABLO were increased in ER-positive breast tumors in comparison with ER-negative samples, although the mechanism of this regulation is still unknown. Public databases showed a possible clinical relevance for this association.

α-Mangostin Synergizes the Antineoplastic Effects of 5-Fluorouracil Allowing a Significant Dose Reduction in Breast Cancer Cells

Breast cancer is the most common neoplasm and the leading cause of cancer death in women worldwide. Although 5-fluorouracil is a conventional chemotherapeutic agent for breast cancer treatment, its use may result in severe side effects. Thus, there is widespread interest in lowering 5-fluorouracil drawbacks, without affecting its therapeutic efficacy by the concomitant use with natural products. Herein, we aimed at evaluating whether α-mangostin, a natural antineoplastic compound, could increase the anticancer effect of 5-fluorouracil in different breast cancer cell lines, allowing for dose reduction. Cell proliferation was evaluated by sulforhodamine-B assays, inhibitory concentrations and potency were calculated by dose-response curves, followed by analysis of their pharmacological interaction by the combination-index method and dose-reduction index. Cell cycle distribution was evaluated by flow cytometry. Each compound inhibited cell proliferation in a dose-dependent manner, the triple negative breast cancer cells being the most sensitive. When 5-fluorouracil and α-mangostin were used concomitantly, synergistic antiproliferative effect was observed. The calculated dose-reduction index suggested that this combination exhibits therapeutic potential for reducing 5-fluorouracil dosage in breast cancer. Mechanistically, the cotreatment induced cell death in a greater extent than each drug alone. Therefore, α-mangostin could be used as a potent co-adjuvant for 5-fluorouracil in breast cancer.

Prioritization of Patients with Abnormal Breast Findings in the Alerta Rosa Navigation Program to Reduce Diagnostic Delays

INTRODUCTION

In Mexico, there are considerable health system delays in the diagnosis and treatment initiation of women with breast cancer. Alerta Rosa is a navigation program in Nuevo Leon that aims to reduce barriers that impede the timely management of these patients.

PATIENTS AND METHODS

Since December 2017, women who registered to receive medical evaluations by Alerta Rosa were stratified based on their clinical characteristics into three priority groups ("Red," "Yellow," and "Green"). According to the category assigned, patients were scheduled imaging studies and medical appointments with breast specialists on a preferential basis.

RESULTS

Up until December 2019, 561 patients were scheduled for medical evaluations. Of them, 59% were classified as "Red," 25% "Yellow," and 16% "Green" priority. The median time from stratification to first medical evaluation was 4, 6, and 7 days, respectively (p = .003). Excluding those who had a prior breast cancer diagnosis, 21 patients were diagnosed by Alerta Rosa, with the initial "Red" priority classification demonstrating a sensitivity of 95% (95% confidence interval [CI], 75.1%-99.9%) and specificity of 42% (95% CI, 37.1%-47.1%) for breast cancer. The median time elapsed from initial patient contact to diagnosis and treatment initiation was 16 days and 39 days, respectively. The majority (72%) of patients were diagnosed at an early stage (0-II).

CONCLUSION

This patient prioritization system adequately identified women with different probabilities of having breast cancer. Efforts to replicate similar triage systems in resource-constrained settings where screening programs are ineffective could prove to be beneficial in reducing diagnostic intervals and achieving early-stage diagnoses.

IMPLICATIONS FOR PRACTICE

Low- and middle-income countries such as Mexico currently lack the infrastructure to achieve effective breast cancer screening and guarantee prompt access to health care when required. To reduce the disease burden in such settings, strategies targeting early detection are urgently needed. Patient navigation programs aid in the reduction of health system intervals and optimize the use of available resources. This article presents the introduction of a triage system based on initial patient concern. Appointment prioritization proved to be successful at reducing health system intervals and achieving early-stage diagnoses by overcoming barriers that impede early access to quality medical care.

Real-World Outcomes Among Older Mexican Women with Breast Cancer Treated with Neoadjuvant Chemotherapy

BACKGROUND

Older patients with breast cancer treated in high-income countries often present with early-stage disease, leading to a lack of information on the use of neoadjuvant chemotherapy in this population. We analyzed the real-world outcomes of older women with breast cancer treated with neoadjuvant chemotherapy at a single institution in Mexico.

MATERIALS AND METHODS

The study included 2,216 patients treated with neoadjuvant chemotherapy. Regarding achievement of pathologic complete response (defined as no invasive residual tumor in the breast and lymph nodes), 243 patients aged ≥65 years were compared with 1,973 patients aged <65 years. Disease-free survival and overall survival were compared between groups according to pathologic complete response and subtype, defined by hormone receptor and human epidermal growth receptor 2 (HER2) status.

RESULTS

Older women were less likely to have a pathologic complete response than their younger counterparts (26.3 vs. 35.3%, p < .001). When response rates by subtype were analyzed, this difference was significant only for women with triple-negative tumors. Achieving less than a pathologic complete response was associated with a greater chance of recurrence, but age was not an independent factor for recurrence for any subtype. Reaching a pathologic complete response was significantly associated with improved survival among older women with breast cancer, with the exception of those with hormone receptor-positive, HER2- disease.

CONCLUSION

Although older women have fewer pathological complete responses, their outcomes after neoadjuvant chemotherapy are comparable to those of younger patients. This is particularly relevant for the treatment of older adults with breast cancer in developing countries, who present in advanced stages and more often need neoadjuvant therapy.

IMPLICATIONS FOR PRACTICE

The majority of older patients with breast cancer in high-income countries present with early-stage disease, leading to a lack of information regarding the use of neoadjuvant chemotherapy in real-world settings. This article reports the outcomes of older Mexican women with breast cancer who received neoadjuvant chemotherapy compared with their younger counterparts. Although older women (particularly those with triple-negative tumors) were less likely to have a pathologic complete response after neoadjuvant treatment, age was not an independent factor for recurrence. Achieving a pathologic complete response was associated with improved survival, regardless of age.

Assessment of diagnostics capacity in hospitals providing surgical care in two Latin American states

BACKGROUND

Diagnostic services are an essential component of high-quality surgical, anesthesia and obstetric (SAO) care. Efforts to scale up SAO care in Latin America have often overlooked diagnostics capacity. This study aims to analyze the capacity of diagnostic services, including radiology, pathology, and laboratory medicine, in hospitals providing SAO care in the states of Chiapas, Mexico and Amazonas, Brazil.

METHODS

A stratified cross-sectional evaluation of diagnostic capacity in hospitals performing surgery in Chiapas and Amazonas was performed using the Surgical Assessment Tool (SAT). National data sources were queried for indicators of diagnostics capacity in terms of workforce, infrastructure and diagnosis utilization. Fisher's exact tests and chi-square tests were used to compare categorical variables between the private and public sector in Chiapas while descriptive statistics are used to compare Amazonas and Chiapas.

FINDINGS

In Chiapas, 53% (n = 17) of public and 34% (n = 20) of private hospitals providing SAO care were assessed. More private hospitals than public hospitals could always provide x-rays (35% vs 23.5%) and ultrasound (85% vs 47.1%). However neither sector could consistently perform basic laboratory testing such as complete blood counts (70.6% public, 65% private). In Amazonas, 30% (n = 18) of rural hospitals were surveyed. Most had functioning x-ray machine (77.8%) and ultrasound (55.6%). The majority of hospitals could provide complete blood count (66.7%) but only one hospital (5.6%) could always perform an infectious panel. Both Chiapas and Amazonas had dramatically fewer diagnostic practitioners per capita in each state compared to the national average capacity.

INTERPRETATION

Facilities providing SAO care in low-resource states in Mexico and Brazil often lack functioning diagnostics services and workforce. Scale-up of diagnostic services is essential to improve SAO care and should occur with emphasis on equitable and adequate resource allocation.

Comparison of characteristics in Mexican women with breast cancer according to healthcare coverage

Objective:

To compare the sociodemographic, diagnostic, clinical, and treatment-related characteristics and outcomes of patients with breast cancer in two hospitals in Mexico according to type of healthcare coverage.

Methods:

A retrospective cohort study of women with breast cancer according to public or private healthcare coverage in two hospitals was done. Patients were treated by the same group of physicians and healthcare infrastructure. Groups were compared using the chi-square test for categorical variables, Mann–Whitney U-test and Student’s t-test for quantitative variables, and Kaplan–Meier estimator and log-rank test for time dependent outcomes (including recurrence-free and overall survival). A value of p < 0.05 was considered statistically significant.

Results:

A total of 282 women were included. Mean age at diagnosis was 52 years. Women with public healthcare coverage were diagnosed more frequently with self-detected tumors (82.8% vs 47.9%, p < 0.001) and advanced clinical stage (III and IV) (31.1% vs 17.8%, p = 0.014). More women with public healthcare insurance underwent initial systemic treatment (41.1% vs 17.8%, p < 0.001) and mastectomy (70.1% vs 54.9%, p = 0.020), and received more chemotherapy (79.4% vs 43.8%, p < 0.001) and adjuvant radiotherapy (68.9% vs 53.4%, p = 0.017). Overall, no differences were found in survival outcomes according to healthcare coverage. Trends suggesting worse recurrence-free and overall survival were observed in patients with public coverage at 3 years follow-up in stage III (85.7% vs 67.3% and 100% vs 84.6%, respectively) and triple negative disease (83.3% vs 74.5% and 100% vs 74.1%, respectively).

Conclusion:

Strategies to promote preventive medicine, diagnostic mammograms, and prompt diagnosis of breast cancer in Mexican women with public health coverage are needed. Access to the main treatment modalities by Seguro Popular and good quality care by an experienced group of physicians likely explains the similar outcomes between patients with private and public healthcare coverage. However, trends suggesting worse survival for patients with public medical coverage with stage III and triple-negative disease should encourage close follow-up.

Prognostic Value of the Pretreatment Neutrophil-to-Lymphocyte Ratio in Different Phenotypes of Locally Advanced Breast Cancer During Neoadjuvant Systemic Treatment

PURPOSE

Neutrophils are among the key cellular players in the inflammatory milieu produced in patients with breast cancer (BC), and strong evidence exists in terms of the prognostic value of assessing the neutrophil-to-lymphocyte ratio (NLR) in patients with BC. In this study we sought to determine whether the baseline NLR correlates with pathological complete response (pCR), disease-free survival (DFS), and overall survival (OS) in patients with locally advanced BC in the neoadjuvant chemotherapy (NAC) setting.

METHODS

We analyzed the pretreatment NLR from the first blood count of patients treated from 2007 to 2015 in terms of pCR, DFS, and OS in patients with locally advanced BC. Patients received standard medical care based on national guidelines.

RESULTS

A total of 1519 patients were included in the study. Median age was 49 years (22-88). The cutoff point for NLR was 2.0. NLR was not associated with pCR or DFS. However, patients with high NLR had worse OS in the presence of triple-negative BC (105.9 months; 95% confidence interval [CI], 100.2-111.5] vs. 98.7 months; 95% CI, 91.1-106.3; P = .029), Her2 overexpression (114.0 months; 95% CI, 110.5-118.0 vs. 100.8 months; 95% CI 95.7-105.9; P = .019), and residual disease after NAC for both phenotypes. Multivariate analysis showed that NLR was independently associated with OS (hazard ratio, 1.4; 95% CI, 1.02-1.95; P = .037).

CONCLUSIONS

Pretreatment NLR in patients with locally advanced BC correlates with OS as an independent prognostic factor. This influence depends on phenotype and residual disease. Routine assessment of this parameter could be an easy and affordable tool for defining prognosis.

Assessing geriatric capacity building needs in public hospitals in Mexico

AIMS

To conduct a needs assessment of public hospitals in Mexico to determine workforce specific capacity building needs in the care of older people.

BACKGROUND

The older population in Mexico is growing rapidly. The healthcare system and workforce may not be prepared to handle the needs of older people, especially those with chronic illnesses who are also disadvantaged socioeconomically. Determining workforce and system needs is important to strategically develop capacity.

METHODS

A needs assessment using a pragmatic qualitative approach structured this study. Semi-structured interviews and focus groups were conducted with healthcare professionals at five public hospitals in Mexico. Directed content analysis techniques analysed the data.

RESULTS

Ninety-two healthcare professionals participated in the study. Three themes emerged, including geriatric service delivery, social changes and human resources for health. Participants reported a lack of gerontology knowledge and related clinical skills deficits to provide care for hospitalised elders and expressed emotional distress related to the lack of resources in their institutions. All healthcare professionals expressed strong concern at the social toll the ageing population had on families. The support of government organisations emerged as a facilitator for adoption of geriatric care principles.

CONCLUSIONS

This qualitative study uncovered important data to inform the implementation of quality improvement and capacity building models for older people care in Mexico. There appears to be strong potential for a culturally appropriate translation of high-income country older people care models within the Mexican healthcare context.

IMPLICATIONS FOR PRACTICE

Findings suggests there is a need to increase geriatric capacity building among helathcare professionals in Mexico. This will be an important step in improving care for hospitalised older people.

Prevalence of germline mutations in the TP53 gene in patients with early-onset breast cancer in the Mexican population

Background

Heterozygous germline TP53 gene mutations result in Li-Fraumeni Syndrome (LFS). Breast cancer (BC) is the most frequent tumor in young women with LFS. An important issue related to BC in the Mexican population is the average age at diagnosis, which is approximately 11 years younger than that of patients in the United States (U.S.) and Europe. The aim of this study was to determine the prevalence of germline mutations in TP53 among young Mexican BC patients.

Methods

We searched for germline mutations in the TP53 gene using targeted next-generation sequencing (NGS) in 78 BC patients younger than 45 years old (yo) who tested negative for BRCA1/2 mutations. A group of 509 Mexican women aged 45yo or older without personal or family BC history (parents/grandparents) was used as a control.

Results

We identified five patients with pathogenic variants in the TP53 gene, equivalent to 6.4% (5/78). Among patients diagnosed at age 36 or younger, 9.4% (5/55) had pathogenic TP53 mutations. Three of these variants were missense mutations (c.844C > T, c.517G > A, and c.604C > T), and the other two mutations were frameshifts (c.291delC and c.273dupC) and had not been reported previously. We also identified a variant of uncertain clinical significance (VUS), c.672G > A, which causes a putative splice donor site mutation. All patients with TP53 mutations had high-grade and HER2-positive tumors. None of the 509 patients in the healthy control group had mutations in TP53.

Conclusions

Among Mexican BC patients diagnosed at a young age, we identified a high proportion with germline mutations in the TP53 gene. All patients with the TP53 mutations had a family history suggestive of LFS. To establish the clinical significance of the VUS found, additional studies are needed. Pathogenic variants of TP53 may explain a substantial fraction of BC in young women in the Mexican population. Importantly, none of these mutations or other pathological variants in TP53 were found in the healthy control group.

Patient Navigation to Enhance Access to Care for Underserved Patients with a Suspicion or Diagnosis of Cancer

BACKGROUND

Interventions aimed at improving access to timely cancer care for patients in low- and middle-income countries (LMIC) are urgently needed. We aimed to evaluate a patient navigation (PN) program to reduce referral time to cancer centers for underserved patients with a suspicion or diagnosis of cancer at a public general hospital in Mexico City.

MATERIALS AND METHODS

From January 2016 to March 2017, consecutive patients aged >18 years with a suspicion or diagnosis of cancer seen at Ajusco Medio General Hospital in Mexico City who required referral to a specialized center for diagnosis or treatment were enrolled. A patient navigator assisted patients with scheduling, completing paperwork, obtaining results in a timely manner, transportation, and addressing other barriers to care. The primary outcome was the proportion of patients who obtained a specialized consultation at a cancer center within the first 3 months after enrollment.

RESULTS

Seventy patients (median age 54, range 19-85) participated in this study. Ninety-six percent (n = 67) identified >1 barrier to cancer care access. The most commonly reported barriers to health care access were financial burden (n = 50) and fear (n = 37). Median time to referral was 7 days (range 0-49), and time to specialist appointment was 27 days (range 1-97). Ninety-one percent of patients successfully obtained appointments at cancer centers in <3 months.

CONCLUSION

Implementing PN in LMIC is feasible, and may lead to shortened referral times for specialized cancer care by helping overcome barriers to health care access among underserved patients.

IMPLICATIONS FOR PRACTICE

A patient navigation program for patients with suspicion or diagnosis of cancer in a second-level hospital was feasible and acceptable. It reduced patient-reported barriers, and referral time to specialized appointments and treatment initiation were within international recommended limits. Patient navigation may improve access to care for underserved patients in developing countries.

Access to innovative cancer medicines in a middle-income country - the case of Mexico

BACKGROUND

Cancer has become the third cause of death in Mexico. Treatment for cancer is often complex and lengthy. New and better medicines enter the market at high prices, which may limit access. Like most Latin American countries, Mexico has an essential cancer medicines list that includes innovative medicines. Their accessibility and use in the public sector remains unknown. Therefore, we describe the use, as a proxy of access, of innovative and essential cancer medicines in the public sector in Mexico, by insurance institution, and by five regions between 2010 to 2016.

METHODS

We used drug utilization research methods to assess the use of eight patented cancer medicines. Through the national transparency platform, we obtained data on the quantities of these medicines used in all public health facilities and social health insurance institutions and recalculated those figures into defined daily dose (DDD) per 1000 population per year.

RESULTS

Overall, the use of all medicines increased over the years, especially for trastuzumab, rituximab and imatinib. The use of innovative medicines was higher per population covered in social health insurance institutions than in governmental facilities. Throughout the study period, the Central region (including Mexico City) has used more medicines per population than the other regions.

CONCLUSIONS

The use and access of some essential innovative cancer medicines has increased over the years, but remains unequal across insurance schemes and regions. Particularly, the Ministry of Health Insurance scheme and Northern and Western regions in the country would benefit from additional efforts to increase access to essential cancer medicines.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transcription factor ATF3 mediates the radioresistance of breast cancer

This study was designed to research the influence of activating transcription factor 3 (ATF3) on the radioresistance of breast cancer. ATF3 expression was measured by qRT‐PCR and immunohistochemistry. Cancerous cell lines were cultured in vitro, and the expression of ATF3 was gauged by both qRT‐PCR and Western blot before and after the radiation therapy. Cellular cycle and apoptosis were analysed by flow cytometry. Changes in the expression of corresponding proteins in the downstream pathways were identified by Western blot. Tumour xenograft was used to evaluate the effect of ATF3 in vivo. ATF3 was observed stronger in breast cancer tissues and cells. After radiation therapy, the expression of ATF3 in breast cancer cells was up‐regulated. Silencing ATF3 could promote G2/M phase block, facilitate cell apoptosis and decrease clonogenic survival rate. The overexpression of ATF3 could curb G2/M‐phase block, cell apoptosis and increase clonogenic survival rate. Overexpression ATF3 could increase radioresistance by up‐regulating the level of phosphorylation of Akt in the PI3K/Akt signalling pathway. Radioresistance of breast cancer cells could be alleviated by inhibiting the PI3K/Akt signalling pathway. ATF3 could also promote radioresistance in vivo. ATF3 gene was able to promote radioresistance of breast cancer cells.

Description of Genetic Variants in BRCA Genes in Mexican Patients with Ovarian Cancer: A First Step towards Implementing Personalized Medicine

Gynecologic cancers are among the leading causes of death worldwide, ovarian cancer being the one with the highest mortality rate. Olaparib is a targeted therapy used in patients presenting mutations in BRCA1 and BRCA2 genes. The aim of this study was to describe BRCA1 and BRCA2 gene variants in Mexican patients with ovarian cancer. Sequencing of BRCA1 and BRCA2 genes from tumors of 50 Mexican patients with ovarian cancer was made in a retrospective, non-randomized, and exploratory study. We found genetic variants in 48 of 50 cases. A total of 76 polymorphic variants were found in BRCA1, of which 50 (66%) had not been previously reported. Furthermore, 104 polymorphic variants were found in BRCA2, of which 63 (60%) had not been reported previously. Of these polymorphisms, 5/76 (6.6%) and 4/104 (3.8%) were classified as pathogenic in BRCA1 and BRCA2, respectively. We have described the genetic variants in BRCA1 and BRCA2 of tumors from Northeast Mexican patients with sporadic ovarian cancers. Our results showed that the use of genetic testing helps recognize patients that carry pathogenic variants which could be beneficial for personalized medicine treatments.

Change in Breast Cancer Screening Knowledge is Associated With Change in Mammogram Intention in Mexican-Origin Women After an Educational Intervention

Purpose:

To determine the relationship between breast cancer screening knowledge and intent to receive a mammogram within 6 months in a sample of Mexican-origin women living in El Paso, Texas.

Methods:

A total of 489 uninsured Mexican-origin women were assigned to treatment or control and completed surveys at pre- and postintervention. Pre-post associations between breast cancer screening knowledge and intent were tested.

Results:

Participants were on average were 56.7 years of age and spoke primarily Spanish (92.6%). Most of the samples had not had a mammogram in 3 or more years (51.6%) and 14.6% had never had a mammogram. At baseline, the majority intended to be screened for breast cancer within the next 6 months (93.4%). At postintervention, half of the intervention group changed their 6-month intent to be screened for breast cancer from likely to unlikely. Change in intent was associated with a change in knowledge of risk of having a first child by the age of 30 and breast cancer being rare after the age of 70.

Discussion:

Intent to be screened for breast cancer in Mexican-origin women may be influenced by the type of knowledge.

Conclusions:

Change in screening knowledge may influence perceived risk that influences intention to be screened.

Psychosocial needs of young breast cancer survivors in Mexico City, Mexico

Objective

Young breast cancer survivors in Mexico face distinct psychosocial challenges that have not been characterized. This study aims to describe the psychosocial needs of young breast cancer survivors in Mexico at 5 or more years of survivorship, identifying areas of focus for early interventions.

Methods

Breast cancer patients diagnosed at age 40 or prior with 5 or more years since diagnosis were invited to participate in one-on-one 30–60 minute semi-structured audio-recorded interviews at the Instituto Nacional de Cancerología in Mexico City. Transcripts were coded using thematic analysis with NVivo software.

Results

25 women participated. Five major phenomena emerged from analysis: (1) minimization of fertility concerns; (2) persistence of body image disturbance over time; (3) barriers to employment during survivorship; (4) impact on family relationships and social networks; & (5) unmet psychological care and informational needs.

Conclusions

Early interventions with a focus on fertility loss education, access to reconstructive surgery and body image support, guidance during return-to-work, assistance with childcare, integration of psychological care and the fulfillment of informational needs could ameliorate long-term psychological and social distress for young breast cancer survivors in Mexico.

Pharmacogenetics of response to neoadjuvant paclitaxel treatment for locally advanced breast cancer

Locally advanced breast cancer (LABC) cases have a varying five-year survival rate, mainly influenced by the tumor response to chemotherapy. Paclitaxel activity (response rate) varies across populations from 21.5% to 84%. There are some reports on genetic traits and paclitaxel; however, there is still considerable residual unexplained variability. In this study, we aimed to test the association between eleven novel markers and tumor response to paclitaxel and to explore if any of them influenced tumor protein expression. We studied a cohort of 140 women with LABC. At baseline, we collected a blood sample (for genotyping), fine needle aspirates (for Western blot), and tumor measurements by imaging. After follow-up, we ascertained the response to paclitaxel monotherapy by comparing the percent change in the pre-, post- tumor measurements after treatment. To allocate exposure, we genotyped eleven SNPs with TaqMan probes on RT-PCR and regressed them to tumor response using linear modeling. In addition, we compared protein expression, between breast tumors and healthy controls, of those genes whose genetic markers were significantly associated with tumor response. After adjusting for multiple clinical covariates, SNPs on the LPHN2, ROBO1, SNTG1, and GRIK1 genes were significant independent predictors of poor tumor response (tumor growth) despite paclitaxel treatment. Moreover, proteins encoded by those genes are significantly downregulated in breast tumor samples.

Semi-Automatic Analysis for Unidimensional Immunoblot Images to Discriminate Breast Cancer Cases Using Time Series Data Mining

Breast cancer (BC) is one of the leading causes of death in adult women worldwide and the best way to reduce mortality and improve prognosis is through early diagnosis. Thus, it is necessary to optimize diagnostic methods; one option could be the automatic detection of patterns in 1D-II. In that respect, through recent analysis of unidimensional Immunoblot Images (1D-II), it was possible to distinguish between women with and without breast disease using as a discrimination criterion the presence of autoantibodies (bands) in their blood. However, the analysis of 1D-II is a difficult task even for an expert, generating great subjectivity and complexity in the process of interpretation.

In the present study, a semi-automatic methodology for the bands’ analysis contained in the 1D-II’s was implemented and evaluated, the bands were extracted using digital image processing techniques. This was possible through the recognition of banding patterns represented as time series to distinguish between three classes: women with breast cancer (BC), women with benign breast pathology (BBP) and women without breast pathology (H). The classification was performed using the machine learning algorithm k-nearest neighbors (KNN) with different parameters over the time series representation.

The semi-automatic method here presented was able to reduce the time, complexity and subjectivity of the image analysis with the performance metrics compared, obtaining similar percentages for both representations. With the traditional analysis, binary representation [Accuracy 72.8%, Precision 73.42% for three classes (BC, BBP and H) and Accuracy 90.91% Accuracy 92.55% Sensitivity 93.57% and Specificity 92.99% for two classes (BC and H)], versus Time series representation [Accuracy 66.4%, Precision 67.07% for three classes (BC, BBP and H) and Accuracy 86.36% Accuracy 87.31% Sensitivity 95.86% and Specificity 85.56% for two classes (BC and H)].

A pilot study of an accelerometer-equipped smartphone to monitor older adults with cancer receiving chemotherapy in Mexico

OBJECTIVES

Older adults with cancer in developing countries face challenges accessing healthcare due to a lack of personnel and infrastructure. A decline in physical activity (defined as a decrease in the number of daily steps) may be a novel method for the timely detection of toxicity in older adults receiving chemotherapy in resource-constrained settings.

MATERIALS AND METHODS

In this feasibility study, patients aged ≥65years starting first-line chemotherapy for solid tumors were given a smartphone with a pedometer application. Daily steps were monitored daily for one cycle. If a ≥15% decrease from baseline was identified, the patient was called and the presence of toxicity assessed. The intervention would be feasible if ≥75% of the subjects recorded steps for ≥75% of the planned chemotherapy days.

RESULTS

Forty patients (median age 73; 57% [N=23] female) were included. Seventy percent (N=28) had stage III-IV disease with 45% (N=18) gastrointestinal, 23% (N=9) breast, and 32% (N=13) other malignancies. Mean pre-treatment daily steps was 3111 (Standard Deviation [SD] 1731), and median follow-up was 21days (range 2-28). Despite having limited exposure to mobile technology, most (93%) patients used the smartphone appropriately, and 85% found it easy to use. Sixty percent of patients (N=24) had toxicities managed over the phone, 27.5% (N=10) were sent for urgent medical attention and 15% (N=6) were hospitalized.

CONCLUSION

Using smartphones to monitor older adults with cancer receiving chemotherapy in a resource-constrained setting is feasible and acceptable. A decrease in the number of daily steps was common and helped to identify chemotherapy toxicity.

Breast cancer genetics in young women: What do we know?

Breast cancer (BC) in young women, generally defined in oncology as women who are 40 years of age or younger, represents 2 out of 10 BC cases in developing countries. Several research studies, including genetic cancer panel tests, genome-wide association studies, expression analyses and polymorphisms reports, have found that young women with BC exhibit a higher genetic susceptibility and specific genomic signature compared to postmenopausal women with BC. Thus, international guidelines recommend genetic counseling for this age population. This review presents the current state of the art of genetics and genomics with regards to young women with BC.

Implementation of a School-Based Educational Program to Increase Breast Cancer Awareness and Promote Intergenerational Transmission of Knowledge in a Rural Mexican Community

BACKGROUND

Rural women have limited access to breast cancer education, which partially contributes to late diagnosis and treatment. In this pilot study, we tested the feasibility of implementing a school-based breast cancer educational program for adolescents in a rural Mexican community. We hypothesized that the adolescents' knowledge on breast cancer would increase as a result of the program, and that there would be intergenerational transmission of that knowledge to their older female relatives.

MATERIALS AND METHODS

Female adolescents from a rural middle school received the educational program. The program would be considered feasible and acceptable if more than 75% reported being satisfied with its contents. Changes in knowledge in the students and their relatives were evaluated using baseline and 4 months follow-up questionnaires.

RESULTS

One hundred twenty-six students were enrolled. The program was considered acceptable by 96% of the participants. The students' knowledge regarding breast cancer increased significantly from baseline to 4 months follow-up (63% to 82%). One hundred ninety-four female relatives completed the initial knowledge questionnaires. The relatives' knowledge regarding breast cancer showed a significant increase from baseline to 4 months follow-up (55% to 61%).

CONCLUSION

Implementing breast cancer educational programs for adolescents in rural communities is feasible and acceptable. The program increased the adolescents' knowledge on breast cancer, and promoted the intergenerational transmission of that knowledge to their female relatives. Intergenerational transmission of knowledge represents a potential method for providing population-based health awareness education globally.

IMPLICATIONS FOR PRACTICE

In limited-resource settings, education is a valuable tool for achieving early detection and downstaging of breast cancer. Unfortunately, rural women lack access to educational opportunities and information about breast cancer, which is a factor contributing to late diagnosis and treatment. In this study, we demonstrated that implementing a school-based breast cancer educational program for female adolescents in a rural Mexican community was feasible, acceptable, and increased their knowledge about breast cancer. Furthermore, the program encouraged the transmission of information to the students' older relatives. Intergenerational transmission of knowledge represents a novel and potentially effective tool in cancer education and promotion.

The impact of the use of intraoperative radiotherapy on costs, travel time and distance for women with breast cancer in the Mexico City Metropolitan Area

BACKGROUND AND OBJECTIVES

The low availability and poor access to external beam radiotherapy (EBRT) in developing countries makes it hard for women with breast cancer to receive breast conservation. We studied the effect of providing intraoperative radiotherapy (IORT) on the travel time, distance, and costs of in the Mexico City Metropolitan Area (MCMA).

METHODS

Sixty-nine patients treated between January 2013 and September 2014 were analyzed. Travel distance and transit time was calculated using Google Maps. The time and distance patients living in the MCMA treated with IORT would have spent if they had received EBRT was calculated. Cost analysis for each modality was performed.

RESULTS

71% (n = 49) lived in the MCMA. Sixteen (33%) received additional EBRT and 33 (66%) received IORT only. Mean driving distance and transit time of those 33 women was 132.6 km (SD 25.7) and 66 min (SD 32.9). Patients from the MCMA receiving IORT alone avoided 990 visits, 43 700 km and 65 400 min in transit. IORT led to a 12% reduction in costs per patient.

CONCLUSIONS

By reducing costs and time needed for patients to receive radiotherapy, IORT could potentially enhance access to breast conservation in resource-limited developing countries.

Exploring disparities in incidence and mortality rates of breast and gynecologic cancers according to the Human Development Index in the Pan-American region

OBJECTIVE

To evaluate whether a country's Human Development Index (HDI) can help explain the differences in the country's breast cancer and gynecological cancer incidence and mortality rates in the Pan-American region.

STUDY DESIGN

Ecological analysis.

METHODS

Pan-American region countries with publicly available data both in GLOBOCAN 2012 and the United Nations Development Report 2012 were included (n = 28). Incidence and mortality rates age-standardized per 100,000 were natural log-transformed for breast cancer, ovarian cancer, corpus uteri cancer, and cervical cancer. The mortality-to-incidence ratio (MIR) was calculated for each site. Pearson's correlation test and a simple linear regression were performed.

RESULTS

The HDI showed a positive correlation with breast cancer and ovarian cancer incidence and mortality rates, respectively, and a negative correlation with cervical cancer incidence and mortality rates. The HDI and corpus uteri cancer showed no association. MIR and the HDI showed a negative correlation for all tumor types except ovarian cancer. An increment in 1 HDI unit leads to changes in cancer rates: in breast cancer incidence β = 4.03 (95% confidence interval [CI] 2.61; 5.45) P < 0.001, breast cancer mortality β = 1.76 (95% CI 0.32; 3.21) P = 0.019, and breast cancer-MIR β = -0.705 (95% CI 0.704; 0.706) P < 0.001; in cervical cancer incidence β = -3.28 (95% CI -4.78; -1.78) P < 0.001, cervical cancer mortality β = -4.63 (95% CI -6.10; -3.17) P < 0.001, and cervical cancer-MIR β = -1.35 (95% CI -1.83; -0.87) P < 0.001; in ovarian cancer incidence β = 3.26 (95% CI 1.78; 4.75) P < 0.001, ovarian cancer mortality β = 1.82 (95% CI 0.44; 3.20) P = 0.012, and ovarian cancer-MIR β = 5.10 (95% CI 3.22; 6.97) P < 0.001; in corpus uteri cancer incidence β = 2.37 (95% CI -0.33; 5.06) P = 0.83, corpus uteri cancer mortality β = 0.68 (95% CI -2.68; 2.82) P = 0.96, and corpus uteri cancer-MIR β = -2.30 (95% CI -3.19; -1.40) P < 0.001.

CONCLUSIONS

A country's HDI should be considered to understand disparities in breast cancer and gynecological cancer in the Pan-American region.

68Ga-DTPA Anti-HER2 positron emission tomography/CT successfully predicts the overexpression of human epidermal growth factor receptor in lung metastases from breast cancer

Molecular identification of a metastatic tumour without the inconvenience of a biopsy and the time required for pathological characterization is possible using molecular imaging. Here, we present the case of a patient with breast cancer in whom ⁶⁸Ga-diethylenetriamine pentaacetic acid anti-human epidermal growth factor receptor 2 positron emission tomography-CT was successfully employed to characterize the expression of human epidermal growth factor receptor 2 in metastatic sites.

Clinical and Epidemiological Profile of Breast Cancer in Mexico: Results of the Seguro Popular

Purpose

One half of the Mexican population lacks comprehensive health care coverage. In 2003, a reform to the General Health Law was approved that led to the creation of the System of Social Protection in Health and made universal health coverage mandatory. The main innovation of this reform was Seguro Popular, which provided coverage for breast cancer. Here we report the outcomes of women with breast cancer treated at a cancer center in Mexico under Seguro Popular.

Materials and Methods

This was a retrospective cohort study that included all patients with breast cancer treated in the Instituto Nacional de Cancerología in Mexico City between January 2007 and December 2013 with Seguro Popular coverage. Demographic and clinical information were collected and survival outcomes were analyzed.

Results

A total of 4,300 women with breast cancer were included in this analysis. Most patients had locally advanced disease at diagnosis (53%, n = 2,293), and 13% (n = 558) presented with stage IV disease. Neoadjuvant chemotherapy was administered to 1,834 patients (52%), with a pathologic complete response in 25.1% (n = 460). Median follow-up was 40.5 months. Five-year survival for the entire cohort was 82% (95% CI, 81% to 84%). Five-year survival was 97% for early-stage disease (95% CI, 95% to 98%), 82% for locally advanced disease (95% CI, 80% to 84%), and 36% for metastatic disease (95% CI, 30% to 42%).

Conclusion

This represents the first description of a cohort of patients with breast cancer treated in Mexico under Seguro Popular. Seguro Popular has allowed our institution, and other Mexican centers, to establish efficient standardized mechanisms to treat patients with breast cancer.

Perspectives on Breast Health Education and Services Among Recent Hispanic Immigrant Women in the Midwest: a Qualitative Study in Lancaster County, Nebraska

Breast cancer is the most common cause of cancer death among Hispanic women in the USA. Throughout the country, Hispanic immigrants face many barriers to achieving optimal breast health. Three focus groups were conducted to explore challenges and opportunities in access to breast health services and information among recent Hispanic immigrant women in Lancaster Country, Nebraska. Respondents perceived breast cancer as a serious issue and were concerned about it, but there were few cues to action to improve health given the limited information and access to services available to low-income Spanish-speaking individuals in the community. Results highlighted the need for culturally and linguistically appropriate health education and services, accessibility and promotion of low-cost screening and treatment services, and inclusive policies to promote preventative healthcare services for all women regardless of immigration status. Health is more than just clinical care, and therefore, it is important to understand the contextual and cultural factors that have resulted in low screening rates and develop methods to address these them. Failure to address these aspects of social determinants of health could hamper efforts to improve breast health and reduce disparities.

Molecular Subtypes and Prognosis in Young Mexican Women With Breast Cancer

INTRODUCTION

Young age represents an adverse prognostic factor in breast cancer (BC), and young women present with more advanced and aggressive disease. In Latin America, BC is increasing in young women, and there is a lack of information regarding the characteristics and outcomes of this patient population.

PATIENTS AND METHODS

We retrospectively analyzed a database of 4315 women treated for BC at a single institution. We compared clinical characteristics, treatment, and survival between women ≤ 40 and > 40 years of age. Survival analyses were performed for each molecular subtype.

RESULTS

A total of 662 women (15.3%) were ≤ 40 years old. Younger women had more advanced disease, higher grade, and a larger proportion of luminal B and triple-negative tumors (P < .001). At 5 years, both disease-free and overall survival (OS) were lower in younger women, although there were no differences after adjusting for stage. Five-year OS was worse for young women with hormone receptor-positive, human epidermal growth factor receptor 2-negative subtype (82% vs. 87.1%; P = .03), but not for those with human epidermal growth factor receptor 2-positive or triple-negative disease. This difference can be attributed to luminal B tumors, which showed a worse 5-year OS in younger women (79.1% vs. 85.2%; P = .03).

CONCLUSION

Although young Mexican patients with BC have more aggressive disease at presentation than older women, only those with luminal B tumors have a worse survival after adjusting for stage. Strategies aimed at downstaging the disease and at improving the treatment of luminal B tumors in this population are needed.

Female breast cancer in Central and South America

RATIONALE AND OBJECTIVE

The burden of breast cancer has increased worldwide. Breast cancer mortality has been increasing in Central and South America (CSA) in the last few decades. We describe the current burden of breast cancer in CSA and review the current status of disease control.

METHODS

We obtained regional- and national-level incidence data from 48 population-based cancer registries in 13 countries and cancer deaths from the WHO mortality database for 18 countries. We estimated world population age-standardized incidence and mortality rates per 100,000 person-years for 2003-2007 and the estimated annual percentage change to describe time trends.

RESULTS

In the most recent 5-year period, Argentina, Brazil, and Uruguay had the highest incidence rates (67.7-71.9) and Bolivia and El Salvador had the lowest (7.9-12.7). For most countries, mortality rates were ≤12.3, except in Uruguay, Argentina and Cuba (14.9-20.5). Age-specific rates increased after the age of 40-50 years and reached a maximum after age 65 years (mean age at diagnosis 56-62 years). Most countries have developed national screening guidelines; however, there is limited capacity for screening.

CONCLUSION

The geographic variation of breast cancer rates may be explained by differences in the prevalence of reproductive patterns, lifestyle factors, early detection, and healthcare access. Extending early-detection programs is challenging because of inequalities in healthcare access and coverage, limited funding, and inadequate infrastructure, and thus it may not be feasible. Given the current status of breast cancer in CSA, data generated by population-based cancer registries is urgently needed for effective planning for cancer control.

High glucose and insulin enhance uPA expression, ROS formation and invasiveness in breast cancer-derived cells

BACKGROUND

Accumulating evidence indicates that type 2 diabetes is associated with an increased risk to develop breast cancer. This risk has been attributed to hyperglycemia, hyperinsulinemia and chronic inflammation. As yet, however, the mechanisms underlying this association are poorly understood. Here, we studied the effect of high glucose and insulin on breast cancer-derived cell proliferation, migration, epithelial-mesenchymal transition (EMT) and invasiveness, as well as its relationship to reactive oxygen species (ROS) production and the plasminogen activation system.

METHODS

MDA-MB-231 cell proliferation, migration and invasion were assessed using 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT), scratch-wound and matrigel transwell assays, respectively. ROS production was determined using 2' 7'-dichlorodihydrofluorescein diacetate. The expression of E-cadherin, vimentin, fibronectin, urokinase plasminogen activator (uPA), its receptor (uPAR) and its inhibitor (PAI-1) were assessed using qRT-PCR and/or Western blotting assays, respectively. uPA activity was determined using gel zymography.

RESULTS

We found that high glucose stimulated MDA-MB-231 cell proliferation, migration and invasion, together with an increased expression of mesenchymal markers (i.e., vimentin and fibronectin). These effects were further enhanced by the simultaneous administration of insulin. In both cases, the invasion and growth responses were found to be associated with an increased expression of uPA, uPAR and PAI-1, as well as an increase in active uPA. An osmolality effect of high glucose was excluded by using mannitol at an equimolar concentration. We also found that all changes induced by high glucose and insulin were attenuated by the anti-oxidant N-acetylcysteine (NAC) and, thus, depended on ROS production.

CONCLUSIONS

From our data we conclude that hyperglycemia and hyperinsulinemia can promote breast cancer cell proliferation, migration and invasion. We found that these features were associated with increased expression of the mesenchymal markers vimentin and fibronectin, as well as increased uPA expression and activation through a mechanism mediated by ROS.

Progress and remaining challenges for cancer control in Latin America and the Caribbean

Cancer is one of the leading causes of mortality worldwide, and an increasing threat in low-income and middle-income countries. Our findings in the 2013 Commission in The Lancet Oncology showed several discrepancies between the cancer landscape in Latin America and more developed countries. We reported that funding for health care was a small percentage of national gross domestic product and the percentage of health-care funds diverted to cancer care was even lower. Funds, insurance coverage, doctors, health-care workers, resources, and equipment were also very inequitably distributed between and within countries. We reported that a scarcity of cancer registries hampered the design of credible cancer plans, including initiatives for primary prevention. When we were commissioned by The Lancet Oncology to write an update to our report, we were sceptical that we would uncover much change. To our surprise and gratification much progress has been made in this short time. We are pleased to highlight structural reforms in health-care systems, new programmes for disenfranchised populations, expansion of cancer registries and cancer plans, and implementation of policies to improve primary cancer prevention.

National and regional breast cancer incidence and mortality trends in Mexico 2001-2011: Analysis of a population-based database

INTRODUCTION

Breast cancer is the most common malignancy in Mexican women since 2006. However, due to a lack of cancer registries, data is scarce. We sought to describe breast cancer trends in Mexico using population-based data from a national database and to analyze geographical and age-related differences in incidence and mortality rates.

METHODS

All incident breast cancer cases reported to the National Epidemiological Surveillance System and all breast cancer deaths registered by the National Institute of Statistics and Geography in Mexico from 2001 to 2011 were included. Incidence and mortality rates were calculated for each age group and for 3 geographic regions of the country. Joinpoint regression analysis was performed to examine trends in BC incidence and mortality. We estimated annual percentage change (APC) using weighted least squares log-linear regression.

RESULTS

We found an increase in the reported national incidence, with an APC of 5.9% (95% CI 4.1-7.7, p<0.05). Women aged 60-65 had the highest increase in incidence (APC 7.89%; 95% CI 5.5 -10.3, p<0.05). Reported incidence rates were significantly increased in the Center and in the South of the country, while in the North they remained stable. Mortality rates also showed a significant increase, with an APC of 0.4% (95% CI 0.1-0.7, p<0.05). Women 85 and older had the highest increase in mortality (APC 2.99%, 95% CI 1.9-4.1; p<0.05).

CONCLUSIONS

The reporting of breast cancer cases in Mexico had a continuous increase, which could reflect population aging, increased availability of screening, an improvement in the number of clinical facilities and better reporting of cases. Although an improvement in the detection of cases is the most likely explanation for our findings, our results point towards an epidemiological transition in Mexico and should help in guiding national policy in developing countries.