Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study

Identification of pseudobaptigenin as a novel polyphenol-based multi-target antagonist of different hormone receptors for breast cancer therapeutics

Breast cancer (BC) is one of the most prevalent cancers in the world and is one of the major reasons for the death of women worldwide. BC is majorly categorized based on the presence or absence of three cell receptors ER, PR and HER2. The latest treatment for BC involves interfering with the production and action of hormones such as estrogen and progesterone. These hormones bind with receptors such as ER and PR and enhance the growth and proliferation of the BC cells. Although the available are effective, the increasing resistance and side effects related to hormonal imbalance are significant and hence there is a need for designing. On the other hand, plant-derivative products have gained a lot of popularity for their promising anti-cancerous activities. Polyphenols are one such group of plant derivatives that have proven to be useful against cancer. In the present study, an in-silico approach was used to search for a polyphenol that can inhibit ER. In this work, a total of 750 polyphenols were taken into consideration. This number was narrowed down to 55, based on their ADMET properties. These 55 polyphenols were then docked to the receptors, ER, PR and HER2. The molecular docking was followed by Molecular Dynamics (MD) simulations. Based on molecular docking and MD simulation results it was concluded that Pseudobaptigenin has the potential to be an inhibitor of ER, PR and HER2.Communicated by Ramaswamy H. Sarma.

Geospatial disparities in survival of patients with breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes cohort (ABC-DO): a prospective cohort study

BACKGROUND

There is an urgent need to improve breast cancer survival in sub-Saharan Africa. Geospatial barriers delay diagnosis and treatment, but their effect on survival in these settings is not well understood. We examined geospatial disparities in 4-year survival in the African Breast Cancer-Disparities in Outcomes cohort.

METHODS

In this prospective cohort study, women (aged ≥18 years) newly diagnosed with breast cancer were recruited from eight hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. They reported sociodemographic information in interviewer-administered questionnaires, and their clinical and treatment data were collected from medical records. Vital status was ascertained by contacting participants or their next of kin every 3 months. The primary outcome was all-cause mortality in relation to rural versus urban residence, straight-line distance, and modelled travel time to hospital, analysed using restricted mean survival time, Cox proportional hazards, and flexible parametric survival models.

FINDINGS

2228 women with breast cancer were recruited between Sept 8, 2014, and Dec 31, 2017. 127 were excluded from analysis (58 had potentially recurrent cancer, had previously received treatment, or had no follow-up; 14 from minority ethnic groups with small sample sizes; and 55 with missing geocoded home addresses). Among the 2101 women included in analysis, 928 (44%) lived in a rural area. 1042 patients had died within 4 years of diagnosis; 4-year survival was 39% (95% CI 36-42) in women in rural areas versus 49% (46-52) in urban areas (unadjusted hazard ratio [HR] 1·24 [95% CI 1·09-1·40]). Among the 734 women living more than 1 h from the hospital, the crude 4-year survival was 37% (95% CI 32-42) in women in rural areas versus 54% (46-62) in women in urban areas (HR 1·35 [95% CI 1·07-1·71] after adjustment for age, stage, and treatment status). Among women in rural areas, mortality rates increased with distance (adjusted HR per 50 km 1·04, 1·01-1·07) and travel time (adjusted HR per h 1·06, 1·02-1·10). Among women with early-stage breast cancer receiving treatment, women in rural areas had a strong survival disadvantage (overall HR 1·54, 1·14-2·07 adjusted for age and stage; >1 h distance adjusted HR 2·14, 1·21-3·78).

INTERPRETATION

Geospatial barriers reduce survival of patients with breast cancer in sub-Saharan Africa. Specific attention is needed to support patients with early-stage breast cancer living in rural areas far from cancer treatment facilities.

FUNDING

US National Institutes of Health (National Cancer Institute), Susan G Komen for the Cure, and the International Agency for Research on Cancer.

Deep Learning for Describing Breast Ultrasound Images with BI-RADS Terms

Breast cancer is the most common cancer in women. Ultrasound is one of the most used techniques for diagnosis, but an expert in the field is necessary to interpret the test. Computer-aided diagnosis (CAD) systems aim to help physicians during this process. Experts use the Breast Imaging-Reporting and Data System (BI-RADS) to describe tumors according to several features (shape, margin, orientation...) and estimate their malignancy, with a common language. To aid in tumor diagnosis with BI-RADS explanations, this paper presents a deep neural network for tumor detection, description, and classification. An expert radiologist described with BI-RADS terms 749 nodules taken from public datasets. The YOLO detection algorithm is used to obtain Regions of Interest (ROIs), and then a model, based on a multi-class classification architecture, receives as input each ROI and outputs the BI-RADS descriptors, the BI-RADS classification (with 6 categories), and a Boolean classification of malignancy. Six hundred of the nodules were used for 10-fold cross-validation (CV) and 149 for testing. The accuracy of this model was compared with state-of-the-art CNNs for the same task. This model outperforms plain classifiers in the agreement with the expert (Cohen's kappa), with a mean over the descriptors of 0.58 in CV and 0.64 in testing, while the second best model yielded kappas of 0.55 and 0.59, respectively. Adding YOLO to the model significantly enhances the performance (0.16 in CV and 0.09 in testing). More importantly, training the model with BI-RADS descriptors enables the explainability of the Boolean malignancy classification without reducing accuracy.

Breast cancer in women by HIV status: A report from the South African National Cancer Registry

BACKGROUND

Breast cancer (BC) is the leading cause of cancer-related morbidity and mortality in women living in South Africa, a country with a high HIV burden. However, characteristics of the double burden of HIV and BC in South Africa have not been properly investigated. We described characteristics of BC cases by HIV status in South Africa.

METHODS

In this nationwide South African study, we obtained BC records for women aged ≥15 years diagnosed in the public health sector between January 2004 and December 2014. We included records from the National Cancer Registry that had been linked to HIV-related laboratory records from the National Health Laboratory Service. We assessed the odds of being HIV positive versus HIV negative in relation to patient-, cancer-, and municipality-related characteristics.

RESULTS

From 2004-2014, 40 520 BC cases were diagnosed in women aged ≥15 years. Of these, 73.5% had unknown HIV status, 18.7% were HIV negative, and 7.7% were HIV positive. The median age at BC diagnosis was 43 years (interquartile range [IQR]: 37-52) in HIV positive and 57 years (IQR: 46-68) in HIV negative women, respectively. The odds of being HIV positive was higher for women who were aged 30-34 years compared to women aged 35-39 years at cancer diagnosis (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.10-1.71), Black versus non-Black (OR 6.41, 95% CI 5.68-7.23), diagnosed with cancer in rural versus urban areas (OR 1.59, 95% CI 1.40-1.82) and diagnosed in municipalities with low and middle (OR 3.46, 95% CI 2.48-4.82) versus high socioeconomic position (OR 2.69, 95% CI 2.11-3.42).

CONCLUSION

HIV status was unknown for the majority of BC patients. Among those with known HIV status, being HIV positive was associated with a younger age at cancer diagnosis, being Black and receiving care in municipalities of poor socioeconomic position. Future studies should examine opportunities to integrate HIV and BC control programs.

Prognostic factors and overall survival of breast cancer in Benin: a hospital-based study

BACKGROUND

In Benin, a country in West Africa, breast cancer is the leading cancer in women, both in terms of incidence and mortality. However, evidence on the mortality of breast cancer and its associated factors is lacking in this country. Our aim was to describe and analyze the clinical, histopathological, and prognostic aspects of breast cancer in Benin.

METHODS

A descriptive and analytical study was carried out at the CNHU-HKM and the CHU-MEL, two major tertiary referral hospitals for breast cancer management located in Cotonou, the capital city of Benin. All breast cancer medical records with histological evidence and immunohistochemistry studies were retrospectively collected between January 1, 2014, and September 30, 2020, in these two tertiary referral hospitals and analyzed in the current study.

RESULTS

Finally, 319 medical records were included. The mean age at diagnosis was 48.74 years. The tumors were most frequently classified as T4 (47.6%) with lymph node involvement N2 (34.5%), and metastases were clinically noted in 21.9% of cases. Stage was reported in the medical records of 284 patients. Tumors were diagnosed at very late AJCC stages: stage III (47.5%) and stage IV (24.7%). Grades SBR 2 (49.2%) and SBR 3 (32.6%) were the most frequent grades. Triple-negative breast cancer (31.3%) was the most common molecular type. The overall 5-year survival was 48.49%. In multivariable analysis, the poor prognostic factors were lymph node invasion (HR = 2.63; p = 0.026; CI: [1.12, 6.17]), the presence of metastasis (HR = 3.64; p < 0.001); CI: [2.36, 5.62] and the immunohistochemical profile (HR = 1.29; p < 0.001; CI: [1.13, 1.48]).

CONCLUSIONS

Breast cancer in Beninese is predominant in young adults and is often diagnosed at a late stage. The survival of breast cancer patients in Benin can be improved by enhancing early diagnosis and multidisciplinary management.

Survival Patterns Among Patients With Breast Cancer in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Importance

Breast cancer is the most prevalent cancer globally with tremendous disparities both within specific regions and across different contexts. The survival pattern of patients with breast cancer remains poorly understood in sub-Saharan African (SSA) countries.

Objective

To investigate the survival patterns of patients with breast cancer in SSA countries and compare the variation across countries and over time.

Data Sources

Embase, PubMed, Web of Science, Scopus, and ProQuest were searched from inception to December 31, 2022, with a manual search of the references.

Study Selection

Cohort studies of human participants that reported 1-, 2-, 3-, 4-, 5-, and 10-year survival from diagnosis among men, women, or both with breast cancer in SSA were included.

Data Extraction and Synthesis

Independent extraction of study characteristics by multiple observers was performed using open-source software, then exported to a standard spreadsheet. A random-effects model using the generalized linear mixed-effects model was used to pool data. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline for reporting was followed.

Main Outcome and Measures

Survival time from diagnosis.

Results

Forty-nine studies were included in the review with a sample size ranging from 21 to 2311 (total, 14 459; 196 [1.35%] men, 13 556 [93.75%] women, and 707 [4.90%] unspecified; mean age range, 38 to 71 years), of which 40 were summarized using meta-analysis. The pooled 1-year survival rate of patients with breast cancer in SSA was 0.79 (95% CI, 0.67-0.88); 2-year survival rate, 0.70 (95% CI, 0.57-0.80); 3-year survival rate, 0.56 (95% CI, 0.45-0.67); 4-year survival rate, 0.54 (95% CI, 0.43-0.65); and 5-year survival rate, 0.40 (95% CI, 0.32-0.49). The subgroup analysis showed that the 5-year survival rate ranged from 0.26 (95% CI, 0.06-0.65) for studies conducted earlier than 2010 to 0.47 (95% CI, 0.32-0.64) for studies conducted later than 2020. Additionally, the 5-year survival rate was lower in countries with a low human development index (HDI) (0.36 [95% CI, 0.25-0.49) compared with a middle HDI (0.46 [95% CI, 0.33-0.60]) and a high HDI (0.54 [95% CI, 0.04-0.97]).

Conclusions and Relevance

In this systematic review and meta-analysis, the survival rates for patients with breast cancer in SSA were higher in countries with a high HDI compared with a low HDI. Enhancing patient survival necessitates a comprehensive approach that involves collaboration from all relevant stakeholders.

From Incidence to Intervention: A Comprehensive Look at Breast Cancer in South Africa

The formidable impact of breast cancer extends globally, with South Africa facing pronounced challenges, including significant disparities in breast cancer screening, treatment and survival along ethnic and socioeconomic lines. Over the last two decades, breast cancer incidence has increased and now accounts for a substantial portion of cancers in women. Ethnic disparities in terms of screening, incidence and survival exacerbate the issue, leading to delayed diagnosis among Black patients and highlighting healthcare inequities. These concerning trends underscore the urgency of enhancing breast cancer screening while mitigating treatment delays, although obstacles within the healthcare system impede progress. The intersection of breast cancer and human immunodeficiency virus (HIV) further complicates matters and particularly affects the Black population. Tackling the aforementioned disparities in breast cancer in South Africa mandates a multifaceted strategy. Robust screening efforts, particularly those targeting marginalised communities, are crucial for early detection. Concurrently, expedited treatment initiation is imperative. Addressing HIV-related complexities requires tailored interventions to ensure effective care. These multifaceted disparities require pan African research and cooperation as well as tailored interventions to enhance breast cancer care within the African region.

Breast Cancer Disparities and Innovations: A Focus on Kosovo

Due to the current limited capacity to provide digital mammography-based screening to all women, and the lack of modern surgical oncology methods, mastectomy is still the predominant form of surgical treatment in many parts of the world. As such there is little incentive to detect breast cancer earlier and significant fear of treatment and outcomes continues to contribute to late presentations. Neoadjuvant chemotherapy, pre-operative breast MRI and surgical mapping techniques can combine forces to allow for more women to be treated with breast conservation, decrease fear of treatment and improve outcomes.

Advanced Breast Cancer Care: The Current Situation and Global Disparities

OBJECTIVES

Advanced breast cancer (ABC) is an incurable disease. The number of people living with ABC has increased globally. Disparities in ABC care exist at both individual and system levels. ABC cases in most low- and middle-income countries (LMICs) are underreported due to a lack of national cancer registries. Harmonized guidelines for resource stratification and capacity building in LMICs are under way.

DATA SOURCES

MEDLINE, Cochrane, and Google Scholar databases were used.

CONCLUSION

To improve ABC outcomes and resolve disparities, more robust health systems or pathways need to be developed across the cancer continuum in addition to social education.

IMPLICATIONS FOR NURSING PRACTICE

So far, the ABC specialist nurse role has been variable globally, and to conquer such variability, an international online nurse education and training program is in practice.

"Not even my husband knows that I have this [breast cancer]": survivors' experiences in accessing, navigating and coping with treatment

PURPOSE

Nigeria has the highest burden of breast cancer (BC) in Africa. While the survival rates for BC are over 90% in many high-income countries; low-and middle-income countries like Nigeria have 40% BC survival rates. Prior studies show that the burden and poor BC survival rates are exacerbated by both health system and individual level factors, yet there is a paucity of literature on the experiences of BC survivors in Nigeria. Hence, this study explored the divergent and convergent experiences of BC survivors in accessing, navigating, and coping with treatment.

METHODS

Participants (N = 24, aged 35 to 73 years) were recruited and engaged in focus group discussions (group 1, n = 11; group 2, n = 13 participants). Transcripts were transcribed verbatim and analyzed with inductive thematic analysis.

RESULTS

Four themes were identified: "I am carrying this [breast cancer] alone," "Living my life," "'God' helped me," and "A very painful journey." Participants described how they concealed their BC diagnosis from family and significant others while accessing and navigating BC treatment. Also, they adopted spiritual beliefs as a coping mechanism while sticking to their treatment and acknowledging the burden of BC on their well-being.

CONCLUSIONS

Our findings explored the emotional burden of BC diagnosis and treatment and the willingness of the BC survivors to find meaning in their diagnosis. Treatment for BC survivors should integrate supportive care and innovative BC access tools to reduce pain and mitigate the burdens of BC.

IMPLICATIONS FOR CANCER SURVIVORS

The integration of innovative technologies for venous access and other treatment needs of BC is crucial and will improve survivorship. Non-disclosure of BC diagnosis is personal and complicated; hence, BC survivors need to be supported at various levels of care and treatment to make meaningful decisions. To improve survivorship, patient engagement is crucial in shared decision-making, collaboration, and active participation in care.

Building pathology capacity in sub-Saharan Africa to improve breast cancer diagnosis and treatment: training laboratory technicians in high-quality manual immunohistochemistry

BACKGROUND

To address the need for a skilled workforce in breast cancer (BC) pathology in sub-Saharan Africa (SSA), we implemented an education program to train laboratory technicians in manual immunohistochemistry (IHC).

METHODS

A quality improvement education project was developed. Interactive webinars were held every six months with didactics and presentations from African experts with experience in IHC. We conducted knowledge assessments and surveys on current practice, equipment, and human resources. A digital mentorship platform (DMP) was created for discussions, sharing SOPs, and networking. For one year (2022-2023), we followed developments in pathology capacity, practice changes, and educational needs. A paired t-test was used to calculate the significance of changes in knowledge immediately after the webinar and comfort level with topics 35 days after the webinar.

RESULTS

Two hundred and sixty six participants from 10 SSA countries attended the first webinar, a series of six lectures on IHC theory, methods, and practice. Ninety-five participants from nine SSA countries provided a baseline assessment of pathology capacity and feedback. Mean knowledge increased by 17.4% immediately after the webinar (from 41.8% pre-webinar to 59.2% post, p =  < 0.0001). Self-reported comfort level in topics 35 days after the webinar increased by 11.3%, but this was not statistically significant (mean 3.36 pre- to 3.74 post, p = 0.1). Over six months, recordings were accessed 412 times. After six months, the second webinar had 93 participants from eight SSA countries. Membership in the DMP increased from 64 to 172; recordings were viewed 412 times in six months; and 113 participants from nine SSA countries completed surveys. Among 74 respondents who perform IHC, 43.5% reported moderate or significant positive practice changes such as improved antigen retrieval techniques and optimization of preanalytical variables. Over half (52.7%, n = 39) reported the quality of slides had moderately or significantly improved. After one year, a third webinar had 98 participants from eight SSA countries. Thirty-eight completed surveys, DMP membership increased to 199, and 1 reported launching IHC in a lab in Nigeria.

CONCLUSIONS

Our program 1) reached hundreds of participants and provided a baseline assessment of pathology capacity across nine SSA countries; 2) created a novel mechanism to build pathology capacity and assess progress with this cohort; and 3) improved practices and the preparation of slides for over half performing manual IHC. After one year, interest was sustained. Tracking impact on diagnosis and treatment of BC in the region is needed long-term.

Inequities in global cancer surgery: Challenges and solutions

The disparity in access to and quality of surgical cancer care between high and low resource settings impacts immediate and long-term oncological outcomes. With cancer incidence and mortality set to increase rapidly in the next few decades, we examine the factors leading to inequities in global cancer surgery, and look at potential solutions to overcome these challenges.

Artificial intelligence auxiliary diagnosis and treatment system for breast cancer in developing countries

BACKGROUND

In many developing countries, a significant number of breast cancer patients are unable to receive timely treatment due to a large population base, high patient numbers, and limited medical resources.

OBJECTIVE

This paper proposes a breast cancer assisted diagnosis system based on electronic medical records. The goal of this system is to address the limitations of existing systems, which primarily rely on structured electronic records and may miss crucial information stored in unstructured records.

METHODS

The proposed approach is a breast cancer assisted diagnosis system based on electronic medical records. The system utilizes breast cancer enhanced convolutional neural networks with semantic initialization filters (BC-INIT-CNN). It extracts highly relevant tumor markers from unstructured medical records to aid in breast cancer staging diagnosis and effectively utilizes the important information present in unstructured records.

RESULTS

The model's performance is assessed using various evaluation metrics. Such as accuracy, ROC curves, and Precision-Recall curves. Comparative analysis demonstrates that the BC-INIT-CNN model outperforms several existing methods in terms of accuracy and computational efficiency.

CONCLUSIONS

The proposed breast cancer assisted diagnosis system based on BC-INIT-CNN showcases the potential to address the challenges faced by developing countries in providing timely treatment to breast cancer patients. By leveraging unstructured medical records and extracting relevant tumor markers, the system enables accurate staging diagnosis and enhances the utilization of valuable information.

[Expression of transferrin receptor 1 and β1-integrins correlates with estrogen receptor status and immune infiltration in breast cancer]

Cancer cells can aberrantly express various markers, including transferrin receptor 1 (CD71) and β1-integrin molecules. Their role in invasion, migration and metastasis has been demonstrated. Determination of their expression in breast cancer (BC) may be an important point to characterize the clinical course of the tumor and prognosis of the disease.

OBJECTIVE

To study of transferrin receptor 1 (CD71) expression by primary breast cancer cells in correlation with tumor cell phenotype.

MATERIAL AND METHODS

Determination of BC phenotype: immunohistochemical staining method (immunofluorescence). Antibodies to ER (estrogen receptors), KL-1 (pancytokeratin), CD71 (transferrin receptor), CD29 (β1-integrins). CD45, CD3, CD4, CD8, CD20 infiltration was also evaluated. ZEISS microscope (AXIOSKOP; Germany), method of G.J. Hammerling et al. Statistical processing: IBM-SPSS Statistics v.21.

RESULTS

63% of BC cases had CD71+ phenotype. CD71-mosaic tumors were observed in 14.4%. β1-integrin expression was monomorphic in 51.6% of cases and mosaic in 38.7%. 85% of ER-positive tumors were CD71-positive with a monomorphic type of reaction; p=0.014. Among ER-negative tumors, CD71-negative reactions were 2-fold more frequent and the monomorphic type was less frequent. ER-positive tumors were CD29-positive in 73%; p=0.031. 45.5% of ER+ tumors were CD29-monomorphic. Among ER-negative tumors, the frequency of CD29-monomorphic tumors was 55%. Significant infiltration by CD3+ cells was predominant in CD71-positive tumors; p=0.016. In the CD29-monomorphic phenotype, CD45+ infiltration was 31.3%, and in the mosaic phenotype, 67.1%.

CONCLUSION

BC aberrantly expresses transferrin receptors, β1-integrins. CD71 expression is associated with ER expression. ER-positive tumors are often monomorphic for CD71. Prominent CD3+ infiltration was present in CD71+ tumors. Expression of β1-integrins correlated with ER+ status and weak immune infiltration.

Identification of hub genes to determine drug-disease correlation in breast carcinomas

The exact molecular mechanism underlying the heterogeneous drug response against breast carcinoma remains to be fully understood. It is urgently required to identify key genes that are intricately associated with varied clinical response of standard anti-cancer drugs, clinically used to treat breast cancer patients. In the present study, the utility of transcriptomic data of breast cancer patients in discerning the clinical drug response using machine learning-based approaches were evaluated. Here, a computational framework has been developed which can be used to identify key genes that can be linked with clinical drug response and progression of cancer, offering an immense opportunity to predict potential prognostic biomarkers and therapeutic targets. The framework concerned utilizes DeSeq2, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), Cytoscape, and machine learning techniques to find these crucial genes. Total RNA extraction and qRT-PCR were performed to quantify relative expression of few hub genes selected from the networks. In our study, we have experimentally checked the expression of few key hub genes like APOA2, DLX5, APOC3, CAMK2B, and PAK6 that were predicted to play an immense role in breast cancer tumorigenesis and progression in response to anti-cancer drug Paclitaxel. However, further experimental validations will be required to get mechanistic insights of these genes in regulating the drug response and cancer progression which will likely to play pivotal role in cancer treatment and precision oncology.

Validation of a Proteomic-Based Prognostic Model for Breast Cancer and Immunological Analysis

Breast cancer (BC) has emerged as an extremely destructive malignancy, causing significant harm to female patients and society at large. Proteomic research holds great promise for early diagnosis and treatment of diseases, and the integration of proteomics with genomics can offer valuable assistance in the early diagnosis, treatment, and improved prognosis of BC patients. In this study, we downloaded breast cancer protein expression data from The Cancer Genome Atlas (TCGA) and combined proteomics with genomics to construct a proteomic-based prognostic model for BC. This model consists of nine proteins (HEREGULIN, IDO, PEA15, MERIT40_pS29, CIITA, AKT2, CD171 DVL3, and CABL9). The accuracy of the model in predicting the survival prognosis of BC patients was further validated through risk curve analysis, survival curve analysis, and independent prognostic analysis. We further confirmed the impact of differential expression of these nine key proteins on overall survival in BC patients, and the differential expression of the key proteins and their encoding genes was validated using immunohistochemical staining. Enrichment analysis revealed functional associations primarily related to PPAR signaling pathway, steroid hormone metabolism, chemokine signaling pathway, DNA conformation changes, immunoglobulin production, and immunoglobulin complex in the high- and low-risk groups. Immune infiltration analysis revealed differential expression of immune cells between the high- and low-risk groups, providing a theoretical basis for subsequent immunotherapy. The model constructed in this study can predict the survival of BC patients, and the identified key proteins may serve as biomarkers to aid in the early diagnosis of BC. Enrichment analysis and immune infiltration analysis provide a necessary theoretical basis for further exploration of the molecular mechanisms and subsequent immunotherapy.

Microswimmer-Assisted Dual-Signal Sensor for Multiple Targets in Whole Blood

Accurate detection of biomarkers in whole blood is an important aspect of diagnostic testing but remains a challenge due to various interferences. However, using a self-calibrating two-signal strategy offers a solution that can overcome interference caused by experimental and environmental factors. Here, we proposed a novel microswimmer {methylene blue (MB)@ZIF-90@aptamer-HER2/3,3',5,5'-tetramethylbenzidine (TMB)@ZIF-90@aptamer-ER}-dual-signal (electrochemical and fluorescence) homogeneous sensor based on functionalized ZIF nanomaterials for one-step simultaneous detection of human epidermal growth factor receptor-2 (HER2) and estrogen receptor (ER) in whole blood. The proposed one-step ZIF-90 synthesis encapsulates TMB and MB with dual-signal properties. HER2 and ER aptamers adsorbed on MB@ZIF-90/TMB@ZIF-90 function as the gate switches. The microswimmer targets the HER2 and ER with adenosine triphosphate (ATP)-driven motion. When targets are present, aptamers dissociate and reduce the microswimmer's surface negative charge. The microswimmer undergoes attack and decomposition by swimming ATP due to the strong coordination force between ATP and Zn2+, leading to the release of MB and TMB. The negative charges on the surface of indium tin oxide enrich MB and TMB with positive charges, thereby increasing the intensities of electrochemical and fluorescence signals. The detection process was completed within 40 min, and the detection limits for ER and HER2 were 8.1 and 5.7 fg/mL respectively, with a linear range of 0.25-20 pg/mL.

Factors leading to the late diagnosis and poor outcomes of breast cancer in Matabeleland South and the Bulawayo Metropolitan Provinces in Zimbabwe

INTRODUCTION

Breast cancer (BC) is the leading cause of female cancer deaths in Africa, and in Zimbabwe, >80% present with advanced disease. A Needs Project (NP) was carried out to determine the key factors responsible for delayed diagnosis and poor BC outcomes and to investigate possible solutions in 6 rural and urban districts of Matabeleland South and Bulawayo Metropolitan Provinces.

METHODS

A mixed method approach was used to collect data in 2 phases. Phase 1: an exploration of key factors leading to poor BC outcomes with >50 professional stakeholders and patient representatives. Phase 2: (i) Quantitative arm; validated questionnaires recording breast cancer knowledge, demographic information and perceived barriers to care administered to women and their relatives (Group 1) and health professionals (HPs) (Group 2). (ii) Qualitative arm; 10 focus group discussions with medical specialists and interested lay representatives (Group 3). The Cochran sample size formulae technique was used to determine the quantitative sample size and data was aggregated and analysed using SPSS Version 23™. Purposive sampling for the qualitative study selected participants with an understanding of BC and the NP. Focus group discussions were recorded and a thematic analysis of the transcriptions was conducted using NVivo9™.

RESULTS

Quantitative analysis of Group 1 data (n = 1107) confirmed that younger women (<30years) had the least knowledge of breast cancer (p<0.001). Just under half of all those surveyed regarded breast cancer as incurable. In Group 2 (n = 298) the largest group of health workers represented were general nurses and midwives (74.2%) in keeping with the structure of health provision in Zimbabwe. Analysis confirmed a strong association between age and awareness of BC incidence (p = 0.002) with respondents aged 30-39 years being both the largest group represented and the least knowledgeable, independent of speciality. Nearly all respondents (90%) supported decentralisation of appropriate breast surgical services to provincial and district hospitals backed up by specialist training. Thematic analysis of focus group discussions (Group 3) identified the following as important contributors to late BC diagnosis and poor outcomes: (i) presentation is delayed by poorly educated women and their families who fear BC and high treatment costs (ii) referral is delayed by health professionals with no access to training, skills or diagnostic equipment (iii), treatment is delayed by a disorganised, over-centralized patient pathway, and a lack of specialist care and inter-disciplinary communication.

CONCLUSION

This study confirms that the reasons for poor BC outcomes in Zimbabwe are complex and multi-factorial. All stakeholders support better user and provider education, diagnostic service reconfiguration, targeted funding, and specialist training.

Epidemiology trends and progress in breast cancer survival: earlier diagnosis, new therapeutics

PURPOSE OF REVIEW

In this review we will critically appraise the latest evidence on breast cancer (BC) survival trends and discuss how these may reflect breakthroughs in early diagnosis and treatment approaches. We will address the wide global inequalities in BC survival and review the ongoing initiatives aimed at improving cancer control worldwide.

RECENT FINDINGS

BC outcomes have improved in high-income countries during the last decades, following the implementation of strategies for early detection and optimal multimodality treatment. Novel therapeutics, such as anti-HER2 targeted treatments, have also contributed to the progress in BC survival. However, BC mortality is still high in low-income countries, due to the lack of optimal healthcare infrastructures. In the context of marked inequities in BC management across world regions, international collaborations such as the Global Breast Cancer Initiative and the Global Initiative for Cancer Registry Development work to foster capacity-building in developing countries, tackle the burden of BC and deliver the Sustainable Development Goals by 2030.

SUMMARY

Collection of robust, high-quality data from population-based cancer registries is crucial to drive and refine public health interventions. Population-based data are also the litmus paper to evaluate the real-world impact of clinical advances and monitor progress.

A Prospective Evaluation of the Quality of Life and Mental Health Implications of Mastectomy Alone on Women in sub-Saharan Africa

OBJECTIVE

Assess quality of life and mental health implications of mastectomy for breast cancer on sub-Saharan African women.

BACKGROUND

Mortality rates amongst women diagnosed with breast cancer in sub-Saharan Africa (SSA) are high, with disparities in survival relative to women in high income countries partly attributed to advanced disease at presentation. Fears of the sequelae of mastectomy are a prominent reason for presentation delays. There is a critical need to better understand the effects of mastectomy on women in SSA to inform preoperative counseling and education for women with breast cancer.

METHODS

Women with breast cancer in Ghana and Ethiopia undergoing mastectomy were followed prospectively. Breast related quality-of-life and mental health measures were evaluated preoperatively, 3 and 6 months postoperatively, using BREAST-Q, PHQ-9, and GAD-7. Bivariate and logistic regression analyses evaluated changes in these measures for the total cohort and between sites.

RESULTS

A total of 133 women from Ghana and Ethiopia were recruited. The majority of women presented with unilateral disease (99%) and underwent unilateral mastectomy (98%) with axillary lymph node dissection. Radiation was more common in Ghana ( P <0.001). Across most BREAST-Q subscales, women from both countries reported significantly decreased scores at 3 months postoperative. At 6 months, the combined cohort reported decreased scores for breast satisfaction (mean difference, -3.4). Women in both countries reported similar improvements in anxiety and depression scores postoperatively.

CONCLUSIONS

Women from Ghana and Ethiopia who underwent mastectomy experienced a decline in breast-related body image while also experiencing decreased levels of depression and anxiety.

Analysis of the Breast Cancer Journey in Namibia

Importance

Breast cancer (BC) is the leading cancer among women in Namibia. Examining the BC journey in this multiracial country where inequalities remain large is needed to inform effective interventions to reduce BC mortality.

Objective

To describe the entire BC journey of Namibian women by race, utilizing the World Health Organization Global Breast Cancer Initiative (GBCI) framework.

Design, Setting, and Participants

This cohort study used the Namibian subset of the African Breast Cancer-Disparities in Outcomes prospective cohort. Participants were all Namibian residents with confirmed incident BC who presented at the main national public oncology center of the Windhoek Central Hospital (WCH). Follow-up started from recruitment (September 8, 2014, to October 5, 2016) and ended up to 3 years after diagnosis (December 13, 2014, to September 27, 2019). Data analysis was conducted from June 2022 to August 2023.

Exposures

Participants' self-reported ethnicities were aggregated into 3 population groups: Black, mixed ancestry, and White.

Main Outcomes and Measures

Three-year overall survival (OS) was examined using Cox models, and summary statistics were used to describe women's BC journey, including GBCI pillar key performance indicators: (1) early stage (TNM I or II) diagnosis (population benchmark ≥60%), (2) prompt diagnosis, ie, 60 days or less to first health care practitioner visit (population benchmark 100%), and (3) completion of recommended multimodal treatment (MT, ie, surgery plus chemotherapy) (population benchmark ≥80%).

Results

Of 405 women, there were 300 (74%) Black (mean [SD] age, 53 [15] years), 49 (12%) mixed ancestry (mean [SD] age, 53 [7] years), and 56 (14%) White (mean [SD] age, 59 [12] years) patients. Three-year OS was lowest in Black women (60% [95% CI, 54%-66%]; mixed ancestry: 80% [95% CI, 65%-89%]; White: 89% [95% CI, 77%-95%]), who had lower prevalence of early stage diagnosis (Black: 37% [95% CI, 31%-42%]; mixed ancestry and White: 75% [95% CI, 66%-83%]) and timely diagnosis (Black: 60% [95% CI, 54%-66%]; mixed ancestry and White: 77% [95% CI, 69%-85%]), while MT completion (Black: 53% [95% CI, 46%-59%]; mixed ancestry and White: 63% [95% CI, 50%-73%]) was low in all women.

Conclusions and Relevance

In this cohort study of 405 Namibian residents with BC, marked racial disparities in survival were paralleled by inequities all along the BC journey. To improve BC survival, interventions are needed to promote earlier diagnosis in Black Namibian women and to increase MT initiation and completion in all women.

The South African breast cancer and HIV outcomes study: Profiling the cancer centres and cohort characteristics, diagnostic pathways, and treatment approaches

The South African Breast Cancer and HIV Outcomes prospective cohort (SABCHO) study was established to investigate survival determinants among HIV-positive and HIV-negative SA women with breast cancer. This paper describes common and unique characteristics of the cancer centres and their participants, examining disparities in pathways to diagnosis, treatment resources and approaches adopted to mitigate resource constraints. The Johannesburg (Jhb), Soweto (Sow), and Durban (Dbn) sites treat mainly urban, relatively better educated and more socioeconomically advantaged patients whereas the Pietermaritzburg (Pmb) and Empangeni (Emp) sites treat predominantly rural, less educated and more impoverished communities The Sow, Jhb, and Emp sites had relatively younger patients (mean ages 54 ±14.5, 55±13.7 and 54±14.3 respectively), whereas patients at the Dbn and Pmb sites, with greater representation of Asian Indian women, were relatively older (mean age 57 ±13.9 and 58 ±14.6 respectively). HIV prevalence among the cohort was high, ranging from 15%-42%, (Cohort obesity (BMI ≥ 30 kg/m2) at 60%, self-reported hypertension (41%) and diabetes (13%). Direct referral of patients from primary care clinics to cancer centre occurred only at the Sow site which uniquely ran an open clinic and where early stage (I and II) proportions were highest at 48.5%. The other sites relied on indirect patient referral from regional hospitals where significant delays in diagnostics occurred and early-stage proportions were a low (15%- 37.3%). The Emp site referred patients for all treatments to the Dbn site located 200km away; the Sow site provided surgery and endocrine treatment services but referred patients to the Jhb site 30 Km away for chemo- and radiation therapy. The Jhb, Dbn and Pmb sites all provided complete oncology treatment services. All treatment centres followed international guidelines for their treatment approaches. Findings may inform policy interventions to address national and regional disparities in breast cancer care.

The Impact of HIV Infection on Neoadjuvant and Adjuvant Chemotherapy Relative Dose Intensity in South African Patients with Breast Cancer

INTRODUCTION

In the South African Breast Cancer and HIV Outcomes (SABCHO) study, we previously found that breast cancer patients living with HIV and treated with neoadjuvant chemotherapy achieve lower rates of complete pathologic response than patients without HIV. We now assess the impact of comorbid HIV on receipt of timely and complete neoadjuvant and adjuvant chemotherapy.

MATERIALS AND METHODS

Since June 2015, the SABCHO study has collected data on women diagnosed with breast cancer at 6 South African hospitals. We selected a sample of participants with stages I-III cancer who received ≥2 doses of neoadjuvant or adjuvant chemotherapy. Data on chemotherapies prescribed and received, filgrastim receipt, and laboratory values measured during treatment were captured from patients' medical records. We calculated the mean relative dose intensity (RDI) for all prescribed chemotherapies. We tested for association between full regimen RDI and HIV status, using linear regression to control for demographic and clinical covariates, and for association of HIV with laboratory abnormalities.

RESULTS

The 166 participants living with HIV and 159 without HIV did not differ in median chemotherapy RDI: 0.89 (interquartile range (IQR) 0.77-0.95) among those living with HIV and 0.87 (IQR 0.77-0.94) among women without HIV. Patients living with HIV experienced more grade 3+ anemia and leukopenia than those without HIV (anemia: 10.8% vs. 1.9%, P = .001; leukopenia: 8.4% vs. 1.9%, P = .008) and were more likely to receive filgrastim (24.7% vs. 10.7%, P = .001).

CONCLUSIONS

HIV status did not impact neoadjuvant or adjuvant chemotherapy RDI, although patients with breast cancer living with HIV experienced more myelotoxicity during treatment.

Geospatial availability of breast cancer treatment modalities and hypothetical access improvement in Ghana: A nationwide survey

Breast cancer in Ghana is a growing public health problem with increasing incidence and poor outcomes. Lack of access to comprehensive treatment in Ghana may be a contributing factor to its high mortality. The purpose of this study was to evaluate the availability of treatments nationwide and systematically identify high yield areas for targeted expansion. We conducted a cross-sectional, nationwide hospital-based survey from November 2020-October 2021. Surveys were conducted in person with trained research assistants and described hospital availability of all breast cancer treatments and personnel. All individual treatment services were reported, and hospitals were further stratified into levels of multi-modal treatment modeled after the National Comprehensive Cancer Network (NCCN) Framework treatment recommendations for low-resource settings. Level 3 included Tamoxifen and surgery (mastectomy with axillary lymph node sampling); Level 2 included Level 3 plus radiation, aromatase inhibitors, lumpectomy, and sentinel lymph node biopsy; Level 1 included Level 2 plus Her2 therapy and breast reconstruction. Hospitals were identified that could expand to these service levels based on existing services, location and personnel. The distance of the total population from treatment services before and after hypothetical expansion was determined with a geospatial analysis. Of the 328 participating hospitals (95% response rate), 9 hospitals had Level 3 care, 0 had Level 2, and 2 had Level 1. Twelve hospitals could expand to Level 3, 1 could expand to Level 2, and 1 could expand to Level 1. With expansion, the population percentage within 75km of Level 1, 2 and 3 care would increase from 42% to 50%, 0 to 6% and 44% to 67%, respectively. Multi-modal breast cancer treatment is available in Ghana, but it is not accessible to most of the population. Leveraging the knowledge of current resources and population proximity provides an opportunity to identify high-yield areas for targeted expansion.

Breast Cancer Germline Genetic Counseling and Testing for Populations of African Heritage Globally: A Scoping Review on Research, Practice, and Bioethical Considerations

PURPOSE

Despite the disproportionately high risk of breast cancer among women of African heritage, little is known about the facilitators and barriers to implementing germline genetic testing and counseling (GT/C).

METHODS

This scoping review followed guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Published manuscripts from database inception through 2021 were sourced from PubMed, Cumulative Index to Nursing and Allied Health Literature via EBSCO, Embase, Cochrane Library, and Scopus. Search terms were used to retrieve articles addressing (1) African heritage, (2) breast cancer, and (3) GT or GC. The screening involved abstract and title review and full-text review. Data were extracted for all articles meeting the inclusion criteria.

RESULTS

A total of 154 studies were included. Most studies that took place were conducted in the United States (71.4%), and most first authors (76.9%) were from the United States. GT was conducted in 73 (49.7%) studies. BRCA1/BRCA2 were the most commonly studied genes for germline mutations. GC was conducted in 49 studies (33.3%), and perspectives on GC were evaluated in 43 (29.3%). The use of racial/ethnic categories varied broadly, although African American was most common (40.1%). Racism was mentioned in three studies (2.0%).

CONCLUSION

There is a growing body of literature on GT/C for breast cancer in women of African heritage. Future studies on GT/C of African populations should consider increased clarity around racial/ethnic categorizations, continued community engagement, and intentional processes for informed consent.

Exploring Challenges Related to Breast Cancer to Identify Opportunities for Advocacy in Hawassa City, Southern Ethiopia: A Community-Based, Qualitative Study

PURPOSE

The aim of this study was to explore breast cancer (BC) challenges to identify opportunities for advocacy in southern Ethiopia in 2022.

METHODS

Twenty-five participants from four local districts (kebeles) in Hawassa City were selected as key contributors to future work. Semistructured in-depth interviews were held for two clinicians, two local health bureau managers, two media managers, and three religious leaders. Two focus group discussions were conducted: one included six BC survivors and a caregiver; the other included two health extension workers, three members of the Women's Development Group, two community volunteers, one kebele leader, and one traditional healer.

RESULTS

To our knowledge, our study was the first time that most participants had assembled. Many referred to patients as victims and BC as a killer disease or curse. Community and religious leaders were concerned about challenges and willing to collaborate. Survivors, providers, and religious leaders were identified as key sources of information, positive messages, and leadership.

CONCLUSION

Recommendations for advocacy work in Hawassa include lobbying for BC as a health priority; including BC within the health extension package; initiating programs for earlier detection; educating the community to remove stigmas of the disease and treatments; working with media to disseminate messages that are inclusive of people in remote areas and speaking different languages; improving availability, affordability, and access to care; and assisting patients with psychosocial support. A strategic collaboration between religious leaders and health care providers was identified to increase community awareness and support advocacy for patients.

Clinicopathological Risk Factors of Unfavorable Outcomes in Vietnamese Women with Primary Invasive Breast Cancer: A Retrospective Cohort Study

Background

The rate of unfavorable outcomes, such as recurrence and death, in women with invasive breast cancer varies widely across countries and populations. Identifying those with high-risk profiles is critical so that early detection, prediction, and intervention can be made to improve their survival rate. Therefore, our study evaluated the rate of unfavorable outcomes and its association with clinicopathological characteristics in Vietnamese women with primary invasive breast cancer.

Methods

A retrospective open cohort study was conducted on Vietnamese women with invasive breast cancer who underwent a mastectomy and were regularly followed up by the hospitals. Kaplan-Meier method was used to estimate the rate of unfavorable outcomes to take into account the follow-up time of each patient. Univariate and multiple Cox regression analyses were conducted to examine the associations between unfavorable outcomes and clinicopathological characteristics.

Results

Among 204 women included in the data analysis, the mean age was 54.4 ± 10.9 years. The majority of patients were diagnosed with early-stage (76.5%) or locally advanced (22.5%) breast cancer. The 5-year rate of unfavorable outcomes was 12.8%, and the 8-year rate was 31.7%. Patients with advanced stages had a higher risk of unfavorable outcomes compared to those with early stages (IA, IIA, T2N1). Patients with lymph node metastases and those with triple-negative molecular classification had significantly higher rates of unfavorable outcomes.

Conclusion

Although Vietnamese women with breast cancer have a relatively low rate of unfavorable outcomes compared to other countries, findings from this study emphasize the importance of early detection and underscore the need for targeted interventions for patients with advanced stages, lymph node metastases, and triple-negative breast cancer to optimize their treatment, outcomes, and overall prognosis.

Rapid Detection of Volatile Organic Metabolites in Urine by High-Pressure Photoionization Mass Spectrometry for Breast Cancer Screening: A Pilot Study

Despite surpassing lung cancer as the most frequently diagnosed cancer, female breast cancer (BC) still lacks rapid detection methods for screening that can be implemented on a large scale in practical clinical settings. However, urine is a readily available biofluid obtained non-invasively and contains numerous volatile organic metabolites (VOMs) that offer valuable metabolic information concerning the onset and progression of diseases. In this work, a rapid method for analysis of VOMs in urine by using high-pressure photon ionization time-of-flight mass spectrometry (HPPI-TOFMS) coupled with dynamic purge injection. A simple pretreatment process of urine samples by adding acid and salt was employed for efficient VOM sampling, and the numbers of metabolites increased and the detection sensitivity was improved after the acid (HCl) and salt (NaCl) addition. The established mass spectrometry detection method was applied to analyze a set of training samples collected from a local hospital, including 24 breast cancer patients and 27 healthy controls. Statistical analysis techniques such as principal component analysis, partial least squares discriminant analysis, and the Mann-Whitney U test were used, and nine VOMs were identified as differential metabolites. Finally, acrolein, 2-pentanone, and methyl allyl sulfide were selected to build a metabolite combination model for distinguishing breast cancer patients from the healthy group, and the achieved sensitivity and specificity were 92.6% and 91.7%, respectively, according to the receiver operating characteristic curve analysis. The results demonstrate that this technology has potential to become a rapid screening tool for breast cancer, with significant room for further development.

PAM50 intrinsic subtypes, risk of recurrence score and breast cancer survival in HIV-positive and HIV-negative patients-a South African cohort study

PURPOSE

Treatment decision making for patients with breast cancer increasingly depends on analysis of markers or systems for estimating risk of breast cancer recurrence. Breast cancer intrinsic subtypes and risk of recurrence (ROR) scores have been found to be valuable in predicting survival and determining optimal treatment for individual patients. We studied the association of breast cancer survival with the PAM50 gene expression assay in HIV-positive and HIV-negative patients.

METHOD

RNA was extracted from formalin-fixed paraffin-embedded specimens of histologically confirmed invasive carcinoma and was purified using the AllPrep® DNA/RNA FFPE kit, Qiagen (Hilden, Germany). The NanoString RUO PAM50 algorithm was used to determine the molecular subtype and the risk of recurrence score of each sample. The overall and disease-free survival were determined with comparison made among HIV-positive and -negative patients. We then generated Kaplan-Meier survival curves, calculated p-values and estimated hazard ratios and their 95% confidence intervals using Cox regression models.

RESULTS

Of the 384 RNA samples analysed, 98.4% met the required RNA quality standard and the specified QC threshold for the test. Luminal B was the most common PAM50 intrinsic subtype and 82.1% of patients were at high risk for disease recurrence based on ROR score. HIV infection, PAM50-based HER2-enriched and basal-like intrinsic subtypes, and high ROR were associated with poor overall and disease-free survival. HIV-positive patients with luminal A & B subtypes had significantly worse survival outcomes than HIV-negative luminal patents.

CONCLUSION

Aggressive tumour biology was common in our cohort. HIV infection, PAM50 HER2-enriched,basal-like intrinsic subtypes and high ROR score were associated with poor overall and disease-free survival. HIV infection impacted survival in patients with luminal subtypes only.

Regional Variation in the Tumor Microenvironment, Immune Escape and Prognostic Factors in Breast Cancer in Sub-Saharan Africa

The low overall survival rates of patients with breast cancer in sub-Saharan Africa (SSA) are driven by regionally differing tumor biology, advanced tumor stages at diagnosis, and limited access to therapy. However, it is not known whether regional differences in the composition of the tumor microenvironment (TME) exist and affect patients' prognosis. In this international, multicentre cohort study, 1,237 formalin-fixed, paraffin-embedded breast cancer samples, including samples of the "African Breast Cancer-Disparities in Outcomes (ABC-DO) Study," were analyzed. The immune cell phenotypes, their spatial distribution in the TME, and immune escape mechanisms of breast cancer samples from SSA and Germany (n = 117) were investigated using histomorphology, conventional and multiplex IHC, and RNA expression analysis. The data revealed no regional differences in the number of tumor-infiltrating lymphocytes (TIL) in the 1,237 SSA breast cancer samples, while the distribution of TILs in different breast cancer IHC subtypes showed regional diversity, particularly when compared with German samples. Higher TIL densities were associated with better survival in the SSA cohort (n = 400), but regional differences concerning the predictive value of TILs existed. High numbers of CD163+ macrophages and CD3+CD8+ T cells accompanied by reduced cytotoxicity, altered IL10 and IFNγ levels and downregulation of MHC class I components were predominantly detected in breast cancer samples from Western SSA. Features of nonimmunogenic breast cancer phenotypes were associated with reduced patient survival (n = 131). We therefore conclude that regional diversity in the distribution of breast cancer subtypes, TME composition, and immune escape mechanisms should be considered for therapy decisions in SSA and the design of personalized therapies. See related Spotlight by Bergin et al., p. 705.

Adaptive immune receptor features related to breast cancer tissue in Kenyan patients: high immunoglobulin gene expression and high levels of gamma-delta T-cells

BACKGROUND

Characterization of the breast cancer (BC) immune response may provide information for a point of intervention, such as application of immunotherapeutic treatments. In this study, we sought to recover and characterize the adaptive immune receptor (IR) recombination reads from genomics files representing Kenyan patients, to better understand the immune response specifically related to those patients.

METHODS

We used a previously applied algorithm and software to obtain productive IR recombination reads from cancer and adjacent normal tissue samples representing 22 Kenyan BC patients.

RESULTS

From both the RNAseq and exome files, there were significantly more T-cell receptor (TCR) recombination reads recovered from tumor samples compared to marginal tissue samples. Also, the immunoglobulin (IG) genes were expressed at a much higher level than the TCR genes (p-value = 0.0183) in the tumor samples. And, the tumor IG CDR3s consistently represented more positively charged amino acid R-groups, in comparison to the marginal tissue, IG CDR3s.

CONCLUSION

For Kenyan patients, a high level of IG expression, representing specific CDR3 chemistries, was associated with BC. These results lay the foundation for studies that could support specific immunotherapeutic interventions for Kenyan BC patients.

Reproductive history and breast cancer survival: Findings from the African breast cancer-Disparities in outcomes cohort and implications of Africa's fertility transition on breast cancer prognosis

Reproductive characteristics are known risk factors for breast cancer but, other than recent birth, their role as prognostic factors is less clear, and has not been studied in Sub-Saharan Africa (SSA). In this setting, we examined whether reproductive factors independently influence breast cancer survival in a subset of the African Breast Cancer-Disparities in Outcomes cohort study. In 1485 women with incident breast cancer recruited between 2014 and 2017, we examined birth cohort changes in reproductive factors, and used Cox models to examine whether reproductive characteristics were associated with all-cause mortality after adjusting for confounders (age, stage, treatment, HIV, and social factors). Four years after diagnosis, 822 (56%) women had died. Median parity was 4 (IQR = 2, 6) and 209 (28%) of premenopausal women had had a recent birth (<3 years prior to cancer diagnosis). Each pregnancy was associated with a 5% increase (95% CI: 2%, 8%) in mortality rates, which held among postmenopausal women (5%, [1%-9%]). Pre-menopausal women with a recent birth had 52% (20%, 92%) higher mortality rates. Fertility trends by birth cohort showed declining parity, increasing age at first birth and declining age at last birth, however the impact of these population-level changes on future average survival was predicted to be very small (<3% absolute gain).

Drivers of disparities in stage at diagnosis among women with breast cancer: South African breast cancers and HIV outcomes cohort

OBJECTIVE

In low- and middle-income countries (LMICs), advanced-stage diagnosis of breast cancer (BC) is common, and this contributes to poor survival. Understanding the determinants of the stage at diagnosis will aid in designing interventions to downstage disease and improve survival from BC in LMICs.

METHODS

Within the South African Breast Cancers and HIV Outcomes (SABCHO) cohort, we examined factors affecting the stage at diagnosis of histologically confirmed invasive breast cancer at five tertiary hospitals in South Africa (SA). The stage was assessed clinically. To examine the associations of the modifiable health system, socio-economic/household and non-modifiable individual factors, hierarchical multivariable logistic regression with odds of late-stage at diagnosis (stage III-IV), was used.

RESULTS

The majority (59%) of the included 3497 women were diagnosed with late-stage BC disease. The effect of health system-level factors on late-stage BC diagnosis was consistent and significant even when adjusted for both socio-economic- and individual-level factors. Women diagnosed in a tertiary hospital that predominantly serves a rural population were 3 times (OR = 2.89 (95% CI: 1.40-5.97) as likely to be associated with late-stage BC diagnosis when compared to those diagnosed at a hospital that predominantly serves an urban population. Taking more than 3 months from identifying the BC problem to the first health system entry (OR = 1.66 (95% CI: 1.38-2.00)), and having luminal B (OR = 1.49 (95% CI: 1.19-1.87)) or HER2-enriched (OR = 1.64 (95% CI: 1.16-2.32)) molecular subtype as compared to luminal A, were associated with a late-stage diagnosis. Whilst having a higher socio-economic level (a wealth index of 5) reduced the probability of late-stage BC at diagnosis, (OR = 0.64 (95% CI: 0.47-0.85)).

CONCLUSION

Advanced-stage diagnosis of BC among women in SA who access health services through the public health system was associated with both modifiable health system-level factors and non-modifiable individual-level factors. These may be considered as elements in interventions to reduce the time to diagnosis of breast cancer in women.

Population-based temporal trends and ethnic disparity in breast cancer mortality in South Africa (1999-2018): Joinpoint and age-period-cohort regression analyses

Globally, breast cancer is the leading cause of cancer deaths, accounting for 15.5% of female cancer deaths in 2020. Breast cancer is also the leading cause of female cancers in South Africa. The rapid epidemiological transition in South Africa may have an impact on the trends in breast cancer mortality in the country. We therefore evaluated the trends in the breast cancer mortality in SA over 20 years (1999-2020).

Methods

Joinpoint regression analyses of the trends in crude and age-standardized mortality rates (ASMR) of breast cancer among South African women were conducted from 1999 to 2018 using mortality data from Statistics South Africa. Age-period-cohort regression analysis was then conducted to evaluate the independent effect of age, period, and cohort on breast cancer mortality, and analysis was stratified by ethnicity.

Results

The mortality rate of breast cancer (from 9.82 to 13.27 per 100,000 women) increased at around 1.4% per annum (Average Annual Percent Change (AAPC): 1.4%, 95% CI:0.8-2.0, P-value< 0.001). Young women aged 30-49 years (1.1%-1.8%, P-value< 0.001) had increased breast cancer mortality. The risk of breast cancer mortality increased among successive birth cohorts from 1924 to 1928 but decreased among recent cohorts born from 1989 to 1993. In 2018, the breast cancer mortality rate among Blacks (9.49/100,000 women) was around half of the rates among the non-Blacks. (Coloreds: 18.11 per 100,000 women; Whites: 17.77/100,000 women; Indian/Asian: 13.24 per 100,000 women).

Conclusions

Contrary to the trends in high- and middle-income countries, breast cancer mortality increased in South Africa especially among young women. Breast cancer prevention programs should be intensified and should also target young women. The marked disparity in ethnic burden of breast cancer should be considered during planning and implementation of interventions.

The impact of HIV on non-adherence for tamoxifen among women with breast cancer in South Africa

PURPOSE

Women living with HIV (WLWH) and breast cancer (BC) have worse overall survival than HIV-negative women with BC, and poor adherence to prescribed tamoxifen is known to contribute to poor survival. We therefore investigated the association of HIV infection with adherence to adjuvant tamoxifen among women with localized hormone receptor (HR)-positive breast cancer in South Africa.

METHODS

Among 4,097 women diagnosed with breast cancer at six hospitals in the prospective South African Breast Cancer and HIV Outcomes (SABCHO) cohort study between July 2015 and December 2020, we focused on black women with stages I-III HR-positive breast cancer who were prescribed 20 mg of adjuvant tamoxifen daily. We collected venous blood once from each participant during a routine clinic visit, and analyzed concentrations of tamoxifen and its metabolites using a triple quadruple mass spectrometer. We defined non-adherence as a tamoxifen level < 60 ng/mL after 3 months of daily tamoxifen use. We compared tamoxifen-related side effects, and concurrent medication use among women with and without HIV and developed multivariable logistic regression models of tamoxifen non-adherence.

RESULTS

Among 369 subjects, 78 (21.1%) were WLWH and 291 (78.9%) were HIV-negative. After a median (interquartile range) time of 13.0 (6.2-25.2) months since tamoxifen initiation, the tamoxifen serum concentration ranged between 1.54 and 943.0 ng/mL and 208 (56.4%) women were non-adherent to tamoxifen. Women < 40 years of age were more likely to be non-adherent than women > 60 years (73.4% vs 52.6%, odds ratio (OR) = 2.49, 95% confidence interval (CI) = 1.26-4.94); likewise, WLWH (70.5% vs 52.6%, OR = 2.16, 95% CI = 1.26-3.70) than HIV-negative women. In an adjusted model WLWH had twice the odds of non-adherence to tamoxifen, compared to HIV-negative women (OR = 2.40, 95% CI = 1.11-5.20).

CONCLUSION

High rates of non-adherence to adjuvant tamoxifen may limit the overall survival of black South African women with HR-positive breast cancer, especially among WLWH.

Multimorbidity and overall survival among women with breast cancer: results from the South African Breast Cancer and HIV Outcomes Study

BACKGROUND

Breast cancer survival in South Africa is low, but when diagnosed with breast cancer, many women in South Africa also have other chronic conditions. We investigated the impact of multimorbidity (≥ 2 other chronic conditions) on overall survival among women with breast cancer in South Africa.

METHODS

Between 1 July 2015 and 31 December 2019, we enrolled women newly diagnosed with breast cancer at six public hospitals participating in the South African Breast Cancer and HIV Outcomes (SABCHO) Study. We examined seven chronic conditions (obesity, hypertension, diabetes, HIV, cerebrovascular diseases (CVD), asthma/chronic obstructive pulmonary disease, and tuberculosis), and we compared socio-demographic, clinical, and treatment factors between patients with and without each condition, and with and without multimorbidity. We investigated the association of multimorbidity with overall survival using multivariable Cox proportional hazard models.

RESULTS

Of 3,261 women included in the analysis, 45% had multimorbidity; obesity (53%), hypertension (41%), HIV (22%), and diabetes (13%) were the most common individual conditions. Women with multimorbidity had poorer overall survival at 3 years than women without multimorbidity in both the full cohort (60.8% vs. 64.3%, p = 0.036) and stage groups: stages I-II, 80.7% vs. 86.3% (p = 0.005), and stage III, 53.0% vs. 59.4% (p = 0.024). In an adjusted model, women with diabetes (hazard ratio (HR) = 1.20, 95% confidence interval (CI) = 1.03-1.41), CVD (HR = 1.43, 95% CI = 1.17-1.76), HIV (HR = 1.21, 95% CI = 1.06-1.38), obesity + HIV (HR = 1.24 95% CI = 1.04-1.48), and multimorbidity (HR = 1.26, 95% CI = 1.13-1.40) had poorer overall survival than women without these conditions.

CONCLUSIONS

Irrespective of the stage, multimorbidity at breast cancer diagnosis was an important prognostic factor for survival in our SABCHO cohort. The high prevalence of multimorbidity in our cohort calls for more comprehensive care to improve outcomes for South African women with breast cancer.

Screening Programs for Breast Cancer: Toward Individualized, Risk-Adapted Strategies of Early Detection

Early detection of breast cancer (BC) comprises two approaches: screening of asymptomatic women in a specified target population at risk (usually a target age range for women at average risk), and early diagnosis for women with BC signs and symptoms. Screening for BC is a key health intervention for early detection. While population-based screening programs have been implemented for age-selected women, the pivotal clinical trials have not addressed the global utility nor the improvement of screening performance by utilizing more refined parameters for patient eligibility, such as individualized risk stratification. In addition, with the exception of the subset of women known to carry germline pathogenetic mutations in (high- or moderately-penetrant) cancer predisposition genes, such as BRCA1 and BRCA2, there has been less success in outreach and service provision for the unaffected relatives of women found to carry a high-risk mutation (i.e., "cascade testing") as it is in these individuals for whom such actionable information can result in cancers (and/or cancer deaths) being averted. Moreover, even in the absence of clinical cancer genetics services, as is the case for the immediate and at least near-term in most countries globally, the capacity to stratify the risk of an individual to develop BC has existed for many years, is available for free online at various sites/platforms, and is increasingly being validated for non-Caucasian populations. Ultimately, a precision approach to BC screening is largely missing. In the present chapter, we aim to address the concept of risk-adapted screening of BC, in multiple facets, and understand if there is a value in the implementation of adapted screening strategies in selected women, outside the established screening prescriptions, in the terms of age-range, screening modality and schedules of imaging.

mHealth in sub-Saharan Africa and Europe: A systematic review comparing the use and availability of mHealth approaches in sub-Saharan Africa and Europe

Background

mHealth can help with healthcare service delivery for various health issues, but there's a significant gap in the availability and use of mHealth systems between sub-Saharan Africa and Europe, despite the ongoing digitalization of the global healthcare system.

Objective

This work aims to compare and investigate the use and availability of mHealth systems in sub-Saharan Africa and Europe, and identify gaps in current mHealth development and implementation in both regions.

Methods

The study adhered to the PRISMA 2020 guidelines for article search and selection to ensure an unbiased comparison between sub-Saharan Africa and Europe. Four databases (Scopus, Web of Science, IEEE Xplore, and PubMed) were used, and articles were evaluated based on predetermined criteria. Details on the mHealth system type, goal, patient type, health concern, and development stage were collected and recorded in a Microsoft Excel worksheet.

Results

The search query produced 1020 articles for sub-Saharan Africa and 2477 articles for Europe. After screening for eligibility, 86 articles for sub-Saharan Africa and 297 articles for Europe were included. To minimize bias, two reviewers conducted the article screening and data retrieval. Sub-Saharan Africa used SMS and call-based mHealth methods for consultation and diagnosis, mainly for young patients such as children and mothers, and for issues such as HIV, pregnancy, childbirth, and child care. Europe relied more on apps, sensors, and wearables for monitoring, with the elderly as the most common patient group, and the most common health issues being cardiovascular disease and heart failure.

Conclusion

Wearable technology and external sensors are heavily used in Europe, whereas they are seldom used in sub-Saharan Africa. More efforts should be made to use the mHealth system to improve health outcomes in both regions, incorporating more cutting-edge technologies like wearables internal and external sensors. Undertaking context-based studies, identifying determinants of mHealth systems use, and considering these determinants during mHealth system design could enhance mHealth availability and utilization.

Survival and predictors of breast cancer mortality in South Ethiopia: A retrospective cohort study

BACKGROUND

Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in over 100 countries. In March 2021, the World Health Organization called on the global community to decrease mortality by 2.5% per year. Despite the high burden of the disease, the survival status and the predictors for mortality are not yet fully determined in many countries in Sub-Saharan Africa, including Ethiopia. Here, we report the survival status and predictors of mortality among breast cancer patients in South Ethiopia as crucial baseline data to be used for the design and monitoring of interventions to improve early detection, diagnosis, and treatment capacity.

METHODS

A hospital-based retrospective cohort study was conducted among 302 female breast cancer patients diagnosed from 2013 to 2018 by reviewing their medical records and telephone interviews. The median survival time was estimated using the Kaplan-Meier survival analysis method. A log-rank test was used to compare the observed differences in survival time among different groups. The Cox proportional hazards regression model was used to identify predictors of mortality. Results are presented using the crude and adjusted as hazard ratios along with their corresponding 95% confidence intervals. Sensitivity analysis was performed with the assumption that loss to follow-up patients might die 3 months after the last hospital visit.

RESULTS

The study participants were followed for a total of 4,685.62 person-months. The median survival time was 50.81 months, which declined to 30.57 months in the worst-case analysis. About 83.4% of patients had advanced-stage disease at presentation. The overall survival probability of patients at two and three years was 73.2% and 63.0% respectively. Independent predictors of mortality were: patients residing in rural areas (adjusted hazard ratio = 2.71, 95% CI: 1.44, 5.09), travel time to a health facility ≥7 hours (adjusted hazard ratio = 3.42, 95% CI: 1.05, 11.10), those who presented within 7-23 months after the onset of symptoms (adjusted hazard ratio = 2.63, 95% CI: 1.22, 5.64), those who presented more than 23 months after the onset of symptoms (adjusted hazard ratio = 2.37, 95% CI: 1.00, 5.59), advanced stage at presentation (adjusted hazard ratio = 3.01, 95% CI: 1.05, 8.59), and patients who never received chemotherapy (adjusted hazard ratio = 6.69, 95% CI: 2.20, 20.30).

CONCLUSION

Beyond three years after diagnosis, patients from southern Ethiopia had a survival rate of less than 60% despite treatment at a tertiary health facility. It is imperative to improve the early detection, diagnosis, and treatment capacities for breast cancer patients to prevent premature death in these women.

Socioeconomic status index is an independent determinant of breast cancer screening practices: Evidence from Eastern China

BACKGROUND

Breast cancer is the most prevalent malignancy affecting Chinese women, and early routine screening is incredibly important for its prevention and control. This study aimed to investigate the role of socioeconomic status (SES) in female breast cancer screening practices using the composite SES index.

METHODS

This cross-sectional study involved 1816 women in Eastern China. Data were collected using an online self-administered questionnaire from January 2020 to May 2021. We used principal component analysis to construct the composite SES index using educational level, annual household income, and occupation. Logistic regression was used to analyze the association between the SES index and breast cancer screening utilization.

RESULTS

Of the participants, 19.27% reported having performed breast self-examination, 12.89% reported having undergone clinical breast examination, and 3.52% reported having received mammography. The SES has a significant influence on the patronage of female breast cancer screening in Eastern China. The composite SES index was found to have a positive and significant association with breast cancer screening practices. An interaction was found between the SES index and patient characteristics, such as health awareness, marital status, and location of residence. In addition, the SES index had a positive effect on breast cancer-related knowledge.

CONCLUSIONS

Socioeconomic inequalities existed in Eastern China and were related to breast cancer screening patronage. The composite SES index was identified as a significant determinant of breast cancer screening practices. Our results highlighted the negative impacts of socioeconomic inequities on female breast cancer screening utilization. This suggests that reducing socioeconomic inequalities in breast cancer screening requires more focused interventions and concerted outreach activities for groups with lower education levels, lower income, or lower occupational classes.

Global and regional estimates of orphans attributed to maternal cancer mortality in 2020

Despite women being disproportionally affected by cancer deaths at young ages, there are no global estimates of the resulting maternal orphans, who experience health and education disadvantages throughout their lives. We estimated the number of children who became maternal orphans in 2020 due to their mother dying from cancer in that year, for 185 countries worldwide and by cause of cancer-related death. Female cancer deaths-by country, cancer type and age (derived from GLOBOCAN estimates)-were multiplied by each woman's estimated number of children under the age of 18 years at the time of her death (fertility data were derived from United Nations World Population Prospects for birth cohort), accounting for child mortality and parity-cancer risk associations. Globally, there were 1,047,000 such orphans. Over half of these were orphans due to maternal deaths from breast (258,000, 25%), cervix (210,000, 20%) and upper-gastrointestinal cancers (136,000, 13%), and most occurred in Asia (48%: India 15%, China 10%, rest of Asia 23%) and Africa (35%). Globally, there were 40 new maternal orphans due to cancer per 100,000 children, with a declining trend with a higher Human Development Index (range: 121 in Malawi to 15 in Malta). An estimated 7 million children were prevalent maternal orphans due to cancer in mid-2020. Accelerating the implementation of the World Health Organization's cervical and breast cancer initiatives has the potential to avert not only millions of preventable female cancer deaths but also the associated, often-overlooked, intergenerational consequences of these deaths.

Current and future burden of breast cancer: Global statistics for 2020 and 2040

BACKGROUND

Breast cancer is the most commonly diagnosed cancer worldwide, and its burden has been rising over the past decades. In this article, we examine and describe the global burden of breast cancer in 2020 and predictions for the year 2040.

METHODS

Estimates of new female breast cancer cases and deaths in 2020 were abstracted from the GLOBOCAN database. Age-standardized incidence and mortality rates were calculated per 100,000 females by country, world region, and level of human development. Predicted cases and deaths were computed based on global demographic projections for the year 2040.

RESULTS

Over 2.3 million new cases and 685,000 deaths from breast cancer occurred in 2020. Large geographic variation across countries and world regions exists, with incidence rates ranging from <40 per 100,000 females in some Asian and African countries, to over 80 per 100,000 in Australia/New Zealand, Northern America, and parts of Europe. Smaller geographical variation was observed for mortality; however, transitioning countries continue to carry a disproportionate share of breast cancer deaths relative to transitioned countries. By 2040, the burden from breast cancer is predicted to increase to over 3 million new cases and 1 million deaths every year because of population growth and ageing alone.

CONCLUSION

Breast cancer is the most common cancer worldwide and continues to have a large impact on the global number of cancer deaths. Global efforts are needed to counteract its growing burden, especially in transitioning countries where incidence is rising rapidly, and mortality rates remain high.

Physical Activity and Breast Cancer Survival-Epidemiologic Evidence and Potential Biologic Mechanisms

PURPOSE OF REVIEW

To review the biologic mechanisms that may be operative between physical activity and survival after breast cancer.

RECENT FINDINGS

Physical activity decreases risk of mortality from breast cancer by up to 40%. Several biologic mechanisms have been hypothesized to explain this association. Previous cohort studies and randomized trials have examined the primary mechanisms that appear to be operative, which involve a decrease in sex hormone levels, insulin resistance, and inflammation. The evidence is still inconsistent and several limitations in the existing literature exist. Understanding the biologic mechanisms involved in the association of physical activity and breast cancer survival will provide more precision to physical activity guidelines for cancer survival. To achieve this objective, future research should include direct measurements of physical activity, sedentary behaviour, and health-related fitness to provide a more comprehensive assessment of these factors and their association with biomarkers and survival after breast cancer.

Survival of patients operated on for breast cancer in Ouagadougou/Burkina Faso

BACKGROUND AND OBJECTIVES

Breast cancer is the most common cancer in women. The objective is to study the survival of patients operated on for breast cancer.

METHODS

Descriptive and analytical study of the survival of patients operated on for breast cancer between January 1, 2013 and December 31, 2020 in Ouagadougou. Survival was assessed by the Kaplan-Meier method and comparisons by the log-rank test. Prognostic factors were determined using the Cox model.

RESULTS

We collected 550 cases. Overall survival at 5 years was 66.2%. Those under 30 years of age had a low 5-year overall survival (53%). The 5-year overall survival was poor in rural patients (63.5%), triple-negative patients (77.2%), HER2+ patients (50.5%) and stage IV patients (29.8%). In multivariate analysis, higher education (p < 0.001) and higher socioeconomic level (p < 0.001) were associated with better prognoses.

CONCLUSIONS

The survival of patients operated on for breast cancer remains to be improved. It is influenced by multiple factors especially the socio-economic and educational level of the patients.