World Health Organization cancer priorities in developing countries

Targeted therapies of curcumin focus on its therapeutic benefits in cancers and human health: Molecular signaling pathway-based approaches and future perspectives

The curry powder spices turmeric (Curcuma longa L.), which contains curcumin (diferuloylmethane), an orange-yellow chemical. Polyphenols are the most commonly used sources of curcumin. It combats oxidative stress and inflammation in diseases, such as hyperlipidemia, metabolic syndrome, arthritis, and depression. Most of these benefits are due to their anti-inflammatory and antioxidant properties. Curcumin consumption leads to decreased bioavailability, resulting in limited absorption, quick metabolism, and quick excretion, which hinders health improvement. Numerous factors can increase its bioavailability. Piperine enhances bioavailability when combined with curcumin in a complex. When combined with other enhancing agents, curcumin has a wide spectrum of health benefits. This review evaluates the therapeutic potential of curcumin with a specific emphasis on its approach based on molecular signaling pathways. This study investigated its influence on the progression of cancer, inflammation, and many health-related mechanisms, such as cell proliferation, apoptosis, and metastasis. Curcumin has a significant potential for the prevention and treatment of various diseases. Curcumin modulates several biochemical pathways and targets involved in cancer growth. Despite its limited tissue accumulation and bioavailability when administered orally, curcumin has proven useful. This review provides an in-depth analysis of curcumin's therapeutic applications, its molecular signaling pathway-based approach, and its potential for precision medicine in cancer and human health.

A Review of Community Awareness for Colorectal Cancer Screening and Prevention in North and Central Asian Countries

OBJECTIVES

Colorectal cancer (CRC) incidence and mortality rates are increasing in low- and middle-income countries (LMIC), including North and Central Asian countries (NCAC). Screening and risk factor reduction can aid in the prevention of colorectal cancer, but communities lack awareness of these screening programs. The review assessed community awareness about CRC screening and prevention in NCAC to facilitate cancer control policies. Study type and methods: For this scoping review, we searched PubMed/Medline, Embase, and the Cochrane Library for articles on community awareness about CRC screening and prevention in NCAC according to inclusion and exclusion criteria.

RESULTS

Eight of 677 articles from five of the 15 NCAC countries met the criteria. Most of the studies utilized a survey design. The results indicated low awareness of the availability of CRC screening and poor knowledge of CRC symptoms. Knowledge of CRC screening modalities was also inadequate. Some countries also lack CRC screening programs.

CONCLUSION

Community unawareness is a significant barrier to screening program utilization and sustenance. Community health awareness programs (CHAP) are needed to improve the uptake of CRC screening in NCAC. The NCAC should include CHAP as an integral component of the CRC control plan. Long-term cancer control in LMIC could be adapted using the step-ladder pyramidal approach.

Anti-proliferative activity of Artemisia marschalliana on cancerous cell lines

BACKGROUND

The genus Artemisia of the Asteraceae family has different species that are used in the treatment of a wide range of diseases, including cancers due to the presence of valuable compounds and important medicinal properties. Various studies on the anti-tumor effect of different species of Artemisia have proven the cytotoxic properties of these plants in cancer treatment, and several anti-cancer compounds of this genus have been purified.

OBJECTIVE

The objective of this study was to investigate the cytotoxicity and related mortality mechanisms of Artemisia marschalliana essential oil and extracts.

METHODS

The essential oil and various extracts of Artemisia marschalliana were elicited using a Soxhlet extractor. Anti-cancer to anti-proliferative activity as MTT assay is measuring cancerous and non-cancerous cell viability. In the next step, the strongest extract fractions were obtained by using the vacuum liquid chromatography method. Flow cytometry was applied to identify the mechanism of cell death, and a Real-time polymerase chain reaction test of apoptosis genes, which encode apoptosis-regulating proteins, was measured to confirm the flow cytometry results.

RESULTS

The strongest extract belonged to dichloromethane extract 60% fraction of the extract on breast cancer cells and 80% fraction on liposarcoma cancer cells showed the most cytotoxicity within 48 h, while, the fractions did not notable cytotoxicity of non-cancerous cells cell. Flow cytometry analysis illustrated the mentioned extract and its fractions kill cancer cell lines through the apoptosis mechanism. Our findings confirmed the flow cytometry results. In addition, the essential oil of Artemisia marschalliana showed a considerable cytotoxic property.

CONCLUSION

Dichloromethane extract of Artemisia marschalliana shoot and its 60 and 80% fraction selectively inhibited the growth of cancer cells by inducing the apoptosis mechanism. Regarding obtained results, 60 and 80% fractions of dichloromethane extract can be a good candidate for future studies in the field of identification and separation of pure cytotoxic compounds.

What women want: A mixed-methods study of women's health priorities, preferences, and experiences in care in three Rwandan rural districts

OBJECTIVE

To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda.

METHODS

We used a mixed-methods, exploratory sequential design. Semi-structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross-sectional quantitative survey based on the qualitative data was administered to women attending health centers.

RESULTS

Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care.

CONCLUSION

These findings provide useful insights to inform development of non-pregnancy-related healthcare services for women in Rwanda according to their priorities and preferences. The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.

A commentary on cancer prevention and control in India: Priorities for realizing SDGs

In India, cancers along with cardiovascular diseases contribute to significant mortality and morbidity. With less than 10 years remaining towards achieving Sustainable development Goals (SDGs), public health systems in India need to be critically assessed and strengthened, for addressing non-communicable diseases (NCDs) in general and cancers in particular. Our Commentary address the public health response to cancer prevention and control, with specific pointers based on emerging evidence. The relevant issues are stratified as: emphasis on the critical appraisal of national programs, strengthening primary health care (PHC) systems, enhancing focus on client and community centricity, exploring integrative approaches to cancer management and stepping up implementation and multidisciplinary research. Ongoing surveillance is essential to assess the current and future trends of cancer as well as the outcomes of prevention and treatment measures. For revitalizing comprehensive PHC, much depends on our epidemiological capacity and surveillance systems which impart information for local planning. It is imperative to address the cultural barriers and societal norms, which limit the acceptability and participation in screening programs. SDG 3 has ushered the wellbeing agenda at an opportune time. There is a compelling need to conduct research on an integrated approach (ayurveda complimenting allopathic medication) for the treatment of cancer. The unique challenges posed by the rise in NCD morbidity in LMIC, requires horizontal integration of the health systems with new services focused on cancer control.

Current studies and future promises of PD-1 signal inhibitors in cervical cancer therapy

PD-1 (Programmed cell death-1) is a receptor that inhibits the activation of T cells and is an important target for cancer immunotherapy. PD-1 expression stays high on antigen-specific T cells that have been stimulated for a long time, making them less responsive to stimuli. Consequently, there has been a recent surge in the number of researchers focusing on how the PD-1 axis delivers inhibitory signals to uncover new therapeutic targets. As an inhibitory signaling mechanism, the PD-1 axis controls immunological responses. Blocking the PD-1 axis has been shown to have long-lasting effects on various cancers, demonstrating the crucial role of PD-1 in blocking anti-tumor immunity. Despite this role, most patients do not respond to PD-1 monotherapy, and some have experienced adverse events. Many challenges remain regarding the PD-1 signaling axis to be addressed. In this review, we outline the most recent research and prospects of PD-1 signal inhibitors to enhance cervical cancer therapy.

Cancer Groundshot: Building a Robust Cancer Control Platform in Addition To Launching the Cancer Moonshot

Cancer Groundshot is a philosophy that calls for prioritization of strategies in global cancer control. The underlying principle of Cancer Groundshot is that one must ensure access to interventions that are already proven to work before focusing on the development of new interventions. In this article, we discuss the philosophy of Cancer Groundshot as it pertains to priorities in cancer care and research in low- and middle-income countries and the utility of technology in addressing global cancer disparities; we also address disparities seen in high-income countries. The oncology community needs to realign our priorities and focus on improving access to high-value cancer control strategies, rather than allocating resources primarily to the development of technologies that provide only marginal gains at a high cost. There are several "low-hanging fruit" actions that will improve access to quality cancer care in low- and middle-income countries and in high-income countries. Worldwide, cancer morbidity and mortality can be averted by implementing highly effective, low-cost interventions that are already known to work, rather than investing in the development of resource-intensive interventions to which most patients will not have access (i.e., we can use Cancer Groundshot to first save more lives before we focus on the "moonshots").

Advances in microfluidics devices and its applications in personalized medicines

Microfluidics is an exponentially growing area and is being used for numerous applications from basic science to advanced biotechnology and medicines. Microfluidics provides a platform to the research community for studying and building new strategies for the diagnosis and therapeutics applications. In the last decade, microfluidic have enriched the field of diagnostics by providing new solutions which was not possible with conventional detection and treatment methods. Microfluidics has the ability to precisely control and perform high-throughput functions. It has been proven as an efficient and rapid method for biological sample preparation, analysis and controlled drug delivery system. Microfluidics plays significant role in personalized medicine. These personalized medicines are used for medical decisions, practices and other interventions as well as for individual patients based on their predicted response or risk of disease. This chapter highlights microfluidics in developing personalized medical applications for its applications in diseases such as cancer, cardiovascular disease, diabetes, pulmonary disease and several others.

Epidemiological Trends of Breast Cancer in Southern Ethiopia: A Seven-Year Retrospective Review

INTRODUCTION

African women are affected by cancer at an early age of their productivity. However, the exact prevalence and incidence of cancer, including breast cancer is not known in most sub-Saharan African countries, including Ethiopia because of lack of well-established cancer registry. This study aims to assess the epidemiology of breast cancer at Hawassa University Comprehensive Specialized Hospital (HUCSH), the biggest referral hospital with cancer treatment center serving the southern part of the country.

METHODS

Retrospective review of charts of all patients with a diagnosis of breast cancer between 2013 and 2019 at HUCSH was conducted. A standardized questionnaire was used to collect relevant data that include sociodemographic, symptoms, type of diagnosis, treatment, and outcomes. Data were entered using epidata version 3.1 and analyzed using MS Excel and SPSS version 20.

RESULTS

Five hundred fifty-nine (18.6%) breast cancer cases were retrieved in 7 years between 2013 and 2019. Of this, 548 (98%) were women. The median ages of the patents were 38 years. Invasive ductal carcinoma was the leading 309 (55.3%) histologic type followed by 185 (33.1%) lobular carcinoma. One hundred seventy-seven (31.7%) were moderately differentiated and 155 (27.7%) were poorly differentiated. Three hundred seventy-two (66.5%) were advanced breast cancer (Stages III and IV). Trends of breast cancer showed the case load is continuously increasing except with a slight reduction of cases in between 2015 and 2016. The majority were advanced breast cancer occurring at an early age by the time diagnosis made. Invasive ductal carcinomas were the predominant one. The trend also showed a continuous increment of cancer case load. Therefore, cancer registration center establishment, community awareness creation, and intensive early detection strategy are mandatory.

New confinement index and new perspective for comparing countries - COVID-19

BACKGROUND AND OBJECTIVE

In the difficult problem of comparing countries regarding their lockdown measures or deaths caused by the COVID-19, there is still no agreement on what is the best strategy to follow. Thus, we propose a new way of comparison countries that avoids the main difficulties in the comparison by using three-dimensional trajectories for this type of data.

METHODS

We introduce a new index to analyze the level of confinement that each country was subject to overtime, based on the Community Mobility Reports published by Google resorting to Principal Component Analysis. Subsequently, by using longitudinal clustering, we divide the European countries into similar groups according to the COVID-19 obits and also to the confinement index. However, to make the most out of the clustering methods we resort to artificial longitudinal data to evaluate both the methods and the indices.

RESULTS

By using artificial data, we discover that Calinski-Harabasz outperformed other internal indices in indicating the real number of clusters. The tests also suggested that K-means with Euclidean distance was the best method among the ones studied. With the application to both the mobility and fatalities datasets, we found two groups in each one.

CONCLUSIONS

Our analysis enables us to discover that European northern countries had more mobility during the first confinement and that the deaths caused by COVID-19 started to drop around the 40th day since the first death.

Extracellular Vesicles (Exosomes) as Immunosuppressive Mediating Variables in Tumor and Chronic Inflammatory Microenvironments

Exosomes are extracellular vesicles released by most of the eukaryotic cells. Exosomes’ components include proteins, lipids, microRNA, circular RNA, long noncoding RNA, DNA, etc. Exosomes may carry both pro and anti-inflammatory cargos; however, exosomes are predominantly filled with immunosuppressive cargos such as enzymes and microRNAs in chronic inflammation. Exosomes have surfaced as essential participants in physiological and pathological intercellular communication. Exosomes may prevent or promote the formation of an aggressive tumor and chronic inflammatory microenvironments, thus influencing tumor and chronic inflammatory progression as well as clinical prognosis. Exosomes, which transmit many signals that may either enhance or constrain immunosuppression of lymphoid and myeloid cell populations in tumors, are increasingly becoming recognized as significant mediators of immune regulation in cancer. In this review, we outline the function of exosomes as mediators of immunosuppression in tumor and chronic inflammatory microenvironments, with the aim to improve cancer therapy.

Implementing Cancer Care in Rwanda: Capacity Building for Treatment and Scale-Up

Background: The majority of countries in sub-Saharan Africa are ill-prepared to address the rising burden of cancer. While some have been able to establish a single cancer referral center, few have been able to scale-up services nationally towards universal health coverage. The literature lacks a step-wise implementation approach for resource-limited countries to move beyond a single-facility implementation strategy and implement a national cancer strategy to expand effective coverage. Methods: We applied an implementation science framework, which describes a four-phase approach: Exploration, Preparation, Implementation, and Sustainment (EPIS). Through this framework, we describe Rwanda’s approach to establish not just a single cancer center, but a national cancer program. Results: By applying EPIS to Rwanda’s implementation approach, we analyzed and identified the implementation strategies and factors, which informed processes of each phase to establish foundational cancer delivery components, including trained staff, diagnostic technology, essential medicines, and medical informatics. These cancer delivery components allowed for the implementation of Rwanda’s first cancer center, while simultaneously serving as the nidus for capacity building of foundational components for future cancer centers. Conclusion: This “progressive scaling” approach ensured that initial investments in the country’s first cancer center was a step toward establishing future cancer centers in the country.

G-quadruplex stabilization via small-molecules as a potential anti-cancer strategy

G-quadruplexes (G4) are secondary four-stranded DNA helical structures consisting of guanine-rich nucleic acids, which can be formed in the promoter regions of several genes under proper conditions. Several cancer cells have been shown to emerge from genomic changes in the expression of crucial growth-regulating genes that allow cells to develop and begin to propagate in an undifferentiated state. Recent attempts have focused on producing treatments targeted at particular protein products of genes that are abnormally expressed. Many of the proteins found are hard to target and considered undruggable due to structural challenges, protein overexpression, or mutations that affect treatment resistance. The utilization of small molecules that stabilize secondary DNA structures existing in several possible oncogenes' promoters and modulate their transcription is a new strategy that avoids some of these problems. In this review, we outline the function of G-quadruplex stabilization in cancer by small-molecules with the aim to improve cancer therapy.

Incidence of sepsis and associated mortality within the first year after cancer diagnosis in middle aged adults: A US population based study

Background

The incidence of sepsis has been rising overall but updated data in cancer patients are lacking. After a cancer diagnosis, incidence of sepsis and overall mortality peak within the first year. However, how much sepsis contributes to mortality remains unclear. We used a multistate model approach to analyze the incidence, risk factors and associated mortality of sepsis within 1 year of cancer diagnosis in middle aged adults.

Methods

Analysis of a large US health insurance claims database (Marketscan) between 2005 and 2014. Patients with a new diagnosis of cancer who received chemotherapy were included. Within a year of diagnosis, we assessed inpatient admissions for sepsis based on ICD-9 codes and survival using hospitalizations, outpatient visits and prescriptions filled. Competing risk and multistate models were used to assess the incidence of sepsis and transition probabilities between cancer, sepsis and death.

Results

119,379 patients (38.9% males), aged 55 (50–60) years, were included; 2,560 developed isolated sepsis, 477 severe sepsis and 1331 septic shock within 1 year, with associated hospital mortality of 14.8%, 30% and 46% respectively. The probability of sepsis increased between 2005 and 2014; at 1 year, its cumulative incidence was 3.7% with a probability of mortality after sepsis of 35.5% (95% CI 21.6%-50.9%). Age, male gender, Charlson comorbidity index, hematological malignancies and metastases at diagnosis were associated with sepsis and mortality.

Conclusions

Incidence and mortality of sepsis were 3.7% and 35.5% at 1 year after cancer diagnosis and were both associated with baseline patient and cancer characteristics.

Prognostic role of microRNA 182 and microRNA 18a in locally advanced triple negative breast cancer

Background

The study assessed the epigenetic regulation and the role of microRNA (miR) expression in locally advanced triple negative breast cancers (TNBC) and comparison with the clinico-pathological variables and survival.

Methods

Fifty patients of locally advanced TNBC during the period 2011–2013 were included. Expression level of test microRNA (miR-182 and miR-18a) was determined using Taqman quantitative Real time polymerase chain reaction (qRT-PCR) from formalin fixed paraffin embedded biopsy blocks. Clinical and demographic information and survival data was retrieved from the Hospital medical records.

Results

An improved clinical complete response (cCR) was observed in patients with age ≥ 45 years (80%), premenopausal status (70%), tumor size < 6 cms (80%), nodal status N0-N1 (95%) and grade II-III tumor (80%). A statistically significant correlation was observed on comparison of cCR with menopausal status (p-value 0.020), T category (p-value 0.018) and the clinical nodal status (p-value 0.003). pCR also correlated with clinical nodal status (p-value 0.008). Epigenetically, miR-18a under expression (< 8.84) was most commonly associated with tumor size < 6 cms (76.7%), clinical nodal status N0-N1 (90%), cCR (60%) and pCR (53.3%). A similar trend was observed with miR-182. Statistical significance was observed with T category (p-values 0.003 and 0.004), clinical nodal status (p-values 0.001 and 0.001), clinical response (p-values 0.002 and 0.002) and pathological response (p-values 0.007 and 0.006) with respect to miR-18a and miR-182, respectively. Also, the menopausal status significantly correlated with the miR-182 expression (p-value 0.009). miR-182 overexpression (≥ 6.32) was not observed in any of the postmenopausal patients. A univariate cox proportional hazard regression model also showed statistical interactions (p-values <0.004).

Conclusion

miR-182 and miR-18a overexpression correlates with worse clinical and pathological tumor characteristics in locally advanced TNBC and hence could be used to predict the outcomes and prognosis in these patients.

[Analysis of Prognosis according to Type of Health Insurance in Five Major Gastrointestinal Cancer Patients in Public Hospitals: Single-institution Retrospective Study]

Background/Aims

Public hospitals were established to provide high quality medical services to low socioeconomic status patients. This study examined the effects of public hospitals on the treatment and prognosis of patients with five-major gastrointestinal (GI) cancers (stomach cancer, colon cancer, liver cancer, bile duct cancer, and pancreatic cancer).

Methods

Among the 1,268 patients treated at Seoul National University Boramae Medical Center from January 2010 to December 2017, 164 (13%) were in the medicare group. The data were analyzed to identify and compare the clinical manifestations, treatment modality, and clinical outcomes between the groups.

Results

No statistically significant differences in the clinical data (age, sex), treatment method, and five-year survival rate were observed between the health insurance group and medicare group in the five major GI cancer patients. On the other hand, some medicare group patients tended more comorbidities and fewer treatment options than health insurance patients.

Conclusions

Public hospitals have a positive effect on the treatment and prognosis in medicare group patients with the five-major GI cancers.

Human MYC G-quadruplex: From discovery to a cancer therapeutic target

Overexpression of the MYC oncogene is a molecular hallmark of both cancer initiation and progression. Targeting MYC is a logical and effective cancer therapeutic strategy. A special DNA secondary structure, the G-quadruplex (G4), is formed within the nuclease hypersensitivity element III₁ (NHE III₁) region, located upstream of the MYC gene's P1 promoter that drives the majority of its transcription. Targeting such G4 structures has been a focus of anticancer therapies in recent decades. Thus, a comprehensive review of the MYC G4 structure and its role as a potential therapeutic target is timely. In this review, we first outline the discovery of the MYC G4 structure and evidence of its formation in vitro and in cells. Then, we describe the functional role of G4 in regulating MYC gene expression. We also summarize three types of MYC G4-interacting proteins that can promote, stabilize and unwind G4 structures. Finally, we discuss G4-binding molecules and the anticancer activities of G4-stabilizing ligands, including small molecular compounds and peptides, and assess their potential as novel anticancer therapeutics.

Wealth-related inequalities of women's knowledge of cervical cancer screening and service utilisation in 18 resource-constrained countries: evidence from a pooled decomposition analysis

INTRODUCTION

Resource-constrained countries (RCCs) have the highest burden of cervical cancer (CC) in the world. Nonetheless, although CC can be prevented through screening for precancerous lesions, only a small proportion of women utilise screening services in RCCs. The objective of this study was to examine the magnitude of inequalities of women's knowledge and utilisation of cervical cancer screening (CCS) services in RCCs.

METHODS

A total of 1,802,413 sample observations from 18 RCC's latest national-level Demographic and Health Surveys (2008 to 2017-18) were analysed to assess wealth-related inequalities in terms of women's knowledge and utilisation of CCS services. Regression-based decomposition analyses were applied in order to compute the contribution to the inequality disparities of the explanatory variables for women's knowledge and utilisation of CCS services.

RESULTS

Overall, approximately 37% of women had knowledge regarding CCS services, of which, 25% belonged to the poorest quintile and approximately 49% from the richest. Twenty-nine percent of women utilised CCS services, ranging from 11% in Tajikistan, 15% in Cote d'Ivoire, 17% in Tanzania, 19% in Zimbabwe and 20% in Kenya to 96% in Colombia. Decomposition analyses determined that factors that reduced inequalities in women's knowledge of CCS services were male-headed households (- 2.24%; 95% CI: - 3.10%, - 1.59%; P < 0.01), currently experiencing amenorrhea (- 1.37%; 95% CI: - 2.37%, - 1.05%; P < 0.05), having no problems accessing medical assistance (- 10.00%; 95% CI: - 12.65%, - 4.89%; P < 0.05), being insured (- 6.94%; 95% CI: - 9.58%, - 4.29%; P < 0.01) and having an urban place of residence (- 9.76%; 95% CI: - 12.59%, - 5.69%; P < 0.01). Similarly, factors that diminished inequality in the utilisation of CCS services were being married (- 8.23%;95% CI: - 12.46%, - 5.80%; P < 0.01), being unemployed (- 14.16%; 95% CI: - 19.23%, - 8.47%; P < 0.01) and living in urban communities (- 9.76%; 95% CI: - 15.62%, - 5.80%; P < 0.01).

CONCLUSIONS

Women's knowledge and utilisation of CCS services in RCCs are unequally distributed. Significant inequalities were identified among socioeconomically deprived women in the majority of countries. There is an urgent need for culturally appropriate community-based awareness and access programs to improve the uptake of CCS services in RCCs.

The Situation of Cancer Treatment in Ethiopia: Challenges and Opportunities

Background

Less attention is given to cancer treatment and control in Ethiopia.

Methods

To investigate the challenges and opportunities facing cancer treatment services in Ethiopia. A purposive sampling technique was applied to recruit the study subjects from Black Lion Specialized Hospital Oncology Department. A semi-structured interview guide was used to investigate challenges and opportunities in oncology service in Ethiopia. Data was transcribed and coded by two independent coders and analyzed thematically in reference to the objectives.

Results

Fifteen professionals from four different disciplines were interviewed on opportunities and challenges facing cancer treatment in Ethiopia. Out of these respondents 3 were senior clinical oncologists while 4 individuals were senior oncology residents. The rest were 2 medical Physicists, 2 radiotherapy technologists and 4 oncology nurses. Majority (80%) of the respondents were males. We demonstrate that the challenges of cancer treatment service in Ethiopia emanate from the patients themselves, the administrating body, the professionals, and the technology limitations. In general, the result of this study was grouped under the following five themes: Customer-related challenges, provider-related challenges, facility-related challenges, technology-related challenges and the opportunities.

Conclusions

Several assignments are waiting for the policy makers, the professionals, the communities and other concerned bodies to combat the alarmingly growing burden of cancer in Ethiopia. Escalating the awareness of the general population about cancer, expanding well-developed diagnostic and treatment centers, and producing well-trained competent oncology professionals are the forefront challenges in combating cancer in Ethiopia.

Diagnostic Accuracy of Axillary Ultrasonography Compared with Intra-operative Pathological Findings in Patients with Breast Cancer

Objective:

Breast cancer is the most common cancer and leading cause of mortality in women worldwide. Diagnosis of axillary lymph node involvement, frequently by axillary ultrasonography (AUS), is an important step in patients with primary breast cancer, while the gold standard pathological examination is only applicable during surgery. Thus, we aimed to evaluate the predictive value of AUS in detection of lymph node involvement.

Methods:

A total of 56 patients with primary breast cancer, who were candidate of mastectomy were included in this study. A single radiologist performed pre-operative axillary sonography for all the patients and reported the results in a checklist. The results were then compared with intra-operative pathological results of lymph node dissection to evaluate the sensitivity, specificity, positive and negative predictive values of AUS in detection of the disease.

Result:

The results showed that pre-operative AUS had a sensitivity of 63.3%, specificity of 84.6%, positive predictive value of 82.6%, and negative predictive value of 66.6%. Correlation between axillary lymph node characteristics revealed that the absence of fatty hilum, cortical thickness, and loss of ovality of the lymph nodes were the most specific factors in detection of lymph nodes’ involvement.

Conclusion:

AUS has a low sensitivity and cannot determine the presence of micro-metastases and suspicious lymph nodes accurately in early stages of the disease, and it seems that defining new parameters may help for increasing the sensitivity and specificity of the axillary lymph node sonography. Apparently, pathological examination remains the gold standard diagnostic method.

Trends on cancer incidence and mortality in Pasto, Colombia. 15 years experience

INTRODUCTION

In Colombia it is necessary to continue producing quality and continuously updated information on the magnitude of cancer, derived from population-based cancer registries to contribute to decision making, and implementation of strategies for health promotion, prevention and treatment of cancer in order to reduce the impact on the population.

OBJECTIVE

To describe the incidence, mortality and cancer trends in Pasto-Colombia from 1998 to 2012.

METHODS

Observational descriptive study of morbi - mortality due to malignant tumours in Pasto. The collection, processing and systematization of the data, was carried out according to international standards for population-based cancer registries. The incidence and mortality rates were calculated by period, sex, age and tumour site.

RESULTS

During the period 1998-2012 there were 8,010 new cases of cancer, of them, 57.7% occurred in females. There were 4,214 deaths reported, 52.0% in females. The incidence (p men= 0.7, p females= 0.3) and mortality (p males= 1.0, p females= 0.0) did not present significant changes over 15 years of observation and the tumours that cause greater morbi-mortality affect the stomach, cervix uteri, breast and prostate.

CONCLUSIONS

Cancer in general, continues to be a serious health problem for the population of Pasto. The global behaviour of cancer incidence and mortality, identify the need to promote and strengthen promotion and prevention programs, especially focused on tumours of the stomach, prostate, breast and cervix uteri that produce greater morbidity and mortality in the population.

Delays in Breast Cancer Detection and Treatment in Developing Countries

Breast cancer is the most common cancer in women in both developed and developing countries and the second most common cancer in the world. Developing countries are increasingly adopting a Western lifestyle, such as changes in diet and delayed first childbirth, lower parity, and shorter periods of breastfeeding, which are important determinants of a higher incidence of breast cancer among those regions. Low- and middle-income countries (LMICs) represent most of the countries with the highest mortality rates, ranging from 40% to 60%. Furthermore, developing countries account for scarce survival data, and the few data available coincide with the observed incidence and mortality differences. Five-year survival rates for breast cancer are much worse for LMICs countries such as Brazil, India, and Algeria in comparison with the United States and Sweden. Paucity of early detection programs explain these poor survival rates, which results in a high proportion of women presenting with late-stage disease, along with lack of adequate diagnosis and treatment facilities. Emphasis is urgently needed on health education, to promote early diagnosis of breast cancer, highlighting the importance of creating more public facilities that provide treatment, which are key components for the improvement in breast cancer care in developing countries.

The Unmet Needs of the Family Caregivers of Patients with Cancer Visiting a Referral Hospital in Iran

Objective:

The complex process of taking care of patients with cancer can affect various aspects of the needs and health of their family caregivers. The present study aims to determine the unmet needs of the family caregivers of patients with cancer and to compare it according to background variables.

Methods:

The present descriptive study recruited 200 family caregivers of patients with cancer visiting a referral hospital in Iran. Sampling was carried out through the convenience method. Data were collected using Shin's comprehensive needs assessment tool in seven domains (health and psychological problems, family/social support, healthcare staff, information, religious/spiritual support, hospital facilities/services, and practical support).

Results:

The mean (±standard deviation) of the total scores of the unmet needs of the family caregivers was 81.73 (±16.82), with a possible range of 0–123. A significant percentage of the family caregivers of patients with cancer had unmet needs in all of the seven domains with different severities. The mean scores were higher in the information, healthcare staff (physicians and nurses), and health and psychological problems domains as compared to the other domains.

Conclusions:

The results showed that the majority of the family caregivers of patients with cancer have many unmet needs, which should be addressed by professional care providers through the development of holistic care programs targeting family caregivers by focusing on information needs and a proper communication process.

Delivery of Global Cancer Care: An International Study of Medical Oncology Workload

Background

To our knowledge, there is no literature that has described medical oncology (MO) workload in the global context. Here, we report results of an international study of global MO workload.

Methods

An online survey was distributed through a snowball method via national oncology societies to chemotherapy-prescribing physicians in 65 countries. Countries were classified into low- or low-middle–income countries (LMICs), upper-middle–income countries (UMICs), and high-income countries (HICs) on the basis of World Bank criteria. Workload was measured as the annual number of new consultations provided to patients with cancer per oncologist.

Results

A total of 1,115 physicians completed the survey: 13% (147 of 1,115) from LMICs, 17% (186 of 1,115) from UMICs, and 70% (782 of 1,115) from HICs. Eighty percent (897 of 1,115) of respondents were medical oncologists, 10% (109 of 1,115) were clinical oncologists, and 10% (109 of 1,115) were other. The median number of annual consults per oncologist was 175 (interquartile range, 75 to 275); 13% (140 of 1,103) saw ≥ 500 new patients in a year. Annual case volume in LMICs (median consults, 425; 40% of respondents seeing > 500 consults) was substantially higher than in UMICs (median consults, 175; 14% > 500) and HICs (median consults, 175; 7% > 500; P < .001). Among LMICs, UMICs, and HICs, median working days per week were 6, 5, and 5, respectively (P < .001). The highest annual case volumes per oncologist were in Pakistan (median consults, 950; 73% > 500 consults), India (median consults, 475; 43% > 500), and Turkey (median consults, 475; 27% > 500).

Conclusion

There is substantial global variation in medical oncology case volumes and clinical workload; this is most striking among LMICs, where huge deficits exist. Additional work is needed, particularly detailed country-level mapping, to quantify activity-based global MO practice and workload to inform training needs and the design of new pathways and models of care.

Smoking and Lung Cancer: A Geo-Regional Perspective

Lung cancer is the leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) represents the most frequently diagnosed subtype of this morbid malignancy. NSCLC is causally linked to tobacco consumption with more than 500 million smokers worldwide at high risk for this fatal malignancy. We are currently lagging in our knowledge of the early molecular (e.g., genomic) effects of smoking in NSCLC pathogenesis that would constitute ideal markers for early detection. This limitation is further amplified when considering the variable etiologic factors in NSCLC pathogenesis among different regions around the globe. In this review, we present our current knowledge of genomic alterations arising during early stages of smoking-induced lung cancer initiation and progression, including discussing the premalignant airway field of injury induced by smoking. The review also underscores the wider spectra and higher age-adjusted rates of tobacco (e.g., water-pipe smoke) consumption, along with elevated environmental carcinogenic exposures and relatively poorer socioeconomic status, in low-middle income countries (LMICs), with Lebanon as an exemplar. This “cocktail” of carcinogenic exposures warrants the pressing need to understand the complex etiology of lung malignancies developing in LMICs such as Lebanon.

Gatekeepers' perceptions of the quality and availability of services for breast and cervical cancer patients in the English-speaking Windward Islands: an exploratory investigation

PURPOSE

Although extensive screening services for breast and cervical cancers are available in the Caribbean, these cancers continue to be the leading causes of cancer death among women in this region. The purpose of this study was to determine the quality and availability of breast and cervical cancer treatment care and support services from the perspective of the gatekeepers who provide care for the patients in the Windward Islands of Dominica, Grenada, St Lucia, and St. Vincent.

METHODS

A qualitative research design using semi-structured, in-depth interviews was used to gather data from gatekeepers who provided oncology prevention and care services to patients for at least one year. Data were collected on availability and quality of cancer care and treatment services and coded using the themes obtained via thematic analysis of the data.

RESULTS

Twenty-three current providers participated in the study (Dominica, 5; Grenada, 7; St. Lucia, 5; St. Vincent and the Grenadines, 6). The participants' years of work experience ranged from 2 to 45 years. The codes encompassed a range of social ecological factors that influence breast and cervical cancer screening and treatment in the Windward Islands. The emergent themes were availability of resources, cost of care, and social support.

CONCLUSION

The findings of this study emphasize the varying social determinants of health that affect breast and cervical cancer prevention and treatment. It also highlights the disparities in availability of treatment within the wider Caribbean. It is necessary to broaden the perspective on health from a purely biomedical paradigm to a social perspective.

Sulfatase inhibitors for recidivist breast cancer treatment: A chemical review

Steroid sulfatase (STS) plays a momentous role in the conversion of sulfated steroids, which are biologically inactive, into biologically active un-sulfated steroid hormones, which support the development and growth of a number of hormone-dependent cancers, including breast cancer. Therefore, inhibitors of STS are supposed to be potential drugs for the treatment of breast and other steroid-dependent cancers. The present review concentrates on broad chemical classification of steroid sulfatase inhibitors. The inhibitors reviewed are classified into four main categories: Steroid sulfamate based inhibitors; Steroid non-sulfamate based inhibitors; Non-steroidal sulfamate based inhibitors; Non-steroidal non-sulfamate based inhibitors. A succinct overview of current treatment of cancer, estradiol precursors, STS enzyme and its role in breast cancer is herein described.

Economic Burden of Cancer in Korea during 2000-2010

PURPOSE

This study estimated the economic burden of cancer in Korea during 2000-2010 by cancer site, gender, age group, and cost component.

MATERIALS AND METHODS

Data came from national health insurance claims data and information from Statistics Korea. Based on the cost of illness method, this study calculated direct, morbidity and mortality cost of cancer in the nation during 2000-2010 by cancer site, gender, and age group.

RESULTS

With an average annual growth rate of 8.9%, the economic burden of cancer in Korea increased from 11,424 to 20,858 million US$ (current US dollars) during 2000-2010. Colorectal, thyroid, and breast cancers became more significant during the period, i.e., the 5th/837, the 11th/257, and the 7th/529 in 2000 to the 3rd/2,210, the 5th/1,724, and the 6th/1,659 in 2010, respectively (rank/amount in million US$ for the total population). In addition, liver and stomach cancers were prominent during the period in terms of the same measures, i.e., the 1st/2,065 and the 2nd/2,036 in 2000 to the 1st/3,114 and the 2nd/3,046 in 2010, respectively. Finally, the share of mortality cost in the total burden dropped from 71% to 51% in Korea during 2000-2010, led by colorectal, thyroid, breast, and prostate cancers during the period. These results show that the economic burden of cancer in Korea is characterized by an increasing importance of chronic components.

CONCLUSION

Incorporation of distinctive epidemiological, sociocultural contexts into Korea's cancer control program, with greater emphasis on primary prevention such as sodium-controlled diet and hepatitis B vaccination, may be needed.

Regional variation in identified cancer care needs of early-career oncologists in China, India, and Pakistan

BACKGROUND

Cancer incidence and mortality is increasing in the developing world. Inequities between low-, middle-, and high-income countries affect disease burden and the infrastructure needs in response to cancer. We surveyed early-career oncologists attending workshops in clinical research in three countries with emerging economies about their perception of the evolving cancer burden.

METHODS

A cross-sectional survey questionnaire was distributed at clinical trial concept development workshops held in Beijing, Lahore, Karachi, and Mumbai at major hospitals to acquire information regarding home-country health conditions and needs.

RESULTS

A total of 100 respondents participated in the workshops held at major hospitals in the region (India = 29, China = 25, Pakistan = 42, and other = 4). Expected consensus on many issues (e.g., emergence of cancer as a significant health issue) was balanced with significant variation in priorities, opportunities, and challenges. Chinese respondents prioritized improvements in cancer-specific care and palliative care, Indian respondents favored improved cancer detection and advancing research in cancer care, and Pakistani respondents prioritized awareness of cancer and improvements in disease detection and cancer care research. For all, the most frequently cited opportunity was help in improving professional cancer education and training.

CONCLUSION

Predominantly early-career oncologists attending clinical research workshops (in China, India, and Pakistan) identified needs for increasing clinical cancer research, professional education, and public awareness of cancer. Decision makers supporting efforts to reduce the burden of cancer worldwide will need to factor the specific needs and aspirations of health care providers in their country in prioritizing health policies and budgets.

Lung cancer staging now and in the future

For a long time lung cancer was associated with a fatalistic approach by healthcare professionals. In recent years, advances in imaging, improved diagnostic techniques and more effective treatment modalities are reasons for optimism. Accurate lung cancer staging is vitally important because treatment options and prognosis differ significantly by stage. The staging algorithm should include a contrast computed tomography (CT) of the chest and the upper abdomen including adrenals, positron emission tomography/CT for staging the mediastinum and to rule out extrathoracic metastasis in patients considered for surgical resection, endosonography-guided needle sampling procedure replacing mediastinoscopy for near complete mediastinal staging, and brain imaging as clinically indicated. Applicability of evidence-based guidelines for staging of lung cancer depends on the available expertise and level of resources and is directly impacted by financial issues. Considering the diversity of healthcare infrastructure and economic performance of Asian countries, optimal and cost-effective use of staging methods appropriate to the available resources is prudent. The pulmonologist plays a central role in the multidisciplinary approach to lung cancer diagnosis, staging and management. Regional respiratory societies such as the Asian Pacific Society of Respirology should work with national respiratory societies to strive for uniform standards of care. For developing countries, a minimum set of care standards should be formulated. Cost-effective delivery of optimal care for lung cancer patients, including staging within the various healthcare systems, should be encouraged and most importantly, tobacco control implementation should receive an absolute priority status in all countries in Asia.

Breast cancer in the global south and the limitations of a biomedical framing: a critical review of the literature

Public health researchers are devoting increasing attention to the growing burden of breast cancer in low-and middle-income countries (LMICs), previously thought to be minimally impacted by this disease. A critical examination of this body of literature is needed to explore the assumptions, advantages and limitations of current approaches. In our critical literature review, we find that researchers and public health practitioners predominantly privilege a biomedical perspective focused on patients' adherence (or non-adherence) to 'preventive' practices, screening behaviours and treatment regimens. Cost-effective 'quick fixes' are prioritized, and prevention is framed in terms of individual 'risk behaviours'. Thus, individuals and communities are held responsible for the success of the biomedical system; traditional belief systems and 'harmful' social practices are problematized. Inherently personal, social and cultural experiences of pain and suffering are neglected or reduced to the issue of chemical palliation. This narrow approach obscures the complex aetiology of the disease and perpetuates silence around power relations. This article calls for a social justice-oriented interrogation of the role of power and inequity in the global breast cancer epidemic, which recognizes the agency and experiences of women (and men) who experience breast cancer in the global south.

Involvement of low- and middle-income countries in randomized controlled trial publications in oncology

Background

We describe trends in participation by investigators from low- and middle-income countries (LMCs) in publications describing oncology randomized control trials (RCTs) over a decade.

Methods

We used Medline to identify RCTs published in English from 1998 to 2008 evaluating treatment in lung, breast, colorectal, stomach and liver cancers. Data on author affiliations, authorship roles, trial characteristics, funding and interventions were extracted from each article. Countries were stratified as low-, middle- or high-income using World Bank data. Interventions were categorized as requiring basic, limited, enhanced or maximal resources as per the Breast Health Global Initiative classification. Logistic regression was used to identify factors associated with authorship by investigators from LMCs.

Results

454 publications were identified. Proportion of articles with at least one LMC author increased over time from 20% in 1998 to 29% in 2008 (p = 0.01), but almost all LMC authors were from middle-income countries. Proportion of articles with at least one LMC author was higher among articles that explicitly reported recruitment in at least one LMC vs those that did not (76% vs 13%). Among 87 articles (19%) that involved authors from LMCs, 17% had LMC authors as first or corresponding authors, and 67% evaluated interventions requiring enhanced or maximal resources. Factors associated with LMC authorship included industry funding (OR = 3.54, p = 0.0001), placebo comparator arm (OR = 2.57, p = 0.02) and palliative intent treatment (OR = 4.00, p = 0.0003).

Conclusion

An increasing number of publications describing oncology RCTs involve authors from LMC countries but primarily in non-leadership roles in industry-funded trials.

Bringing cancer care to the poor: experiences from Rwanda

The knowledge and tools to cure many cancer patients exist in developed countries but are unavailable to many who live in the developing world, resulting in unnecessary loss of life. Bringing cancer care to the poor, particularly to low-income countries, is a great challenge, but it is one that we believe can be met through partnerships, careful planning and a set of guiding principles. Alongside vaccinations, screening and other cancer-prevention efforts, treatment must be a central component of any cancer programme from the start. It is also critical that these programmes include implementation research to determine programmatic efficacy, where gaps in care still exist and where improvements can be made. This article discusses these issues using the example of Rwanda's expanding national cancer programme.

Cancer in Africa 2012

BACKGROUND

Noncommunicable diseases, and especially cancers, are recognized as an increasing problem for low and middle income countries. Effective control programs require adequate information on the size, nature, and evolution of the health problem that they pose.

METHODS

We present estimates of the incidence and mortality of cancer in Africa in 2012, derived from "GLOBOCAN 2012," published by the International Agency for Research on Cancer.

RESULTS

There were 847,000 new cancer cases (6% of the world total) and 591,000 deaths (7.2% of the world total) in the 54 countries of Africa in 2012, with about three quarters in the 47 countries of Sub-Saharan Africa. While the cancer profiles often differ markedly between regions, the most common cancers in men were prostate (16.4% of new cancers), liver (10.7%), and Kaposi sarcoma (6.7%); in women, by far the most important are cancers of the breast (27.6% of all cancers) and cervix uteri (20.4%).

CONCLUSIONS

There are still deficiencies in surveillance systems, particularly in Sub-Saharan Africa and, specifically, of their most vital component, population-based cancer registries. With the number of annual cancer cases and deaths likely to increase by at least 70% by 2030, there is a pressing need for a coordinated approach to improving the extent and quality of services for cancer control in Africa, and better surveillance systems with which they can be planned and monitored.

IMPACT

The results are the best data currently available and provide a reasonable appraisal of the cancer situation in Africa.

Improving access to analgesic drugs for patients with cancer in sub-Saharan Africa

WHO expects the burden of cancer in sub-Saharan Africa to grow rapidly in coming years and for incidence to exceed 1 million per year by 2030. As a result of late presentation to health facilities and little access to diagnostic technology, roughly 80% of cases are in terminal stages at the time of diagnosis, and a large proportion of patients have moderate to severe pain that needs treatment with opioid analgesics. However, consumption of opioid analgesics in the region is low and data suggest that at least 88% of cancer deaths with moderate to severe pain are untreated. Access to essential drugs for pain relief is limited by legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of health-care providers, procurement difficulties, weak health systems, and concerns about diversion, addiction, and misuse. However, recent initiatives characterised by cooperation between national governments and local and international non-governmental organisations are improving access to pain relief. Efforts underway in Uganda, Kenya, and Nigeria provide examples of challenges faced and innovative approaches adopted and form the basis of a proposed framework to improve access to pain relief for patients with cancer across the region.

Cancer in developing countries: the next most preventable pandemic. The global problem of cancer

Cancer is a global problem that accounts for almost 13% of deaths worldwide, a number similar to the 7 million deaths each year from HIV/AIDS, TB and malaria combined According to Globocan it is estimated that by 2020, there will be between 15 and 17 million new cases of cancer every year, 60% of which will be in developing countries. Moreover, the survival rates in these regions are often half those of developed countries. However, cancer is potentially the most preventable disease; with current resources, one-third of tumors could be preventable, and another one-third of newly diagnosed cancer patients could experience increased survival or early-stage detection. There have been proposed several strategies and programs to ameliorate cancer prevention and treatment in less developed countries. If all these proposed strategies are taken into consideration, worldwide cancer care, control and survival in low-income countries may improve in the years to come.

Clinical preventive services in Guatemala: a cross-sectional survey of internal medicine physicians

BACKGROUND

Guatemala is currently undergoing an epidemiologic transition. Preventive services are key to reducing the burden of non-communicable diseases, and smoking counseling and cessation are among the most cost-effective and wide-reaching strategies. Internal medicine physicians are fundamental to providing such services, and their knowledge is a cornerstone of non-communicable disease control.

METHODS

A national cross-sectional survey was conducted in 2011 to evaluate knowledge of clinical preventive services for non-communicable diseases. Interns, residents, and attending physicians of the internal medicine departments of all teaching hospitals in Guatemala completed a self-administered questionnaire. Participants' responses were contrasted with the Guatemalan Ministry of Health (MoH) prevention guidelines and the US Preventive Services Task Force (USPSTF) recommendations. Analysis compared knowledge of recommendations within and between hospitals.

RESULTS

In response to simulated patient scenarios, all services were recommended by more than half of physicians regardless of MoH or USPSTF recommendations. Prioritization was adequate according to the MoH guidelines but not including other potentially effective services (e.g. colorectal cancer and lipid disorder screenings). With the exception of colorectal and prostate cancer screening, less frequently recommended by interns, there was no difference in recommendation rates by level.

CONCLUSION

Guatemalan internal medicine physicians' knowledge on preventive services recommendations for non-communicable diseases is limited, and prioritization did not reflect cost-effectiveness. Based on these data we recommend that preventive medicine training be strengthened and development of evidence-based guidelines for low-middle income countries be a priority.

Cancer burden in Africa and opportunities for prevention

Cancer is an emerging public health problem in Africa. About 715,000 new cancer cases and 542,000 cancer deaths occurred in 2008 on the continent, with these numbers expected to double in the next 20 years simply because of the aging and growth of the population. Furthermore, cancers such as lung, female breast, and prostate cancers are diagnosed at much higher frequencies than in the past because of changes in lifestyle factors and detection practices associated with urbanization and economic development. Breast cancer in women and prostate cancer in men have now become the most commonly diagnosed cancers in many Sub-Saharan African countries, replacing cervical and liver cancers. In most African countries, cancer control programs and the provision of early detection and treatment services are limited despite this increasing burden. This paper reviews the current patterns of cancer in Africa and the opportunities for reducing the burden through the application of resource level interventions, including implementation of vaccinations for liver and cervical cancers, tobacco control policies for smoking-related cancers, and low-tech early detection methods for cervical cancer, as well as pain relief at the palliative stage of cancer.

Life experiences of women with breast cancer in south western Turkey: a qualitative study

PURPOSE

This qualitative study explores the experience of women living with breast cancer.

METHODS

The study was conducted among eight women with ongoing breast cancer chemotherapy treatment, which occurred in an ambulatory unit. The data were collected using semi-structured and in-depth individual interviews. All interviews were tape-recorded, and the results were obtained by analysing the content of the recorded data.

RESULTS

Three major themes related to the experiences of women living with breast cancer were identified. They are as follows: (1) needs (the need for spouse and family support, the need to worship, and the need to receive and share information), (2) living with losses (loss of the breast and of one's hair), and (3) changes (changes in one's normal life, change in self-perception, changes in the perception of the value of health, and a greater appreciation for life).

CONCLUSIONS

This study was conducted to increase awareness concerning women's perceptions of their care and various needs during breast cancer treatment. The results of this study challenge health care providers and educators to be more aware of the difficulties that women face when living with breast cancer.

Cancer research: past, present and future

Research into cancer over the past 10 years has diverged enormously, partly based on the large number of new technologies that are now at our finger tips. With areas of cancer research so disparate, it is not always easy to identify where the next new findings and therapies might come from. With this in mind, we asked four leading cancer researchers from around the world what, in their opinion, we have learnt over the past 10 years and how we should progress in the next 10 years.

Breast cancer in developing countries: opportunities for improved survival

Breast cancer survival in the USA has continually improved over the last six decades and has largely been accredited to the use of mammography, advanced surgical procedures, and adjuvant therapies. Data indicate, however, that there were substantial improvements in survival in the USA even prior to these technological and diagnostic advances, suggesting important opportunities for early detection and treatment in low- and middle-income countries where these options are often unavailable and/or unaffordable. Thus, while continuing to strive for increased access to more advanced technology, improving survival in these settings should be more immediately achievable through increased awareness of breast cancer and of the potential for successful treatment, a high-quality primary care system without economic or cultural barriers to access, and a well-functioning referral system for basic surgical and hormonal treatment.