Breast cancer screening in sub-Saharan Africa: a systematic review and ethical appraisal

Exploring the State of Cancer Imaging Research in Africa

INTRODUCTION

The growing cancer burden in Africa demands urgent action. Medical imaging is crucial for cancer diagnosis and management and is an essential enabler of precision medicine. To understand the readiness for quantitative imaging analysis to support cancer management in Africa, we analyzed the utilization patterns of imaging modalities for cancer research across the continent.

METHODS

We retrieved articles by systematically searching PubMed, using a combination of search terms {"Neoplasm"} AND {"Radiology" or "Diagnostic imaging" or "Radiography" or "Interventional Radiology" or "Radiotherapy" or "Radiation Oncology"} AND {Africa∗ or 54 African countries}. Articles describing cancer diagnosis or management in humans with the utilization of imaging were included. Exclusion criteria were review articles, non-English articles, publications before 2000, noncancer diagnoses, and studies conducted outside Africa.

RESULTS

The analysis of diagnostic imaging in Africa revealed a diverse utilization pattern across different cancer types and regions. The literature search identified 107 publications on cancer imaging in Africa. The studies were carried out in 19 African countries on 12 different cancer types with 6 imaging modalities identified. Most cancer imaging research studies used multiple imaging modalities. Ultrasound was the most used distinct imaging modality and MRI was the least frequently used. Most research studies originated from Nigeria, South Africa, and Egypt.

CONCLUSION

We demonstrate substantial variability in the presence of imaging modalities, widespread utilization of ultrasonography, and limited availability of advanced imaging modalities for cancer research.

Global burden and attributable risk factors of breast cancer in young women: historical trends from 1990 to 2019 and forecasts to 2030 by sociodemographic index regions and countries

Background

Breast cancer in young women (BCY) is much less common but has significant health sequelae and societal costs. We aimed to evaluate the global and regional burden of breast cancer in women aged 15-39 years from 1990 to 2019.

Methods

We collected detailed data on breast cancer from the Global Burden of Disease Study 2019 (GBD 2019) Data Resources. The age-standardised incidence rate (ASIR), age-standardised mortality rate (ASMR), age-standardised disability-adjusted life years rate (ASDR), and estimated annual percentage change (EAPC) were used to assess the disease burden of BCY. The Bayesian Age-Period-Cohort model was used to forecast disease burden from 2020 to 2030.

Results

From 1990 to 2019, significant increases in ASIR were found for BCY (EAPC = 0.59, 95% confidence interval (CI) = 0.5 to 0.68), whereas decreases in ASMR (EAPC = -0.41, 95% CI = -0.53 to -0.3) and ASDR (EAPC = -0.35, 95% CI = -0.46 to -0.24). Across countries with varying sociodemographic indexes (SDI), all regions showed an upward trend in BCY morbidity, except for countries with a high SDI. While mortality and DALYs rates have decreased in countries with high, high-middle, and middle SDI, they have increased in countries with low-middle and low SDI. Countries with lower SDIs are projected to bear the greatest burden of BCY over the next decade, including both low and low-middle categories. Alcohol use was the main risk factor attributed to BCY deaths in most countries, while exposure to second hand smoke was the predominant risk factor for BCY deaths in middle and low-middle SDI countries.

Conclusions

The burden of breast cancer in young women is on the rise worldwide, and there are significant regional differences. Countries with a low-middle or low SDI face even more challenges, as they experienced a more significant and increasing BCY burden than countries with higher SDIs.

Oncoplastic Breast-Conserving Surgery in African Women: A Systematic Review

PURPOSE

Breast cancer is the most frequently diagnosed cancer in women worldwide. Surgery is a major treatment modality for breast cancer, and over the years, breast-conserving surgeries with breast radiation have shown similar outcomes with mastectomy. Not much is known about the frequency and outcome of breast-conserving surgery in Africa. This systematic review provides a comprehensive summary of the evidence evaluating cosmetic and oncologic outcomes after oncoplastic breast-conserving surgery (OBCS) for breast cancer in African women.

METHODS

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases were systematically searched for studies on African women undergoing OBCS. The oncologic and cosmetic outcomes, as well as the localization and reconstruction techniques, were evaluated. Descriptive statistics were used to summarize the frequency and proportions of the extracted variables.

RESULTS

The literature search yielded 266 articles but only 26 of these were included in the review. Majority of the studies were from Egypt and South Africa. These studies collectively evaluated 1,896 patients with a mean age of 48.2 years and a mean follow-up period of 36.9 months. The most common histopathology was T2 (71.4%) invasive ductal carcinoma. Hook wire localization was the most common technique used for nonpalpable lesions in 85.3% of patients. Of the studies reporting oncoplastic technique, the latissimus dorsi volume replacement technique was the most reported (15%). Most patients were satisfied with their cosmetic outcome. Seroma was the most common postoperative complication (44.6%). Among studies that reported oncologic outcome data, the crude overall survival and disease-free survival were 93.1% and 89.4%, respectively.

CONCLUSION

This systematic review revealed that the outcome of OBCS in African women compares with that in developed countries.

Cancer Screening in Low- and Middle-Income Countries

The worldwide cancer burden is growing, and populations residing in low- and middle-income countries (LMICs) are experiencing a disproportionate extent of this growth. Breast, colorectal, and cervical cancers are among the top 10 most frequently diagnosed malignancies, and they also account for a substantial degree of cancer mortality internationally. Effective screening strategies are available for all three of these cancers. Individuals from LMICs face substantial cost and access barriers to early detection programs, and late stage at diagnosis continues to be a major cause for cancer mortality in these communities. This chapter will review the epidemiology of breast, colorectal, and cervical cancers, and will explore prospects for improving global control through novel approaches to screening in cost-constrained environments.

A model to enhance breast cancer screening among rural women aged 40-75 years in Sub-Saharan Africa (SSA): A scoping review

INTRODUCTION AND BACKGROUND

It is claimed that very little research has been done in Africa on breast cancer screening to identify the best method that can be adopted to have early detection of the malignancy. Breast cancer is a growing burden globally and in Sub-Saharan Africa (SSA). There is a rise in breast cancer mortality in SSA. This is caused by limited breast cancer screening or early detection practices due to limited resources which makes mammography unaffordable by the majority of women. This problem is more prevalent in elderly women living in rural areas where limited or no breast cancer screening is taking place. Downstaging which is context-specific is recommended for African countries but more studies are required to confirm its effectiveness.

OBJECTIVES

This review aims to identify the gaps in the literature focusing on strategies to enhance breast cancer screening among elderly women aged 40-75 years who reside in rural areas.

INCLUSION CRITERIA

The articles to be reviewed should focus on screening for the elderly women population that reside in rural areas and should fall within the age range of 40-75 years. Other phrases that can be included instead of breast cancer screening could be early detection measures, early diagnosis, or downstaging.

METHODOLOGY

The methodology was guided by the published manual for Joana Briggs Institute for scoping reviews. A search of the relevant studies was conducted on 4 October 2022 across PubMed, SCOPUS, Embase, and EBSCO Host databases. The systematic literature search strategy was developed and carried out using the Medical Subject Heading (MeSH) database. The eligibility criteria were developed using the Participants, Concept, and Context framework. Only articles written in English and published between 2010 and 2022 were considered. Removal of duplications was done first, followed by screening using the article title and abstract and then using full-text articles. The results of the search were profiled on the PRISMAScR flow chart diagram. Themes were identified from the conclusions of the reviewed studies.

RESULTS

After searching 78 citations were identified. These were screened and only 8 were left after the different stages of screening. The reviewed articles were published between 2010 and 2020. The majority (75%) of the studies were surveys except for two which were qualitative and all done in Kenya. No mixed methodology study was done. No study focused on developing a model to enhance breast cancer screening among rural women aged 40-75 years although there are very few countries in Africa with established nationwide breast cancer screening guidelines.

CONCLUSION

There are limited studies done on breast cancer screening of elderly rural women in SSA. No study was done to identify a model to enhance breast cancer screening among the rural elderly women population. None of the reviewed studies utilized the mixed methodology design to have an in-depth context-specific understanding to pave the way for the implementation of downstaging which is recommended for countries with limited resources.

CONTRIBUTION

The scoping review indicated the gap in research in terms of breast cancer screening among women aged 40-75 years who reside in rural areas and highlighted the future need for such studies to make downstaging effective.

Breast cancer: Epidemiology, risk factors and screening

Breast cancer is a global health concern with a significant impact on the well-being of women. Worldwide, the past several decades have witnessed changes in the incidence and mortality of breast cancer. Additionally, epidemiological data reveal distinct geographic and demographic disparities globally. A range of modifiable and non-modifiable risk factors are established as being associated with an increased risk of developing breast cancer. This review discusses genetic, hormonal, behavioral, environmental, and breast-related risk factors. Screening plays a critical role in the effective management of breast cancer. Various screening modalities, including mammography, ultrasound, magnetic resonance imaging (MRI), and physical examination, have different applications, and a combination of these modalities is applied in practice. Current screening recommendations are based on factors including age and risk, with a significant emphasis on minimizing potential harms to achieve an optimal benefits-to-harms ratio. This review provides a comprehensive insight into the epidemiology, risk factors, and screening of breast cancer. Understanding these elements is crucial for improving breast cancer management and reducing its burden on affected individuals and healthcare systems.

Breast cancer epidemiology and sociodemographic differences in BRICS-plus countries from 1990 to 2019: An age period cohort analysis

Background

Breast cancer (BC) is a major health concern in the BRICS-plus, a group of developing nations consisting of Brazil, Russia, India, China, South Africa, and 30 other Asian countries, with nearly half of the world's population. This study aims to identify potential risk factors contributing to the burden of BC by assessing its epidemiological and socio-demographic changes.

Methods

Data on BC outcomes were obtained from the 2019 Global Burden of Disease Survey. The age-period-cohort (APC) modeling technique was used to evaluate the nonlinear impacts of age, cohort, and period on BC outcomes and reported risk attributable mortality and disability adjusted life years (DALYs) rate changes between 1990 and 2019.

Results

In 2019, there were 0.90 million female BC cases and 0.35 million deaths in the BRICS-plus region, with China and India having the largest proportion of incident cases and deaths, followed by Pakistan. Lesotho experienced the highest annualized rates of change (AROC: 2.61%; 95%UI: 1.99-2.99) in the past three decades. Birth cohorts' impact on BC varies greatly between the BRICS-plus nations, with Pakistan suffering the largest risk increase in the most recent cohort. High body mass index (BMI), high fasting plasma glucose (FPG), and a diet high in red meat contributed to the highest death and DALYs rates in most BRICS-plus nations in 2019, and there was a strong negative link between SDI and death and DALYs rate.

Conclusions

The study found that the burden of BC varies significantly between BRICS-plus regions. Thus, BRICS-plus nations should prioritise BC prevention, raise public awareness, and implement screening efficiency measures to reduce the burden of BC in the future, as well as strengthen public health policies and initiatives for important populations based on their characteristics and adaptability.

Training health workers in clinical breast examination for early detection of breast cancer in low- and middle-income countries

BACKGROUND

Most women living in low- and middle-income countries (LMICs) present with advanced-stage breast cancer. Limitations of poor serviceable health systems, restricted access to treatment facilities, and lack of breast cancer screening programmes all likely contribute to the late presentation of women with breast cancer living in these countries. Women are diagnosed with advanced disease and frequently do not complete their care due to a number of factors, including financial reasons as health expenditure is largely out of pocket resulting in financial toxicity; health system failures, such as missing services or health worker lack of awareness on common signs and symptoms of cancer; and sociocultural barriers, such as stigma and use of alternative therapies. Clinical breast examination (CBE) is an inexpensive early detection technique for breast cancer in women with palpable breast masses. Training health workers from LMICs to conduct CBE has the potential to improve the quality of the technique and the ability of health workers to detect breast cancers early.

OBJECTIVES

To assess whether training in CBE affects the ability of health workers in LMICs to detect early breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Specialised Registry, CENTRAL, MEDLINE, Embase, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal, and ClinicalTrials.gov up to 17 July 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including individual and cluster-RCTs), quasi-experimental studies and controlled before-and-after studies if they fulfilled the eligibility criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, and extracted data, assessed risk of bias, and assessed the certainty of the evidence using the GRADE approach. We performed statistical analysis using Review Manager software and presented the main findings of the review in a summary of findings table.

MAIN RESULTS

We included four RCTs that screened a total population of 947,190 women for breast cancer, out of which 593 breast cancers were diagnosed. All included studies were cluster-RCTs; two were conducted in India, one in the Philippines, and one in Rwanda. Health workers trained to perform CBE in the included studies were primary health workers, nurses, midwives, and community health workers. Three of the four included studies reported on the primary outcome (breast cancer stage at the time of presentation). Amongst secondary outcomes, included studies reported CBE coverage, follow-up, accuracy of health worker-performed CBE, and breast cancer mortality. None of the included studies reported knowledge attitude practice (KAP) outcomes and cost-effectiveness. Three studies reported diagnosis of breast cancer at early stage (at stage 0+I+II), suggesting that training health workers in CBE may increase the number of women detected with breast cancer at an early stage compared to the non-training group (45% detected versus 31% detected; risk ratio (RR) 1.44, 95% confidence interval (CI) 1.01 to 2.06; three studies; 593 participants; I2 = 0%; low-certainty evidence). Three studies reported diagnosis at late stage (III+IV) suggesting that training health workers in CBE may slightly reduce the number of women detected with breast cancer at late stage compared to the non-training group (13% detected versus 42%, RR 0.58, 95% CI 0.36 to 0.94; three studies; 593 participants; I2 = 52%; low-certainty evidence). Regarding secondary outcomes, two studies reported breast cancer mortality, implying that the evidence is uncertain for the impact on breast cancer mortality (RR 0.88, 95% CI 0.24 to 3.26; two studies; 355 participants; I2 = 68%; very low-certainty evidence). Due to the study heterogeneity, we could not conduct meta-analysis for accuracy of health worker-performed CBE, CBE coverage, and completion of follow-up, and therefore reported narratively using the 'Synthesis without meta-analysis' (SWiM) guideline. Sensitivity of health worker-performed CBE was reported to be 53.2% and 51.7%; while specificity was reported to be 100% and 94.3% respectively in two included studies (very low-certainty evidence). One trial reported CBE coverage with a mean adherence of 67.07% for the first four screening rounds (low-certainty evidence). One trial reported follow-up suggesting that compliance rates for diagnostic confirmation following a positive CBE were 68.29%, 71.20%, 78.84% and 79.98% during the respective first four rounds of screening in the intervention group compared to 90.88%, 82.96%, 79.56% and 80.39% during the respective four rounds of screening in the control group.

AUTHORS' CONCLUSIONS

Our review findings suggest some benefit of training health workers from LMICs in CBE on early detection of breast cancer. However, the evidence regarding mortality, accuracy of health worker-performed CBE, and completion of follow up is uncertain and requires further evaluation.

Prevalence and associated factors of breast cancer screening among nuns in the Catholic Archdiocese of Nairobi

Introduction

breast cancer is a significant global challenge. The risk of breast cancer among nuns is high mainly due to the basis of nulliparity. Among the effective approaches to addressing breast cancer is early screening. However, there are concerns over the uptake of screening across all populations, including nuns. The objective of the study is to determine the prevalence and the associated factors of breast cancer screening among nuns in the Catholic Archdiocese of Nairobi.

Methods

this research used the analytical cross-sectional design. A total of 384 nuns in the Catholic Archdiocese of Nairobi were recruited using a stratified sampling. Structured questionnaires were used to collect data. Chi-square and binary logistic regression were used to determine association between social-demographic factors and breast cancer screening. Statistical package for social sciences (SPSS version 26) was used for analysis. The level of significance was investigated at p<0.05.

Results

our findings revealed that the prevalence of breast cancer screening among nuns was 30.7%. The findings established that those who had knowledge on breast cancer screening (AOR=25.52, 95%CI: 8.87 - 73.45, p<0.001) and those who had congregational financial support (AOR=1.97, 95%CI: 1.68 - 5.74, p=0.021) were more likely to undergo breast cancer screening. Those who had hospital check-up for in more than six months prior to the study (AOR=0.001, 95%CI: 0.000 - 0.008, p<0.001) and those who never had a hospital check-up, (AOR=0.001, 95%CI: 0.000 - 0.006, p<0.001) were less likely to undergo breast cancer screening.

Conclusion

the findings have shown low uptake of breast cancer screening amongst nuns in the Catholic Archdiocese in Nairobi. Knowledge on breast cancer screening access to congregational support and hospital check-up have been identified as key factors associated with breast cancer screening. Therefore, there is a need to create adequate awareness be created and the Catholic reverend sisters educated through aggressive education campaign programs so as to eliminate misconceptions relating to the topic. Also, to integrate free access to screening services in the government health institutions for nuns.

Factors associated with the uptake of clinical breast examination among women of reproductive age in Lesotho: analysis of a national survey

BACKGROUND

In low-resource settings with weak health systems, the WHO recommends clinical breast examination (CBE) as the most cost-effective breast screening modality for women. Evidence shows that biennial CBE leads to significant downstaging of breast cancer in all women. Breast cancer is the second most common cancer among women in Lesotho with a weaker healthcare system and a low breast cancer screening rate. This study investigated the prevalence and factors associated with the uptake of CBE among women of reproductive age in Lesotho.

METHODS

This study used cross-sectional data from the 2014 Lesotho Demographic and Health Survey. A sample of 6584 reproductive-age women was included in this study. We conducted both descriptive and multivariable logistic regression analyses. The study results were presented in frequencies, percentages, and adjusted odds ratios (aOR) with their corresponding confidence intervals (CIs).

RESULTS

The prevalence of CBE uptake was 9.73% (95% CI: 8.91, 10.61). Women who were covered by health insurance (aOR = 2.31, 95% CI [1.37, 3.88]), those who were pregnant (aOR = 2.34, 95% CI [1.64, 3.35]), those who had one to three children (aOR = 1.81, 95% CI [1.29,2.52]), and women who frequently read newspapers or magazines (aOR = 1.33, 95% CI [1.02,1.72]) were more likely to undergo CBE than their counterparts. Women who were aware of breast cancer (aOR = 2.54, 95% CI [1.63,3.97]), those who have ever had breast self-examination (BSE) within the last 12 months prior to the study (aOR = 5.30, 95% CI [4.35,6.46]), and those who visited the health facility in the last 12 months prior to the study (aOR = 1.57, 95% CI [1.27,1.95]) were also more likely to undergo CBE than their counterparts. Women residing in the Qacha's-nek region (aOR = 0.42, 95% CI [0.26,0.67]) were less likely to undergo CBE than those in the Botha-bothe region.

CONCLUSION

The study found a low prevalence of CBE uptake among reproductive-age women in Lesotho. Factors associated with CBE uptake include health insurance coverage, being pregnant, those who had one to three children, exposure to media, breast cancer awareness, ever had BSE, and those who visited a health facility. To increase CBE uptake, these factors should be considered when designing cancer screening interventions and policies in order to help reduce the burden of breast cancer in Lesotho.

A qualitative study to explore healthcare providers' perspectives on barriers and enablers to early detection of breast and cervical cancers among women attending primary healthcare clinics in Johannesburg, South Africa

Low-and-middle income countries (LMICs) contribute approximately 70% of global cancer deaths, and the cancer incidence in these countries is rapidly increasing. Sub-Saharan African (SSA) countries, including South Africa (SA), bear some of the world's highest cancer case fatality rates, largely attributed to late diagnosis. We explored contextual enablers and barriers for early detection of breast and cervical cancers according to facility managers and clinical staff at primary healthcare clinics in the Soweto neighbourhood of Johannesburg, South Africa. We conducted qualitative in-depth interviews (IDIs) between August and November 2021 amongst 13 healthcare provider nurses and doctors as well as 9 facility managers at eight public healthcare clinics in Johannesburg. IDIs were audio-recorded, transcribed verbatim, and entered into NVIVO for framework data analysis. Analysis was stratified by healthcare provider role and identified apriori around the themes of barriers and facilitators for early detection and management of breast and cervical cancers. Findings were conceptualised within the socioecological model and then explored within the capability, opportunity and motivation model of behaviour (COM-B) for pathways that potentially influence the low screening provision and uptake. The findings revealed provider perceptions of insufficient South African Department of Health (SA DOH) training support and staff rotations resulting in providers lacking knowledge and skills on cancer, screening policies and techniques. This coupled with provider perceptions of poor patient cancer and screening knowledge revealed low capacity for cancer screening. Providers also perceived opportunity for cancer screening to be undermined by the limited screening services mandated by the SA DOH, insufficient providers, inadequate facilities, supplies and barriers to accessing laboratory results. Providers perceived women to prefer to self-medicate and consult with traditional healers and access primary care for curative services only. These findings compound the low opportunity to provide and demand cancer screening services. And because the National SA Health Department is perceived by providers not to prioritize cancer nor involve primary care stakeholders in policy and performance indicator development, overworked, unwelcoming providers have little motivation to learn screening skills and provide screening services. Providers reported that patients preferred to go elsewhere and that women perceived cervical cancer screening as painful. These perceptions must be confirmed for veracity among policy and patient stakeholders. Nevertheless, cost-effective interventions can be implemented to address these perceived barriers including multistakeholder education, mobile and tent screening facilities and using existing community fieldworkers and NGO partners in providing screening services. Our results revealed provider perspectives of complex barriers to the early detection and management of breast and cervical cancers in primary health clinic settings in Greater Soweto. These barriers together appear potentially to produce compounding effects, and therefore there is a need to research the cumulative impact but also engage with stakeholder groups to verify findings and create awareness. Additionally, opportunities do exist to intervene across the cancer care continuum in South Africa to address these barriers by improving the quality and volume of provider cancer screening services, and in turn, increasing the community demand and uptake for these services.