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Martei YM, Mokokwe L, Ngwako N, Kebuang K, Setlhako DI, Gabaatlhole G, Baaitse B, Segadimo T, Shulman LN, Barg F, Gaolebale BE. Development, acceptability and usability of culturally appropriate survivor narrative videos for breast cancer treatment in Botswana: a pilot study. BMJ Open 2024; 14:e073867. [PMID: 38296302 PMCID: PMC10828869 DOI: 10.1136/bmjopen-2023-073867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 12/14/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Narrative communication has demonstrated effectiveness in promoting positive health behaviours, delivering support and coping with complex decision-making. Formal research evaluating this intervention for cancer treatment in Africa is lacking. We aimed to develop, and assess acceptability and usability of survivor video narrative interventions for breast cancer treatment in Botswana. DESIGN A pilot study design. SETTING Single-centre, tertiary hospital, sub-Saharan Africa. PARTICIPANTS Eight women, ≥18 years old, with stages I-III breast cancer were enrolled for the video intervention. 106 women, ≥18 years old, with stages I-IV breast cancer viewed the narrative videos and 98 completed the acceptability and usability surveys. INTERVENTION Survivor narrative videos were developed using the theory of planned behaviour and using a purposive sample of Batswana, Setswana-speaking, breast cancer survivors, who had completed systemic treatment and surgery with high rates of adherence to the prescribed treatment plan. PRIMARY OUTCOMES We assessed acceptability and usability among prospectively enrolled patients presenting for routine breast cancer care at Princess Marina Hospital in Botswana, using a 13-item survey. RESULTS Participants expressed high acceptability and usability of the videos, including 99% (97/98) who strongly agreed/agreed that the video presentations were easy to understand, 92% (90/98) who would recommend to other survivors and 94% (92/98) who wished there were more videos. Additionally, 89% (87/98) agreed or strongly agreed that the one-on-one instruction on how to use the tablet was helpful and 87% (85/98) that the video player was easy to use. CONCLUSION Culturally appropriate survivor video narratives have high acceptability and usability among patients with breast cancer in Botswana. There is an opportunity to leverage this intervention in routine breast cancer care for treatment support. Future studies will test the implementation and effectiveness of narrative videos on a wider scale, including for patients being treated for other cancers.
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Affiliation(s)
- Yehoda M Martei
- Department of Medicine (Hematology - Oncology Division), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lebogang Mokokwe
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- University of Botswana, Gaborone, Botswana
| | | | | | | | | | | | | | - Lawrence N Shulman
- Department of Medicine (Hematology - Oncology Division), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances Barg
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Wondimagegnehu A, Teferra S, Assefa M, Zebrack B, Addissie A, Kantelhardt EJ. "How can a woman live without having a breast?": challenges related to mastectomy in Ethiopia. BMC Cancer 2024; 24:60. [PMID: 38212706 PMCID: PMC10782697 DOI: 10.1186/s12885-023-11801-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Although mastectomy is the standard treatment modality for breast cancer patients in Ethiopia, our previous study revealed that one in five patients do not receive the recommended procedure, half due to patient refusal or lack of returning to the hospital. Therefore, this study aimed to explore reasons for refusing mastectomy and identify challenges among breast cancer patients in Ethiopia. METHODS An explorative qualitative study was conducted in four hospitals located in the towns of Woliso, Butajira, Hossana, and Assela. A total of 14 in-depth interviews (IDIs) and eight focus group discussions (FGDs) were held with breast cancer patients, patient relatives, and health professionals. Four semi-structured interview guides were used to facilitate the IDIs and FDGs. All recorded IDIs and FGDs were transcribed and translated verbatim and entered in NVivo 12 software. Emerging ideas were categorised and explained using an inductive content analysis approach. RESULTS Our participants reported that particularly elderly and very young women refuse to have mastectomy. The main reasons identified in this study were summarised into six themes: (i) fear of the surgical procedure, (ii) religious beliefs and practice, (iii) utilisation of traditional treatments, (iv) in relation to having a baby and breastfeeding their children (young patients often request to remove only the lump, leaving their breast tissue intact), (v) lack of awareness about the disease, and (vi) sociocultural factors and advice from the community that influence women, since breasts are considered an attribute of femininity, beauty, and motherhood. In addition, knowing someone who died after mastectomy emerged as a main reason for not having breast cancer surgery. CONCLUSIONS High refusal rate for mastectomy has direct implication on increased breast cancer mortality. Hence, expansion of radiotherapy service is instrumental to initiate breast-conserving surgery as an alternative surgical procedure, especially for young women with early-stage breast cancer. Involving religious leaders, traditional healers, and breast cancer survivors could be an effective strategy to persuade newly diagnosed breast cancer patients. Addressing individual patient psychosocial needs and preferences may substantially improve retention of breast cancer patients in the health system.
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Affiliation(s)
- Abigiya Wondimagegnehu
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle, Germany.
| | - Solomon Teferra
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mathewos Assefa
- Department of Oncology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bradley Zebrack
- School of Social Work, University of Michigan, Ann Arbor, USA
| | - Adamu Addissie
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle, Germany
| | - Eva J Kantelhardt
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle, Germany
- Department of Gynecology, Martin-Luther-University, Halle (Saale), Germany
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Martei YM, Obasohan M, Mokokwe L, Ralefala T, Mosepele M, Gross R, Barg FK. Stigma and Social Determinants of Health Associated With Fidelity to Guideline-Concordant Therapy in Patients With Breast Cancer Living With and Without HIV in Botswana. Oncologist 2023; 28:e1230-e1238. [PMID: 37405697 PMCID: PMC10712728 DOI: 10.1093/oncolo/oyad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/01/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Patients with breast cancer in sub-Saharan Africa (SSA) experience a disproportionate burden of mortality. Fidelity to treatment guidelines, defined as receiving optimal dose and frequency of prescribed treatments, improves survival. We sought to identify patient factors associated with treatment fidelity and how this may differ for people with HIV (PWH) and breast cancer. METHODS We conducted a qualitative study of women who initiated outpatient treatment for stages I-III breast cancer in Botswana, with deviance sampling of high- and low-fidelity patients. One-on-one interviews were conducted using semi-structured guides informed by the Theory of Planned Behavior. The sample size was determined by thematic saturation. Transcribed interviews were double coded with an integrated analytic approach. RESULTS We enrolled 15 high- and 15 low-fidelity participants from August 25, 2020 to December 15, 2020, including 10 PWH (4 high, 6 low fidelity). Ninety-three percent had stage III disease. Barriers to treatment fidelity included stigma, social determinants of health (SDOH), and health system barriers. Acceptance and de-stigmatization, peer and other social support, increased knowledge and self-efficacy were identified as facilitators. The COVID-19 pandemic amplified existing socioeconomic stressors. Unique barriers and facilitators identified by PWH included intersectional stigma, and HIV and cancer care integration, respectively. CONCLUSION We identified multilevel modifiable patient and health system factors associated with fidelity. The facilitators provide opportunities for leveraging existing strengths within the Botswana context to design implementation strategies to increase treatment fidelity to guideline-concordant breast cancer therapy. However, PWH experienced unique barriers, suggesting that interventions to address fidelity may need to be tailored to specific comorbidities.
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Affiliation(s)
- Yehoda M Martei
- Department of Medicine (Hematology-Oncology), University of Pennsylvania, Philadelphia, PA, USA
| | - Modesty Obasohan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lebogang Mokokwe
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | | | - Robert Gross
- Department of Medicine (Infectious Diseases), University of Pennsylvania, Philadelphia, PA, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
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Rubagumya F, Wilson B, Shyirambere C, Manirakiza A, Mugenzi P, Chamberlin M, Hopman WM, Booth C. Assessing the utilization of cancer medicines in Rwanda: an analysis of treatment patterns. Ecancermedicalscience 2023; 17:1631. [PMID: 38414961 PMCID: PMC10898888 DOI: 10.3332/ecancer.2023.1631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Indexed: 02/29/2024] Open
Abstract
Introduction Cancer is a growing public health concern in Africa, especially in low- and middle-income countries (LMICs) like Rwanda. Increased cancer incidences translate into increased utilisation of cancer medicine. Access to affordable cancer medicines in Rwanda is a pressing issue as the National Health Insurance plan does not provide coverage for cancer medicines. In this study, we investigated the utilisation patterns of cancer medicines in Rwanda. Methods This retrospective cross-sectional study was conducted at all referral hospitals (n = 3) capable of delivering chemotherapy in Rwanda. The data collection was over a period of 6 months, during which a team of trained research assistants reviewed a convenience sample of selected patient charts. Both paper charts and electronic medical records were used to collect patients' data, including cancer type, stage, treatment setting, type of drugs or regimen used and completed cycles. Data were analysed using descriptive statistics. Results A total of 630 patients received chemotherapy during the study period and were included. Seventy-seven percent (n = 486) were female and mean age was 51 (SD ± 13). Among all patients receiving chemotherapy, 43% (n = 270) had breast cancer, 22% (n = 140) had cervical cancer and 19% (n = 121) had colorectal cancer. The majority of patients (71%) had a community-based insurance. Butaro Cancer Centre treated the most patients (48%, n = 303). Thirty-six percent (221/630) had stage III cancer. The most common regimens within the cohort were adriamycin, cyclophosphamide and taxane, capecitabine and oxaliplatin (CAPOX), paclitaxel + carboplatin and a single agent cisplatin given concurrently with radiotherapy. The proportion of chemotherapy that was given in the curative and palliative setting was 72% and 28% respectively. Conclusion Access to affordable cancer medicines remains a challenge in Rwanda. The study's findings provide valuable information on the utilisation patterns of cancer medicines in Rwanda, which can be used to guide policy decisions and improve cancer care in the country.
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Affiliation(s)
- Fidel Rubagumya
- Department of Oncology, Rwanda Military Hospital, KK 739 Street, Kicukiro, PO BOX 4016, Kigali, Rwanda
- Research for Development (RD) Rwanda, Kigali, Rwanda
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON K7L 3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Brooke Wilson
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON K7L 3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON K7L 3N6, Canada
- School of Public Health, University of New South Wales, Sydney, NSW 2052, Australia
| | | | - Achille Manirakiza
- Oncology Unit, Department of Medicine, King Faisal Hospital, PO BOX 2534, Kigali, Rwanda
| | - Pacifique Mugenzi
- Department of Oncology, Rwanda Military Hospital, KK 739 Street, Kicukiro, PO BOX 4016, Kigali, Rwanda
| | | | | | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON K7L 3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON K7L 3N6, Canada
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5
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Amouzou KS, Ketevi AA, Sambiani DM, Caroli A. Female breast cancer in sub-Saharan Africa: A PRISMA-S-compliant systematic review of surgery. J Surg Oncol 2021; 125:336-351. [PMID: 34738640 DOI: 10.1002/jso.26720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/25/2021] [Accepted: 09/25/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND In sub-Saharan countries (SSAs), the advanced stage at diagnosis and the limited surgical interventions of female breast cancer (FBC) lead to poor outcomes. This study assessed current modalities of FBC surgeries. METHODS Six literature databases (Medline, Embase, African Journal Online, Google Scholar, Web of Science, Cochrane Library) were searched, plus a manual search, in 2011-2021. We included primary data studies with any setting and presurgeries or postsurgeries treatments, we excluded non-English language studies, editorials, and grey literature. RESULTS The search yielded 21 observational studies (16 retrospective, 3 prospective, and 2 case reports). Of the total 6900 patients, 4121 (60%) patients underwent FBC surgical excision only, and 751/2779 (27%) conservative surgery (BCS) or therapy (BCT). All studies reported similar use of mastectomy (>60%), the FBC surgical excision/reconstruction studies displayed more neoadjuvant chemotherapy (536/2779, 19% vs. 215/4121, 5%), and radiotherapy or adjuvant radiotherapy (1461/2779, 52% vs. 411/3921, 4%). Patients' age, histological classification, staging, and follow-up data were often missing. CONCLUSIONS The FBC complexity requires structured management by general and plastic surgeons, radiotherapy specialists, and obstetrician-gynecologists through shared guidelines, protocols, and specific programs of public health. In SSAs, FBC surgical strategies should point at decreasing radical mastectomy and increasing BCS/BCT.
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Affiliation(s)
- Komla Séna Amouzou
- Department of Surgery, University of Lomé, Sylvanus Olympio Teaching Hospital, Lomé, Togo
| | - Ameyo Ayoko Ketevi
- Department of Gynaecology, University of Lomé, Sylvanus Olympio Teaching Hospital, Lomé, Togo
| | | | - Angela Caroli
- Radiotherapy Unit, Centro di Riferimento Oncologico, IRCCS-National Cancer Institute, Aviano, Pordenone, Italy
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Utilization and predictors of postmastectomy radiation receipt in an Oncology Center in Zimbabwe. Breast Cancer Res Treat 2021; 189:701-709. [PMID: 34387794 DOI: 10.1007/s10549-021-06338-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Few sub-Saharan African studies have ascertained utilization for postmastectomy radiation (PMRT) for breast cancer, the second most common cancer among African women. We estimated PMRT utilization and identified predictors of PMRT receipt in Zimbabwe. METHODS Retrospective patient cohort included non-metastatic breast cancer patients treated from 2014 to 2019. PMRT eligibility was assigned per NCCN guidelines. Patients receiving chemotherapy for non-metastatic disease were also included. The primary endpoint was receipt of PMRT, defined as chest wall with/without regional nodal radiation. Predictors of receiving PMRT were identified using logistic regression. Model performance was evaluated using the c statistic and Hosmer-Lemeshow test for goodness-of-fit. RESULTS 201 women with localized disease and median follow-up of 11.4 months (IQR 3.3-17.9) were analyzed. PMRT was indicated in 177 women and utilized in 59(33.3%). Insurance coverage, clinical nodal involvement, higher grade, positive margins, and hormone therapy receipt were associated with higher odds of PMRT receipt. In adjusted models, no hormone therapy (aOR 0.12, 95% CI 0.043, 0.35) and missing grade (aOR 0.07, 95% CI 0.01, 0.38) were associated with lower odds of PMRT receipt. The resulting c statistic was 0.84, with Hosmer-Lemeshow p-value of 0.93 indicating good model fit. CONCLUSION PMRT was utilized in 33% of those meeting NCCN criteria. Missing grade and no endocrine therapy receipt were associated with reduced likelihood of PMRT utilization. In addition to practice adjustments such as increasing hypofractionation and increasing patient access to standard oncologic testing at diagnosis could increase postmastectomy utilization.
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Elmore SNC, Mushonga M, Iyer HS, Kanda C, Chibonda S, Chipidza F, Makunike Mutasa R, Muchuweti D, Muguti EG, Maunganidze A, Ndlovu N, Bellon JR, Nyakabau AM. Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018. Cancer Med 2021; 10:3489-3498. [PMID: 33973399 PMCID: PMC8178482 DOI: 10.1002/cam4.3764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/24/2022] Open
Abstract
Background Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub‐Saharan Africa (SSA) with radiotherapy access. Methods A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non‐adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease. Results In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43–61). Receptor status was missing for 71% (248). 199 (57%) had non‐metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post‐mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study‐defined non‐adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non‐adherence (aOR: 0.18, 95% CI: 0.09, 0.36). Conclusions Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient‐level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.
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Affiliation(s)
- Shekinah Nefreteri Cluff Elmore
- Harvard Radiation Oncology Program, Boston, USA.,Harvard Medical School, Boston, USA.,Department of Radiation Oncology, University of North Carolina, Chapel Hill, USA
| | - Melinda Mushonga
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe
| | | | - Caroline Kanda
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe
| | - Shirley Chibonda
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe
| | - Fallon Chipidza
- Harvard Radiation Oncology Program, Boston, USA.,Harvard Medical School, Boston, USA.,Department of Radiation Oncology, Dana-Faber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rudo Makunike Mutasa
- Department of Pathology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - David Muchuweti
- Department of Surgery, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Edwin G Muguti
- Department of Surgery, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Aspect Maunganidze
- Department of Surgery, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Ntokozo Ndlovu
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe.,Department of Oncology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Jennifer Ruth Bellon
- Department of Radiation Oncology, Dana-Faber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna Mary Nyakabau
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe.,Department of Pathology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe.,Cancerserve Trust, Harare, Zimbabwe
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Popli P, Gutterman EM, Omene C, Ganesan S, Mills D, Marlink R. Receptor-Defined Breast Cancer in Five East African Countries and Its Implications for Treatment: Systematic Review and Meta-Analysis. JCO Glob Oncol 2021; 7:289-301. [PMID: 33591798 PMCID: PMC8081496 DOI: 10.1200/go.20.00398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) are determinants of treatment and mortality for patients with breast cancer (BC). In East Africa, the estimated 5-year survival (37.7%) is far lower than the US average (90%). This meta-analysis investigates BC receptor subtypes within five East African countries to ascertain cross-country patterns and prioritize treatment needs. METHODS From a PubMed search, January 1, 1998-June 30, 2019, for all English-only BC articles for Ethiopia, Kenya, Rwanda, Tanzania, and Uganda, eligible studies had receptor distributions for female BC samples ≥ 30 patients. Outcomes were proportions of ER+, PR+, and HER2-positive (HER2+), and/or molecular subtypes. Data included study characteristics and mean or median patient age. Using metaprop, Stata 16, we estimated pooled proportions (ES) with 95% CIs and assessed heterogeneity. RESULTS Among 36 BC studies with receptor data, 21 met criteria. Weighted mean age was 47.5 years and median, 48. Overall ES were as follows: 55% for ER-positive (ER+) (95% CI, 47 to 62), 23% for HER2+ (95% CI, 20 to 26), and 27% for triple-negative BC (TNBC) (95% CI, 23 to 32). CONCLUSION We found differences between countries, for example, lower distribution of TNBC in Ethiopia (21%) compared with Uganda (35%). ER+, the dominant BC subtype overall at 55%, emphasizes the need to prioritize endocrine therapy. Overall proportions of HER2+ BC (with or without ER+ or PR+), 23%, approached proportions of TNBC, 27%, yet HER2 testing and treatment were infrequent. Testing and reporting of receptor subtypes would promote delivery of more effective treatment reducing the mortality disparity.
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Affiliation(s)
- Pallvi Popli
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Coral Omene
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Shridar Ganesan
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Richard Marlink
- Rutgers Global Health Institute, and Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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O'Neil DS, Chen WC, Ayeni O, Nietz S, Buccimazza I, Singh U, Čačala S, Stopforth L, Joffe M, Crew KD, Jacobson JS, Neugut AI, Ruff P, Cubasch H. Breast Cancer Care Quality in South Africa's Public Health System: An Evaluation Using American Society of Clinical Oncology/National Quality Forum Measures. J Glob Oncol 2020; 5:1-16. [PMID: 31770052 PMCID: PMC6882520 DOI: 10.1200/jgo.19.00171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The quality of breast cancer care in sub-Saharan Africa contributes to the region’s dismal breast cancer mortality. ASCO has issued quality measures focusing on delivery of adjuvant chemotherapy, radiotherapy, and endocrine therapy. We applied these measures in five South African public hospitals and analyzed factors associated with care concordance. MATERIALS AND METHODS Among 1,736 women with breast cancer who were enrolled in the South African Breast Cancer and HIV Outcomes study over 24 months, we evaluated care using ASCO’s three measures. We also evaluated adjuvant chemotherapy receipt in 957 women with an indication. We used logistic regression to estimate associations between measure-concordant care and patient factors. RESULTS Of 235 women with hormone receptor–negative cancer, 173 (74%) began adjuvant chemotherapy within 120 days from diagnosis. Of 194 patients who received breast-conserving surgery, 73 (37%) began radiotherapy within 365 days from diagnosis. Of 999 women with hormone receptor–positive cancer, 719 (72%) initiated endocrine therapy within 365 days from diagnosis. Chemotherapy and radiotherapy measure-concordant care were more common among women residing < 20 km from the hospital (odds ratio [OR], 1.79; 95% CI, 1.32 to 2.44 and OR, 3.17; 95% CI, 1.57 to 6.42). Endocrine therapy measure-concordant care was more common among English-speaking women (OR, 2.12; 95% CI, 1.12 to 4.02). Participating hospitals varied in care concordance. HIV infection did not affect care quality. CONCLUSION More timely delivery of chemotherapy, radiotherapy, and endocrine therapy is needed in South Africa, particularly for women living > 20 km from the hospital or not speaking English. Focused quality improvement efforts could support that goal.
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Affiliation(s)
- Daniel S O'Neil
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Wenlong Carl Chen
- Wits Health Consortium, Johannesburg, South Africa.,National Cancer Registry, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | - Oluwatosin Ayeni
- Wits Health Consortium, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Nietz
- Wits Health Consortium, Johannesburg, South Africa.,Charlotte Maxeke Johannesburg Academic Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Ines Buccimazza
- Wits Health Consortium, Johannesburg, South Africa.,Inkosi Albert Luthuli Central Hospital, Durban and Ngwelezane Hospital, University of KwaZulu Natal, Empangeni, KwaZulu Natal, South Africa
| | - Urishka Singh
- Wits Health Consortium, Johannesburg, South Africa.,Inkosi Albert Luthuli Central Hospital, Durban and Ngwelezane Hospital, University of KwaZulu Natal, Empangeni, KwaZulu Natal, South Africa
| | - Sharon Čačala
- Wits Health Consortium, Johannesburg, South Africa.,Grey's Hospital, University of KwaZulu Natal, Pietermaritzburg, KwaZulu Natal, South Africa
| | - Laura Stopforth
- Wits Health Consortium, Johannesburg, South Africa.,Grey's Hospital, University of KwaZulu Natal, Pietermaritzburg, KwaZulu Natal, South Africa
| | - Maureen Joffe
- Wits Health Consortium, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Paul Ruff
- Wits Health Consortium, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa.,Chris Hani Baragwanath Academic Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Herbert Cubasch
- Wits Health Consortium, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa.,Chris Hani Baragwanath Academic Hospital, University of Witwatersrand, Johannesburg, South Africa
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10
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Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda. Ann Glob Health 2020; 86:33. [PMID: 32257833 PMCID: PMC7101006 DOI: 10.5334/aogh.2697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: In rural sub-Saharan Africa, access to care for severe non-communicable diseases (NCDs) is limited due to myriad delivery challenges. We describe the implementation, patient characteristics, and retention rate of an integrated NCD clinic inclusive of cancer services at a district hospital in rural Rwanda. Methods: In 2006, the Rwandan Ministry of Health at Rwinkwavu District Hospital (RDH) and Partners In Health established an integrated NCD clinic focused on nurse-led care of severe NCDs, within a single delivery platform. Implementation modifications were made in 2011 to include cancer services. For this descriptive study, we abstracted medical record data for 15 months after first clinic visit for all patients who enrolled in the NCD clinic between 1 July 2012 and 30 June 2014. We report descriptive statistics of patient characteristics and retention. Results: Three hundred forty-seven patients enrolled during the study period: oncology – 71.8%, hypertension – 10.4%, heart failure – 11.0%, diabetes – 5.5%, and chronic respiratory disease (CRD) – 1.4%. Twelve-month retention rates were: oncology – 81.6%, CRD – 60.0%, hypertension – 75.0%, diabetes – 73.7%, and heart failure – 47.4%. Conclusions: The integrated NCD clinic filled a gap in accessible care for severe NCDs, including cancer, at rural district hospitals. This novel approach has illustrated good retention rates.
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Freeman EE, Busakhala N, Regan S, Asirwa FC, Wenger M, Seth D, Moon KC, Semeere A, Maurer T, Wools-Kaloustian K, Bassett I, Martin J. Real-world use of chemotherapy for Kaposi's sarcoma in a large community-based HIV primary care system in Kenya. BMC Cancer 2020; 20:71. [PMID: 31996161 PMCID: PMC6990575 DOI: 10.1186/s12885-019-6506-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 12/30/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa. METHODS We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines. RESULTS Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/μl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%). CONCLUSIONS A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting.
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Affiliation(s)
- Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, 55 Fruit Street, Boston MA, MA, 02114, USA.
| | | | - Susan Regan
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, 55 Fruit Street, Boston MA, MA, 02114, USA
| | - Fredrick Chite Asirwa
- AMPATH, Moi University, Eldoret, Kenya
- Indiana University, Indianapolis, Indiana, USA
| | | | - Divya Seth
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, 55 Fruit Street, Boston MA, MA, 02114, USA
| | - Khatiya Chelidze Moon
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, 55 Fruit Street, Boston MA, MA, 02114, USA
| | - Aggrey Semeere
- University of California, San Francisco, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Toby Maurer
- University of California, San Francisco, USA
| | | | - Ingrid Bassett
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, 55 Fruit Street, Boston MA, MA, 02114, USA
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de Sanjose S, Tsu VD. Prevention of cervical and breast cancer mortality in low- and middle-income countries: a window of opportunity. Int J Womens Health 2019; 11:381-386. [PMID: 31308762 PMCID: PMC6617716 DOI: 10.2147/ijwh.s197115] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/16/2019] [Indexed: 02/02/2023] Open
Abstract
Breast and cervical cancer are the two most common women’s cancers worldwide. Countries have invested for decades in early detection programs for breast and cervical cancer through screening, community education, and opportunistic case detection by health professionals. However, effectiveness in low- and middle-income countries (LMICs) has been limited due to low coverage, insufficient laboratory capacities for diagnosis, health information systems (HIS) that are not designed to track patients or monitor program performance, barriers that inhibit women’s uptake of services, and inadequate treatment options. Even where some screening activities exist, there has not been sufficient attention to ensuring completion of appropriate diagnosis and treatment after women receive a positive screening test result or report symptoms suggesting cervical or breast cancer. Because of this failure to provide adequate follow-up care, these women miss the potential benefit from early detection and have a higher than average risk to develop cancer or progress to more advanced cancer stages that could have been avoided. There are several critical steps in a woman’s journey from good health to elevated cancer risk, then to cancer prevention or diagnosis, and finally to treatment. There is a window of opportunity that extends from the time a positive finding is identified—by a cervical or breast screening test or recognition of a breast abnormality—to the point when cervical precancer treatment is delivered or a treatment plan for diagnosed breast cancer is initiated. Building on existing health systems and adapting measurable, affordable, and culturally acceptable interventions can achieve a lasting impact. If women can successfully navigate this window of opportunity, they can avoid progression to cervical cancer or greatly reduce the need for invasive treatments for breast cancer and improve their chances for survival and improved quality of life. We propose several actions that can lead us on the path towards reduction of this cancer burden.
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Affiliation(s)
| | - Vivien D Tsu
- Sexual and Reproductive Health, PATH, Seattle, WA, USA
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Gershon N, Berchenko Y, Hall PS, Goldstein DA. Cost effectiveness and affordability of trastuzumab in sub-Saharan Africa for early stage HER2-positive breast cancer. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2019; 17:5. [PMID: 30867655 PMCID: PMC6396469 DOI: 10.1186/s12962-019-0174-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 02/19/2019] [Indexed: 01/20/2023] Open
Abstract
Background Breast cancer is the second most common cancer worldwide, the most common among women, and the most frequent cause of death among women in less developed regions. Trastuzumab is a humanized monoclonal antibody that downregulates the extracellular domain of the HER2 protein. Using trastuzumab to treat women with localized HER2-positive breast cancer has been shown to improve survival. The objective of this study is to explore the cost-effectiveness of adjuvant trastuzumab, from a societal perspective, in 11 African countries. In addition, we aimed to establish value-based prices for trastuzumab based on the gross domestic product per capita in each country. Methods We developed a Markov model in order to assess the costs and benefits associated with trastuzumab treatment over a lifetime horizon. A probabilistic sensitivity analysis was performed in order to estimate the impact of uncertainty of parameter-values on the results. Efficacy inputs were derived using clinical trial data from non-African countries. Results In the base case analysis, trastuzumab yielded a gain ranging from 0.92 LYs in Nigeria to 1.07 LYs in South Africa, and 0.9 QALYs in Nigeria to 1.02 QALYs in South Africa. The incremental cost ranged from 19,561 USD in Nigeria to 19,997 USD in Congo, and an incremental cost-effectiveness ratio ranging from 19,534 USD/QALY in South Africa to 21,697 USD/QALY in Nigeria. Using willingness to pay estimates based on World Health Organization recommendations, trastuzumab appear to not be cost-effective in all countries analyzed. Cost-effectiveness estimates were most sensitive to the discount rate, trastuzumab cost, and the hazard ratio. Conclusions Trastuzumab does not appear to be cost effective in the African countries analyzed. In order for trastuzumab to be cost-effective, the costs of treatment would require significant discounts. Electronic supplementary material The online version of this article (10.1186/s12962-019-0174-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Noga Gershon
- 1Ben-Gurion University of the Negev, P.O.B. 653, Beer-Sheva, 8410501 Israel
| | - Yakir Berchenko
- 1Ben-Gurion University of the Negev, P.O.B. 653, Beer-Sheva, 8410501 Israel
| | - Peter S Hall
- 2Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh, UK
| | - Daniel A Goldstein
- 3Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel.,4Department of Health Policy and Management, University of North Carolina, Chapel Hill, USA
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O'Neil DS, Nietz S, Buccimazza I, Singh U, Čačala S, Stopforth LW, Joffe M, Jacobson JS, Neugut AI, Crew KD, Ruff P, Cubasch H. Neoadjuvant Chemotherapy Use for Nonmetastatic Breast Cancer at Five Public South African Hospitals and Impact on Time to Initial Cancer Therapy. Oncologist 2018; 24:933-944. [PMID: 30518615 PMCID: PMC6656461 DOI: 10.1634/theoncologist.2018-0535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/06/2018] [Indexed: 12/18/2022] Open
Abstract
In sub‐Saharan Africa, clinical decisions can be affected by resource constraints. This article analyzes the clinical and sociodemographic factors associated with receiving neoadjuvant chemotherapy among patients from a previously existing cohort: women enrolled in the prospective South African Breast Cancer and HIV Outcomes study. Background. In the U.S., neoadjuvant chemotherapy (NAC) for nonmetastatic breast cancer (BC) is used with extensive disease and aggressive molecular subtypes. Little is known about the influence of demographic characteristics, clinical factors, and resource constraints on NAC use in Africa. Materials and Methods. We studied NAC use in a cohort of women with stage I–III BC enrolled in the South African Breast Cancer and HIV Outcomes study at five hospitals. We analyzed associations between NAC receipt and sociodemographic and clinical factors, and we developed Cox regression models for predictors of time to first treatment with NAC versus surgery. Results. Of 810 patients, 505 (62.3%) received NAC. Multivariate analysis found associations between NAC use and black race (odds ratio [OR] 0.49; 95% confidence limit [CI], 0.25–0.96), younger age (OR 0.95; 95% CI, 0.92–0.97 for each year), T‐stage (T4 versus T1: OR 136.29; 95% CI, 41.80–444.44), N‐stage (N2 versus N0: OR 35.64; 95% CI, 16.56–76.73), and subtype (triple‐negative versus luminal A: OR 5.16; 95% CI, 1.88–14.12). Sites differed in NAC use (Site D versus Site A: OR 5.73; 95% CI, 2.72–12.08; Site B versus Site A: OR 0.37; 95% CI, 0.16–0.86) and time to first treatment: Site A, 50 days to NAC versus 30 days to primary surgery (hazard ratio [HR] 1.84; 95% CI, 1.25–2.71); Site D, 101 days to NAC versus 126 days to primary surgery (HR 0.49; 95% CI, 0.27–0.89). Conclusion. NAC use for BC at these South African hospitals was associated with both tumor characteristics and heterogenous resource constraints. Implications for Practice. Using data from a large breast cancer cohort treated in South Africa's public healthcare system, the authors looked at determinants of neoadjuvant chemotherapy use and time to initiate treatment. It was found that neoadjuvant chemotherapy was associated with increasing tumor burden and aggressive molecular subtypes, demonstrating clinically appropriate care in a lower resource setting. Results of this study also showed that time to treatment differences between chemotherapy and surgery varied by hospital, suggesting that differences in resource limitations were influencing clinical decision making. Practice guidelines and care quality metrics designed for low‐ and middle‐income countries should accommodate heterogeneity of available resources.
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Affiliation(s)
- Daniel S O'Neil
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York New York, USA
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York New York, USA
| | - Sarah Nietz
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- Department of Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Ines Buccimazza
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- Departments of Surgery and Oncology, Inkosi Albert Luthuli Central Hospital, Durban and Ngwelezane Hospital, University of KwaZulu-Natal, Empangeni, KwaZulu-Natal, South Africa
| | - Urishka Singh
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- Departments of Surgery and Oncology, Inkosi Albert Luthuli Central Hospital, Durban and Ngwelezane Hospital, University of KwaZulu-Natal, Empangeni, KwaZulu-Natal, South Africa
| | - Sharon Čačala
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- Departments of Surgery and Oncology, Grey's Hospital, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Laura W Stopforth
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- Departments of Surgery and Oncology, Grey's Hospital, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Maureen Joffe
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- MRC Developmental Pathways to Health Research Unit, Department of Pediatrics, University of Witwatersrand, Johannesburg, Gauteng, South Africa
- South Africa Medical Research Council Common Epithelial Cancers Research Centre, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Judith S Jacobson
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York New York, USA
| | - Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York New York, USA
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York New York, USA
| | - Katherine D Crew
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York New York, USA
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York New York, USA
| | - Paul Ruff
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- Division of Medical Oncology, Department of Medicine, University of Witwatersrand, Johannesburg, Gauteng, South Africa
- South Africa Medical Research Council Common Epithelial Cancers Research Centre, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Herbert Cubasch
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, Gauteng, South Africa
- Department of Surgery, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Gauteng, South Africa
- South Africa Medical Research Council Common Epithelial Cancers Research Centre, University of Witwatersrand, Johannesburg, Gauteng, South Africa
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The Role of Quality Measures in Improving Breast Cancer Care in Low-Income Countries. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0288-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Dusengimana JMV, Hategekimana V, Borg R, Hedt-Gauthier B, Gupta N, Troyan S, Shulman LN, Nzayisenga I, Fadelu T, Mpunga T, Pace LE. Pregnancy-associated breast cancer in rural Rwanda: the experience of the Butaro Cancer Center of Excellence. BMC Cancer 2018; 18:634. [PMID: 29866062 PMCID: PMC5987575 DOI: 10.1186/s12885-018-4535-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 05/21/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Breast cancer is the most common malignancy encountered during pregnancy. However, the burden of pregnancy-associated breast cancer (PABC) and subsequent care is understudied in sub-Saharan Africa (SSA). Here, we describe the characteristics, diagnostic delays and treatment of women with PABC seeking care at a rural cancer referral facility in Rwanda. METHODS Data from female patients aged 18-50 years with pathologically confirmed breast cancer who presented for treatment between July 1, 2012 and February 28, 2014 were retrospectively reviewed. PABC was defined as breast cancer diagnosed in a woman who was pregnant or breastfeeding. Numbers and frequencies are reported for demographic and diagnostic delay variables and Wilcoxon rank sum and Fisher's exact tests are used to compare characteristics of women with PABC to women with non-PABC at the alpha = 0.05 significance level. Treatment and outcomes are described for women with PABC only. RESULTS Of the 117 women with breast cancer, 12 (10.3%) had PABC based on medical record review. The only significant demographic differences were that women with PABC were younger (p = 0.006) and more likely to be married (p = 0.035) compared to women with non-PABC. There were no significant differences in diagnostic delays or stage at diagnosis between women with PABC and women with non-PABC women. Eleven of the women with PABC received treatment, three had documented treatment delays or modifications due to their pregnancy or breastfeeding, and four stopped breastfeeding to initiate treatment. At the end of the study period, six patients were alive, three were deceased and three patients were lost to follow-up. CONCLUSIONS PABC was relatively common in our cohort but may have been underreported. Although patients with PABC did not experience greater diagnostic delays, most had treatment modifications, emphasizing the potential value of PABC-specific treatment protocols in SSA. Larger prospective studies of PABC are needed to better understand particular challenges faced by these patients and inform policies and practices to optimize care for women with PABC in Rwanda and similar settings.
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Affiliation(s)
| | | | - Ryan Borg
- Partners In Health/Inshuti Mu Buzima, P.O.Box 3432, Kigali, Rwanda
| | - Bethany Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, P.O.Box 3432, Kigali, Rwanda
- Harvard Medical School, Boston, MA USA
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima, P.O.Box 3432, Kigali, Rwanda
- Harvard Medical School, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
| | - Susan Troyan
- Harvard Medical School, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
| | | | | | | | | | - Lydia E. Pace
- Harvard Medical School, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
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