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Nguyen HTH, Nguyen OTK, Tran TN, Nguyen AC, Liamputtong P, Bui LK. The impacts of cancer treatment on lifestyle habits and mental health in Vietnamese women: an exploratory qualitative study. Support Care Cancer 2024; 32:654. [PMID: 39259391 DOI: 10.1007/s00520-024-08831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 08/22/2024] [Indexed: 09/13/2024]
Abstract
AIMS This qualitative study explores the experiences of women after cancer treatment in terms of habit changes and mental health impact. METHOD The study involved 10 women who had undergone cancer treatment, recruited from three major hospitals in Hanoi, Vietnam. Data were collected through semi-structured interviews, which were transcribed and analyzed using thematic analysis. RESULTS The findings of the study shed light on the various factors influencing lifestyle behavior and mental health changes among women after cancer treatment. Ten participants, aged 39 to 64 years, shared experiences including dietary changes, sleep disruptions, and reliance on non-scientific sources for health decisions. Initially shocked by their diagnosis, many transitioned to acceptance, adopting a "giving-in" attitude. Cultural beliefs, word-of-mouth sharing, and social support networks played significant roles in shaping post-treatment lifestyle changes, coping mechanisms, information-seeking behaviors, and mental health. CONCLUSION The study highlights the need for accessible and scientifically verified information for women after cancer treatment to make informed decisions about their health. It emphasizes the importance of addressing traditional beliefs and promoting evidence-based practices. Moreover, the study underscores the importance of social support and relationships in coping with the challenges of post-cancer experiences.
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Affiliation(s)
- Huyen Thi Hoa Nguyen
- College of Health Sciences, VinUniversity, Hanoi, Vietnam.
- Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | | | - Tran Ngoc Tran
- College of Health Sciences, VinUniversity, Hanoi, Vietnam
| | | | - Pranee Liamputtong
- College of Health Sciences, VinUniversity, Hanoi, Vietnam
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Linh Khanh Bui
- College of Health Sciences, VinUniversity, Hanoi, Vietnam
- Hanoi Medical University, Hanoi, Vietnam
- School of Nursing and Midwifery, Griffith University, Brisbane, Australia
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Caeser R, Chiang J, Tan ES, Tai ES, Ngeow J. Cascade testing for hereditary cancer in Singapore: how population genomics help guide clinical policy. Fam Cancer 2024; 23:133-140. [PMID: 38662262 DOI: 10.1007/s10689-024-00376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 04/26/2024]
Abstract
Hereditary Cancer makes up around 5-10% of all cancers. It is important to diagnose hereditary cancer in a timely fashion, as not only do patients require long-term care from a young age, but their relatives also require management. The main approach to capture at-risk relatives is cascade testing. It involves genetic testing of relatives of the first detected carrier of a pathogenic variant in a family i.e. the proband. The current standard of care for cascade testing is a patient-mediated approach. Probands are then advised to inform and encourage family members to undergo genetic testing. In Singapore, cascade testing is inefficient, around 10-15%, lower than the 30% global average. Here, we describe the cascade testing process and its effort to increase testing in Singapore. Precision Health Research, Singapore (PRECISE), was set up to coordinate Singapore's National Precision Medicine strategy and has awarded five clinical implementation pilots, with one of them seeking to identify strategies for how cascade testing for hereditary cancer can be increased in a safe and cost-efficient manner. Achieving this will be done through addressing barriers such as cost, manpower shortages, exploring a digital channel for contacting at-risk relatives, and getting a deeper insight into why genetic testing gets declined. If successful, it will likely result in care pathways that are a cost-effective public health intervention for identifying individuals at risk. Surveillance and management of those unaffected at-risk individuals, if caught early, will result in improved patient outcomes, and further reduce the healthcare burden for the economy.
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Affiliation(s)
- Rebecca Caeser
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
- Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Jianbang Chiang
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
- Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Ee Shien Tan
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore
- Genetics Service, Department of Pediatrics, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
| | - E Shyong Tai
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Precision Health Research, Singapore, Singapore
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore.
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3
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Feliciano EJG, Ho FDV, Yee K, Paguio JA, Eala MAB, Robredo JPG, Ng K, Lim J, Pyone KT, Peralta CA, Flores JA, Yao JS, Santos PMG, Ang CDU, Lasco G, Chan JSK, Tse G, Tangco ED, Kingham TP, Chitapanarux I, Bhoo-Pathy N, Legaspi GD, Dee EC. Cancer disparities in Southeast Asia: intersectionality and a call to action. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 41:100971. [PMID: 38053740 PMCID: PMC10694578 DOI: 10.1016/j.lanwpc.2023.100971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/27/2023] [Accepted: 11/05/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Erin Jay G. Feliciano
- School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
- Department of Medicine, NYC H+H/Elmhurst, Icahn School of Medicine at Mt. Sinai, Queens, NY, USA
| | | | - Kaisin Yee
- SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - Joseph A. Paguio
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Michelle Ann B. Eala
- University of the Philippines College of Medicine, Manila, Philippines
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Janine Patricia G. Robredo
- School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
- Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA
| | - Kenrick Ng
- Department of Medical Oncology, St Bartholomew’s Hospital, Bart’s Health NHS Trust, London, UK
| | - Jasmine Lim
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khin Thuzar Pyone
- Radiation Oncology Department, Yangon General Hospital Yangon, Myanmar
| | | | | | - J. Seth Yao
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Patricia Mae G. Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Daniel U. Ang
- Department of Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, University of Santo Tomas Hospital, Manila, Philippines
| | - Gideon Lasco
- Development Studies Program, Ateneo de Manila University, Quezon City, Philippines
- Department of Anthropology, University of the Philippines Diliman, Quezon City, Philippines
| | | | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
- Kent and Medway Medical School, Canterbury, UK
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Enrico D. Tangco
- Department of Radiation Oncology, The Medical City, Pasig City, Philippines
| | - T. Peter Kingham
- Department of Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Imjai Chitapanarux
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nirmala Bhoo-Pathy
- Centre for Epidemiology and Evidence Based Practice, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Gerardo D. Legaspi
- Division of Neurosurgery, Department of Neurosciences, University of the Philippines Manila, Philippine General Hospital, Metro Manila, Philippines
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Arevalo MVPN, Maslog EAS, Manlongat KD, Ornos EDB, Chitapanarux I, Eala MAB, Dee EC. Social determinants of sex disparities in cancer in Southeast Asia. iScience 2023; 26:107110. [PMID: 37456827 PMCID: PMC10339016 DOI: 10.1016/j.isci.2023.107110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Sex disparities in cancer exist along the cancer spectrum, ranging from genomic predisposition and behavioral risk factors to access to screening, diagnostics, treatment, and survivorship care. A growing body of research is studying the biological underpinnings of these differences, from cancer risk to tumor biology to treatment response. It is well known, however, that the social determinants of health play a large role across the cancer disease continuum, which encompasses risk, prevention, diagnosis, treatment, survivorship, rehabilitation, and palliative care. Less literature focuses on the gendered disparities that are epidemiologic in nature, especially in Southeast Asia (SEA), a diverse region that is home to nearly 670 million people, where most are lower middle income countries, and where socioeconomic and cultural factors increase cancer risk for women. In this review, we highlight the social drivers of gendered disparities, namely the geographic, environmental, sociocultural, economic, and political forces that contribute to the increased mortality and poorer health outcomes in the region.
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Affiliation(s)
| | | | | | - Eric David B. Ornos
- College of Medicine, University of the Philippines, 1000 Manila, Philippines
| | - Imjai Chitapanarux
- Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Northern Thai Research Group of Radiation Oncology (NTRG-RO), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Michelle Ann B. Eala
- College of Medicine, University of the Philippines, 1000 Manila, Philippines
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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5
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Yap YS. Outcomes in breast cancer-does ethnicity matter? ESMO Open 2023; 8:101564. [PMID: 37290358 DOI: 10.1016/j.esmoop.2023.101564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 06/10/2023] Open
Abstract
Ethnic or racial differences in breast cancer (BC) survival outcomes have been reported, but current data are largely restricted to comparisons between African Americans and non-Hispanic whites. Most analyses have traditionally been based on self-reported race which may not always be accurate, or are oversimplified in their classification. With increasing globalization, quantification of the genetic ancestry from genomic data may offer a solution to infer the complex makeup from admixture of races. Focusing on the larger and the latest studies, we will discuss recent findings on the differing host and tumor biology that may be driving these disparities, in addition to the extrinsic environmental or lifestyle factors. Socioeconomic disparities with lower cancer literacy may lead to late presentation, poorer adherence to treatment, and other lifestyle factors such as unhealthy diet, obesity, and inadequate physical activity. These hardships may also result in greater allostatic load, which is in turn associated with aggressive BC features in disadvantaged populations. Epigenetic reprogramming may mediate the effects of the environment or lifestyle factors on gene expression, with ensuing differences in BC characteristics and outcome. There is increasing evidence that germline genetics can influence somatic gene alterations or expression, as well as modulate the tumor or immune microenvironment. Although the precise mechanisms remain elusive, this may account for the varying distribution of different BC subtypes across ethnicities. These gaps in our knowledge highlight the need to interrogate the multiomics landscape of BC in diverse populations, ideally in large-scale collaborative settings with standardized methodology for the comparisons to be statistically robust. Together with improving BC awareness and access to good quality health care, a holistic approach with insights of the biological underpinnings is much needed to eradicate ethnic disparities in BC outcomes.
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Affiliation(s)
- Y-S Yap
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.
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Nik Ab Kadir MN, Yaacob NM, Yusof SN, Ab Hadi IS, Musa KI, Mohd Isa SA, Bahtiar B, Adam F, Yahya MM, Hairon SM. Development of Predictive Models for Survival among Women with Breast Cancer in Malaysia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15335. [PMID: 36430052 PMCID: PMC9690612 DOI: 10.3390/ijerph192215335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 06/16/2023]
Abstract
Prediction of survival probabilities based on models developed by other countries has shown inconsistent findings among Malaysian patients. This study aimed to develop predictive models for survival among women with breast cancer in Malaysia. A retrospective cohort study was conducted involving patients who were diagnosed between 2012 and 2016 in seven breast cancer centres, where their survival status was followed until 31 December 2021. A total of 13 predictors were selected to model five-year survival probabilities by applying Cox proportional hazards (PH), artificial neural networks (ANN), and decision tree (DT) classification analysis. The random-split dataset strategy was used to develop and measure the models' performance. Among 1006 patients, the majority were Malay, with ductal carcinoma, hormone-sensitive, HER2-negative, at T2-, N1-stage, without metastasis, received surgery and chemotherapy. The estimated five-year survival rate was 60.5% (95% CI: 57.6, 63.6). For Cox PH, the c-index was 0.82 for model derivation and 0.81 for validation. The model was well-calibrated. The Cox PH model outperformed the DT and ANN models in most performance indices, with the Cox PH model having the highest accuracy of 0.841. The accuracies of the DT and ANN models were 0.811 and 0.821, respectively. The Cox PH model is more useful for survival prediction in this study's setting.
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Affiliation(s)
- Mohd Nasrullah Nik Ab Kadir
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Najib Majdi Yaacob
- Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Siti Norbayah Yusof
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Federal Territory of Putrajaya, Malaysia
| | - Imi Sairi Ab Hadi
- Breast and Endocrine Surgery Unit, Department of Surgery, Hospital Raja Perempuan Zainab II, Ministry of Health Malaysia, Kota Bharu 15586, Kelantan, Malaysia
| | - Kamarul Imran Musa
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Seoparjoo Azmel Mohd Isa
- Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Balqis Bahtiar
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Federal Territory of Putrajaya, Malaysia
| | - Farzaana Adam
- Public Health Division, Penang State Health Department, Ministry of Health Malaysia, Georgetown 10590, Penang, Malaysia
| | - Maya Mazuwin Yahya
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Suhaily Mohd Hairon
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
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Dhakal R, Noula M, Roupa Z, Yamasaki EN. A Scoping Review on the Status of Female Breast Cancer in Asia with a Special Focus on Nepal. BREAST CANCER: TARGETS AND THERAPY 2022; 14:229-246. [PMID: 36052152 PMCID: PMC9427118 DOI: 10.2147/bctt.s366530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/26/2022] [Indexed: 12/24/2022]
Abstract
This study aimed to provide updated evidence on the status of female breast cancer and cancer treatment facilities in Asia, with a special focus on Nepal. This review used search phrases that included, breast neoplasm or cancer, health status, epidemiology, breast cancer survivors, cancer care facilities, Asia, Nepal. Researchers examined databases from January 2011 to December 2020 (PubMed, PMC, Google Scholar, and the reference lists of included papers). Studies of any design and reviews, were included in the study, except for qualitative studies. The study findings are presented in a narrative synthesis format using Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. An initial search resulted in 974 papers, and 896 were reviewed after being checked for duplication using the Zotero software. Accordingly, utilizing the inclusion and exclusion criteria, 188 publications were selected, and after review of titles and abstracts, an additional 98 papers were removed for different reasons. Finally, the study looked at 90 female breast cancer papers. Results showed that the number of cases of breast cancer is growing all around the world, including in Asia and Nepal. Age, early menarche, late menopause, nulliparity, positive family history, excessive fat consumption, alcohol, and smoking are all frequent risk factors for breast cancer found in Asian women. Breast self-examination, clinical breast examination, and mammography screening are common methods for detecting breast carcinoma. Chemotherapy, radiation, and modified mastectomy are commonly used options for treatment. The number of breast cancer survivors is growing throughout the world, indicating better clinical care. There is a paucity of survival data in many Asian countries, including Nepal. There is also a scarcity of health workforce specialized in cancer care and treatment, as well as a few health facilities that are available to treat cancer cases in many Asian countries, including Nepal.
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Affiliation(s)
- Rojana Dhakal
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
- Department of Nursing, School of Health and Allied Sciences, Pokhara University, Kaski, Gandaki Province, Nepal
- Correspondence: Rojana Dhakal, Department of Nursing, School of Health and Allied Sciences, Pokhara University, Kaski, Gandaki Province, Nepal, Email ;
| | - Maria Noula
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
| | - Zoe Roupa
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
| | - Edna N Yamasaki
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
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Nik Ab Kadir MN, Hairon SM, Yaacob NM, Ab Manan A, Ali N. Prognostic Factors for Bladder Cancer Patients in Malaysia: A Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053029. [PMID: 35270721 PMCID: PMC8910605 DOI: 10.3390/ijerph19053029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 12/24/2022]
Abstract
Background: Malaysia has the third highest crude mortality rates of bladder cancer within Southeast Asia. We aimed to identify the prognostic factors for bladder cancer patients in Malaysia. Methods: A retrospective population-based study was conducted among patients diagnosed between 2007 and 2011. Death date until 31 December 2016 was updated. Cox proportional hazard regression analysis was performed to examine clinical variables as prognostic factors of death. Results: Identified prognostic factors of 1828 analyzed patients were age groups, ethnicity, morphology, stage, and surgery. As compared to patients aged 15–44, the adjusted Hazard Ratio for those aged 45–54, 55–64, 65–74, and ≥75 were 1.59, 1.87, 2.46, and 3.47, respectively. Malay and other ethnic groups had 1.22- and 1.40-times the risk of death compared to Chinese. Patients with squamous cell carcinoma were at 1.47-times the hazard of death compared to urothelial carcinoma patients. Stages II, III and IV patients had 2.20-, 2.98-, and 4.12-times the risk of death as compared to stage I. Patients who did not receive surgery were at 50% increased hazard of death. Conclusion: Early detection and/or surgery, especially for those more than 75 years old, Malay, and squamous cell carcinoma could potentially improve survival. The findings could inform national cancer control programs.
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Affiliation(s)
- Mohd Nasrullah Nik Ab Kadir
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
| | - Suhaily Mohd Hairon
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Correspondence:
| | - Najib Majdi Yaacob
- Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
| | - Azizah Ab Manan
- Timur Laut District Health Office, Penang State Health Department, Ministry of Health Malaysia, Georgetown 11600, Penang, Malaysia;
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Selangor, Malaysia;
| | - Nabihah Ali
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Selangor, Malaysia;
- Public Health Medicine Department, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Sabah, Malaysia
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9
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Ho PJ, Khng AJ, Loh HW, Ho WK, Yip CH, Mohd-Taib NA, Tan VKM, Tan BKT, Tan SM, Tan EY, Lim SH, Jamaris S, Sim Y, Wong FY, Ngeow J, Lim EH, Tai MC, Wijaya EA, Lee SC, Chan CW, Buhari SA, Chan PMY, Chen JJC, Seah JCM, Lee WP, Mok CW, Lim GH, Woo E, Kim SW, Lee JW, Lee MH, Park SK, Dunning AM, Easton DF, Schmidt MK, Teo SH, Li J, Hartman M. Germline breast cancer susceptibility genes, tumor characteristics, and survival. Genome Med 2021; 13:185. [PMID: 34857041 PMCID: PMC8638193 DOI: 10.1186/s13073-021-00978-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/24/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Mutations in certain genes are known to increase breast cancer risk. We study the relevance of rare protein-truncating variants (PTVs) that may result in loss-of-function in breast cancer susceptibility genes on tumor characteristics and survival in 8852 breast cancer patients of Asian descent. METHODS Gene panel sequencing was performed for 34 known or suspected breast cancer predisposition genes, of which nine genes (ATM, BRCA1, BRCA2, CHEK2, PALB2, BARD1, RAD51C, RAD51D, and TP53) were associated with breast cancer risk. Associations between PTV carriership in one or more genes and tumor characteristics were examined using multinomial logistic regression. Ten-year overall survival was estimated using Cox regression models in 6477 breast cancer patients after excluding older patients (≥75years) and stage 0 and IV disease. RESULTS PTV9genes carriership (n = 690) was significantly associated (p < 0.001) with more aggressive tumor characteristics including high grade (poorly vs well-differentiated, odds ratio [95% confidence interval] 3.48 [2.35-5.17], moderately vs well-differentiated 2.33 [1.56-3.49]), as well as luminal B [HER-] and triple-negative subtypes (vs luminal A 2.15 [1.58-2.92] and 2.85 [2.17-3.73], respectively), adjusted for age at diagnosis, study, and ethnicity. Associations with grade and luminal B [HER2-] subtype remained significant after excluding BRCA1/2 carriers. PTV25genes carriership (n = 289, excluding carriers of the nine genes associated with breast cancer) was not associated with tumor characteristics. However, PTV25genes carriership, but not PTV9genes carriership, was suggested to be associated with worse 10-year overall survival (hazard ratio [CI] 1.63 [1.16-2.28]). CONCLUSIONS PTV9genes carriership is associated with more aggressive tumors. Variants in other genes might be associated with the survival of breast cancer patients. The finding that PTV carriership is not just associated with higher breast cancer risk, but also more severe and fatal forms of the disease, suggests that genetic testing has the potential to provide additional health information and help healthy individuals make screening decisions.
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Affiliation(s)
- Peh Joo Ho
- Genome Institute of Singapore, Human Genetics, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Alexis J. Khng
- Genome Institute of Singapore, Human Genetics, Singapore, Singapore
| | - Hui Wen Loh
- Genome Institute of Singapore, Human Genetics, Singapore, Singapore
| | - Weang-Kee Ho
- School of Mathematical Sciences, Faculty of Science and Engineering, University of Nottingham Malaysia, Jalan Broga, 43500 Semenyih, Selangor Malaysia
- Cancer Research Malaysia, 1 Jalan SS12/1A, 47500 Subang Jaya, Selangor Malaysia
| | - Cheng Har Yip
- Subang Jaya Medical Centre, Jalan SS 12/1A, 47500 Subang Jaya, Selangor Malaysia
| | - Nur Aishah Mohd-Taib
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- UM Cancer Research Institute, Kuala Lumpur, Malaysia
| | - Veronique Kiak Mien Tan
- Department of Breast Surgery, Singapore General Hospital, Singapore, Singapore
- Division of Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Benita Kiat-Tee Tan
- Department of Breast Surgery, Singapore General Hospital, Singapore, Singapore
- Division of Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Su-Ming Tan
- Division of Breast Surgery, Changi General Hospital, Singapore, Singapore
| | - Ern Yu Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, 308433 Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Institute of Molecular and Cell Biology, Singapore, Singapore
| | - Swee Ho Lim
- KK Breast Department, KK Women’s and Children’s Hospital, Singapore, 229899 Singapore
| | - Suniza Jamaris
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- UM Cancer Research Institute, Kuala Lumpur, Malaysia
| | - Yirong Sim
- Department of Breast Surgery, Singapore General Hospital, Singapore, Singapore
- Division of Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Fuh Yong Wong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Joanne Ngeow
- Lee Kong Chian School of Medicine, Nanyang Technology University, Singapore, Singapore
- Cancer Genetics Service, National Cancer Centre Singapore, Singapore, Singapore
- Oncology Academic Clinical Program, Duke NUS, Singapore, Singapore
| | - Elaine Hsuen Lim
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Mei Chee Tai
- Cancer Research Malaysia, 1 Jalan SS12/1A, 47500 Subang Jaya, Selangor Malaysia
| | | | - Soo Chin Lee
- Department of Hematology-oncology, National University Cancer Institute, National University Health System, Singapore, 119074 Singapore
| | - Ching Wan Chan
- Department of Surgery, University Surgical Cluster, National University Hospital, Singapore, Singapore
| | - Shaik Ahmad Buhari
- Department of Surgery, University Surgical Cluster, National University Hospital, Singapore, Singapore
| | - Patrick M. Y. Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, 308433 Singapore
| | - Juliana J. C. Chen
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, 308433 Singapore
| | | | - Wai Peng Lee
- Division of Breast Surgery, Changi General Hospital, Singapore, Singapore
| | - Chi Wei Mok
- Division of Breast Surgery, Changi General Hospital, Singapore, Singapore
| | - Geok Hoon Lim
- KK Breast Department, KK Women’s and Children’s Hospital, Singapore, 229899 Singapore
| | - Evan Woo
- KK Breast Department, KK Women’s and Children’s Hospital, Singapore, 229899 Singapore
| | - Sung-Won Kim
- Department of Surgery, Breast Care Center, Daerim St. Mary’s Hospital, Seoul, Korea
| | - Jong Won Lee
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Min Hyuk Lee
- Department of Surgery, Soonchunhyang University and Hospital, Seoul, Republic of Korea
| | - Sue K. Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Alison M. Dunning
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Marjanka K. Schmidt
- Division of Molecular Pathology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Soo-Hwang Teo
- Cancer Research Malaysia, 1 Jalan SS12/1A, 47500 Subang Jaya, Selangor Malaysia
- Department of Surgery, Faculty of Medicine, University of Malaya, Jalan Universiti, 50630 Kuala Lumpur, Malaysia
| | - Jingmei Li
- Genome Institute of Singapore, Human Genetics, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Mikael Hartman
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Department of Surgery, University Surgical Cluster, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
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10
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Subramaniam S, Kong YC, Zaharah H, Uiterwaal CSPM, Richard A, Taib NA, Deniel A, Chee KH, Bustamam RS, See MH, Fong A, Yip CH, Bhoo-Pathy N. Baseline cardiovascular comorbidities, and the influence on cancer treatment decision-making in women with breast cancer. Ecancermedicalscience 2021; 15:1293. [PMID: 34824616 PMCID: PMC8580595 DOI: 10.3332/ecancer.2021.1293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose To measure the baseline prevalence of cardiovascular disease (CVD), its modifiable and non-modifiable risk factors in breast cancer patients, and determine their association with adjuvant treatment decision-making. Method From 2016 to 2017, 2,127 women newly-diagnosed with breast cancer were prospectively recruited. Participants’ cardiovascular biomarkers were measured prior to adjuvant treatment decision-making. Clinical data and medical histories were obtained from hospital records. Adjuvant treatment decisions were collated 6–8 months after recruitment. A priori risk of cardiotoxicity was predicted using the Cardiotoxicity Risk Score. Results Mean age was 54 years. Eighty-five patients had pre-existing cardiac diseases and 30 had prior stroke. Baseline prevalence of hypertension was 47.8%. Close to 20% had diabetes mellitus, or were obese. Dyslipidaemia was present in 65.3%. The proportion of women presenting with ≥2 modifiable CVD risk factors at initial cancer diagnosis was substantial, irrespective of age. Significant ethnic variations were observed. Multivariable analyses showed that pre-existing CVD was consistently associated with lower administration of adjuvant breast cancer therapies (odds ratio for chemotherapy: 0.32, 95% confidence interval: 0.17–0.58). However, presence of multiple risk factors of CVD did not appear to influence adjuvant treatment decision-making. In this study, 63.6% of patients were predicted to have high risks of developing cardiotoxicities attributed to a high baseline burden of CVD risk factors and anthracycline administration. Conclusion While recent guidelines recommend routine assessment of cardiovascular comorbidities in cancer patients prior to initiation of anticancer therapies, this study highlights the prevailing gap in knowledge on how such data may be used to optimise cancer treatment decision-making.
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Affiliation(s)
- Shridevi Subramaniam
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia.,Centre of Clinical Epidemiology, Institute for Clinical Research, National Institutes of Health, Setia Alam, 40170 Shah Alam, Malaysia
| | - Yek-Ching Kong
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia.,Centre for Epidemiology and Evidence-Based Practice, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
| | - Hafizah Zaharah
- Department of Radiotherapy & Oncology, National Cancer Institute, 62250 Putrajaya, Malaysia
| | - Cuno S P M Uiterwaal
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Andrea Richard
- Centre of Clinical Epidemiology, Institute for Clinical Research, National Institutes of Health, Setia Alam, 40170 Shah Alam, Malaysia
| | - Nur Aishah Taib
- Department of Surgery, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
| | - Azura Deniel
- Department of Radiotherapy and Oncology, Hospital Kuala Lumpur, 50586 Kuala Lumpur, Malaysia
| | - Kok-Han Chee
- Cardiology Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
| | - Ros Suzanna Bustamam
- Department of Radiotherapy and Oncology, Hospital Kuala Lumpur, 50586 Kuala Lumpur, Malaysia
| | - Mee-Hoong See
- Department of Surgery, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
| | - Alan Fong
- Sarawak Heart Centre, 94300 Kota Samarahan, Sarawak, Malaysia
| | - Cheng-Har Yip
- Subang Jaya Medical Centre, 47500 Subang Jaya, Selangor, Malaysia
| | - Nirmala Bhoo-Pathy
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia.,Centre for Epidemiology and Evidence-Based Practice, Faculty of Medicine, Universiti Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
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11
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Breast Cancer Screening in Semi-Rural Malaysia: Utilisation and Barriers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312293. [PMID: 34886015 PMCID: PMC8656961 DOI: 10.3390/ijerph182312293] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022]
Abstract
Breast cancer (BC) is the commonest cancer in Malaysia. Delayed diagnosis is a significant cause of BC mortality in the country. Early diagnosis and screening are vital strategies in mortality reduction. This study assessed the level of utilisation and barriers for breast self-examination (BSE), clinical breast examination (CBE) and mammogram in a semi-rural population in Malaysia and compared these across the different ethnic groups. This cross-sectional study was conducted among women aged 40 years and above, embedded within a health and demographic surveillance site (HDSS) in Segamat, Malaysia. Trained data collectors collected data on screening and barriers during home visits. Study participants (n = 250) were aged 59.4 ± 10.9 years and represented Malaysia's three major ethnic groups. Practice of regular BSE, CBE uptake (ever) and mammogram (ever) was 23.2%, 36% and 22.4%, respectively. Regular BSE practice was highest in the Malay ethnic group and least among the Chinese. Regular CBE was very low in all ethnic groups (<5%). Mammogram uptake was highest among Chinese (34.4%), followed by Indians (30.4%) and Malays (16.6%). After adjusting for other socio-demographic variables, Malay ethnicity was positively associated with regular BSE (adjusted OR = 5.26, 95% CI 2.05, 13.50) and negatively associated with having had a mammogram (adjusted OR = 0.3, 95% CI 0.15, 0.57). Lower education was negatively associated (adjusted OR = 0.36, 95% CI 0.17, 0.74) with mammogram attendance (ever). Emotional and financial barriers were the most reported types of barriers, specifically, fear of diagnosis (74.8%), cost of diagnosis (69.6%) and fear of losing a breast (66.4%). Malay women more commonly reported most barriers compared to other ethnic groups. Screening uptake was low among semi-rural women in Malaysia. Implementing culturally appropriate interventions that consider ethnic differences is crucial to empowering women to engage in BC screening initiatives in these communities.
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12
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Kiew SJ, Majid HA, Mohd Taib NA. A qualitative exploration: Dietary behaviour of Malaysian breast cancer survivors. Eur J Cancer Care (Engl) 2021; 31:e13530. [PMID: 34693588 DOI: 10.1111/ecc.13530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 09/22/2021] [Accepted: 10/04/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study aimed to explore the dietary practices and factors affecting Malaysian breast cancer survivors' dietary behaviours. METHODS We conducted an in-depth qualitative interview on 20 participants from a cohort study. An ecological framework was used to construct the semi-structured topic guide. The interviews were audio-recorded and transcribed verbatim. Thematic analysis with theoretical saturation was used in data analysis. RESULTS The participants were found to have variable dietary practices that either followed or did not follow dietary recommendations. The social environment was critical as most women relied on family and friends for food choices; additionally, individuals in charge of food preparation had to prepare food based on their family member preferences. Furthermore, individuals had difficulty sustaining healthy dietary changes during the acute survivorship phase due to a lack of health consciousness and difficulty in healthy food access. Notably, there was a lack of dietary guidance from health care professionals, especially dietitians, in long-term survivorship care. CONCLUSION This study highlights the lack of breast cancer survivors' healthy diet and lifestyle knowledge. A holistic multidisciplinary approach involving individual, social, physical, and macro-level environmental elements are crucial to influencing healthy eating behaviours.
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Affiliation(s)
- Siew Juan Kiew
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Hazreen Abdul Majid
- Centre for Population Health and Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Nutrition, Faculty of Public Health, University of Airlangga, Surabaya, Indonesia
| | - Nur Aishah Mohd Taib
- UM Cancer Research Institute and Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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13
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Abdullah N, Mohamed N. Influence of cultural practices on breast cancer risks, stage at presentation and outcome in a multi-ethnic developing country. Oncol Lett 2021; 22:806. [PMID: 34630713 PMCID: PMC8488330 DOI: 10.3892/ol.2021.13067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/23/2021] [Indexed: 12/09/2022] Open
Abstract
Malaysia is a developing country made up of three main ethnicities: Malay, Chinese and Indian. There are significant ethnic differences with regard to the type of daily food and cooking methods, contraception, breast-feeding preferences, confinement period and care, postmenopausal intake and influence of the traditional healer. Breast cancer is the most common cancer among Malaysian women across all three ethnicities. However, the National Cancer Registry and local medical centres have documented ethnic differences in breast cancer risk (Chinese, 40.7 per 100,000; Indian, 38.1 per 100,000; Malay, 31.5 per 100,000), peak age (youngest in the Malays), stage at presentation (largest percentage at advanced stage among the Malays) and survival (poorest survival rate among the Malays). The Malays have several practices that are protective against breast cancer compared with the Chinese. However, the Malays have strong beliefs in the traditional healer, which contribute to the delay in getting treatment, causing a poor outcome and a low survival rate. The highest BRCA1 and 2 genetic mutation incidence is amongst the Chinese, but the Malays have the largest triple-negative breast cancer rates. These factors may also contribute to the statistical breast cancer data.
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Affiliation(s)
- Norlia Abdullah
- Department of Surgery, University Kebangsaan Malaysia Medical Centre, 56000 Kuala Lumpur, Malaysia
| | - Norazlina Mohamed
- Department of Pharmacology, University Kebangsaan Malaysia Medical Centre, 56000 Kuala Lumpur, Malaysia
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14
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Wong WJ, Zainudin SP, Koo YH, Ho KY, Lee ZJ, Wong KH. Young breast cancer and the influence of ethnicity in Sandakan: A 3-year retrospective cross-sectional study. Asia Pac J Clin Oncol 2021; 18:e227-e234. [PMID: 34185957 DOI: 10.1111/ajco.13596] [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: 08/29/2019] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Breast cancer (BC) is the most common cancer in Malaysia, with incidence increasing with age. There have been demonstrated differences in age of presentation and tumour biology when comparing ethnicities. Twenty percent of Caucasian women present before 50 years old, but almost 50% of Southeast Asian (SEA) women present before 50. However, BC in Indigenous sub-groups has not yet been studied. Sandakan is a city in Sabah with a large Indigenous population. Current nationwide screening guidelines are based on the U.S. Preventive Task Force 2009 Guidelines, which may not represent our population. We aim to examine the age of incidence for our local population, for local screening recommendations. METHOD Retrospective cross-sectional study, including all consecutive cases of epithelial invasive tumours, from January 2016 to December 2018. Other histological types were excluded. Univariate and multivariate analyses were performed. RESULT A total of 115 breast tumours were identified. Ten tumours were excluded (five ductal carcinoma in situ, four phyllodes, and one sarcoma), leaving a study population of 105 patients. Median age of presentation was 53 years (min 30; max 97). A total of 41.9% presented before the age of 50. Patients of Indigenous ethnic origins were 11 years younger at presentation than non-Indigenous women. Tumour grade was more likely to be higher among Indigenous women. CONCLUSION Median age of presentation of BC in Sandakan matches regional data; however, patients of Indigenous ethnic groups present even earlier. Screening guidelines should consider the growing evidence of young BC in SEA.
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Affiliation(s)
- Wei Jin Wong
- Department of General Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Syaza Putri Zainudin
- Department of General Surgery, Faculty of Medicine and Health Sciences, University Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Yee Hoong Koo
- Department of General Surgery, Duchess of Kent Hospital, Sandakan, Malaysia
| | - Kah Yee Ho
- Department of General Surgery, Duchess of Kent Hospital, Sandakan, Malaysia
| | - Zhong Jie Lee
- Department of General Surgery, Duchess of Kent Hospital, Sandakan, Malaysia
| | - Kwong Hui Wong
- Department of General Surgery, Duchess of Kent Hospital, Sandakan, Malaysia
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15
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Tan KF, Adam F, Hussin H, Mohd Mujar NM. A comparison of breast cancer survival across different age groups: a multicentric database study in Penang, Malaysia. Epidemiol Health 2021; 43:e2021038. [PMID: 34044478 PMCID: PMC8510833 DOI: 10.4178/epih.e2021038] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 05/25/2021] [Indexed: 12/24/2022] Open
Abstract
This study compared breast cancer survival and the prognostic factors across different age groups of women in Penang, Malaysia. Data on 2,166 women with breast cancer who had been diagnosed between 2010 and 2014 were extracted from the Penang Breast Cancer Registry and stratified into 3 age groups: young (< 40 years old), middle-aged (40-59 years old), and elderly (≥ 60 years). The overall and relative survival rates were calculated using the life table method, median survival time was calculated using the Kaplan-Meier method, and comparisons between groups were conducted using the log-rank test. Prognostic factors were analyzed using a Cox proportional hazards model. The 5-year overall and breast cancer-specific survival rates for women with breast cancer in Penang were 72.9% and 75.2%, with a mean survival time of 92.5 months and 95.1 months, respectively. The 5-year breast cancer-specific survival rates for young, middle-aged, and elderly women were 74.9%, 77.8%, and 71.4%, respectively, with a mean survival time of 95.7 months, 97.5 months, and 91.2 months. There was a significant difference in breast cancer survival between age groups, with elderly women showing the lowest survival rate, followed by young and middle-aged women. Disease stage was the most prominent prognostic factor for all age groups. Survival rates and prognostic factors differed according to age group. Treatment planning for breast cancer patients should be age-specific to promote better cancer care and survival.
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Affiliation(s)
- King Fang Tan
- Institute Latihan Kementerian Kesihatan Malaysia Sultan Azlan Shah, Ministry of Health Malaysia, Perak, Malaysia.,Lifestyle Science Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
| | - Farzaana Adam
- Penang State Health Department, Ministry of Health Malaysia, Penang, Malaysia
| | - Hasmah Hussin
- Women Cancer Unit (UNITA), Clinical Section of Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia.,Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
| | - Noor Mastura Mohd Mujar
- Lifestyle Science Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
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16
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Hanis TM, Yaacob NM, Mohd Hairon S, Abdullah S. Net survival differences of breast cancer between stages at diagnosis and age groups in the east coast region of West Malaysia: a retrospective cohort study. BMJ Open 2021; 11:e043642. [PMID: 34006546 PMCID: PMC8130742 DOI: 10.1136/bmjopen-2020-043642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Estimation of the net survival of breast cancer helps in assessing breast cancer burden at a population level. Thus, this study aims to estimate the net survival of breast cancer at different cancer staging and age at diagnosis in the east coast region of West Malaysia. SETTING Kelantan, Malaysia. PARTICIPANTS All breast cancer cases diagnosed in 2007 and 2011 identified from Kelantan Cancer Registry. DESIGN This retrospective cohort study used a relative survival approach to estimate the net survival of patients with breast cancer. Thus, two data were needed; breast cancer data from Kelantan Cancer Registry and general population mortality data for Kelantan population. PRIMARY AND SECONDARY OUTCOME MEASURES Net survival according to stage and age group at diagnosis at 1, 3 and 5 years following diagnosis. RESULTS The highest net survival was observed among stage I and II breast cancer cases, while the lowest net survival was observed among stage IV breast cancer cases. In term of age at diagnosis, breast cancer cases aged 65 and older had the best net survival compared with the other age groups. CONCLUSION The age at diagnosis had a minimal impact on the net survival compared with the stage at diagnosis. The finding of this study is applicable to other populations with similar breast cancer profile.
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Affiliation(s)
- Tengku Muhammad Hanis
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Malaysia
| | - Najib Majdi Yaacob
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Malaysia
| | - Suhaily Mohd Hairon
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Malaysia
| | - Sarimah Abdullah
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Malaysia
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17
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Cohort profile: The Singapore Breast Cancer Cohort (SGBCC), a multi-center breast cancer cohort for evaluation of phenotypic risk factors and genetic markers. PLoS One 2021; 16:e0250102. [PMID: 33901219 PMCID: PMC8075208 DOI: 10.1371/journal.pone.0250102] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/30/2021] [Indexed: 01/04/2023] Open
Abstract
This article aims to provide a detailed description of the Singapore Breast Cancer Cohort (SGBCC), an ongoing multi-ethnic cohort established with the overarching goal to identify genetic markers for breast cancer risk, prognosis and treatment response, as well as to understand the ethnic differences in disease risk and outcome in an Asian setting. The cohort comprises of breast cancer patients aged 21 years and above from six public hospitals which diagnose and treat nearly 76% breast cancer cases in Singapore. Self-reported data on sociodemographic and lifestyle, reproductive risk factors, medical history and family history of breast or ovarian cancer is collected using a structured questionnaire. Clinical data on tumour characteristics, and treatment modalities are obtained through medical record. Bio-specimens (blood or saliva) is collected at recruitment. Follow-up on survival information is done through routine linkage with the Registry of Births and Deaths. As of 31 December 2016, 7,768 subjects have been recruited to the study with 76% subjects contributed bio-specimens. The SGBCC provides a valuable platform which offers a unique, large and rich resource for new research ideas on breast cancer related phenotypic risk factors and genetic markers.
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18
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Zainordin NH, Abd Talib R, Shahril MR, Sulaiman S, A Karim N. Dietary Changes and Its Impact on Quality of Life among Malay Breast and Gynaecological Cancer Survivors in Malaysia. Asian Pac J Cancer Prev 2020; 21:3689-3696. [PMID: 33369469 PMCID: PMC8046325 DOI: 10.31557/apjcp.2020.21.12.3689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Fear of cancer recurrent, side effects of treatment and belief in food taboos encourage cancer survivors to make changes in their dietary practices after diagnosis of cancer. The objective of this study was to determine the impact of dietary changes on quality of life (QoL) among Malay breast and gynaecological cancer survivors. METHODS Questionnaire of dietary changes was modified from WHEL study and adapted to typical Malay's food intake in Malaysia. A total of 23 items were listed and categorized by types of food and cooking methods. Four categories of changes "increased", "decreased", "no changes" or "stopped" were used to determine the changes in dietary practices. Score one (+1) is given to positive changes by reference to WCRF/AICR and Malaysia Dietary Guideline healthy eating recommendations. Malay EORTC QLQ-C30 were used to determine the QoL. Sociodemographic, clinical characteristics and anthropometric measurement were also collected. RESULTS The mean age of the subjects (n=77) was 50.7±7.8 years old with duration of survivorship 4.0±3.1 years. Subjects mean BMI was 27.8±4.9 kg/m2 which indicate subjects were 31.2% overweight and 32.5% obese. The percentage score of positive dietary changes was 34.7±16.4%. Positive dietary changes were increased intake of green leafy vegetable (49.4%), cruciferous vegetable (46.8%) and boiling cooking methods (45.5%). Subjects reduced their intake of red meat (42.9%), sugar (53.2%) and fried cooking method (44.2%). Subjects stopped consuming milk (41.6%), c 2008-5862 heese (33.8%) and sweetened condensed milk (33.8%). With increasing positive dietary changes, there was a significant improvement on emotional function (rs=0.27; p=0.016) and reduced fatigue symptoms (rs=-0.24; p=0.033). CONCLUSION Positive changes in dietary intake improved emotional function and reduced fatigue symptoms after cancer treatment. By knowing the trend of food changes after cancer treatment, enables the formation of healthy food intervention implemented more effective.
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Affiliation(s)
- Nadzirah Hanis Zainordin
- Nutritional Sciences Programme, Center for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Ruzita Abd Talib
- Nutritional Sciences Programme, Center for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Mohd Razif Shahril
- School of Nutrition and Dietetics, Faculty of Health Sciences, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Nerus, Terengganu, Malaysia
| | - Suhaina Sulaiman
- Dietetics Programme, Centre for Healthy Aging and Wellness (H-Care), School of Healthcare Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Norimah A Karim
- Nutritional Sciences Programme, Center for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
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19
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Low SYY, Cheng H, Zou R, Ng LP, Kuick CH, Syed Sulaiman NB, Chang KTE, Low DCY, Zhou L, Seow WT. Molecular exploration of paediatric intracranial germinomas from multi-ethnic Singapore. BMC Neurol 2020; 20:415. [PMID: 33187494 PMCID: PMC7666528 DOI: 10.1186/s12883-020-01981-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/28/2020] [Indexed: 02/07/2023] Open
Abstract
Background Germinomas (IG) account for up to 50% of all intracranial germ cell tumours. These tumours are reputed to be more prevalent in Oriental populations in comparison to Western cohorts. Biological characteristics of IG in other ethnic groups are unknown. Singapore is a multi-ethnic country with diverse cultures. Owing to inter-racial heterogeneity, the authors hypothesize there are molecular differences between paediatric IG patients in our local population. The aims of this study are exploratory: firstly, to identify molecular characteristics in this tumour type and circulating CSF unique to different racial cohorts; and next, to corroborate our findings with published literature. Methods This is a single-institution, retrospective study of prospectively collected data. Inclusion criteria encompass all paediatric patients with histologically confirmed IG. Excess CSF and brain tumour tissues are collected for molecular analysis. Tumour tissues are subjected to a next generation sequencing (NGS) targeted panel for KIT and PDGRA. All CSF samples are profiled via a high-throughput miRNA multiplexed workflow. Results are then corroborated with existing literature and public databases. Results In our cohort of 14 patients, there are KIT exon variants in the tumour tissues and CSF miRNAs corroborative with published studies. Separately, there are also KIT exon variants and miRNAs not previously highlighted in IG. A subgroup analysis demonstrates differential CSF miRNAs between Chinese and Malay IG patients. Conclusion This is the first in-depth molecular study of a mixed ethnic population of paediatric IGs from a Southeast Asian cohort. Validation studies are required to assess the relevance of novel findings in our study. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-020-01981-0.
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Affiliation(s)
- Sharon Yin Yee Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore. .,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 30843, Singapore. .,VIVA-KKH Paediatric Brain and Solid Tumours Laboratory, Singapore, Singapore.
| | - He Cheng
- Bioprocessing Technology Institute, A*STAR, Singapore, Singapore.,MiRXES Pte Ltd, 10 Biopolis Road, Chromos, Singapore, 138670, Singapore
| | - Ruiyang Zou
- Bioprocessing Technology Institute, A*STAR, Singapore, Singapore.,MiRXES Pte Ltd, 10 Biopolis Road, Chromos, Singapore, 138670, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Chik Hong Kuick
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Nurfarhanah Bte Syed Sulaiman
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,VIVA-KKH Paediatric Brain and Solid Tumours Laboratory, Singapore, Singapore
| | - Kenneth Tou En Chang
- VIVA-KKH Paediatric Brain and Solid Tumours Laboratory, Singapore, Singapore.,Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - David Chyi Yeu Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 30843, Singapore
| | - Lihan Zhou
- Bioprocessing Technology Institute, A*STAR, Singapore, Singapore.,MiRXES Pte Ltd, 10 Biopolis Road, Chromos, Singapore, 138670, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 30843, Singapore
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Bhattacharyya GS, Doval DC, Desai CJ, Chaturvedi H, Sharma S, Somashekhar S. Overview of Breast Cancer and Implications of Overtreatment of Early-Stage Breast Cancer: An Indian Perspective. JCO Glob Oncol 2020; 6:789-798. [PMID: 32511068 PMCID: PMC7328098 DOI: 10.1200/go.20.00033] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/15/2022] Open
Abstract
The prevalence and mortality of breast cancer is increasing in Asian countries, including India. With advances in medical technology leading to better detection and characterization of the disease, it has been possible to classify breast cancer into various subtypes using markers, which helps predict the risk of distant recurrence, response to therapy, and prognosis using a combination of molecular and clinical parameters. Breast cancer and its therapy, mainly surgery, systemic therapy (anticancer chemotherapy, hormonal therapy, targeted therapy, and immunotherapy), and radiation therapy, are associated with significant adverse influences on physical and mental health, quality of life, and the economic status of the patient and her family. The fear of recurrence and its devastating effects often leads to overtreatment, with a toxic cost to the patient financially and physically in cases in which this is not required. This article discusses some aspects of a breast cancer diagnosis and its impact on the various facets of the life of the patient and her family. It further elucidates the role of prognostic factors, the currently available biomarkers and prognostic signatures, and the importance of ethnically validating biomarkers and prognostic signatures.
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Affiliation(s)
| | - Dinesh C. Doval
- Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Chirag J. Desai
- Vedanta Institute of Medical Sciences, Ahmedabad, Gujarat, India
| | | | - Sanjay Sharma
- Asian Cancer Institute, Somaiya Ayurvihar, Mumbai, Maharashtra, India
| | - S.P. Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Center, Manipal Hospital, Bengaluru, India
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21
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Impact of deviation from guideline recommended treatment on breast cancer survival in Asia. Sci Rep 2020; 10:1330. [PMID: 31992769 PMCID: PMC6987174 DOI: 10.1038/s41598-020-58007-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022] Open
Abstract
Breast cancer survival has improved with significant progress in treatment and disease management. However, compliance with treatment varies. Treatment guidelines for older patients are unclear. We aim to identify predictors of noncompliance with recommended therapy in a large breast cancer population and assess the impact of noncompliance on survival. Our study included 19,241 non-metastatic female breast cancer patients, of whom 3,158 (16%) died within 10 years post-diagnosis (median survival = 5.8 years). We studied the association between treatment noncompliance and factors with logistic regression, and the impact of treatment noncompliance on survival with a flexible parametric survival model framework. The highest proportion of noncompliance was observed for chemotherapy (18%). Predictors of noncompliance with chemotherapy, radiotherapy and endocrine therapy included age, tumor size, nodal involvement and subtype (except radiotherapy). Factors associated with not receiving surgery included age and subtype. Treatment noncompliance was associated with worse overall survival for surgery (HR: 2.26 [1.80-2.83]), chemotherapy (1.25 [1.11-1.41]), radiotherapy (2.28 [1.94-2.69]) and endocrine therapy (1.70 [1.41-2.04]). Worse survival was similarly observed in older patients for whom guidelines generally do not apply. Our results highlight the importance of following appropriate treatment as recommended by current guidelines. Older patients may benefit from similar recommendations.
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Hanis TM, Yaacob NM, Hairon SM, Abdullah S, Nordin N, Abdullah NH, Ariffin MFM. Modelling excess mortality among breast cancer patients in the North East Region of Peninsular Malaysia, 2007-2011: a population-based study. BMC Public Health 2019; 19:1754. [PMID: 31888561 PMCID: PMC6937984 DOI: 10.1186/s12889-019-8113-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/19/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Measurement of breast cancer burden and identification of its influencing factors help in the development of public health policy and strategy against the disease. This study aimed to examine the variability of the excess mortality of female breast cancer patients in the North East Region of Peninsular Malaysia. METHODS This retrospective cohort study was conducted using breast cancer data from the Kelantan Cancer Registry between 2007 and 2011, and Kelantan general population mortality data. The breast cancer cases were followed up for 5 years until 2016. Out of 598 cases, 549 cases met the study criteria and were included in the analysis. Modelling of excess mortality was conducted using Poisson regression. RESULTS Excess mortality of breast cancer varied according to age group (50 years old and below vs above 50 years old, Adj. EHR: 1.47; 95% CI: 1.31, 4.09; P = 0.004), ethnicity (Malay vs non-Malay, Adj. EHR: 2.31; 95% CI: 1.11, 1.96; P = 0.008), and stage (stage III and IV vs. stage I and II, Adj. EHR: 5.75; 95% CI: 4.24, 7.81; P < 0.001). CONCLUSIONS Public health policy and strategy aim to improve cancer survival should focus more on patients presented at age below 50 years old, Malay ethnicity, and at a later stage.
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Affiliation(s)
- Tengku Muhammad Hanis
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Najib Majdi Yaacob
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia.
| | - Suhaily Mohd Hairon
- Department of Community Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Sarimah Abdullah
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Noorfariza Nordin
- Department of Community Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Noor Hashimah Abdullah
- Kelantan State Health Department, Aras 5, Wisma Persekutuan Kota Bharu, Jalan Bayam, 15590, Kota Bharu, Kelantan, Malaysia
| | - Mohd Faiz Md Ariffin
- Kelantan State Health Department, Aras 5, Wisma Persekutuan Kota Bharu, Jalan Bayam, 15590, Kota Bharu, Kelantan, Malaysia
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23
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Momenimovahed Z, Salehiniya H. Epidemiological characteristics of and risk factors for breast cancer in the world. BREAST CANCER (DOVE MEDICAL PRESS) 2019; 11:151-164. [PMID: 31040712 PMCID: PMC6462164 DOI: 10.2147/bctt.s176070] [Citation(s) in RCA: 328] [Impact Index Per Article: 65.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIM Breast cancer is the most common cancer among women and one of the most important causes of death among them. This review aimed to investigate the incidence and mortality rates of breast cancer and to identify the risk factors for breast cancer in the world. MATERIALS AND METHODS A search was performed in PubMed, Web of Science, and Scopus databases without any time restrictions. The search keywords included the following terms: breast cancer, risk factors, incidence, and mortality and a combination of these terms. Studies published in English that referred to various aspects of breast cancer including epidemiology and risk factors were included in the study. Overall, 142 articles published in English were included in the study. RESULTS Based on the published studies, the incidence rate of breast cancer varies greatly with race and ethnicity and is higher in developed countries. Results of this study show that mortality rate of breast cancer is higher in less developed regions. The findings of this study demonstrated that various risk factors including demographic, reproductive, hormonal, hereditary, breast related, and lifestyle contribute to the incidence of breast cancer. CONCLUSION The results of this study indicated that incidence and mortality rates of breast cancer is rising, so design and implementation of screening programs and the control of risk factors seem essential.
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Affiliation(s)
- Zohre Momenimovahed
- Qom University of Medical Sciences, Qom, Iran
- Department of Reproductive Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Salehiniya
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran,
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran,
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24
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Mohamad NE, Yeap SK, Abu N, Lim KL, Zamberi NR, Nordin N, Sharifuddin SA, Long K, Alitheen NB. In vitro and in vivo antitumour effects of coconut water vinegar on 4T1 breast cancer cells. Food Nutr Res 2019; 63:1616. [PMID: 30814922 PMCID: PMC6387426 DOI: 10.29219/fnr.v63.1616] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 09/12/2018] [Accepted: 11/28/2018] [Indexed: 01/01/2023] Open
Abstract
Background Coconut water and vinegars have been reported to possess potential anti-tumour and immunostimulatory effects. However, the anti-tumour, anti-inflammatory and immunostimulatory effects of coconut water vinegar have yet to be tested. Objective This study investigated the in vitro and in vivo anti-tumour effects of coconut water vinegar on 4T1 breast cancer cells. Methods The 4T1 cells were treated with freeze-dried coconut water vinegar and subjected to MTT cell viability, BrdU, annexin V/PI apoptosis, cell cycle and wound healing assays for the in vitro analysis. For the in vivo chemopreventive evaluation, mice challenged with 4T1 cells were treated with 0.08or 2.00 mL/kg body weight of fresh coconut water vinegar for 28 days. Tumour weight, apoptosis of tumour cells, metastasis and immunity of untreated mice and coconut water vinegar-treated 4T1 challenged mice were compared. Results Freeze-dried coconut water vinegar reduced the cell viability, induced apoptosis and delayed the wound healing effect of 4T1 cells in vitro. In vivo, coconut water vinegar delayed 4T1 breast cancer progression in mice by inducing apoptosis and delaying the metastasis. Furthermore, coconut water vinegar also promoted immune cell cytotoxicity and production of anticancer cytokines. The results indicate that coconut water vinegar delays breast cancer progression by inducing apoptosis in breast cancer cells, suppressing metastasis and activating anti-tumour immunity. Conclusion Coconut water vinegar is a potential health food ingredient with a chemopreventive effect.
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Affiliation(s)
- Nurul Elyani Mohamad
- Department of Cell and Molecular Biology, Faculty of Biotechnology and Biomolecular Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Swee Keong Yeap
- China-ASEAN College of Marine Sciences, Xiamen University Malaysia, Jalan Sunsuria, Bandar Sunsuria, Sepang, Selangor, Malaysia.,Institute of Bioscience, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Nadiah Abu
- Department of Cell and Molecular Biology, Faculty of Biotechnology and Biomolecular Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.,UKM Medical Centre, UKM Medical Molecular Biology Institute (UMBI), Cheras, Wilayah Persekutuan, Malaysia
| | - Kian Lam Lim
- Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Sungai Long Campus, Jalan Sungai Long, Bandar Sungai Long, Cheras, Kajang, Selangor, Malaysia
| | - Nur Rizi Zamberi
- Department of Cell and Molecular Biology, Faculty of Biotechnology and Biomolecular Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Noraini Nordin
- Department of Cell and Molecular Biology, Faculty of Biotechnology and Biomolecular Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Shaiful Adzni Sharifuddin
- Biotechnology Research Centre, Malaysian Agricultural Research and Development Institute (MARDI), Serdang, Selangor, Malaysia
| | - Kamariah Long
- Biotechnology Research Centre, Malaysian Agricultural Research and Development Institute (MARDI), Serdang, Selangor, Malaysia
| | - Noorjahan Banu Alitheen
- Department of Cell and Molecular Biology, Faculty of Biotechnology and Biomolecular Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.,Institute of Bioscience, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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25
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Shaw T, Ishak D, Lie D, Menon S, Courtney E, Li ST, Ngeow J. The influence of Malay cultural beliefs on breast cancer screening and genetic testing: A focus group study. Psychooncology 2018; 27:2855-2861. [PMID: 30264524 DOI: 10.1002/pon.4902] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/30/2018] [Accepted: 09/24/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Malays comprise an Asian cultural group reported to have low breast cancer screening uptake rates and poor cancer outcomes. Little is known about Malay cultural factors influencing beliefs and practice of cancer screening and genetic testing. Our study aims to explore health beliefs of Malay women around breast cancer screening and genetic testing. METHODS We conducted focus groups among healthy English-speaking Malay women in Singapore, aged 40 to 69 years, using a structured guide developed through literature review, expertise input and participant refinement. Thematic analysis was conducted to extract dominant themes representing key motivators and barriers to screening and genetic testing. We used grounded theory to interpret results and derive a framework of understanding, with implications for improving uptake of services. RESULTS Five focus groups (four to six participants per group) comprising 27 women were conducted to theme saturation. Major themes were (a) spiritual and religious beliefs act as barriers towards uptake of screening and genetic testing; (b) preference for traditional medicine competes with Western medicine recommendations; (c) family and community influence health-related decisions, complexed by differences in intergenerational beliefs creating contrasting attitudes towards screening and prevention. CONCLUSIONS Decisions to participate in breast cancer screening and genetic testing are influenced by cultural, traditional, spiritual/religious, and intergenerational beliefs. Strategies to increase uptake should include acknowledgement and integration of these beliefs into counseling and education and collaboration with key influential Malay stakeholders and leaders.
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Affiliation(s)
- Tarryn Shaw
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre, Singapore
| | - Diana Ishak
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre, Singapore
| | - Désirée Lie
- Office of Clinical Sciences, Duke-NUS Medical School, Singapore
| | - Sapna Menon
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre, Singapore
| | - Eliza Courtney
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre, Singapore
| | - Shao-Tzu Li
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre, Singapore
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,Institute of Molecular and Cell Biology, Agency for Science Technology and Research (A*Star), Singapore
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26
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Virani S, Wetzel EC, Laohawiriyakamol S, Boonyaphiphat P, Geater A, Kleer CG, Pang J, Rentschler KM, Colacino JA, de Leon CFM, Rozek LS, Sriplung H. Ethnic disparity in breast cancer survival in southern Thai women. Cancer Epidemiol 2018; 54:82-89. [PMID: 29684800 DOI: 10.1016/j.canep.2018.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/18/2018] [Accepted: 02/21/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Breast cancer has the highest incidence in women of all cancers and its burden is expected to continue to increase worldwide, especially in middle-income countries such as Thailand. The southern region of Thailand is unique in that it is comprised of 30% Muslims, whereas the rest of Thailand is 95% Buddhist. Breast cancer incidence and survival differ between these religious groups, but the association between clinical subtype of breast cancer and survival has not yet been assessed. METHODS Here we characterized differences in breast cancer survival with consideration to clinical subtype by religious group (Muslim Thai and Buddhist Thai women). We compared distributions of age, stage and clinical subtype and assessed overall survival by religion. RESULTS Our findings show that Muslim Thai women with breast cancer are diagnosed at a younger age, at later stages and have shorter overall survival times compared to Buddhist Thai women with breast cancer. We also observe a higher proportion of triple negative tumors characterized in Muslim Thai women. CONCLUSIONS Our findings confirm previous studies that have shown lower survival rates in Muslim Thai women compared to Buddhist women with breast cancer and offer novel information on subtype distribution. To date, this is the first study assessing clinical subtypes in southern Thailand by religious status. IMPACT Our findings are critical in providing information on the role of clinical subtype in cancer disparities and provide evidence from the Southeast Asian region for global studies on breast cancer survival.
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Affiliation(s)
- Shama Virani
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Elizabeth C Wetzel
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | | | - Pleumjit Boonyaphiphat
- Department of Pathology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Alan Geater
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Celina G Kleer
- Department of Pathology University of Michigan, Ann Arbor, MI USA
| | - Judy Pang
- Department of Pathology University of Michigan, Ann Arbor, MI USA
| | - Katie M Rentschler
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Justin A Colacino
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Carlos F Mendes de Leon
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Laura S Rozek
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI USA.
| | - Hutcha Sriplung
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
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27
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Fayer VA, Guerra MR, Cintra JRD, Bustamante-Teixeira MT. Ten-year survival and prognostic factors for breast cancer in the southeast region of Brazil. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2018; 19:766-778. [PMID: 28146166 DOI: 10.1590/1980-5497201600040007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 05/31/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction: Breast cancer is an important public health issue in many parts of the world. Thus, it shows relevant incidence and is considered one of the main causes of death from cancer among women. Objective: To analyze ten-year survival and prognostic factors in women with invasive breast cancer. Methods: The cohort was composed of 195 women assisted in an oncology referral center in the municipality of Juiz de Fora, state of Minas Gerais, Brazil, who were diagnosed with the disease in 2000 and 2001. Sociodemographic, tumoral, health service, and treatment-related characteristics were analyzed. The Kaplan-Meier method was used to estimate the survival functions and the Cox model of proportional hazards for the evaluation of prognostic factors. Results: The ten-year survival after diagnosis was of 56.3%. The major independent prognostic factors associated with increased risk of death were tumor size > 2.0 cm (hazard ratio - HR = 1.9; confidence interval - 95%CI 1.0 - 3.2) and presence of compromised lymph nodes (HR = 3.7; 95%CI 2.1 - 5.9). Conclusion: These findings reinforce the need of adopting actions that ensure access of the target population to the recommended diagnostic and therapeutic modalities, thus contributing to achieve earlier diagnosis and better survival rates.
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Affiliation(s)
- Vívian Assis Fayer
- Programa de Pós-Graduação em Saúde Coletiva, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brasil
| | - Maximiliano Ribeiro Guerra
- Programa de Pós-Graduação em Saúde Coletiva, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brasil
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28
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Ho PJ, Hartman M, Gernaat SAM, Cook AR, Lee SC, Hupkens L, Verkooijen HM. Associations between workability and patient-reported physical, psychological and social outcomes in breast cancer survivors: a cross-sectional study. Support Care Cancer 2018; 26:2815-2824. [PMID: 29511953 DOI: 10.1007/s00520-018-4132-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 02/25/2018] [Indexed: 11/12/2022]
Abstract
PURPOSE Workability is of increasing importance especially in Asia given the increasing incidence rates and young age of onset of breast cancer. This study explores the determinants of employment and suboptimal workability. And evaluate the association between workability and patient-reported physical, psychological, and social outcomes. METHODS In a hospital-based cross-sectional study, 327 breast cancer survivors, < 65 years of age and > 1 year post-diagnosis were recruited. Employed survivors filled out the workability index, which measures a person's capacity to meet work demands in relation to current health status. The EORTC-QLQ-C30, EORTC-QLQ-BR23, hospital anxiety and depression scale, multidimensional fatigue inventory, and brief pain index were administered. Fisher's exact test and Kruskal-Wallis test were used to test for associations of workability and employment status with demographic, clinical characteristics, and patient-reported outcomes. Linear models with standardised scores for patient-reported outcomes were fitted to study the associations of workability with patient-reported outcomes. RESULTS Of the 327 survivors, < 65 years of age (working age), 140 (43%) were in full-time and 34 (10%) in part-time employment. Employed survivors were younger at time of diagnosis and at time of survey. Employment status was not associated with time since diagnosis, ethnicity, or clinical characteristics. Suboptimal workability was present in 37% of employed survivors of the working age, and more common in jobs that include physical work activities. Higher level of depression, financial difficulty and physical fatigue, more breast symptoms, and poorer global health status were independently associated with poorer workability. CONCLUSIONS Lower employment and reduced workability in breast cancer survivors is common, and reduced workability is associated with higher levels of depression, financial difficulty and physical fatigue, more breast symptoms, and poorer global health status. Longitudinal research on psychosocial support with workability in Asia may find tailored approach to improve or maintain workability in employed breast cancer patients.
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Affiliation(s)
- Peh Joo Ho
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Mikael Hartman
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore. .,Department of Surgery, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore.
| | - Sofie A M Gernaat
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alex R Cook
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Soo Chin Lee
- National Health System, National University Cancer Institute, Singapore, Singapore
| | - Leon Hupkens
- Nyenrode Business University, Breukelen, The Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
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29
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Zulkipli AF, Islam T, Mohd Taib NA, Dahlui M, Bhoo-Pathy N, Al-Sadat N, Abdul Majid H, Hussain S. Use of Complementary and Alternative Medicine Among Newly Diagnosed Breast Cancer Patients in Malaysia: An Early Report From the MyBCC Study. Integr Cancer Ther 2017; 17:312-321. [PMID: 29218996 PMCID: PMC6041923 DOI: 10.1177/1534735417745248] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background. The use of complementary and alternative medicine (CAM) has increased and little is known on CAM use during the initial period. Therefore, the aim was to determine prevalence of CAM use among newly diagnosed breast cancer patients prior to seeking conventional treatment. Methods. This is a cross-sectional study involved interviewing newly diagnosed breast cancer patients in the University Malaya Medical Centre (UMMC) using a structured questionnaire. Eligible respondents were interviewedduring a routine clinical visit. Results. A total of 400 patients were interviewed, of whom 139 (34.8%) were CAM users. Dietary supplementation (n = 107, 77.0%) was the most frequently used type of CAM, followed by spiritual healing (n = 40, 28.8%) and traditional Chinese medicine (n = 32, 23.0%). Malay ethnic group (n = 61, 43.9%) was the largest group of CAM users, followed by Chinese (n = 57, 41.0%) and Indian (n = 20, 14.4%). Majority of these CAM users (n = 87, 73.1%) did not disclose the use of CAM to their doctors. Most of them used remedies based on the recommendation of family and friends. Malay ethnicity and patients with 3 or more comorbidities were more likely to use CAM. Conclusion. There is substantial use of CAM among breast cancer patients in UMMC prior to seeking hospital treatment, and the most popular CAM modality is dietary supplements. Since, the majority of CAM users do not disclose the use of CAM to their physicians, therefore health care providers should ensure that those patients who are likely to use CAM are appropriately counseled and advised.
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Affiliation(s)
| | - Tania Islam
- 1 University of Malaya, Kuala Lumpur, Malaysia
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30
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Xin WR, Kwok LL, Yong WF. Screening Uptake Differences Are Not Implicated in Poorer Breast Cancer Outcomes among Singaporean Malay Women. J Breast Cancer 2017; 20:183-191. [PMID: 28690655 PMCID: PMC5500402 DOI: 10.4048/jbc.2017.20.2.183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 03/01/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was undertaken to examine the impact of screening and race on breast cancer outcomes in Singapore. Methods An institutional database was reviewed, and invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS) data were analyzed separately. Overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were assessed. Results The study included 6,180 IDC and 1,031 DCIS patients. The median follow-up time was 4.1 years. Among IDC patients, Malay women were the youngest when first diagnosed, and were more likely to present with advanced stage disease. Malay women also had the highest proportion of T3 and T4 tumors at 14.2%, compared with Chinese women at 8.7% and Indian women at 9.6% (p<0.001). Malay women had a higher incidence of node-positive disease at 58.3% compared with Chinese women at 46.4% and Indian women at 54.9% (p<0.001). Malay subjects also had higher-grade tumors; 61.8% had grade 3 tumors compared with 45.8% of Chinese women and 52% of Indian women (p<0.001). Furthermore, tumors in Malay subjects were less endocrine-sensitive and more human epidermal growth factor receptor 2 enriched. Malay women had the lowest 5- and 10-year OS, DFS, and CSS rates (p<0.001). After separating clinically and screen-detected tumors, multivariate analysis showed that race was still significant for outcomes. For screen-detected tumors, the OS hazard ratio (HR) for Malay women compared to Chinese women was 5.78 (95% confidence interval [CI], 2.64–12.64), the DFS HR was 2.18 (95% CI, 1.19–3.99), and the CSS HR was 5.93 (95% CI, 2.15–16.39). For DCIS, there were no statistically significant differences in the tumor size, grade, histology subtypes, or hormone sensitivity. Conclusion Malay race is a poor prognostic factor in both clinically and screen-detected IDC. Special attention should be given to the detection and follow-up of breast cancer in this group.
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Affiliation(s)
- Wong Ru Xin
- Department of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Li-Lian Kwok
- Department of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Wong Fuh Yong
- Department of Radiation Oncology, National Cancer Centre Singapore, Singapore
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31
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Chen JG, Zhu J, Zhang YH, Zhang YX, Yao DF, Chen YS, Lu JH, Ding LL, Chen HZ, Zhu CY, Yang LP, Zhu YR, Qiang FL. Cancer survival in Qidong between 1972 and 2011: A population-based analysis. Mol Clin Oncol 2017; 6:944-954. [PMID: 28588795 PMCID: PMC5451853 DOI: 10.3892/mco.2017.1234] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 03/07/2017] [Indexed: 01/07/2023] Open
Abstract
Population-based cancer survival is an improved index for evaluating the overall efficiency of cancer health services in a given region. The current study analysed the observed survival and relative survival of leading cancer sites from a population-based cancer registry between 1972 and 2011 in Qidong, China. A total of 92,780 incident cases with cancer were registered and followed-up for survival status. The main sites of the cancer types, based on the rank order of incidence, were the liver, stomach, lung, colon and rectum, oesophagus, breast, pancreas, leukaemia, brain and central nervous system (B and CNS), bladder, blood [non-Hodgkin's lymphoma (NHL)] and cervix. For all malignancies combined, the 5-year observed survival was 13.18% and the relative survival was 15.80%. Females had higher observed survival and relative survival (19.32 and 22.71%, respectively) compared with males (9.63 and 11.68%, respectively). The cancer sites with the highest five-year relative survival rates were the female breast, bladder, cervix and colon and rectum; followed by NHL, stomach, B and CNS cancer and leukaemia. The poorest survival rates were cancers of oesophagus, lung, pancreas and liver. Higher survival rates were observed in younger patients compared with older patients. Cancers of the oesophagus, female breast and bladder were associated with higher survival in middle-aged groups. Improved survival rates in the most recent two 5-year calendar periods were identified for stomach, lung, colon and rectum, oesophagus, female breast and bladder cancer, as well as leukaemia and NHL. The observations of the current study provide the opportunity for evaluation of the survival outcomes of frequent cancer sites that reflects the changes and improvement in a rural area in China.
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Affiliation(s)
- Jian-Guo Chen
- Qidong Cancer Registry, Qidong Liver Cancer Institute, Qidong, Jiangsu 226200, P.R. China
- Nantong University Tumour Hospital/Institute, Nantong, Jiangsu 226361, P.R. China
| | - Jian Zhu
- Qidong Cancer Registry, Qidong Liver Cancer Institute, Qidong, Jiangsu 226200, P.R. China
| | - Yong-Hui Zhang
- Qidong Cancer Registry, Qidong Liver Cancer Institute, Qidong, Jiangsu 226200, P.R. China
| | - Yi-Xin Zhang
- Nantong University Tumour Hospital/Institute, Nantong, Jiangsu 226361, P.R. China
| | - Deng-Fu Yao
- Affiliated Hospital of Nantong University, Nantong, Jiangsu 226000, P.R. China
| | - Yong-Sheng Chen
- Qidong Cancer Registry, Qidong Liver Cancer Institute, Qidong, Jiangsu 226200, P.R. China
| | - Jian-Hua Lu
- Qidong Cancer Registry, Qidong Liver Cancer Institute, Qidong, Jiangsu 226200, P.R. China
| | - Lu-Lu Ding
- Qidong Cancer Registry, Qidong Liver Cancer Institute, Qidong, Jiangsu 226200, P.R. China
| | - Hai-Zhen Chen
- Nantong University Tumour Hospital/Institute, Nantong, Jiangsu 226361, P.R. China
| | - Chao-Yong Zhu
- Nantong University Tumour Hospital/Institute, Nantong, Jiangsu 226361, P.R. China
| | - Li-Ping Yang
- Nantong University Tumour Hospital/Institute, Nantong, Jiangsu 226361, P.R. China
| | - Yuan-Rong Zhu
- Qidong Cancer Registry, Qidong Liver Cancer Institute, Qidong, Jiangsu 226200, P.R. China
| | - Fu-Lin Qiang
- Nantong University Tumour Hospital/Institute, Nantong, Jiangsu 226361, P.R. China
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Sim N, Soh S, Ang CH, Hing CH, Lee HJ, Nallathamby V, Yap YL, Ong WC, Lim TC, Lim J. Breast reconstruction rate and profile in a Singapore patient population: a National University Hospital experience. Singapore Med J 2017; 59:300-304. [PMID: 28503698 DOI: 10.11622/smedj.2017035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Breast reconstruction is an integral part of breast cancer management with the aim of restoring a breast to its natural form. There is increasing awareness among women that it is a safe procedure and its benefits extend beyond aesthetics. Our aim was to establish the rate of breast reconstruction and provide an overview of the patients who underwent breast reconstruction at National University Hospital (NUH), Singapore. METHODS We evaluated factors that impact a patient's decision to proceed with breast reconstruction, such as ethnicity, age, time and type of implant. We retrospectively reviewed the medical records of women who had breast cancer and underwent breast surgery at NUH between 2001 and 2010. RESULTS The breast reconstruction rate in this study was 24.3%. There were 241 patients who underwent breast reconstruction surgeries (including delayed and immediate procedures) among 993 patients for whom mastectomies were done for breast cancer. Chinese patients were the largest ethnic group who underwent breast reconstruction after mastectomy (74.3%). Within a single ethnic patient group, Malay women had the largest proportion of women undergoing breast reconstruction (60.0%). The youngest woman in whom cancer was detected in our study was aged 20 years. Malay women showed the greatest preference for autologous tissue breast reconstruction (92.3%). The median age at cancer diagnosis of our cohort was 46 years. CONCLUSION We noted increases in the age of patients undergoing breast reconstruction and the proportion of breast reconstruction cases over the ten-year study period.
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Affiliation(s)
- Nadia Sim
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sharon Soh
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chuan Han Ang
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Chor Hoong Hing
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Surgery, National University Health System, Singapore
| | - Han Jing Lee
- Department of Surgery, National University Health System, Singapore.,Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Vigneswaran Nallathamby
- Department of Surgery, National University Health System, Singapore.,Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Yan Lin Yap
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Wei Chen Ong
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Thiam Chye Lim
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
| | - Jane Lim
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System, Singapore
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Gernaat SAM, Ho PJ, Rijnberg N, Lee SC, Lim SH, Yap YS, Grobbee DE, Hartman M, Verkooijen HM. Risk of death from cardiovascular disease following breast cancer in Southeast Asia: a prospective cohort study. Sci Rep 2017; 7:1365. [PMID: 28465587 PMCID: PMC5430976 DOI: 10.1038/s41598-017-01540-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/31/2017] [Indexed: 01/24/2023] Open
Abstract
Breast cancer incidence and survival is high in Southeast Asia. As such, many women diagnosed with breast cancer are at risk of dying of other causes. Given the increased risk of cardiotoxicity induced by breast cancer treatments, it is important to identify patients at high risk of cardiovascular disease (CVD) mortality. The aim of this study was to investigate if this risk varies by age and ethnicity. Patient details were obtained from 5,868 Chinese, Malay, and Indian women diagnosed with in situ or non-metastasized invasive breast cancer at the National University Hospital of Singapore and KK Women's and Children's Hospital in Singapore. Death causes were obtained from the National Registry of Births and Deaths. Flexible parametric survival models estimated CVD mortality rates and hazard ratios. During a median follow-up of six years, 1,010 deaths occurred of which 6.8% were due to CVD. CVD mortality rates of older women peaked within the first year following diagnosis and increased over time since diagnosis. Indian had more than double the risk of CVD mortality than Chinese, independent of age at diagnosis and stage. Taking ethnicity and age into account may promote CVD risk stratification and management in (Southeast Asian) women with breast cancer.
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Affiliation(s)
- S A M Gernaat
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Department of Epidemiology, Utrecht, 3584, CX, The Netherlands.
| | - P J Ho
- National University of Singapore, Saw Swee Hock School of Public Health, Singapore, 117549, Singapore
| | - N Rijnberg
- Academic Medical Center, Division of Internal Medicine, Amsterdam, 1105 AZ, The Netherlands
| | - S C Lee
- National University Cancer Institute, National University Health System, Department of Hematology-oncology, Singapore, 119074, Singapore
| | - S H Lim
- KK Women's and Children's Hospital, KK Breast Department, Singapore, 229899, Singapore
| | - Y S Yap
- National Cancer Centre Singapore, Division of Medical Oncology, Singapore, 169610, Singapore
| | - D E Grobbee
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Department of Epidemiology, Utrecht, 3584, CX, The Netherlands
| | - M Hartman
- National University Hospital Singapore, Department of Surgery, Singapore, 119074, Singapore
| | - H M Verkooijen
- University Medical Center Utrecht, Imaging Division, Utrecht, 3584 CX, The Netherlands
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Mohd Mujar NM, Dahlui M, Emran NA, Abdul Hadi I, Wai YY, Arulanantham S, Hooi CC, Mohd Taib NA. Complementary and alternative medicine (CAM) use and delays in presentation and diagnosis of breast cancer patients in public hospitals in Malaysia. PLoS One 2017; 12:e0176394. [PMID: 28448541 PMCID: PMC5407802 DOI: 10.1371/journal.pone.0176394] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Complementary and alternative medicine (CAM) is widely used among the breast cancer patients in Malaysia. Delays in presentation, diagnosis and treatment have been shown to impact the disease prognosis. There is considerable use of CAM amongst breast cancer patients. CAM use has been cited as a cause of delay in diagnosis and treatments in qualitative studies, however there had not been any confirmatory study that confirms its impact on delays. The purpose of this study was to evaluate whether the use of CAM among newly diagnosed breast cancer patients was associated with delays in presentation, diagnosis or treatment of breast cancer. This multi-centre cross-sectional study evaluating the time points of the individual breast cancer patients' journey from first visit, resolution of diagnosis and treatments was conducted in six public hospitals in Malaysia. All newly diagnosed breast cancer patients from 1st January to 31st December 2012 were recruited. Data were collected through medical records review and patient interview by using a structured questionnaire. Complementary and alternative medicine (CAM) was defined as the use of any methods and products not included in conventional allopathic medicine before commencement of treatments. Presentation delay was defined as time taken from symptom discovery to first presentation of more than 3 months. The time points were categorised to diagnosis delay was defined as time taken from first presentation to diagnosis of more than 1 month and treatment delay was defined as time taken from diagnosis to initial treatment of more than 1 month. Multiple logistic regression was used for analysis. A total number of 340 patients participated in this study. The prevalence of CAM use was 46.5% (n = 158). Malay ethnicity (OR 3.32; 95% CI: 1.85, 5.97) and not interpreting symptom as cancerous (OR 1.79; 95% CI: 1.10, 2.92) were significantly associated with CAM use. The use of CAM was associated with delays in presentation (OR 1.65; 95% CI: 1.05, 2.59), diagnosis (OR 2.42; 95% CI: 1.56, 3.77) and treatment of breast cancer (OR 1.74; 95% CI: 1.11, 2.72) on univariate analyses. However, after adjusting with other covariates, CAM use was associated with delays in presentation (OR 1.71; 95% CI: 1.05, 2.78) and diagnosis (OR 2.58; 95% CI: 1.59, 4.17) but not for treatment of breast cancer (OR 1.58; 95% CI: 0.98, 2.55). The prevalence of CAM use among the breast cancer patients was high. Women of Malay ethnicity and not interpreting symptom as cancerous were significantly associated with CAM use. The use of CAM is significantly associated with delay in presentation and resolution of diagnosis. This study suggests further evaluation of access to breast cancer care is needed as poor access may cause the use of CAM. However, since public hospitals in Malaysia are heavily subsidized and readily available to the population, CAM use may impact delays in presentation and diagnosis.
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Affiliation(s)
- Noor Mastura Mohd Mujar
- Cluster of Healthy Lifestyle, Advanced Medical and Dental Institute, University Science of Malaysia, Penang, Malaysia
| | - Maznah Dahlui
- Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | | | | | | | - Nur Aishah Mohd Taib
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Advanced Stage at Presentation Remains a Major Factor Contributing to Breast Cancer Survival Disparity between Public and Private Hospitals in a Middle-Income Country. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14040427. [PMID: 28420149 PMCID: PMC5409628 DOI: 10.3390/ijerph14040427] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/31/2022]
Abstract
Background: Survival disparities in cancer are known to occur between public and private hospitals. We compared breast cancer presentation, treatment and survival between a public academic hospital and a private hospital in a middle-income country. Methods: The demographics, clinical characteristics, treatment and overall survival (OS) of 2767 patients with invasive breast carcinoma diagnosed between 2001 and 2011 in the public hospital were compared with 1199 patients from the private hospital. Results: Compared to patients in the private hospital, patients from the public hospital were older at presentation, and had more advanced cancer stages. They were also more likely to receive mastectomy and chemotherapy but less radiotherapy. The five-year OS in public patients was significantly lower than in private patients (71.6% vs. 86.8%). This difference was largely attributed to discrepancies in stage at diagnosis and, although to a much smaller extent, to demographic differences and treatment disparities. Even following adjustment for these factors, patients in the public hospital remained at increased risk of mortality compared to their counterparts in the private hospital (Hazard Ratio: 1.59; 95% Confidence Interval: 1.36–1.85). Conclusion: Late stage at diagnosis appears to be a major contributing factor explaining the breast cancer survival disparity between public and private patients in this middle-income setting.
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Demchig D, Mello-Thoms C, Brennan PC. Breast cancer in Mongolia: an increasingly important health policy issue. BREAST CANCER-TARGETS AND THERAPY 2017; 9:29-38. [PMID: 28176935 PMCID: PMC5268367 DOI: 10.2147/bctt.s125584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Breast cancer is a leading cause of cancer-related death for women in both developed and developing countries. The incidence and mortality of breast cancer in Mongolia, while low compared with other counties, has been increasing on an annual basis. In addition, in Mongolia, approximately 90% of the patients are diagnosed at a late stage, resulting in high mortality, with the majority of individuals diagnosed with breast cancer dying within 5 years of diagnosis. Breast cancer screening plays an important role in reducing mortality in Western countries and has been adopted by a number of Asian countries; however, no such approach exists in Mongolia. In a country of limited resources, implementation of expensive health strategies such as screening requires effective allocations of resources and the identification of the most effective imaging methods. This requirement relies on recent accurate data; however, at this time, there is a paucity of information around breast cancer in Mongolia. Until data around features of the disease are available, effective strategies to diagnose breast cancer that recognize the economic climate in Mongolia cannot be implemented and the impact of breast cancer is likely to increase.
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Affiliation(s)
- Delgermaa Demchig
- Medical Image Optimization and Perception Group (MIOPeG), Faculty of Health Science, The University of Sydney, Sydney, NSW, Australia
| | - Claudia Mello-Thoms
- Medical Image Optimization and Perception Group (MIOPeG), Faculty of Health Science, The University of Sydney, Sydney, NSW, Australia
| | - Patrick C Brennan
- Medical Image Optimization and Perception Group (MIOPeG), Faculty of Health Science, The University of Sydney, Sydney, NSW, Australia
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Lim LY, Miao H, Lim JSJ, Lee SC, Bhoo‐Pathy N, Yip CH, Taib NABM, Chan P, Tan EY, Lim SH, Lim GH, Woo E, Tan YS, Lee JA, Wong M, Tan PH, Ong KW, Wong FY, Yap YS, Hartman M. Outcome after neoadjuvant chemotherapy in Asian breast cancer patients. Cancer Med 2017; 6:173-185. [PMID: 28000426 PMCID: PMC5269707 DOI: 10.1002/cam4.985] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 10/27/2016] [Accepted: 10/28/2016] [Indexed: 01/27/2023] Open
Abstract
We aim to identify clinicopathologic predictors for response to neoadjuvant chemotherapy and to evaluate the prognostic value of pathologic complete response (pCR) on survival in Asia. This study included 915 breast cancer patients who underwent neoadjuvant chemotherapy at five public hospitals in Singapore and Malaysia. pCR following neoadjuvant chemotherapy was defined as 1) no residual invasive tumor cells in the breast (ypT0/is) and 2) no residual invasive tumor cells in the breast and axillary lymph nodes (ypT0/is ypN0). Association between pCR and clinicopathologic characteristics and treatment were evaluated using chi-square test and multivariable logistic regression. Kaplan-Meier analysis and log-rank test, stratified by other prognostic factors, were conducted to compare overall survival between patients who achieved pCR and patients who did not. Overall, 4.4% of nonmetastatic patients received neoadjuvant chemotherapy. The median age of preoperatively treated patients was 50 years. pCR rates were 18.1% (pCR ypT0/is) and 14.4% (pCR ypT0/is ypN0), respectively. pCR rate was the highest among women who had higher grade, smaller size, estrogen receptor negative, human epidermal growth factor receptor 2-positive disease or receiving taxane-based neoadjuvant chemotherapy. Patients who achieved pCR had better overall survival than those who did not. In subgroup analysis, the survival advantage was only significant among women with estrogen receptor-negative tumors. Patients with poor prognostic profile are more likely to achieve pCR and particularly when receiving taxane-containing chemotherapy. pCR is a significant prognostic factor for overall survival especially in estrogen receptor-negative breast cancers.
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Affiliation(s)
- Li Yan Lim
- Department of SurgeryNational University Health System1E Kent Ridge RoadSingapore119228Singapore
| | - Hui Miao
- Saw Swee Hock School of Public HealthNational University of SingaporeTahir Foundation Building, 12 Science Drive 2Singapore117549Singapore
| | - Joline S. J. Lim
- Department of Hematology OncologyNational University Health System1E Kent Ridge RoadSingapore119228Singapore
| | - Soo Chin Lee
- Department of Hematology OncologyNational University Health System1E Kent Ridge RoadSingapore119228Singapore
| | - Nirmala Bhoo‐Pathy
- Julius Centre University MalayaFaculty of MedicineUniversity of MalayaKuala Lumpur50603Malaysia
| | - Cheng Har Yip
- Department of SurgeryFaculty of MedicineUniversity of MalayaKuala Lumpur50603Malaysia
| | - Nur Aishah B. M. Taib
- Department of SurgeryFaculty of MedicineUniversity of MalayaKuala Lumpur50603Malaysia
| | - Patrick Chan
- Department of SurgeryTan Tock Seng Hospital11 Jalan Tan Tock SengSingapore308433Singapore
| | - Ern Yu Tan
- Department of SurgeryTan Tock Seng Hospital11 Jalan Tan Tock SengSingapore308433Singapore
| | - Swee Ho Lim
- Breast DepartmentKK Women's and Children's Hospital100 Bukit Timah RoadSingapore229899Singapore
| | - Geok Hoon Lim
- Breast DepartmentKK Women's and Children's Hospital100 Bukit Timah RoadSingapore229899Singapore
| | - Evan Woo
- Breast DepartmentKK Women's and Children's Hospital100 Bukit Timah RoadSingapore229899Singapore
| | - Yia Swam Tan
- Breast DepartmentKK Women's and Children's Hospital100 Bukit Timah RoadSingapore229899Singapore
| | - Jung Ah Lee
- Breast DepartmentKK Women's and Children's Hospital100 Bukit Timah RoadSingapore229899Singapore
| | - Mabel Wong
- Department of Medical OncologyNational Cancer Centre Singapore11 Hospital DriveSingapore169610Singapore
| | - Puay Hoon Tan
- Department of PathologySingapore General Hospital20 College RoadSingapore169856Singapore
| | - Kong Wee Ong
- Division of Surgical OncologyNational Cancer Centre Singapore11 Hospital DriveSingapore169610Singapore
| | - Fuh Yong Wong
- Division of Radiation OncologyNational Cancer Centre Singapore11 Hospital DriveSingapore169610Singapore
| | - Yoon Sim Yap
- Breast DepartmentKK Women's and Children's Hospital100 Bukit Timah RoadSingapore229899Singapore
- Department of Medical OncologyNational Cancer Centre Singapore11 Hospital DriveSingapore169610Singapore
| | - Mikael Hartman
- Saw Swee Hock School of Public HealthNational University of SingaporeTahir Foundation Building, 12 Science Drive 2Singapore117549Singapore
- Department of SurgeryNational University of Singapore and National University Health System1E Kent Ridge RoadSingapore119228Singapore
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Bhoo-Pathy N, Balakrishnan N, See MH, Taib NA, Yip CH. Missed Opportunities for Loco-Regional Treatment of Elderly Women with Breast Cancer. World J Surg 2016; 40:2913-2921. [PMID: 27456497 DOI: 10.1007/s00268-016-3658-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Factors associated with surgery, adjuvant radiotherapy, and chemotherapy and whether there were missed opportunities for treatment in elderly patients were determined in an Asian setting. METHODS All 5616 patients, diagnosed with breast cancer in University Malaya Medical Centre from 1999 to 2013 were included. In 945 elderly patients (aged 65 years and above), multivariable logistic regression was performed to identify factors associated with treatment, following adjustment for age, ethnicity, tumor, and other treatment characteristics. The impact of lack of treatment on survival of the elderly was assessed while accounting for comorbidities. RESULTS One in five elderly patients had comorbidities. Compared to younger patients, the elderly had more favorable tumor characteristics, and received less loco-regional treatment and chemotherapy. Within stage I-IIIa elderly breast cancer patients, 10 % did not receive any surgery. These patients were older, more likely to be Malays, have comorbidities, and bigger tumors. In elderlies with indications for adjuvant radiotherapy, no irradiation (30 %) was associated with increasing age, comorbidity, and the absence of systemic therapy. Hormone therapy was optimal, but only 35 % of elderly women with ER negative tumors received chemotherapy. Compared to elderly women who received adequate treatment, those not receiving surgery (adjusted hazard ratio: 2.30, 95 %CI: 1.10-4.79), or radiotherapy (adjusted hazard ratio: 1.56, 95 %CI: 1.10-2.19), were associated with higher mortality. Less than 25 % of the survival discrepancy between elderly women receiving loco-regional treatment and no treatment were attributed to excess comorbidities in untreated patients. CONCLUSION While the presence of comorbidities significantly influenced loco-regional treatment decisions in the elderly, it was only able to explain the lower survival rates in untreated patients up to a certain extent, suggesting missed opportunities for treatment.
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Affiliation(s)
- Nirmala Bhoo-Pathy
- Julius Centre University of Malaya (Centre for Clinical Epidemiology and Evidence Based Medicine), Faculty of Medicine, University of Malaya, 50603, Lembah Pantai, Kuala Lumpur, Malaysia. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, Netherlands.
| | - Nanthini Balakrishnan
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Mee-Hoong See
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Nur Aishah Taib
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Cheng-Har Yip
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Knight A, Hwa YS, Hashim H. Complementary alternative medicine use amongst breast cancer patients in the Northern region of peninsular Malaysia. Asian Pac J Cancer Prev 2016; 16:3125-30. [PMID: 25921108 DOI: 10.7314/apjcp.2015.16.8.3125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breast cancer is a common cancer affecting women in Malaysia and the use of complementary/ alternative medicine (CAM) has been associated with delays in getting treatment. The aim of the study was to explore the use of CAM and the influencing factors in the Northern region of Peninsular Malaysia. MATERIALS AND METHODS This was a cross-sectional descriptive study on a convenience sample of 100 Malaysian breast cancer survivors. FINDINGS The reported use of CAM among the breast cancer survivors was lower than in other studies but the types of CAM used had a similar pattern with nutrition supplements/vitamins being the most common. The factors that positively influenced the use of complimentary/traditional therapy were income and getting information from television or radio. Survivors with access to internet/blogs appear to have lower odds of using complimentary/traditional therapy compared to the respondents who reported no such access. CONCLUSIONS Information transmitted via television and radio appears to have a positive influence on CAM use by breast cancer patients compared to other information sources and it is important to ensure that such information is accurate and impartial.
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Affiliation(s)
- Aishah Knight
- Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia E-mail :
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Lee WC, Haron MR, Yu KL, Chong FLT, Goh A, Azmi S. Economic Analysis of Intravenous vs. Subcutaneously Administered Trastuzumab for the Treatment of HER2+ Early Breast Cancer in Malaysia. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/abcr.2016.51001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lim JNW, Potrata B, Simonella L, Ng CWQ, Aw TC, Dahlui M, Hartman M, Mazlan R, Taib NA. Barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia: a qualitative multicentre study. BMJ Open 2015; 5:e009863. [PMID: 26692558 PMCID: PMC4691764 DOI: 10.1136/bmjopen-2015-009863] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To explore and compare barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia. DESIGN A qualitative interview study with thematic analysis of transcripts. PARTICIPANTS 67 patients with self-discovered breast symptoms were included in the analysis. Of these, 36% were of Malay ethnicity, 39% were Chinese and 25% Indian, with an average age of 58 years (range 24-82 years). The number of women diagnosed at early stages of cancer almost equalled those at advanced stages. Approximately three-quarters presented with a painless lump, one-quarter experienced a painful lump and 10% had atypical symptoms. SETTING University hospital setting in Singapore and Malaysia. RESULTS Patients revealed barriers to early presentation not previously reported: the poor quality of online website information about breast symptoms, financial issues and the negative influence of relatives in both countries, while perceived poor quality of care and services in state-run hospitals and misdiagnosis by healthcare professionals were reported in Malaysia. The pattern of presentation by ethnicity remained unchanged where more Malay delayed help-seeking and had more advanced cancer compared to Chinese and Indian patients. CONCLUSIONS There are few differences in the pattern of presentation and in the reported barriers to seek medical care after symptom discovery between Singapore and Malaysia despite their differing economic status. Strategies to reduce delayed presentation are: a need to improve knowledge of disease, symptoms and causes, quality of care and services, and quality of online information; and addressing fear of diagnosis, treatment and hospitalisation, with more effort focused on the Malay ethnic group. Training is needed to avoid missed diagnoses and other factors contributing to delay among health professionals.
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Affiliation(s)
- Jennifer NW Lim
- Faculty of Medical Science, Anglia Ruskin University, Cambridge, UK
| | | | - Leonardo Simonella
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Celene WQ Ng
- Department of Surgery, National University Health System, Singapore, Singapore
| | - Tar-Ching Aw
- Faculty of Medicine and Health Sciences, University of United Arab Emirates, Al Ain, United Arab Emirates
| | - Maznah Dahlui
- Social Preventive Medicine Department, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mikael Hartman
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Department of Surgery, National University Health System, Singapore, Singapore
| | - Rifhan Mazlan
- Department of Surgery, Faculty of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Nur Aishah Taib
- Department of Surgery, Faculty of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
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Fan L, Goss PE, Strasser-Weippl K. Current Status and Future Projections of Breast Cancer in Asia. Breast Care (Basel) 2015; 10:372-8. [PMID: 26989355 PMCID: PMC4789872 DOI: 10.1159/000441818] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Asia is the world's largest continent comprising about 3/5 of the human population. Breast cancer is the most common type of cancer and the second leading cause of cancer-related deaths among women in Asia, accounting for 39% of all breast cancers diagnosed worldwide. The incidence of breast cancer in Asia varies widely across the continent and is still lower than in Western countries, but the proportional contribution of Asia to the global breast cancer rates is increasing rapidly in parallel to the socioeconomic development. However, the mortality-to-incidence ratios are much higher for Asia than for Western countries. Most Asian countries are low- and middle-income countries (LMICs) where breast cancer presents at a younger age and a later stage, and where patients are more likely to die from the disease than those in Western countries. Moreover, diagnostic workup, treatment and palliative services are inadequate in most Asian LMICs. In this review, we present an overview of the breast cancer risk factors and epidemiology, control measures, and cancer care among Asian countries.
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Affiliation(s)
- Lei Fan
- Breast Cancer Institute, Cancer Hospital, Department of Oncology, Shanghai Medical College, Institutes of Biomedical Science, Fudan University, Shanghai, China
| | - Paul E. Goss
- Global Cancer Institute, Boston, MA, USA
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Bhoo-Pathy N, Verkooijen HM, Tan EY, Miao H, Taib NAM, Brand JS, Dent RA, See MH, Subramaniam S, Chan P, Lee SC, Hartman M, Yip CH. Trends in presentation, management and survival of patients with de novo metastatic breast cancer in a Southeast Asian setting. Sci Rep 2015; 5:16252. [PMID: 26536962 PMCID: PMC4633674 DOI: 10.1038/srep16252] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 10/12/2015] [Indexed: 01/18/2023] Open
Abstract
Up to 25% of breast cancer patients in Asia present with de novo metastatic disease. We examined the survival trends of Asian patients with metastatic breast cancer over fifteen years. The impact of changes in patient’s demography, tumor characteristics, tumor burden, and treatment on survival trend were examined. Patients with de novo metastatic breast cancer from three hospitals in Malaysia and Singapore (N = 856) were grouped by year of diagnosis: 1996–2000, 2001–2005 and 2006–2010. Step-wise multivariable Poisson regression was used to estimate the contribution of above-mentioned factors on the survival trend. Proportions of patients presenting with metastatic breast cancer were 10% in 1996–2000, 7% in 2001–2005, and 9% in 2006–2010. Patients in 2006–2010 were significantly older, appeared to have higher disease burden, and received more chemotherapy, endocrine therapy, and surgery of primary tumor. The three-year relative survival in the above periods were 20·6% (95% CI: 13·9%–28·2%), 28·8% (95% CI: 23·4%–34·2%), and 33·6% (95% CI: 28·8%–38·5%), respectively. Adjustment for treatment considerably attenuated the relative excess risk of mortality in recent years, compared to other factors. Substantial improvements in survival were observed in patients with de novo metastatic breast cancer in this study.
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Affiliation(s)
- Nirmala Bhoo-Pathy
- Julius Centre University of Malaya, Centre for Evidence Based Medicine and Clinical Epidemiology, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia.,Julius Center for Health Sciences and Primary Care, University Medical Center, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Helena Marieke Verkooijen
- Saw Swee Hock School of Public Health, National University of Singapore, MD3, 16 Medical Drive, Singapore 117597
| | - Ern-Yu Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Hui Miao
- Saw Swee Hock School of Public Health, National University of Singapore, MD3, 16 Medical Drive, Singapore 117597
| | - Nur Aishah Mohd Taib
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
| | - Judith S Brand
- Institution of Medical Epidemiology and Biostatistics, Karolinska Instituet, Nobels Väg 12A, 171 77 Stockholm, Sweden
| | - Rebecca A Dent
- National Cancer Centre Singapore, 11 Hospital Dr, Singapore 169610.,Duke-NUS Graduate Medical School Singapore, 8 College Road, Singapore 169857
| | - Mee-Hoong See
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
| | - ShriDevi Subramaniam
- National Clinical Research Centre, Level 3, Dermatology Block, Kuala Lumpur Hospital, 50586 Jalan Pahang, Kuala Lumpur, Malaysia
| | - Patrick Chan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Soo-Chin Lee
- Department of Hematology Oncology, National University Cancer Institute, National University Health System, Singapore 119228
| | - Mikael Hartman
- Saw Swee Hock School of Public Health, National University of Singapore, MD3, 16 Medical Drive, Singapore 117597
| | - Cheng-Har Yip
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
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Chin FW, Chan SC, Abdul Rahman S, Noor Akmal S, Rosli R. CYP2D6 Genetic Polymorphisms and Phenotypes in Different Ethnicities of Malaysian Breast Cancer Patients. Breast J 2015; 22:54-62. [DOI: 10.1111/tbj.12518] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Fee Wai Chin
- Genetic Medicine Research Centre; Faculty of Medicine and Health Sciences; Universiti Putra Malaysia; Serdang Selangor Malaysia
| | - Soon Choy Chan
- Perdana University Graduate School of Medicine (PUGSOM); Serdang Selangor Malaysia
| | - Sabariah Abdul Rahman
- Medical Education Unit; Faculty of Medicine; Universiti Teknologi MARA; Batu Caves Selangor Malaysia
- Laboratory of Medical Sciences; Faculty of Medicine; Universiti Teknologi MARA; Sungai Buloh Selangor Malaysia
| | - Sharifah Noor Akmal
- Department of Pathology; Faculty of Medicine; Universiti Kebangsaan Malaysia Medical Centre; Cheras Kuala Lumpur Malaysia
| | - Rozita Rosli
- Genetic Medicine Research Centre; Faculty of Medicine and Health Sciences; Universiti Putra Malaysia; Serdang Selangor Malaysia
- UPM-MAKNA Cancer Research Laboratory; Institute of Bioscience; Universiti Putra Malaysia; Serdang Selangor Malaysia
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Islam T, Bhoo-Pathy N, Su TT, Majid HA, Nahar AM, Ng CG, Dahlui M, Hussain S, Cantwell M, Murray L, Taib NA. The Malaysian Breast Cancer Survivorship Cohort (MyBCC): a study protocol. BMJ Open 2015; 5:e008643. [PMID: 26503386 PMCID: PMC4636649 DOI: 10.1136/bmjopen-2015-008643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Over recent decades, the burden of breast cancer has been increasing at an alarming rate in Asia. Prognostic research findings from Western countries may not readily be adapted to Asia, as the outcome of breast cancer depends on a multitude of factors ranging from genetic, clinical and histological predictors, to lifestyle and social predictors. The primary aim of this study is to determine the impact of lifestyle (eg, nutrition, physical activity), mental and sociocultural condition, on the overall survival and quality of life (QoL) among multiethnic Malaysian women following diagnosis of breast cancer. This study aims to advance the evidence on prognostic factors of breast cancer within the Asian setting. The findings may guide management of patients with breast cancer not only during active treatment but also during the survivorship period. METHODS This hospital-based prospective cohort study will comprise patients with breast cancer (18 years and above), managed in the University Malaya Medical Centre (UMMC). We aim to recruit 1000 cancer survivors over a 6-year period. Data collection will occur at baseline (within 3 months of diagnosis), 6 months, and 1, 3 and 5 years following diagnosis. The primary outcomes are disease-free survival and overall survival, and secondary outcome is QoL. Factors measured are demographic and socioeconomic factors, lifestyle factors (eg, dietary intake, physical activity), anthropometry measurements (eg, height, weight, waist, hip circumference, body fat analysis), psychosocial aspects, and complementary and alternative medicine (CAM) usage. ETHICS AND DISSEMINATION This protocol was approved by the UMMC Ethical Committee in January 2012. All participants are required to provide written informed consent. The findings from our cohort study will be disseminated via scientific publication as well as presentation to stakeholders including the patients, clinicians, the public and policymakers, via appropriate avenues.
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Affiliation(s)
- Tania Islam
- Faculty of Medicine, Centre for Population Health (CePH) and Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Faculty of Medicine, Department of Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - Nirmala Bhoo-Pathy
- Faculty of Medicine, Julius Centre University of Malaya, University of Malaya, Kuala Lumpur, Malaysia
| | - Tin Tin Su
- Faculty of Medicine, Centre for Population Health (CePH) and Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Hazreen Abdul Majid
- Faculty of Medicine, Centre for Population Health (CePH) and Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Azmi Mohd Nahar
- Faculty of Medicine, Department of Sports Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chong Guan Ng
- Department of Psychological Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Maznah Dahlui
- Faculty of Medicine, Centre for Population Health (CePH) and Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Samsinah Hussain
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Marie Cantwell
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Liam Murray
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Nur Aishah Taib
- Faculty of Medicine, Department of Surgery, University of Malaya, Kuala Lumpur, Malaysia
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Vaisy A, Lotfinejad S, Zhian F. Risk of cancer with combined oral contraceptive use among Iranian women. Asian Pac J Cancer Prev 2015; 15:5517-22. [PMID: 25081657 DOI: 10.7314/apjcp.2014.15.14.5517] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Oral contraceptive use is the most common type of contraception. More than 300 million women worldwide take oral contraceptives every day. However, there is a concern about the relationship with the incidence of cancer. This analytical retrospective study aimed to investigate the relationship between the incidence of cervical and breast cancers and oral contraceptive use in 128 Iranian patients with cervical cancer, 235 with breast cancer and equal numbers of controls. Data were collected through interviews with an organized set of questions. Details were also extracted from patient files. Data were analyzed using Student's t-test, chi-square and Fisher's exact tests, and Pearson's correlation analysis. The result revealed correlations between both cervical and breast cancers and history of contraceptive pills use. While cervical cancer significantly correlated with duration of use of pills, breast cancer had significant correlations with the type of oral contraceptive and age at first use. No significant relationships were found between the two types of cancer and age at discontinuation of oral contraceptives, patterns of use, and intervals from the last use. The use of oral contraceptives may triple the incidence of cervical cancer and doubles the incidence of breast cancer. Therefore, performing Pap smears every six months and breast cancer screening are warranted for long-term oral contraceptive users.
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Affiliation(s)
- Afasaneh Vaisy
- Department of Midwifery, Mahabad Branch Islamic Azad University and Department of Pathology, Faculty of Medicin, Urmia University of Medical Sciences, Pathologist, Mahabad, Iran E-mail :
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Leow JJ, Lim VW, Lingam P, Go KTS, Teo LT. Ethnic disparities in trauma mortality outcomes. World J Surg 2015; 38:1694-8. [PMID: 24510246 DOI: 10.1007/s00268-014-2459-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ethnic disparities in trauma mortality outcomes have been demonstrated in the United States according to the US National Trauma Data Bank. The aim of this study was to determine the effect of race/ethnicity on trauma mortality in Singapore. METHODS This was a retrospective review of patients aged 18-64 years with an injury severity score (ISS) ≥ 9 in the Trauma Registry of Tan Tock Seng Hospital, a 1,300-bed trauma center in Singapore, from 2006 to 2010. Chinese, Malay, and Indian patients were compared with patients of other ethnic groups. Multiple logistic regression analyses determined differences in survival rates after adjusting for demographics, anatomic and physiologic ISS and revised trauma score, mechanism or type of injury. RESULTS A total of 4,186 patients (66.4 % of the database) met the inclusion criteria. Most patients were male (76.3 %) and young (mean age 40 years). Using Chinese as the reference group, we found no statistically significant differences in unadjusted or adjusted mortality rates among the ethnic groups. Independent predictors of mortality included age [odds ratio (OR) 1.05, 95 % confidence interval (CI) 1.03-1.06, p < 0.0001], presence of severe head injury (OR 1.75, 95 % CI 1.13-2.69, p = 0.012), and increasing ISS (p < 0.0001). CONCLUSIONS Ethnicity is not an independent predictor of trauma mortality outcomes in the Singapore population. Our findings contrast with those from the United States, where race/ethnicity (Black and Hispanic) remains a strong independent risk factor for trauma mortality. This study attests to the success of the Singapore health care/trauma system in delivering the same quality of care regardless of ethnicity.
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Affiliation(s)
- Jeffrey J Leow
- Trauma Services, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore,
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Pijnappel EN, Bhoo-Pathy N, Suniza J, See MH, Tan GH, Yip CH, Hartman M, Taib NA, Verkooijen HM. Prediction of lymph node involvement in patients with breast tumors measuring 3-5 cm in a middle-income setting: the role of CancerMath. World J Surg 2015; 38:3133-7. [PMID: 25167896 DOI: 10.1007/s00268-014-2752-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In settings with limited resources, sentinel lymph node biopsy (SNB) is only offered to breast cancer patients with small tumors and a low a priori risk of axillary metastases. OBJECTIVE We investigated whether CancerMath, a free online prediction tool for axillary lymph node involvement, is able to identify women at low risk of axillary lymph node metastases in Malaysian women with 3-5 cm tumors, with the aim to offer SNB in a targeted, cost-effective way. METHODS Women with non-metastatic breast cancers, measuring 3-5 cm were identified within the University Malaya Medical Centre (UMMC) breast cancer registry. We compared CancerMath-predicted probabilities of lymph node involvement between women with versus without lymph node metastases. The discriminative performance of CancerMath was tested using receiver operating characteristic (ROC) analysis. RESULTS Out of 1,017 patients, 520 (51 %) had axillary involvement. Tumors of women with axillary involvement were more often estrogen-receptor positive, progesterone-receptor positive, and human epidermal growth factor receptor (HER)-2 positive. The mean CancerMath score was higher in women with axillary involvement than in those without (53.5 vs. 51.3, p = 0.001). In terms of discrimination, CancerMath performed poorly, with an area under the ROC curve of 0.553 (95 % confidence interval CI 0.518-0.588). Attempts to optimize the CancerMath model by adding ethnicity and HER2 to the model did not improve discriminatory performance. CONCLUSION For Malaysian women with tumors measuring 3-5 cm, CancerMath is unable to accurately predict lymph node involvement and is therefore not helpful in the identification of women at low risk of node-positive disease who could benefit from SNB.
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Affiliation(s)
- E N Pijnappel
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands,
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Kim Y, Yoo KY, Goodman MT. Differences in Incidence, Mortality and Survival of Breast Cancer by Regions and Countries in Asia and Contributing Factors. Asian Pac J Cancer Prev 2015; 16:2857-70. [DOI: 10.7314/apjcp.2015.16.7.2857] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Wong HS, Subramaniam S, Alias Z, Taib NA, Ho GF, Ng CH, Yip CH, Verkooijen HM, Hartman M, Bhoo-Pathy N. The predictive accuracy of PREDICT: a personalized decision-making tool for Southeast Asian women with breast cancer. Medicine (Baltimore) 2015; 94:e593. [PMID: 25715267 PMCID: PMC4554151 DOI: 10.1097/md.0000000000000593] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Web-based prognostication tools may provide a simple and economically feasible option to aid prognostication and selection of chemotherapy in early breast cancers. We validated PREDICT, a free online breast cancer prognostication and treatment benefit tool, in a resource-limited setting. All 1480 patients who underwent complete surgical treatment for stages I to III breast cancer from 1998 to 2006 were identified from the prospective breast cancer registry of University Malaya Medical Centre, Kuala Lumpur, Malaysia. Calibration was evaluated by comparing the model-predicted overall survival (OS) with patients' actual OS. Model discrimination was tested using receiver-operating characteristic (ROC) analysis. Median age at diagnosis was 50 years. The median tumor size at presentation was 3 cm and 54% of patients had lymph node-negative disease. About 55% of women had estrogen receptor-positive breast cancer. Overall, the model-predicted 5 and 10-year OS was 86.3% and 77.5%, respectively, whereas the observed 5 and 10-year OS was 87.6% (difference: -1.3%) and 74.2% (difference: 3.3%), respectively; P values for goodness-of-fit test were 0.18 and 0.12, respectively. The program was accurate in most subgroups of patients, but significantly overestimated survival in patients aged <40 years, and in those receiving neoadjuvant chemotherapy. PREDICT performed well in terms of discrimination; areas under ROC curve were 0.78 (95% confidence interval [CI]: 0.74-0.81) and 0.73 (95% CI: 0.68-0.78) for 5 and 10-year OS, respectively. Based on its accurate performance in this study, PREDICT may be clinically useful in prognosticating women with breast cancer and personalizing breast cancer treatment in resource-limited settings.
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Affiliation(s)
- Hoong-Seam Wong
- From the National Clinical Research Centre (HSW, SS), Level 3, Dermatology Block, Kuala Lumpur Hospital, Jalan Pahang; Department of Surgery (ZA, NAT, CHN, CHY); Department of Oncology (GFH), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Imaging Division (HMV), University Medical Center Utrecht, Utrecht, The Netherlands; Saw Swee Hock School of Public Health (HMV, MH), National University of Singapore; Department of Surgery (MH), Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore; Julius Centre University of Malaya (NBP), Centre for Clinical Epidemiology and Evidence-Based Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; and Julius Center for Health Sciences and Primary Care (NBP), University Medical Center Utrecht, Utrecht, The Netherlands
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