Management of locally advanced and metastatic breast cancer: guidelines, infrastructures and low resource settings

Barriers to Radiotherapy Access in Sub-Saharan Africa for Patients with Cancer: A Systematic Review

BACKGROUND

Access to radiotherapy services is critical for effective cancer treatment, yet patients in sub-Saharan Africa face numerous barriers to accessing these services. The region is experiencing a significant increase in cancer cases, with a more than 85% increase in cancer cases reported in the past decade, highlighting the critical role of radiotherapy in enhancing patient prognosis. This systematic review aims to explore the barriers to radiotherapy access in sub-Saharan Africa. The barriers explored will be used to inform the development of the framework to improve access to radiotherapy in the Gauteng provinces, South Africa.

METHODS

A systematic search of electronic databases was conducted to identify relevant studies published between January 2013 and December 2023. Studies reporting on barriers to radiotherapy access in SSA were included and put into four categories of barriers: health system factors, patient sociodemographic factors, patient factors, and provider factors. Data were synthesised using thematic analysis.

RESULTS

This review identifies geographical, financial, cultural, logistical, and systemic barriers to radiotherapy access in sub-Saharan Africa, including limited infrastructure, long travel distances, and inequitable distribution of services. Systemic barriers, including policy gaps and governance issues, also contribute to the inequitable distribution of radiotherapy services in the region.

CONCLUSIONS

This systematic review highlights the diverse array of barriers to radiotherapy access in sub-Saharan Africa and emphasises the urgent need for targeted interventions to address these challenges.

Design, synthesis and biological evaluation of combretastatin A-4 sulfamate derivatives as potential anti-cancer agents

A series of combretastatin A-4 (CA-4) sulfamate derivatives were synthesized and their structure-activity relationship on tubulin, arylsulfatase and tumor cell antiproliferation inhibition was studied. Among them, compound 16a showed excellent potency as well as CA-4 under the same conditions against six tumor cells including HTC-116, HeLa, HepG2, MGC803, MKN45 and MCF-7 cells, respectively. Molecular docking revealed that several important hydrogen bond interactions were formed between the sulfamate group of 16a and the colchicine binding site of tubulin and steroid sulfatase respectively. Although compound 16a was less active than CA-4 in regard to its in vitro activity as an inhibitor of tubulin polymerization, it was effective as an inhibitor of arylsulfatase. This novel combretastatin A-4 sulfamate derivative has the potential to be developed as a dual inhibitor of tubulin polymerization and arylsulfatase for cancer therapy.

Enhancing global access to cancer medicines

Globally, cancer is the second leading cause of death, with numbers greatly exceeding those for human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria combined. Limited access to timely diagnosis, to affordable, effective treatment, and to high-quality care are just some of the factors that lead to disparities in cancer survival between countries and within countries. In this article, the authors consider various factors that prevent access to cancer medicines (particularly access to essential cancer medicines). Even if an essential cancer medicine is included on a national medicines list, cost might preclude its use, it might be prescribed or used inappropriately, weak infrastructure might prevent it being accessed by those who could benefit, or quality might not be guaranteed. Potential strategies to address the access problems are discussed, including universal health coverage for essential cancer medicines, fairer methods for pricing cancer medicines, reducing development costs, optimizing regulation, and improving reliability in the global supply chain. Optimizing schedules for cancer therapy could reduce not only costs, but also adverse events, and improve access. More and better biomarkers are required to target patients who are most likely to benefit from cancer medicines. The optimum use of cancer medicines depends on the effective delivery of several services allied to oncology (including laboratory, imaging, surgery, and radiotherapy). Investment is necessary in all aspects of cancer care, from these supportive services to technologies, and the training of health care workers and other staff.

Research needs in breast cancer

New research questions emerge as medical needs continue to evolve and as we improve our understanding of cancer biology and treatment of malignancies. Although significant advances have been made in some areas of breast cancer research resulting in improvements in therapies and outcomes over the last few decades, other areas have not benefited to the same degree and we continue to have many gaps in our knowledge. This article summarizes the 12 short and medium-term clinical research needs in breast cancer deemed as priorities in 2016 by a panel of experts, in an attempt to focus and accelerate future research in the most needed areas: (i) de-escalate breast cancer therapies in early breast cancer without sacrificing outcomes; (ii) explore optimal adjuvant treatment durations; (iii) develop better tools and strategies to identify patients with genetic predisposition; (iv) improve care in young patients with breast cancer; (v) develop tools to speed up drug development in biomarker-defined populations; (vi) identify and validate targets that mediate resistance to chemotherapy, endocrine therapy and anti-HER2 therapies; (vii) evaluate the efficacy of local-regional treatments for metastatic disease; (viii) better define the optimal sequence of treatments in the metastatic setting; (ix) evaluate the clinical impact of intra-patient heterogeneity (intra-tumor, inter-tumor and inter-lesion heterogeneity); (x) better understand the biology and identify new targets in triple-negative breast cancer; (xi) better understand immune surveillance in breast cancer and further develop immunotherapies; and (xii) increase survivorship research efforts including supportive care and quality of life.

Primary surgical treatment of locally advanced breast cancer in low resource settings

•Optimum management of locally advanced breast cancer is multidisciplinary.•Neoadjuvant chemotherapy is mainstay of management.•Primary surgical treatment may be acceptable in selected patients.