How Effective is the Treatment of Locally Advanced and Metastatic Breast Cancer in Developing Centres?: A Retrospective Review

Survival Patterns Among Patients With Breast Cancer in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Importance

Breast cancer is the most prevalent cancer globally with tremendous disparities both within specific regions and across different contexts. The survival pattern of patients with breast cancer remains poorly understood in sub-Saharan African (SSA) countries.

Objective

To investigate the survival patterns of patients with breast cancer in SSA countries and compare the variation across countries and over time.

Data Sources

Embase, PubMed, Web of Science, Scopus, and ProQuest were searched from inception to December 31, 2022, with a manual search of the references.

Study Selection

Cohort studies of human participants that reported 1-, 2-, 3-, 4-, 5-, and 10-year survival from diagnosis among men, women, or both with breast cancer in SSA were included.

Data Extraction and Synthesis

Independent extraction of study characteristics by multiple observers was performed using open-source software, then exported to a standard spreadsheet. A random-effects model using the generalized linear mixed-effects model was used to pool data. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline for reporting was followed.

Main Outcome and Measures

Survival time from diagnosis.

Results

Forty-nine studies were included in the review with a sample size ranging from 21 to 2311 (total, 14 459; 196 [1.35%] men, 13 556 [93.75%] women, and 707 [4.90%] unspecified; mean age range, 38 to 71 years), of which 40 were summarized using meta-analysis. The pooled 1-year survival rate of patients with breast cancer in SSA was 0.79 (95% CI, 0.67-0.88); 2-year survival rate, 0.70 (95% CI, 0.57-0.80); 3-year survival rate, 0.56 (95% CI, 0.45-0.67); 4-year survival rate, 0.54 (95% CI, 0.43-0.65); and 5-year survival rate, 0.40 (95% CI, 0.32-0.49). The subgroup analysis showed that the 5-year survival rate ranged from 0.26 (95% CI, 0.06-0.65) for studies conducted earlier than 2010 to 0.47 (95% CI, 0.32-0.64) for studies conducted later than 2020. Additionally, the 5-year survival rate was lower in countries with a low human development index (HDI) (0.36 [95% CI, 0.25-0.49) compared with a middle HDI (0.46 [95% CI, 0.33-0.60]) and a high HDI (0.54 [95% CI, 0.04-0.97]).

Conclusions and Relevance

In this systematic review and meta-analysis, the survival rates for patients with breast cancer in SSA were higher in countries with a high HDI compared with a low HDI. Enhancing patient survival necessitates a comprehensive approach that involves collaboration from all relevant stakeholders.

iBreastExam: Time for Formal Operation in Nepal

iBreastExam device can be a solution to the increasing problem of advanced breast cancer cases diagnosed late as a screening device often useful in low resource and low manpower settings like Nepal

Prognostic role of matrix metalloproteinase 9 in early breast cancer

MMP9 is involved in extracellular matrix degradation during various physiological and pathological conditions, including tumorigenesis. The present study aimed to assess the prognostic role of intratumoral MMP9 and to determine its association with circulating tumor cells (CTCs) in patients with early breast cancer. A total of 318 patients with primary breast cancer (PBC) were enrolled into the present study. Specimens were subjected to immunohistochemistry analysis, using the MMP9 monoclonal antibody. MMP9 expression was scored using a weighted histoscore (WH). The results demonstrated that the mean WH ± SEM for MMP9 expression was significantly higher in breast tumor cells compared with tumor associated stromas (132.0±5.2 vs. 50.8±3.7; P<0.00001). Furthermore, a positive association was observed between MMP9 expression, the hormone positive status and proliferation index of analysed breast cancer tumour cells. Notably, the prognostic role of MMP9 was not observed in tumor cells [hazard ratio (HR) =0.96; 95% confidence interval (CI), 0.58-1.59; P=0.864] or tumor associated stroma (HR=1.29; 95% CI, 0.60-2.78; P=0.547). Subgroup analysis demonstrated that patients that were HR negative or triple negative, with low MMP9 expression in tumor cells and stroma had a significantly improved disease-free survival than patients with high MMP9 expression. Taken together, the results of the present study demonstrated that high MMP9 expression in PBC was associated with favorable tumor characteristics. However, the prognostic value of MMP9 was limited to only the HR negative and CTC epithelial-to-mesenchymal transition positive subgroups. Thus, analyzing MMP9 tumor expression may help identify patients with increased risk of disease recurrence in these subgroups.

Presentation intervals and the impact of delay on breast cancer progression in a black African population

Background

The help-seeking interval and primary-care interval are points of delays in breast cancer presentation. To inform future intervention targeting early diagnosis of breast cancer, we described the contribution of each interval to the delay and the impact of delay on tumor progression.

Method

We conducted a multicentered survey from June 2017 to May 2018 hypothesizing that most patients visited the first healthcare provider within 60 days of tumor detection. Inferential statistics were by t-test, chi-square test, and Wilcoxon-Signed Rank test at p-value 0.05 or 95% confidence limits. Time-to-event was by survival method. Multivariate analysis was by logistic regression.

Results

Respondents were females between 24 and 95 years (n = 420). Most respondents visited FHP within 60 days of detecting symptoms (230 (60, 95% CI 53–63). Most had long primary-care (237 of 377 (64 95% CI 59–68) and detection-to-specialist (293 (73% (95% CI 68–77)) intervals. The primary care interval (median 106 days, IQR 13–337) was longer than the help-seeking interval (median 42 days, IQR 7–150) Wilcoxon signed-rank test p = 0.001. There was a strong correlation between the length of primary care interval and the detection-to-specialist interval (r = 0.9, 95% CI 0.88–0.92). Patronizing the hospital, receiving the correct advice, and having a big tumor (> 5 cm) were associated with short intervals.

Tumors were detected early, but most became advanced before arriving at the specialist clinic. The difference in tumor size between detection and arriving at a specialist clinic was 5.0 ± 4.9 cm (95% CI 4.0–5.0). The hazard of progressing from early to locally advanced disease was least in the first 30 days (3%). The hazard was 31% in 90 days.

Conclusion

Most respondents presented early to the first healthcare provider, but most arrived late at a specialist clinic. The primary care interval was longer than the help-seeking interval. Most tumors were early at detection but locally advanced before arriving in a specialist clinic. Interventions aiming to shorten the primary care interval will have the most impact on time to breast cancer presentation for specialist oncology care in Nigeria.

Prevalence of Themes Linked to Delayed Presentation of Breast Cancer in Africa: A Meta-Analysis of Patient-Reported Studies

PURPOSE

The prevalence of themes linked to delay in presentation of breast cancer (BC) and their underlying factors vary considerably throughout Africa. Regional differences and trends are largely unreported. The purpose of this research was to provide summary estimates of the prevalence and distribution of the themes and underlying factors linked to delay in the presentation of BC, regional variation, and trends in an effort to identify targets for intervention.

DESIGN

We screened articles found through PubMed/Medline, African Journal OnLine, Science Direct, Google/Google Scholar, and ResearchGate. We included patient-reported surveys on the reasons linked to delayed presentation under 6 previously identified themes: symptom misinterpretation, fear, preference for alternative care, social influence, hospital-related factors, and access factors. The meta-analytical procedure in MetaXL used the quality-effect model.

RESULTS

Twelve of the 236 identified articles were eligible for this review. The overall summary estimate of late presentation (> 90 days) was 54% (95% CI, 23 to 85) and was worst in the eastern and central regions. Symptom misinterpretation was the most common theme (50%; 95% CI, 21 to 56), followed by fear (17%; 95% CI, 3 to 27), hospital-related theme (11%; 95% CI, 1 to 21), preference for alternative care (10%; 95% CI, 0 to 21), social influence (7%; 95% CI, 0 to 14), and access-related theme (6%; 95% CI, 0 to 13). The most common factor underlying symptom misinterpretation was mischaracterizing the breast lesion as benign (60%; 95% CI, 4 to 100) which surpassed lack of awareness in the last decade. Misdiagnosis and failure to refer were the dominant hospital-related factors.

CONCLUSION

Modifiable factors such as mischaracterizing malignant masses as benign, fear, misdiagnosis, and failure to refer were the prevalent factors contributing to delays throughout Africa. These factors are promising targets for intervention.

Characteristics and follow-up of metastatic breast cancer in Ethiopia: A cohort study of 573 women

OBJECTIVES

There is little information on characteristics, treatment and outcome of metastatic breast cancer (mBC) patients in low-income countries. This study aims to describe mBC in the setting of Ethiopia.

MATERIALS AND METHODS

A retrospective cohort study was conducted among all female mBC patients from the only oncologic hospital in Addis Ababa 01/2006 to 12/2010. Time between first metastasis and known death or loss to follow-up for more than six months as surrogate for death were used for Cox proportional hazards model.

RESULTS

A total of 573 patients were included; 188 (32.8%) women with de novo mBC (dnmBC) and 385 women with recurrent mBC (rmBC). The average age at time of first metastasis was 43.7 (standard deviation 11.9) years with an average survival probability of twelve months. Negative hormone receptor status, only present in 29% (Hazard ratio HR = 2.28 [95% confidence interval CI 1.56-3.32] p < 0.001), and grade 3 (HR = 1.72 [95% CI 1.15-2.55] p = 0.008) had significant influence on survival. Patients with initial bone metastasis (HR = 0.63 [95% CI 0.48-0.83] p = 0.001) had best chances of survival compared to more common initial visceral metastasis. About 35% of the patients received chemotherapy and 30.5% were on endocrine therapy.

CONCLUSION

The lower survival for mBC in Addis Ababa compared to that from Western countries is presumably due to the later presentation at the hospital and lack of standard therapy. An unexpected high proportion of patients with hormone receptor positive mBC encourage consequent utilization of endocrine therapy to improve the quality of palliative care in this cohort.

Relationship between tumour size and response to neoadjuvant chemotherapy among breast cancer patients in a tertiary center in Nigeria

Background

Tumour biology, physiologic features such as growth fraction and physical features such as size may influence response of breast cancer to neoadjuvant chemotherapy. Molecular biology is an established basis for predicting response and selecting neoadjuvant chemotherapy. Whether physical characteristics such as size should influence chemotherapy regimen is inconclusive and has not been adequately studied in developing countries.

Aim

To determine the relationship between breast tumour size and response to neoadjuvant chemotherapy and hence define the role of tumour size during selection of neoadjuvant chemotherapy regimen for locally advanced breast cancer.

Method

Records of women managed at the University of Ilorin Teaching Hospital, Ilorin Nigeria, with neoadjuvant chemotherapy (NAC) for locally advanced breast cancer were reviewed between January 2013 and June 2015. Data was analyzed as 2 subgroups; primary tumour ≥100mm as group 1 and primary tumour ≥100mm as group 2. Primary outcome was 50% reduction in tumour size. Comparison was by chi-square test of independence at p value 0.05.

Results

57 records were reviewed (group1=24, group2=33). Majority (37( 65%)) were premenopausal. Mean age was 47.9 ± 13.1 (range 28–85). NAC was either taxane or anthracycline based regimen. Median chemotherapy dose was 4 (range 2–6). Widest diameter of tumours was 30mm to 180mm (mean 96 ±3.8mm, median 100mm). Mean tumour diameter for groups 1 and 2 was 7.2 ±1.6mm and 12.2± 2.9mm respectively. 50% reduction in tumour size was 45.8% and 6.0% for groups 1 and 2 respectively (p=0.0001)

Conclusion

There was relationship between breast tumour size and response to neoadjuvant chemotherapy at a cut-off of 10mm. Well-designed prospective studies are required to confirm this relationship.