Determinants of Advanced Stage at Initial Diagnosis of Breast Cancer in Pakistan: Adverse Tumor Biology vs Delay in Diagnosis

Invasive Lobular Carcinoma in Premenopausal Woman: A Delayed Diagnosis Due to Socio-Cultural Factors Prevalent in Pakistan

A 41-year-old premenopausal woman presented to the outpatient department with a diagnosis of invasive lobular carcinoma. She noticed a lump a year back but did not seek medical attention due to many socio-cultural factors prevalent in Pakistan that prevent her from seeking medical attention earlier. She came in for a check-up after increasing in size of the lump. The bilateral mammogram showed large areas of asymmetrical density in the left upper quadrant. It was followed by an ultrasound-guided biopsy which confirmed the diagnosis of invasive lobular carcinoma. Due to stage 3, it was recommended to have CT and an MRI of the breast to assess the extent of the disease. Tissue immunohistochemistry was also requested, which came back as ER-positive, PR-positive, and HER2/neu negative. MRI of the breast revealed a 4.2 x 3.3cm heterogeneously enhancing asymmetric mass-like enhancement area within the left breast outer quadrant with an adjacent spiculated nodular lesion measuring 2.2 cm. CT chest/abdomen/pelvis with contrast showed left breast with minimal parenchymal asymmetry and a small 9 mm node seen in the left axilla. There was no evidence of metastasis. The patient was started on neoadjuvant therapy to minimize systemic disease, followed by mastectomy. This case highlights socio-cultural factors prevalent in Pakistan that lead to delays in the diagnosis and treatment of invasive lobular carcinoma. The outcome had been better if the patient sought medical attention sooner at an earlier stage. We also propose strategies to raise awareness in Pakistan for the timely diagnosis and treatment of breast cancer.

Factors associated with late-stage diagnosis of breast cancer among Egyptian women

Background

Detecting Breast Cancer (BC) at earlier stages comes with a better prognosis, while diagnosis at late stages has poor outcomes and escalating mortality rates from the disease. The study aims to understand the factors associated with the late-stage diagnosis of BC in Egypt.

Design and Methods

A sample of 400 women with a pathologically confirmed BC were enrolled from one of the main tertiary cancer hospitals in Egypt. A cross-sectional study design was conducted. The collected data included: clinical characteristics of the tumor, socio-demographic characteristics of the studied women, reproductive and medical history, screening practices, and the time from symptom onset to definite diagnosis as suspected predictors to the stage of BC at diagnosis. Data was analyzed by crude odds ratios (95% confidence interval) and multivariate logistic regression analysis.

Results

The study revealed that 47.5% were diagnosed at late stages (40% at stage III/ 7.5% at stage IV), while (52.5%) were diagnosed at early stages (6.5% at stage I/46% at stage II). A binary logistic regression model showed that unmarried females (p=0.012), had non-luminal molecular subtype of BC including HER2 enriched and triple-negative tumors (p<0.001), presentation with breast changes and a non-palpable lump (p=0.024) or non-breast symptoms (P=0.002), a delay longer than 3 months to the first presentation by patients (p<0.001), and a delay to definite diagnosis longer than 1 month by providers (p<0.001) were significant risk factors of late-stage diagnosis of BC.

Conclusions

Late-stage diagnosis of BC in Egypt is associated with the aggressiveness of some molecular subtypes and other important modifiable factors that should be addressed.

Factors Influencing Total Delay of Breast Cancer in Northeast of China

Objectives

Delay in diagnosis and treatment, called total delay, could probably result in lower survival rates in breast cancer patients. This study aimed to investigate the factors associated with the comprehensive delay behaviors and to evaluate its effect on outcomes in patients with breast cancer in Dalian, a northeast city of China.

Methods

A retrospective chart review was conducted using a cancer registry dataset including 298 patients. The Kaplan–Meier survival analysis was used to identify the threshold of total delay, dividing the patients into a group with significant uncertainty and a group without substantial delay. The factors associated with the significant total delay were investigated from the potential candidates, like income level and marital status, by using the chi-squared test. The difference of the clinicopathologic characteristics between the patients grouped by the significant total delay, like tumor size and lymph node metastasis, was also investigated to find out the effect of the total delay.

Results

A total of 238 charts were used for analysis. The mean age was 57.3. The median of total delays was 3.75 months. Thirty days was identified as a threshold, more than which the total delay can lead to worse survival. Patients’ marital status (p = 0.010), income levels (p = 0.003), smoking status (p = 0.031), initial visiting hospital level (p = 0.005), self-health care (p = 0.001), and self-concern about initial symptom (p ≈ 0.000) were identified as the independent predictors of the total delay. Metastasis (p ≈ 0.000) was identified as the significant result relating to the significant total delay.

Conclusions

A total delay of more than 30 days predicts worse survival in breast cancer patients in Dalian. Several factors, like patients’ marital status and income levels, can be considered to be relevant to the significant total delay. We recommend that these factors be used to predict the potential patients with the significant total delay in the clinical practice.

Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review

OBJECTIVES

Addressing the barriers to early breast and cervical cancer diagnosis in low and middle-income countries (LMICs) requires a sound understanding and accurate assessment of diagnostic timeliness. This review aimed to map the current evidence on the time to breast and cervical cancer diagnosis and associated factors in LMICs.

DESIGN

Scoping review.

SOURCES

MEDLINE (via PubMed), Cochrane Library, Scopus and CINAHL.

ELIGIBILITY CRITERIA

Studies describing the time to diagnosis and associated factors in the context of breast and cervical cancer in LMICs published from 1 January 2010 to 20 May 2021.

STUDY SELECTION AND DATA SYNTHESIS

Two reviewers independently screened all abstracts and full texts using predefined inclusion criteria. The review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Evidence was narratively synthesised using predefined themes.

RESULTS

Twenty-six studies conducted across 24 LMICs were included in the review, most (24/26) of which focused on breast cancer. Studies varied considerably in their conceptualisation and assessment of diagnostic time, events, intervals and delays, with a minority of the studies reporting the use of validated methods and tools. Patient-related intervals and delays were more frequently evaluated and reported than provider-related and health system-related intervals and delays. Across studies, there were variations in the estimated lengths of the appraisal, help-seeking, patient and diagnostic intervals for both cancers and the factors associated with them.

CONCLUSIONS

Despite the significant burden of breast and cervical cancer in LMICs, there is limited information on the timeliness of diagnosis of these cancers. Major limitations included variations in conceptualisation and assessment of diagnostic events and intervals. These underscore the need for the use of validated and standardised tools, to improve accuracy and translation of findings to better inform interventions for addressing diagnostic delays in LMICs.

Association of breast cancer reporting delays and care intervals with tumor size in patients with advanced disease

In Pakistan, breast cancer (BC) is frequently diagnosed with advanced disease. We aimed to examine the association of breast tumor size with reasons of reporting delays, care intervals in patients with advanced disease. This cross-sectional study enrolled 392 BC patients from tertiary care hospitals. Data were collected from August 2018-March 2019. Chi-square for significance and logistic regression for association were used. Patients between 31 and 45 years of age (51%), rural residents (39%), lower-class (88.4%), no family history (17.1%), at stage-IV (36%) and patient interval >90 days (70%, p = .034) presented with large tumor size (>5 cm). Tumor size was significantly associated with area of residence (p = .043), social-class (p = .027), family history (p = .004), smoking (p = .021), nipple discharge (p = .004), recurrence (p = .024), and metastasis (p = .007). Patient-interval was associated with poor knowledge (OR;4.3,p = .0001), influence of traditional healers (OR;2.3,p = .05), religion (OR;3.9,p = .0001), finances (OR;2.4,p = .045), and competing life priorities (OR;2.9,p = .026). In-adjusted linear regression model, area of residences, education, social-class, family-history, recurrence, cancer type, and patient interval (β;0.110,p = .030) were found to be independent predictors of tumor size. In conclusion, education, family history, area of residence, social class, recurrence, cancer stage and patient interval, co-influenced by religion, finances, life priorities, traditional healers, and poor knowledge, were independent predictors of tumor size in BC patients.

Patient Delay in Breast Cancer Diagnosis in Two Hospitals in Karachi, Pakistan: Preventive and Life-Saving Measures Needed

PURPOSE

Patients with breast cancer in Pakistan commonly present with advanced disease. The objectives of this study were to evaluate the frequency and length of delays in seeking medical consultation and to assess the factors associated with them.

METHODS

Four hundred ninety-nine patients with newly diagnosed breast cancer were enrolled and interviewed over the period from February 2015 to August 2017. Information on sociodemographic factors, delay to medical consultation, stage of breast cancer at presentation, and tumor characteristics of the breast cancer were collected through face-to-face interviews and medical file review.

RESULTS

The mean (standard deviation) age of patients with breast cancer was 48.0 (12.3) years. The mean (standard deviation) patient delay was 15.7 (25.9) months, with 55.2% of women detecting a breast lump but not seeking a medical consultation because of a lack of awareness about the significance of the lump. A total of 9.4% of the women decided to seek treatment initially using complementary and alternative medicine and traditional treatment; 9.4% of the women presented to a health care provider with a breast lump but no action was taken, and they were wrongly reassured about the lump without mammography or biopsy. For 26% of the women, the delay in presentation was caused by anxiety, fears and misconceptions regarding diagnosis and treatment, and other social factors including possible adverse effects on their relationship with their husband. Multivariable analysis showed a strong association of lower socioeconomic status (odds ratio [OR], 8.11 [95% CI, 2.46 to 26.69]) and late stage of breast cancer (OR, 4.83 [95% CI, 1.74 to 13.39]) with a patient delay of ≥ 3 months.

CONCLUSION

Patient delay is a serious problem in Pakistan. There is an urgent need for intensive and comprehensive breast cancer education that addresses the myths and misconceptions related to breast cancer.

Factors Associated With Treatment Delay in Breast Cancer: A Prospective Study

Introduction The frequency of breast cancer (BC) is increasing among Pakistani females. It has been estimated that one out every nine women is predicted to develop BC, which is the highest disease occurring rate in the Asian population. The study aimed to evaluate the factors responsible for delay in diagnosis of BC in Sindh, Pakistan. Methodology This study was conducted at the Medical Oncology Department of Jinnah Postgraduate Medical Center Karachi from December 2018 to June 2019. All women between 17 and 80 years diagnosed with BC who had treatment delay of more than six months were included in the study using a non-probability consecutive sampling technique. The face-to-face interviews were conducted by the researcher himself and all the data regarding demographics and factors related to treatment delay of BC was noted in a structured questionnaire. Data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY). Results Appointment delay was significantly associated with a treatment-seeking delay in patients (p=0.03). Lack of awareness was another significant factor associated with treatment delay in BC patients. About 50 (70.4%) women who reported a lack of awareness sought treatment after 10 months of their first onset of symptoms (p=0.001). Cultural beliefs were a significant cause of treatment delay of 10-12 months in 71.8% of patients (p=0.021). Financial constraints significantly correlated with treatment delay (p=0.015). Conclusion The cultural beliefs, poor financial status, and lack of awareness are the significant factors for the treatment delay in BC patients. Promoting female health awareness can tackle many of these issues.

Beliefs and perceptions about breast cancer among the people living in rural and less privileged areas in Sindh, Pakistan

Purpose

Globally, women suffer from a lack of knowledge about breast cancer (BC), its symptoms and treatment. The purpose of this paper is to examine how people living in rural and less developed areas in Pakistan perceive BC. The study investigates the level of knowledge about BC in rural communities and analyses how the prevalent perceptions and beliefs impact women's lives and delay the diagnosis.

Design/methodology/approach

This study is based on 42 in-depth interviews with the women who have undergone BC treatment during the past five years. The participants were interviewed were the residents of the northern Sindh, southern Pakistan.

Findings

Findings show that BC was perceived as a contagious disease transmitted through touching or being physically close to the patient. Some women were abandoned by their husbands because of this perception. Faith in fatalism and the perception that BC is an incurable disease were common in communities with low socio-economic status. This is likely to affect the prevention and early detection of BC.

Originality/value

The study shows a strong co-relation of awareness with the prevalent perceptions regarding BC. Therefore, we recommend promoting health literacy and introducing culturally specific interventions in remote communities to enhance their understanding of the available treatment and help remove misconceptions about BC.

Estimates of past and future time trends in age-specific breast cancer incidence among women in Karachi, Pakistan: 2004-2025

Background

The current demographic trends indicate that breast cancer will pose an even greater public health concern in future for Pakistan. Details on the incidence, disease severity and mortality in respect of breast cancer are limited and without such data, therefore, future health policies or systems in respect of this disease cannot be strategically planned or implemented. The aim of this study was to examine past trends of age-specific breast cancer incidence rates (2004–2015), and to estimate the future volume of breast cancer cases in Karachi through the year 2025.

Methods

Two statistical methods, namely the functional time series models and the log-linear regression model were used; additionally, their real forecasting efficacy in epidemic time series was also evaluated.

Results

In the past, women aged 60–64 years had the highest overall breast cancer incidence rates, while from 2016 to 2025, large increases in breast cancer rates among women aged 50 to 64 years are expected. The total projected breast cancer incidence will increase by approximately 23.1% in 2020 to 60.7% in 2025. Cases of breast cancer diagnosed in younger women, aged 30–34 years, will increase from 70.7 to 130.6% in 2020 and 2025 relative to 2015.

Conclusions

The breast cancer incidence appeared to have been rising more rapidly among post-menopausal women (aged 55 to 59), while a stable increase in incidence in the youngest age group (15–29 years) of women is expected. The results also infer an expected increase in incidence cases of breast cancer among middle aged women in Karachi, Pakistan. An increase in the number of incident cases of cancer has implications for understanding the health-care needs of growing population and the subsequent demands on health-care system.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7330-z) contains supplementary material, which is available to authorized users.

CCR5 blockage by maraviroc: a potential therapeutic option for metastatic breast cancer

PURPOSE

Bone metastasis is observed in up to 70% of breast cancer patients. The currently available treatment options are palliative in nature. Chemokine receptor 5 (CCR5) has gained attention as therapeutic target in various malignancies. Here, we investigated the effects of targeting CCR5 by its antagonist maraviroc in metastatic breast cancer cells.

METHODS

In response to maraviroc exposure, cytotoxicity was assessed using an MTT proliferation assay, whereas the effects on colony formation and migration were assessed using colony formation, transwell chamber migration and scratch wound healing assays, respectively. Apoptosis-related activities were investigated using nuclear staining, annexin-V FITC staining and Western blotting. Cell cycle changes were analysed using flow cytometry and qRT-PCR for cell cycle relevant genes. A nude rat model for breast cancer bone metastasis was used to evaluate the in vivo efficacy of CCR5 targeting by maraviroc. Circulatory levels of the three cognate ligands for CCR5 (CCL3, CCL4, CCL5) were analysed in sera of breast cancer patients using ELISA.

RESULTS

We found that blockade of CCR5 attenuated the proliferation, colony formation and migration of metastatic breast cancer cells, and induced apoptosis and arrest in the G1 phase of the cell cycle. Expression profiling highlighted the involvement of cell cycle related signalling cascades. We also found that treatment with maraviroc significantly inhibited bone metastasis in nude rats implanted with MDA-MB-231 breast cancer cells. Finally, we found that the circulatory levels of three cognate ligands for the CCR5 receptor varied between breast cancer patients and healthy controls.

CONCLUSION

Our findings indicate that targeting CCR5 may be an effective strategy to combat breast cancer bone metastasis.

Identifying the reasons for delayed presentation of Pakistani breast cancer patients at a tertiary care hospital

Background

Delay in seeking health care by breast cancer patients is associated with advanced stage of disease at presentation and poor survival rates. This study aimed to identify the reasons for delayed presentation and their association with various sociodemographic variables.

Methods

A total of 200 female patients with abnormal clinical findings, ie, lump or palpable mass, were consecutively invited for this study. Diagnostic delay was defined as a consultation with a health care provider more than 3 months from the appearance of the first symptoms. Sociodemographic variables, presenting symptoms, knowledge about diseases and its symptoms, time between seeking medical attention after appearance of symptoms and causes of delayed presentation were investigated. Chi-squared and logistic regression tests for significance and associations were used.

Results

Among 125 women with breast cancer fulfilling the inclusion criteria, aged 24–75 years, 88.8% (n=111) presented late (≥3 months) and 59% presented with advanced stage of disease (stage III/IV). The majority (65.6%) were older than 40 years of age, 99.2% were married, 60.8% had <8 years of education, 67.2% had poor social status, and 64.8% had a negative family history of any cancer type. Almost all patients (96%) complained about the presence of a painless lump in their breast. Ignorance of disease or the presence of painless lumps in the breast and low financial resources for therapy (81.1%) were the main variables associated with delayed presentation. Educational factors (P<0.001, OR 4.682) and social status (P<0.001, OR 1.8) were also associated with delayed presentation.

Conclusion

Our study highlighted the variables associated with delayed presentation in Pakistani breast cancer patients. A significant number of patients presented late owing to misconceptions and poor knowledge about the disease and its symptoms, while illiteracy and poor social status were the major contributing factors for delayed presentation, resulting in an advanced presentation of disease and ultimately a decreased survival rate.

Unraveling the South African Breast Cancer Story: The Relationship of Patients, Delay to Diagnosis, and Tumor Biology With Stage at Presentation in an Urban Setting

BACKGROUND

Adverse outcomes from breast cancer disproportionately affect women in sub-Saharan Africa, with delay the most studied contribution to advanced stage at presentation. However, tumor molecular biology and its contribution to advanced stage are yet to be explored.

MATERIALS AND METHODS

Patients newly diagnosed with breast cancer in a South African tertiary breast center completed a questionnaire and file review concerning socioeconomics, delay to care, stage at presentation, and molecular characteristics. Logistic regression was done to determine the relative risk of advanced stage presentation.

RESULTS

Advanced stage was present in 70.1% (n = 162) of the 231 participants, with 55.8% stage III (n = 129) and 32% (n = 72) having a T4 tumor. The median age was 56 y with 21.6% (n = 47) aged <45 y. Most common subtype was luminal B (57.7%, n = 128) followed by luminal A (21.6%, n = 48), triple negative (13.9%, n = 31), and HER2 positive (6.7%, n = 15). Lobular cancer (incidence risk ratio [IRR], 1.29; 95% confidence interval [CI], 1.03-1.62), high grade and intermediate grade tumors (IRR, 1.90; 95% CI, 1.15-3.13 and IRR, 1.95; 95% CI, 1.18-3.22, respectively), high Ki67 proliferation index (IRR, 1.30; 95% CI, 1.02-1.66), and HER2 overexpression (IRR, 1.32; 95% CI, 1.12-1.55) were more likely to present with advanced disease, as were luminal B (HER2+) cancers (adjusted IRR [aIRR], 1.46; 95% CI, 1.10-1.95). Although on univariate analysis Black and young participants were both more likely to have advanced stage (IRR, 1.23; 95% CI, 1.01-1.49 and IRR, 1.25; 95% CI, 1.04-1.51, respectively), in multivariate analysis controlling for tumor biology and delay, these were no longer significant (aIRR, 1.12; 95% CI, 0.91-1.37 and aIRR, 1.17; 95% CI, 0.94-1.48, respectively).

CONCLUSIONS

Tumor biology has a compelling role in the etiology of advanced-stage disease irrespective of socioeconomic factors. Accurate pathologic assessment is important in planning breast cancer care in Africa.