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Mezger NCS, Hämmerl L, Griesel M, Seraphin TP, Joko-Fru YW, Feuchtner J, Zietsman A, Péko JF, Tadesse F, Buziba NG, Wabinga H, Nyanchama M, Chokunonga E, Kéita M, N’da G, Lorenzoni CF, Akele-Akpo MT, Mezger JM, Binder M, Liu B, Bauer M, Henke O, Jemal A, Kantelhardt EJ. Guideline Concordance of Treatment and Outcomes Among Adult Non-Hodgkin Lymphoma Patients in Sub-Saharan Africa: A Multinational, Population-Based Cohort. Oncologist 2023; 28:e1017-e1030. [PMID: 37368350 PMCID: PMC10628567 DOI: 10.1093/oncolo/oyad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/24/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Although non-Hodgkin lymphoma (NHL) is the 6th most common malignancy in Sub-Saharan Africa (SSA), little is known about its management and outcome. Herein, we examined treatment patterns and survival among NHL patients. METHODS We obtained a random sample of adult patients diagnosed between 2011 and 2015 from 11 population-based cancer registries in 10 SSA countries. Descriptive statistics for lymphoma-directed therapy (LDT) and degree of concordance with National Comprehensive Cancer Network (NCCN) guidelines were calculated, and survival rates were estimated. FINDINGS Of 516 patients included in the study, sub-classification was available for 42.1% (121 high-grade and 64 low-grade B-cell lymphoma, 15 T-cell lymphoma and 17 otherwise sub-classified NHL), whilst the remaining 57.9% were unclassified. Any LDT was identified for 195 of all patients (37.8%). NCCN guideline-recommended treatment was initiated in 21 patients. This corresponds to 4.1% of all 516 patients, and to 11.7% of 180 patients with sub-classified B-cell lymphoma and NCCN guidelines available. Deviations from guideline-recommended treatment were initiated in another 49 (9.5% of 516, 27.2% of 180). By registry, the proportion of all patients receiving guideline-concordant LDT ranged from 30.8% in Namibia to 0% in Maputo and Bamako. Concordance with treatment recommendations was not assessable in 75.1% of patients (records not traced (43.2%), traced but no sub-classification identified (27.8%), traced but no guidelines available (4.1%)). By registry, diagnostic work-up was in part importantly limited, thus impeding guideline evaluation significantly. Overall 1-year survival was 61.2% (95%CI 55.3%-67.1%). Poor ECOG performance status, advanced stage, less than 5 cycles and absence of chemo (immuno-) therapy were associated with unfavorable survival, while HIV status, age, and gender did not impact survival. In diffuse large B-cell lymphoma, initiation of guideline-concordant treatment was associated with favorable survival. INTERPRETATION This study shows that a majority of NHL patients in SSA are untreated or undertreated, resulting in unfavorable survival. Investments in enhanced diagnostic services, provision of chemo(immuno-)therapy and supportive care will likely improve outcomes in the region.
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Affiliation(s)
- Nikolaus Christian Simon Mezger
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Lucia Hämmerl
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Mirko Griesel
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Tobias Paul Seraphin
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Yvonne Walburga Joko-Fru
- African Cancer Registry Network, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jana Feuchtner
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Annelle Zietsman
- African Cancer Registry Network, Oxford, UK
- Dr AB May Cancer Care Centre, Windhoek, Namibia
| | - Jean-Félix Péko
- African Cancer Registry Network, Oxford, UK
- Registre des cancers de Brazzaville, Brazzaville, Republic of the Congo
| | - Fisihatsion Tadesse
- African Cancer Registry Network, Oxford, UK
- Division of Hematology, Department of Internal Medicine, University and Black Lion Hospital, Addis Ababa, Ethiopia
| | - Nathan Gyabi Buziba
- African Cancer Registry Network, Oxford, UK
- Eldoret Cancer Registry, School of Medicine, Moi University, Eldoret, Kenya
| | - Henry Wabinga
- African Cancer Registry Network, Oxford, UK
- Kampala Cancer Registry, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nyanchama
- African Cancer Registry Network, Oxford, UK
- National Cancer Registry, Kenya Medical Research Institute, Nairobi, Kenya
| | - Eric Chokunonga
- African Cancer Registry Network, Oxford, UK
- Zimbabwe National Cancer Registry, Harare, Zimbabwe
| | - Mamadou Kéita
- African Cancer Registry Network, Oxford, UK
- Service du Laboratoire d’Anatomie et Cytologie Pathologique, Bamako, Mali
- CHU du point G , Bamako, Mali
| | - Guy N’da
- African Cancer Registry Network, Oxford, UK
- Registre des cancers d’Abidjan, Abidjan, Côte d’Ivoire
| | - Cesaltina Ferreira Lorenzoni
- African Cancer Registry Network, Oxford, UK
- Departamento de Patologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Hospital Central de Maputo, Mozambique
- Registo de Cancro, Ministério da Saúde, Maputo, Mozambique
| | - Marie-Thérèse Akele-Akpo
- African Cancer Registry Network, Oxford, UK
- Département d’anatomo-pathologie, Faculté des Sciences de la Santé, Cotonou, Benin
| | | | - Mascha Binder
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Biying Liu
- African Cancer Registry Network, Oxford, UK
| | - Marcus Bauer
- Institute of Pathology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Oliver Henke
- Section Global Health, Institute for Public Health and Hygiene, University Hospital Bonn, Germany
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, USA
| | - Eva Johanna Kantelhardt
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Boucheron P, Zietsman A, Pontac J, Hansen R, Anderson BO, Togawa K, Macharia PM, Foerster M, Schüz J, dos-Santos-Silva I, McCormack V. Analysis of the Breast Cancer Journey in Namibia. JAMA Netw Open 2023; 6:e2341402. [PMID: 37921764 PMCID: PMC10625043 DOI: 10.1001/jamanetworkopen.2023.41402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/23/2023] [Indexed: 11/04/2023] Open
Abstract
Importance Breast cancer (BC) is the leading cancer among women in Namibia. Examining the BC journey in this multiracial country where inequalities remain large is needed to inform effective interventions to reduce BC mortality. Objective To describe the entire BC journey of Namibian women by race, utilizing the World Health Organization Global Breast Cancer Initiative (GBCI) framework. Design, Setting, and Participants This cohort study used the Namibian subset of the African Breast Cancer-Disparities in Outcomes prospective cohort. Participants were all Namibian residents with confirmed incident BC who presented at the main national public oncology center of the Windhoek Central Hospital (WCH). Follow-up started from recruitment (September 8, 2014, to October 5, 2016) and ended up to 3 years after diagnosis (December 13, 2014, to September 27, 2019). Data analysis was conducted from June 2022 to August 2023. Exposures Participants' self-reported ethnicities were aggregated into 3 population groups: Black, mixed ancestry, and White. Main Outcomes and Measures Three-year overall survival (OS) was examined using Cox models, and summary statistics were used to describe women's BC journey, including GBCI pillar key performance indicators: (1) early stage (TNM I or II) diagnosis (population benchmark ≥60%), (2) prompt diagnosis, ie, 60 days or less to first health care practitioner visit (population benchmark 100%), and (3) completion of recommended multimodal treatment (MT, ie, surgery plus chemotherapy) (population benchmark ≥80%). Results Of 405 women, there were 300 (74%) Black (mean [SD] age, 53 [15] years), 49 (12%) mixed ancestry (mean [SD] age, 53 [7] years), and 56 (14%) White (mean [SD] age, 59 [12] years) patients. Three-year OS was lowest in Black women (60% [95% CI, 54%-66%]; mixed ancestry: 80% [95% CI, 65%-89%]; White: 89% [95% CI, 77%-95%]), who had lower prevalence of early stage diagnosis (Black: 37% [95% CI, 31%-42%]; mixed ancestry and White: 75% [95% CI, 66%-83%]) and timely diagnosis (Black: 60% [95% CI, 54%-66%]; mixed ancestry and White: 77% [95% CI, 69%-85%]), while MT completion (Black: 53% [95% CI, 46%-59%]; mixed ancestry and White: 63% [95% CI, 50%-73%]) was low in all women. Conclusions and Relevance In this cohort study of 405 Namibian residents with BC, marked racial disparities in survival were paralleled by inequities all along the BC journey. To improve BC survival, interventions are needed to promote earlier diagnosis in Black Namibian women and to increase MT initiation and completion in all women.
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Affiliation(s)
- Pauline Boucheron
- International Agency for Research on Cancer, Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Annelle Zietsman
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Johanna Pontac
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Rolf Hansen
- Cancer Association of Namibia, Windhoek, Namibia
| | | | - Kayo Togawa
- International Agency for Research on Cancer, Environment and Lifestyle Epidemiology Branch, Lyon, France
- National Cancer Centre Institute for Cancer Control, Division of Population Data Science, Tokyo, Japan
| | - Peter M. Macharia
- Population Health Unit, Kenya Medical Research Institute–Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Milena Foerster
- International Agency for Research on Cancer, Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Joachim Schüz
- International Agency for Research on Cancer, Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Isabel dos-Santos-Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Valerie McCormack
- International Agency for Research on Cancer, Environment and Lifestyle Epidemiology Branch, Lyon, France
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Bauer M, Vetter M, Stückrath K, Yohannes M, Desalegn Z, Yalew T, Bekuretsion Y, Kenea TW, Joffe M, van den Berg EJ, Nikulu JI, Bakarou K, Manraj SS, Ogunbiyi OJ, Ekanem IO, Igbinoba F, Diomande M, Adebamowo C, Dzamalala CP, Anele AA, Zietsman A, Galukande M, Foerster M, dos-Santos-Silva I, Liu B, Santos P, Jemal A, Abebe T, Wickenhauser C, Seliger B, McCormack V, Kantelhardt EJ. Regional Variation in the Tumor Microenvironment, Immune Escape and Prognostic Factors in Breast Cancer in Sub-Saharan Africa. Cancer Immunol Res 2023; 11:720-731. [PMID: 37058582 PMCID: PMC10552870 DOI: 10.1158/2326-6066.cir-22-0795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/18/2023] [Accepted: 04/10/2023] [Indexed: 04/16/2023]
Abstract
The low overall survival rates of patients with breast cancer in sub-Saharan Africa (SSA) are driven by regionally differing tumor biology, advanced tumor stages at diagnosis, and limited access to therapy. However, it is not known whether regional differences in the composition of the tumor microenvironment (TME) exist and affect patients' prognosis. In this international, multicentre cohort study, 1,237 formalin-fixed, paraffin-embedded breast cancer samples, including samples of the "African Breast Cancer-Disparities in Outcomes (ABC-DO) Study," were analyzed. The immune cell phenotypes, their spatial distribution in the TME, and immune escape mechanisms of breast cancer samples from SSA and Germany (n = 117) were investigated using histomorphology, conventional and multiplex IHC, and RNA expression analysis. The data revealed no regional differences in the number of tumor-infiltrating lymphocytes (TIL) in the 1,237 SSA breast cancer samples, while the distribution of TILs in different breast cancer IHC subtypes showed regional diversity, particularly when compared with German samples. Higher TIL densities were associated with better survival in the SSA cohort (n = 400), but regional differences concerning the predictive value of TILs existed. High numbers of CD163+ macrophages and CD3+CD8+ T cells accompanied by reduced cytotoxicity, altered IL10 and IFNγ levels and downregulation of MHC class I components were predominantly detected in breast cancer samples from Western SSA. Features of nonimmunogenic breast cancer phenotypes were associated with reduced patient survival (n = 131). We therefore conclude that regional diversity in the distribution of breast cancer subtypes, TME composition, and immune escape mechanisms should be considered for therapy decisions in SSA and the design of personalized therapies. See related Spotlight by Bergin et al., p. 705.
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Affiliation(s)
- Marcus Bauer
- Department of Pathology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Martina Vetter
- Department of Gynecology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kathrin Stückrath
- Department of Gynecology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Meron Yohannes
- Department of Medical Laboratory Science, College of Health sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zelalem Desalegn
- Department of Microbiology, Immunology & Parasitology, School of Medicine, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tewodros Yalew
- Department of Pathology, Tikur Anbessa Specialized University Hospital, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yonas Bekuretsion
- Department of Pathology, Tikur Anbessa Specialized University Hospital, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tariku W. Kenea
- Department of Surgery, Aira General Hospital, Aira, Ethiopia
| | - Maureen Joffe
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, South Africa and U Witwatersrand, Faculty of Health Sciences, Strengthening Oncology Services Research Unit
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eunice J van den Berg
- Department of Anatomical Pathology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - Julien I. Nikulu
- Ligue congolaise contre le cancer, l’Unité Pilote du GFAOP, Lubumbashi, Democratic Republic of the Congo
| | - Kamate Bakarou
- Service d’anatomie, Cytologie Pathologique au C.H.U. du point G BP:333, Bamako, Mali
| | - Shyam S. Manraj
- Central Health Laboratory, Victoria Hospital, Candos, Mauritius
| | - Olufemi J. Ogunbiyi
- Department of Pathology, University College Hospital, Ibadan, Oyo state, Nigeria
| | - Ima-Obong Ekanem
- Department of Pathology, Calabar Cancer Registry, University of Calabar Teaching Hospital, Calabar, Nigeria
| | | | - Mohenou Diomande
- Service d’anatomie et cytologie pathologiques, Abidjan, Côte d’Ivoire
| | - Clement Adebamowo
- Department of Epidemiology and Public Health, and the Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore
| | | | | | - Annelle Zietsman
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Moses Galukande
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Milena Foerster
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Isabel dos-Santos-Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM)
| | - Biying Liu
- African Cancer Registry Network, Oxford, United Kingdom
| | - Pablo Santos
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia, USA
| | - Tamrat Abebe
- Department of Medical Laboratory Science, College of Health sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Claudia Wickenhauser
- Department of Pathology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Barbara Seliger
- Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute of Translational Immunology, Medical School ‘Theodor Fontane, Brandenburg an der Havel, Germany
- Fraunhofer Institute for Immunology, Leipzig, Germany
| | - Valerie McCormack
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Eva J. Kantelhardt
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
- Department of Gynecology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Boucheron P, Anele A, Offiah AU, Zietsman A, Galukande M, Parham G, Pinder LF, Anderson BO, Foerster M, Schüz J, Dos-Santos-Silva I, McCormack V. Reproductive history and breast cancer survival: Findings from the African breast cancer-Disparities in outcomes cohort and implications of Africa's fertility transition on breast cancer prognosis. Int J Cancer 2023; 152:1804-1816. [PMID: 36545890 PMCID: PMC10070810 DOI: 10.1002/ijc.34411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
Reproductive characteristics are known risk factors for breast cancer but, other than recent birth, their role as prognostic factors is less clear, and has not been studied in Sub-Saharan Africa (SSA). In this setting, we examined whether reproductive factors independently influence breast cancer survival in a subset of the African Breast Cancer-Disparities in Outcomes cohort study. In 1485 women with incident breast cancer recruited between 2014 and 2017, we examined birth cohort changes in reproductive factors, and used Cox models to examine whether reproductive characteristics were associated with all-cause mortality after adjusting for confounders (age, stage, treatment, HIV, and social factors). Four years after diagnosis, 822 (56%) women had died. Median parity was 4 (IQR = 2, 6) and 209 (28%) of premenopausal women had had a recent birth (<3 years prior to cancer diagnosis). Each pregnancy was associated with a 5% increase (95% CI: 2%, 8%) in mortality rates, which held among postmenopausal women (5%, [1%-9%]). Pre-menopausal women with a recent birth had 52% (20%, 92%) higher mortality rates. Fertility trends by birth cohort showed declining parity, increasing age at first birth and declining age at last birth, however the impact of these population-level changes on future average survival was predicted to be very small (<3% absolute gain).
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Affiliation(s)
- Pauline Boucheron
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | | | - Awa U Offiah
- Abia State University Teaching Hospital, Aba, Nigeria
| | - Annelle Zietsman
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Moses Galukande
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Groesbeck Parham
- Department of Obstetrics and Gynaecology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Benjamin O Anderson
- University of Washington, Seattle, Washington, USA.,World Health Organization, Geneva, Switzerland
| | - Milena Foerster
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Joachim Schüz
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Valerie McCormack
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
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Foerster M, McCormack V, Anderson BO, Boucheron P, Zietsman A, Cubasch H, Joffe M, Anele A, Offiah S, Galukande M, Parham G, Pinder LF, Ginsburg O, Schüz J, Dos-Santos-Silva I, Kantelhardt EJ. Treatment guideline concordance, initiation, and abandonment in patients with non-metastatic breast cancer from the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort in sub-Saharan Africa: a prospective cohort study. Lancet Oncol 2022; 23:729-738. [PMID: 35550274 PMCID: PMC10036870 DOI: 10.1016/s1470-2045(22)00198-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Comprehensive breast cancer management is essential to achieve high breast cancer survival; however, detailed reports of the treatment regimens received by patients are scarce in sub-Saharan Africa where survival is low. We aimed to examine treatment initiation, guideline concordance, and abandonment in patients with non-metastatic breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort. METHODS The ABC-DO prospective cohort study recruited women (aged ≥18 years) with newly diagnosed invasive breast cancer in eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, Uganda, South Africa, and Zambia). We analysed treatments received by women who were classified as non-metastatic (M0) at the initial presentation. Data on surgery, radiotherapy, and systemic therapies were obtained from medical records and a self-reported follow-up questionnaire at 6 months after the diagnosis, follow-up calls every 3 months, and a baseline questionnaire. Initiation, completion, and abandonment of treatment modalities and combined therapy regimens were examined overall, by country-specific groups, and by clinical factors relevant for guideline-based treatment. FINDINGS Of 2313 women recruited into the ABC-DO study between Sept 10, 2014, and Dec 31, 2017, 2226 had histologically or clinically confirmed breast cancer. Of these 2226 women, 510 were excluded from the present analysis because 378 had metastatic disease, 37 were prevalent cases (defined as those previously diagnosed with breast cancer >2 years before baseline), 82 had unknown TNM stage, and 13 were White or Asian women in South Africa (number was too small for analysis). After a median follow-up of 5·2 years (IQR 4·6-5·9), 1163 (68%) of 1716 women underwent breast cancer surgery. Surgery and systemic therapy (ie, multimodality treatment) with radiotherapy was initiated in 370 (36%) of 1028 women with localised tumours versus 156 (23%) of 688 women with locally advanced tumours, whereas multimodality treatment without radiotherapy was initiated in 386 (38%) versus 167 (24%) women, respectively. Of 1530 patients requiring chemotherapy (which excludes 105 who died within 6 months after baseline), 1013 (66%) initiated treatment of neoadjuvant chemotherapy or surgery within 3 months after baseline, which was adequately completed by 359 (35%) of 1013 women, marginally completed by 284 (28%), abandoned by 200 (20%), and unknown in 151 (15%). 19 (2%) women died within 6 months after chemotherapy initiation. Of 1375 women in whom endocrine therapy was indicated, this treatment was initiated in 920, and lasted at least 3 years in 367 (40%) women. Treatment disparities between country-specific groups were substantial for all therapy regimens. INTERPRETATION A high proportion of patients with non-metastatic breast cancer did not initiate, did not fully complete, or abandoned treatment with surgery, systemic therapy, radiotherapy, or an appropriate combination of these, highlighting the need for improved treatment access and completion in sub-Saharan Africa to potentially prevent premature breast cancer deaths. FUNDING National Institutes of Health (National Cancer Institute), Susan G Komen, and the International Agency for Research on Cancer.
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Affiliation(s)
- Milena Foerster
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France.
| | - Valerie McCormack
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Pauline Boucheron
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Herbert Cubasch
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Maureen Joffe
- Non-Communicable Diseases Research Division, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Groesbeck Parham
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Leeya F Pinder
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Ophira Ginsburg
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | - Joachim Schüz
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Eva J Kantelhardt
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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6
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Chasimpha S, McCormack V, Cubasch H, Joffe M, Zietsman A, Galukande M, Parham G, Pinder LF, Anele A, Adisa CA, Offiah AU, Anderson BO, Boucheron P, Foerster M, Schüz J, Dos-Santos-Silva I. Disparities in breast cancer survival between women with and without HIV across sub-Saharan Africa (ABC-DO): a prospective, cohort study. Lancet HIV 2022; 9:e160-e171. [PMID: 35245508 PMCID: PMC9031563 DOI: 10.1016/s2352-3018(21)00326-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/13/2021] [Accepted: 12/07/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Studies have shown increased mortality among women living with HIV diagnosed with breast cancer compared with HIV-negative women with breast cancer. We aimed to examine how this HIV differential varies by patient or breast tumour characteristics. METHODS The African Breast Cancer-Disparities in Outcomes (ABC-DO) study is a prospective cohort of women (aged ≥18 years) with incident breast cancer recruited consecutively at diagnosis (2014-17) from hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. Detailed clinical and epidemiological data, including self-reported or tested HIV status, were collected at baseline. Participants were actively followed up via telephone calls every 3 months. The primary outcome was all-cause mortality, assessed in all women who had at least one updated vital status after baseline interview. Using Cox regression, we examined differences in overall survival by HIV status in the cohort, and across country and patient subgroups, adjusted for age, tumour grade, and tumour stage at cancer diagnosis. FINDINGS Between Sept 8, 2014, and Dec 31, 2017, we recruited 2154 women with primary breast cancer, 519 of whom were excluded due to their countries having small numbers of women with HIV for comparison. Among the remaining 1635 women, 313 (19%) were living with HIV, 1184 (72%) were HIV negative, and 138 (9%) had unknown HIV status. At breast cancer diagnosis, women with HIV were younger and had lower body-mass index (BMI) than their HIV-negative counterparts, but had similar tumour stage, grade, and receptor subtypes. At the end of the follow-up (Jan 1, 2019), a higher proportion of women with HIV (137 [44%] of 313) had died than had HIV-negative women (432 [37%] of 1184). Crude 3-year survival was 9% lower for women with HIV (46% [95% CI 40-53]) than for HIV-negative women (55% [52-59]; hazard ratio (HR) 1·41 [1·15-1·74]). The HIV survival differential did not differ by age, BMI, tumour subtype, or tumour grade, but was stronger in women with non-metastatic disease (3-year survival 52% HIV-positive vs 63% HIV-negative women, adjusted HR 1·65 [1·30-2·10]), whereas women with metastatic cancer had low survival, regardless of HIV status. INTERPRETATION The larger survival deficit among women with HIV with non-metastatic breast cancer calls for a better understanding of the reasons underlying this differential (eg, biological mechanisms, health behaviours, detrimental HIV-breast cancer treatment interactions, or higher HIV background mortality) to inform strategies for reducing mortality among this patient group. FUNDING Susan G Komen, International Agency for Research on Cancer, National Cancer Institute, and UK-Commonwealth Scholarships.
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Affiliation(s)
- Steady Chasimpha
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - Valerie McCormack
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | - Herbert Cubasch
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa; Non-Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
| | - Maureen Joffe
- Non-Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa; Non-Communicable Diseases Research Division, University of Witwatersrand, Johannesburg, South Africa; MRC Developmental Pathways to Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Annelle Zietsman
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Moses Galukande
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Groesbeck Parham
- Department of Obstetrics and Gynaecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Leeya F Pinder
- Department of Obstetrics and Gynaecology, Women and Newborn Hospital, Lusaka, Zambia; Department of Obstetrics and Gynaecology, University of Washington, Seattle, WA, USA
| | - Angelica Anele
- Breast Oncology Unit, Federal Medical Centre, Owerri, Nigeria
| | | | | | - Benjamin O Anderson
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - Pauline Boucheron
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | - Milena Foerster
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | - Joachim Schüz
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, Lyon, France
| | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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7
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Joko-Fru WY, Griesel M, Mezger NCS, Hämmerl L, Seraphin TP, Feuchtner J, Wabinga H, N'da G, Mathewos A, Kamaté B, Nsonde Malanda J, Gnangnon FHR, Chesumbai GC, Korir A, Lorenzoni C, Zietsman A, Borok MZ, Liu B, Thomssen C, McGale P, Jemal A, Parkin DM, Kantelhardt EJ. Breast Cancer Diagnostics, Therapy, and Outcomes in Sub-Saharan Africa: A Population-Based Registry Study. J Natl Compr Canc Netw 2021; 20:jnccn20412. [PMID: 34965508 DOI: 10.6004/jnccn.2021.7011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 01/20/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Breast cancer (BC) is the most common cancer in sub-Saharan Africa (SSA). However, little is known about the actual therapy received by women with BC and their survival outcome at the population level in SSA. This study aims to describe the cancer-directed therapy received by patients with BC at the population level in SSA, compare these results with the NCCN Harmonized Guidelines for SSA (NCCN Harmonized Guidelines), and evaluate the impact on survival. METHODS Random samples of patients with BC (≥40 patients per registry), diagnosed from 2009 through 2015, were drawn from 11 urban population-based cancer registries from 10 countries (Benin, Congo, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mozambique, Namibia, Uganda, and Zimbabwe). Active methods were used to update the therapy and outcome data of diagnosed patients ("traced patients"). Excess hazards of death by therapy use were modeled in a relative survival context. RESULTS A total of 809 patients were included. Additional information was traced for 517 patients (63.8%), and this proportion varied by registry. One in 5 traced patients met the minimum diagnostic criteria (cancer stage and hormone receptor status known) for use of the NCCN Harmonized Guidelines. The hormone receptor status was unknown for 72.5% of patients. Of the traced patients with stage I-III BC (n=320), 50.9% received inadequate or no cancer-directed therapy. Access to therapy differed by registry area. Initiation of adequate therapy and early-stage diagnosis were the most important determinants of survival. CONCLUSIONS Downstaging BC and improving access to diagnostics and care are necessary steps to increase guideline adherence and improve survival for women in SSA. It will also be important to strengthen health systems and facilities for data management in SSA to facilitate patient follow-up and disease surveillance.
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Affiliation(s)
- Walburga Yvonne Joko-Fru
- 1Nuffield Department of Population Health, University of Oxford
- 2The African Cancer Registry Network, INCTR African Registry Programme, Oxford, United Kingdom
| | - Mirko Griesel
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Nikolaus Christian Simon Mezger
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Lucia Hämmerl
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Tobias Paul Seraphin
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Jana Feuchtner
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Henry Wabinga
- 4Kampala Cancer Registry, Makerere University School of Medicine, Kampala, Uganda
| | - Guy N'da
- 5Registre des cancers d'Abidjan, Abidjan, Côte d'Ivoire
| | - Assefa Mathewos
- 6Radiotherapy Center, Addis-Ababa-University, Addis Ababa, Ethiopia
| | | | | | | | | | - Anne Korir
- 11Nairobi Cancer Registry, Nairobi, Kenya
| | - Cesaltina Lorenzoni
- 12Maputo City Cancer Registry, Maputo City, Mozambique
- 13Department of Pathology, Faculty of Medicine, Eduardo Mondlane University, Maputo Central Hospital, Maputo, Mozambique
| | | | | | - Biying Liu
- 2The African Cancer Registry Network, INCTR African Registry Programme, Oxford, United Kingdom
| | - Christoph Thomssen
- 16Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Paul McGale
- 1Nuffield Department of Population Health, University of Oxford
| | - Ahmedin Jemal
- 17Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Donald Maxwell Parkin
- 1Nuffield Department of Population Health, University of Oxford
- 2The African Cancer Registry Network, INCTR African Registry Programme, Oxford, United Kingdom
- 18International Agency for Research in Cancer, Lyon, France
| | - Eva Johanna Kantelhardt
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- 16Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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8
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Boucheron P, Anele A, Zietsman A, Galukande M, Parham G, Pinder LF, Andersson TML, Anderson BO, Foerster M, Schüz J, Dos Santos Silva I, McCormack V. Self-reported arm and shoulder problems in breast cancer survivors in Sub-Saharan Africa: the African Breast Cancer-Disparities in Outcomes cohort study. Breast Cancer Res 2021; 23:109. [PMID: 34819118 PMCID: PMC8611842 DOI: 10.1186/s13058-021-01486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
Background Arm and shoulder problems (ASP), including lymphedema, were common among women with breast cancer in high-income countries before sentinel lymph node biopsy became the standard of care. Although ASP impair quality of life, as they affect daily life activities, their frequency and determinants in Sub-Saharan Africa remain unclear.
Methods All women newly diagnosed with breast cancer at the Namibian, Ugandan, Nigerian, and Zambian sites of the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort study were included. At each 3-month follow-up interview, women answered the EORTC-QLQ-Br23 questionnaire, including three ASP items: shoulder/arm pain, arm stiffness, and arm/hand swelling. We estimated the cumulative incidence of first self-reported ASP, overall and stratified by study and treatment status, with deaths treated as competing events. To identify determinants of ASP, we estimated cause-specific hazard ratios using Cox models stratified by study site. Results Among 1476 women, up to 4 years after diagnosis, 43% (95% CI 40–46), 36% (33–38) and 23% (20–25), respectively, self-reported having experienced arm/shoulder pain, stiffness and arm/hand swelling at least once. Although risks of self-reported ASP differed between sites, a more advanced breast cancer stage at diagnosis, having a lower socioeconomic position and receiving treatment increased the risk of reporting an ASP. Conclusion ASP are very common in breast cancer survivors in Sub-Saharan Africa. They are influenced by different factors than those observed in high-income countries. There is a need to raise awareness and improve management of ASP within the African setting. Supplementary Information The online version contains supplementary material available at 10.1186/s13058-021-01486-9.
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Affiliation(s)
- Pauline Boucheron
- International Agency for Research On Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France.
| | | | - Annelle Zietsman
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Moses Galukande
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Groesbeck Parham
- Department of Obstetrics and Gynaecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | - Therese M-L Andersson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Benjamin O Anderson
- University of Washington, Seattle, WA, USA.,World Health Organization, Geneva, Switzerland
| | - Milena Foerster
- International Agency for Research On Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Joachim Schüz
- International Agency for Research On Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | | | - Valerie McCormack
- International Agency for Research On Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
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9
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Ayeni OA, Norris SA, Joffe M, Cubasch H, Galukande M, Zietsman A, Parham G, Adisa C, Anele A, Schüz J, Anderson BO, Foerster M, dos Santos Silva I, McCormack VA. Preexisting morbidity profile of women newly diagnosed with breast cancer in sub-Saharan Africa: African Breast Cancer-Disparities in Outcomes study. Int J Cancer 2021; 148:2158-2170. [PMID: 33180326 PMCID: PMC8129872 DOI: 10.1002/ijc.33387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/21/2020] [Accepted: 10/15/2020] [Indexed: 12/24/2022]
Abstract
The presence of preexisting morbidities poses a challenge to cancer patient care. There is little information on the profile and prevalence of multi-morbidities in breast cancer patients across middle income countries (MIC) to lower income countries (LIC) in sub-Saharan Africa (SSA). The African Breast Cancer-Disparities in Outcomes (ABC-DO) breast cancer cohort spans upper MICs South Africa and Namibia, lower MICs Zambia and Nigeria and LIC Uganda. At cancer diagnosis, seven morbidities were assessed: obesity, hypertension, diabetes, asthma/chronic obstructive pulmonary disease, heart disease, tuberculosis and HIV. Logistic regression models were used to assess determinants of morbidities and the influence of morbidities on advanced stage (stage III/IV) breast cancer diagnosis. Among 2189 women, morbidity prevalence was the highest for obesity (35%, country-specific range 15-57%), hypertension (32%, 15-51%) and HIV (16%, 2-26%) then for diabetes (7%, 4%-10%), asthma (4%, 2%-10%), tuberculosis (4%, 0%-8%) and heart disease (3%, 1%-7%). Obesity and hypertension were more common in upper MICs and in higher socioeconomic groups. Overall, 27% of women had at least two preexisting morbidities. Older women were more likely to have obesity (odds ratio: 1.09 per 10 years, 95% CI 1.01-1.18), hypertension (1.98, 1.81-2.17), diabetes (1.51, 1.32-1.74) and heart disease (1.69, 1.37-2.09) and were less likely to be HIV positive (0.64, 0.58-0.71). Multi-morbidity was not associated with stage at diagnosis, with the exception of earlier stage in obese and hypertensive women. Breast cancer patients in higher income countries and higher social groups in SSA face the additional burden of preexisting non-communicable diseases, particularly obesity and hypertension, exacerbated by HIV in Southern/Eastern Africa.
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Affiliation(s)
- Oluwatosin A. Ayeni
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgGautengSouth Africa
- Noncommunicable Diseases Research DivisionWits Health Consortium (PTY) LtdJohannesburgGautengSouth Africa
| | - Shane A. Norris
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgGautengSouth Africa
- Noncommunicable Diseases Research DivisionWits Health Consortium (PTY) LtdJohannesburgGautengSouth Africa
| | - Maureen Joffe
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgGautengSouth Africa
- Noncommunicable Diseases Research DivisionWits Health Consortium (PTY) LtdJohannesburgGautengSouth Africa
| | - Herbert Cubasch
- Noncommunicable Diseases Research DivisionWits Health Consortium (PTY) LtdJohannesburgGautengSouth Africa
- Department of Surgery, Chris Hani Baragwanath Academic Hospital and Faculty of Health SciencesUniversity of WitwatersrandJohannesburgGautengSouth Africa
| | | | | | - Groesbeck Parham
- Department of Obstetrics and GynecologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Charles Adisa
- Department of SurgeryAbia State University Teaching HospitalAbaNigeria
| | - Angelica Anele
- Department of SurgeryFederal Medical CentreOwerriNigeria
| | - Joachim Schüz
- Section of Environment and RadiationInternational Agency for Research on Cancer, (IARC/WHO)LyonFrance
| | | | - Milena Foerster
- Section of Environment and RadiationInternational Agency for Research on Cancer, (IARC/WHO)LyonFrance
| | - Isabel dos Santos Silva
- Department of Non‐communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Valerie A. McCormack
- Section of Environment and RadiationInternational Agency for Research on Cancer, (IARC/WHO)LyonFrance
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10
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Togawa K, Anderson BO, Foerster M, Galukande M, Zietsman A, Pontac J, Anele A, Adisa C, Parham G, Pinder LF, McKenzie F, Schüz J, dos Santos‐Silva I, McCormack V. Geospatial barriers to healthcare access for breast cancer diagnosis in sub-Saharan African settings: The African Breast Cancer-Disparities in Outcomes Cohort Study. Int J Cancer 2021; 148:2212-2226. [PMID: 33197280 PMCID: PMC8048597 DOI: 10.1002/ijc.33400] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/07/2020] [Accepted: 10/15/2020] [Indexed: 02/03/2023]
Abstract
We examined the geospatial dimension of delays to diagnosis of breast cancer in a prospective study of 1541 women newly diagnosed in the African Breast Cancer-Disparities in Outcomes (ABC-DO) Study. Women were recruited at cancer treatment facilities in Namibia, Nigeria, Uganda and Zambia. The baseline interview included information used to generate the geospatial features: urban/rural residence, travel mode to treatment facility and straight-line distances from home to first-care provider and to diagnostic/treatment facility, categorized into country/ethnicity (population)-specific quartiles. These factors were investigated in relation to delay in diagnosis (≥3 months since first symptom) and late stage at diagnosis (TNM: III, IV) using logistic regression, adjusted for population group and sociodemographic characteristics. The median (interquartile range) distances to first provider and diagnostic and treatment facilities were 5 (1-37), 17 (3-105) and 62 (5-289) km, respectively. The majority had a delay in diagnosis (74%) and diagnosis at late stage (64%). Distance to first provider was not associated with delay in diagnosis or late stage at diagnosis. Rural residence was associated with delay, but the association did not persist after adjustment for sociodemographic characteristics. Distance to the diagnostic/treatment facility was associated with delay (highest vs lowest quartile: odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.08-2.27) and late stage (overall: OR = 1.47, CI = 1.05-2.06; without Nigerian hospitals where mostly local residents were treated: OR = 1.73, CI = 1.18-2.54). These findings underscore the need for measures addressing the geospatial barriers to early diagnosis in sub-Saharan African settings, including providing transport or travel allowance and decentralizing diagnostic services.
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Affiliation(s)
- Kayo Togawa
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
| | - Benjamin O. Anderson
- Division of Public Health SciencesFred Hutchinson Cancer Research
- Center and Department of SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Milena Foerster
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
| | | | - Annelle Zietsman
- Dr AB May Cancer Care CentreWindhoek Central HospitalWindhoekNamibia
| | - Johanna Pontac
- College of Health SciencesMakerere UniversityKampalaUganda
| | - Angelica Anele
- Surgery/General/Oncology unitFederal Medical CentreOwerriNigeria
| | - Charles Adisa
- Department of SurgeryAbia State University Teaching HospitalAbaNigeria
| | - Groesbeck Parham
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel HillZambia
| | - Leeya F. Pinder
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWAUSA
- Department of Obstetrics and GynaecologyWomen and Newborn HospitalLusakaZambia
| | - Fiona McKenzie
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
| | - Joachim Schüz
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
| | - Isabel dos Santos‐Silva
- Department of Non‐communicable Diseases EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Valerie McCormack
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
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11
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Galukande M, Schüz J, Anderson BO, Zietsman A, Adisa C, Anele A, Parham G, Pinder LF, Mutumba S, Lombe D, Cabanes A, Foerster M, dos-Santos-Silva I, McCormack V. Maternally Orphaned Children and Intergenerational Concerns Associated With Breast Cancer Deaths Among Women in Sub-Saharan Africa. JAMA Oncol 2021; 7:285-289. [PMID: 33355599 PMCID: PMC7758819 DOI: 10.1001/jamaoncol.2020.6583] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/29/2020] [Indexed: 11/17/2022]
Abstract
IMPORTANCE Low breast cancer survival in sub-Saharan Africa's young population increases the likelihood that breast cancer deaths result in maternal orphans, ie, children (<18 years) losing their mother. OBJECTIVE To estimate the number of maternal orphans and their ages for every 100 breast cancer deaths in sub-Saharan African settings during 2014-2019 and to describe family concerns about the orphaned children. DESIGN, SETTING, AND PARTICIPANTS Deaths occurring between September 1, 2014, and July 1, 2019, in the African Breast Cancer-Disparities in Outcomes (ABC-DO) were examined in a cohort of women diagnosed with breast cancer during 2014-2017 at major cancer treatment hospitals in Namibia, Nigeria, Uganda, and Zambia. The cohort was actively followed up for vital status via a trimonthly mobile phone call to each woman or her next of kin (typically a partner, husband, or child). MAIN OUTCOMES AND MEASURES The number (Poisson counts) and ages of new orphans at the time of maternal death. RESULTS This cohort study found that a total of 795 deaths resulted in 964 new maternal orphans, with deaths occurring in women younger than 50 years accounting for 85% of the orphans. For every 100 deaths in women younger than 50 years, there were 210 new orphans (95% CI, 196-225) overall, with country-specific estimates of 189 in Nigerian, 180 in Namibian, 222 in Ugandan, and 247 in Zambian Black women. For every 100 deaths of the women at any age, there were 121 maternal orphans, 17% of whom were younger than 5 years, 32% aged 5 to 9 years, and 51% aged 10 to 17 years at the time of maternal death. In follow-up interviews, families' concerns for children's education and childcare were reported to be exacerbated by the financial expenses associated with cancer treatment. CONCLUSIONS AND RELEVANCE This study provides evidence that the number of maternal orphans due to breast cancer exceeds the number of breast cancer deaths among women in sub-Saharan Africa. The intergenerational consequences associated with cancer deaths in sub-Saharan Africa appear to be large and support the need for continued action to improve survival.
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Affiliation(s)
- Moses Galukande
- Department of Surgery, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joachim Schüz
- Branch of Environment and Lifestyle Epidemiology, International Agency for Research on Cancer, Lyon, France
| | | | | | - Charles Adisa
- Department of Surgery, Abia State University Teaching Hospital Nigeria, Aba, Abia, Nigeria
| | - Angelica Anele
- Breast Oncology Unit, Federal Medical Centre Owerri, Nigeria
| | - Groesbeck Parham
- UNC Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Leeya F. Pinder
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Songiso Mutumba
- Outpatient Department, Matero Level One Hospital, Lusaka, Zambia
| | - Dorothy Lombe
- Department of Oncology, Cancer Diseases Hospital, Lusaka, Zambia
| | | | - Milena Foerster
- Branch of Environment and Lifestyle Epidemiology, International Agency for Research on Cancer, Lyon, France
| | - Isabel dos-Santos-Silva
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Valerie McCormack
- Branch of Environment and Lifestyle Epidemiology, International Agency for Research on Cancer, Lyon, France
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Foerster M, McKenzie F, Zietsman A, Galukande M, Anele A, Adisa C, Parham G, Pinder L, Schüz J, McCormack V, dos‐Santos‐Silva I. Dissecting the journey to breast cancer diagnosis in sub-Saharan Africa: Findings from the multicountry ABC-DO cohort study. Int J Cancer 2021; 148:340-351. [PMID: 32663320 PMCID: PMC7754476 DOI: 10.1002/ijc.33209] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/29/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022]
Abstract
Most breast cancer patients in sub-Saharan Africa are diagnosed at advanced stages after prolonged symptomatic periods. In the multicountry African Breast Cancer-Disparities in Outcomes cohort, we dissected the diagnostic journey to inform downstaging interventions. At hospital presentation for breast cancer, women recalled their diagnostic journey, including dates of first noticing symptoms and health-care provider (HCP) visits. Negative binomial regression models were used to identify correlates of the length of the diagnostic journey. Among 1429 women, the median (inter-quartile range) length (months) of the diagnostic journey ranged from 11.3 (5.7-21.2) in Ugandan, 8.2 (3.4-16.4) in Zambian, 6.5 (2.4-15.7) in Namibian-black to 5.6 (2.3-13.1) in Nigerian and 2.4 (0.6-5.5) in Namibian-non-black women. Time from first HCP contact to diagnosis represented, on average, 58% to 79% of the diagnostic journey in each setting except Nigeria where most women presented directly to the diagnostic hospital with advanced disease. The median number of HCPs visited was 1 to 4 per woman, but time intervals between visits were long. Women who attributed their initial symptoms to cancer had a 4.1 months (absolute) reduced diagnostic journey than those who did not, while less-educated (none/primary) women had a 3.6 months longer journey than more educated women. In most settings the long journey to breast cancer diagnosis was not primarily due to late first presentation but to prolonged delays after first presentation to diagnosis. Promotion of breast cancer awareness and implementation of accelerated referral pathways for women with suspicious symptoms are vital to downstaging the disease in the region.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Joachim Schüz
- International Agency for Research on CancerLyonFrance
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Foerster M, Anele A, Adisa C, Galukande M, Parham G, Zietsman A, Oyamienlen CS, Iwuoha KC, Ezeigbo E, Bakengesa E, Kaggwa A, Naamala A, Nteziryayo A, Nakazibwe T, Pinder LF, Walubita E, Pontac J, Anderson BO, McKenzie F, Schüz J, Dos Santos Silva I, McCormack V. Few Losses to Follow-up in a Sub-Saharan African Cancer Cohort via Active Mobile Health Follow-up. Am J Epidemiol 2020; 189:1185-1196. [PMID: 32383449 DOI: 10.1093/aje/kwaa070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 11/13/2022] Open
Abstract
Accurate survival estimates are needed for guiding cancer control efforts in sub-Saharan Africa, but previous studies have been hampered by unknown biases due to excessive loss to follow-up (LTFU). In the African Breast Cancer-Disparities in Outcomes Study, a prospective breast cancer cohort study, we implemented active mobile health follow-up, telephoning each woman or her next-of-kin (NOK) trimonthly on her mobile phone to update information on her vital status. Dates of every contact with women/NOK were analyzed from diagnosis in 2014-2017 to the earliest of September 1, 2018, death, or 3 years postdiagnosis. The cumulative incidence of being LTFU was calculated considering deaths as competing events. In all, 1,490 women were followed for a median of 24.2 (interquartile range (IQR), 14.2-34.5) months, corresponding to 8,529 successful contacts (77% of total contacts) with the women/NOK. Median time between successful contacts was 3.0 (IQR, 3.0-3.7) months. In all, 71 women (5.3%) were LTFU at 3 years: 0.8% in Nigeria, 2.2% in Namibia, and 5.6% in Uganda. Because of temporary discontinuity of active follow-up, 20.3% of women were LTFU after 2 years in Zambia. The median time to study notification of a death was 9.1 (IQR, 3.9-14.0) weeks. Although the present study was not a randomized controlled trial, in this cancer cohort with active mobile health follow-up, LTFU was much lower than in previous studies and enabled estimation of up-to-date and reliable cancer survival.
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14
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McCormack V, McKenzie F, Foerster M, Zietsman A, Galukande M, Adisa C, Anele A, Parham G, Pinder LF, Cubasch H, Joffe M, Beaney T, Quaresma M, Togawa K, Abedi-Ardekani B, Anderson BO, Schüz J, Dos-Santos-Silva I. Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study. Lancet Glob Health 2020; 8:e1203-e1212. [PMID: 32827482 PMCID: PMC7450275 DOI: 10.1016/s2214-109x(20)30261-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Breast cancer is the second leading cause of death from cancer in women in sub-Saharan Africa, yet there are few well characterised large-scale survival studies with complete follow-up data. We aimed to provide robust survival estimates in women in this setting and apportion the survival gaps. METHODS The African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort study was done at eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, South Africa, Uganda, and Zambia). We prospectively recruited women (aged ≥18 years) who attended these hospitals with suspected breast cancer. Women were actively followed up by use of a telephone call once every 3 months, and a mobile health application was used to keep a dynamic record of follow-up calls due. We collected detailed sociodemographic, clinical, and treatment data. The primary outcome was 3-year overall survival, analysed by use of flexible proportional mortality models, and we predicted survival under scenarios of modified distributions of risk factors. FINDINGS Between Sept 8, 2014, and Dec 31, 2017, 2313 women were recruited from these eight hospitals, of whom 85 did not have breast cancer. Of the remaining 2228 women with breast cancer, 58 women with previous treatment or recurrence, and 14 women from small racial groups (white and Asian women in South Africa), were excluded. Of the 2156 women analysed, 1840 (85%) were histologically confirmed, 129 (6%) were cytologically confirmed, and 187 (9%) were clinically confirmed to have breast cancer. 2156 (97%) women were followed up for up to 3 years or up to Jan 1, 2019, whichever was earlier. Up to this date, 879 (41%) of these women had died, 1118 (52%) were alive, and 159 (7%) were censored early. 3-year overall survival was 50% (95% CI 48-53), but we observed variations in 3-year survival between different races in Namibia (from 90% in white women to 56% in Black women) and in South Africa (from 76% in mixed-race women to 59% in Black women), and between different countries (44-47% in Uganda and Zambia vs 36% in Nigeria). 215 (10%) of all women had died within 6 months of diagnosis, but 3-year overall survival remained low in women who survived to this timepoint (58%). Among survival determinants, improvements in early diagnosis and treatment were predicted to contribute to the largest increases in survival, with a combined absolute increase in survival of up to 22% in Nigeria, Zambia, and Uganda, when compared with the contributions of other factors (such as HIV or aggressive subtypes). INTERPRETATION Large variations in breast cancer survival in sub-Saharan African countries indicate that improvements are possible. At least a third of the projected 416 000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable downstaging and improvements in treatment. Improving survival in socially disadvantaged women warrants special attention. FUNDING Susan G Komen and the International Agency for Research on Cancer.
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Affiliation(s)
- Valerie McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France.
| | - Fiona McKenzie
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Milena Foerster
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Annelle Zietsman
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Moses Galukande
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Adisa
- Department of Surgery, Abia State University Teaching Hospital, Aba, Nigeria
| | - Angelica Anele
- Breast Oncology Unit, Federal Medical Centre, Owerri, Nigeria
| | - Groesbeck Parham
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Leeya F Pinder
- Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia; Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Herbert Cubasch
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa; Non-Communicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
| | - Maureen Joffe
- Non-Communicable Diseases Research Division, University of the Witwatersrand, Johannesburg, South Africa; Noncommunicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa; MRC Developmental Pathways to Health Research Unit, Department of Pediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Thomas Beaney
- Department of Primary Care and Public Health, Imperial College London, UK
| | - Manuela Quaresma
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kayo Togawa
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | | | - Benjamin O Anderson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Joachim Schüz
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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15
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Mezger NCS, Feuchtner J, Griesel M, Hämmerl L, Seraphin TP, Zietsman A, Péko JF, Tadesse F, Buziba NG, Wabinga H, Nyanchama M, Borok MZ, Kéita M, N'da G, Lorenzoni CF, Akele-Akpo MT, Gottschick C, Binder M, Mezger J, Jemal A, Parkin DM, Wickenhauser C, Kantelhardt EJ. Clinical presentation and diagnosis of adult patients with non-Hodgkin lymphoma in Sub-Saharan Africa. Br J Haematol 2020; 190:209-221. [PMID: 32181503 DOI: 10.1111/bjh.16575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 12/24/2022]
Abstract
Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in Sub-Saharan Africa (SSA). Comprehensive diagnostics of NHL are essential for effective treatment. Our objective was to assess the frequency of NHL subtypes, disease stage and further diagnostic aspects. Eleven population-based cancer registries in 10 countries participated in our observational study. A random sample of 516 patients was included. Histological confirmation of NHL was available for 76.2% and cytological confirmation for another 17.3%. NHL subclassification was determined in 42.1%. Of these, diffuse large B cell lymphoma, chronic lymphocytic leukaemia and Burkitt lymphoma were the most common subtypes identified (48.8%, 18.4% and 6.0%, respectively). We traced 293 patients, for whom recorded data were amended using clinical records. For these, information on stage, human immunodeficiency virus (HIV) status and Eastern Cooperative Oncology Group Performance Status (ECOG PS) was available for 60.8%, 52.6% and 45.1%, respectively. Stage at diagnosis was advanced for 130 of 178 (73.0%) patients, HIV status was positive for 97 of 154 (63.0%) and ECOG PS was ≥2 for 81 of 132 (61.4%). Knowledge about NHL subclassification and baseline clinical characteristics is crucial for guideline-recommended treatment. Hence, regionally adapted investments in pathological capacity, as well as standardised clinical diagnostics, will significantly improve the therapeutic precision for NHL in SSA.
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Affiliation(s)
- Nikolaus C S Mezger
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Jana Feuchtner
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Mirko Griesel
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Lucia Hämmerl
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Tobias P Seraphin
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Annelle Zietsman
- African Cancer Registry Network, Oxford, UK.,Dr AB May Cancer Care Centre, Windhoek, Namibia
| | - Jean-Félix Péko
- African Cancer Registry Network, Oxford, UK.,Registre des Cancers de Brazzaville, Brazzaville, Republic of the Congo
| | - Fisihatsion Tadesse
- African Cancer Registry Network, Oxford, UK.,Division of Hematology, Department of Internal Medicine, University and Black Lion Hospital, Addis Ababa, Ethiopia
| | - Nathan G Buziba
- African Cancer Registry Network, Oxford, UK.,Eldoret Cancer Registry, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Henry Wabinga
- African Cancer Registry Network, Oxford, UK.,Kampala Cancer Registry, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nyanchama
- African Cancer Registry Network, Oxford, UK.,National Cancer Registry, Kenya Medical Research Institute, Nairobi, Kenya
| | - Margaret Z Borok
- African Cancer Registry Network, Oxford, UK.,Zimbabwe National Cancer Registry, Harare, Zimbabwe
| | - Mamadou Kéita
- African Cancer Registry Network, Oxford, UK.,Service du Laboratoire d'Anatomie et Cytologie Pathologique, CHU du point G, Bamako, Mali
| | - Guy N'da
- African Cancer Registry Network, Oxford, UK.,Registre des Cancers d'Abidjan, Abidjan, Côte d'Ivoire
| | - Cesaltina F Lorenzoni
- African Cancer Registry Network, Oxford, UK.,Departamento de Patologia, Faculdade de Medicina Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Marie-Thérèse Akele-Akpo
- African Cancer Registry Network, Oxford, UK.,Département d'Anatomo-Pathologie, Faculté des Sciences de la Santé, Cotonou, Benin
| | - Cornelia Gottschick
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Mascha Binder
- Department of Internal Medicine IV, Oncology and Hematology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Donald M Parkin
- African Cancer Registry Network, Oxford, UK.,Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Claudia Wickenhauser
- Institute of Pathology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Eva J Kantelhardt
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany.,Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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16
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Foerster M, Anderson BO, McKenzie F, Galukande M, Anele A, Adisa C, Zietsman A, Schuz J, dos Santos Silva I, McCormack V. Inequities in breast cancer treatment in sub-Saharan Africa: findings from a prospective multi-country observational study. Breast Cancer Res 2019; 21:93. [PMID: 31409419 PMCID: PMC6691541 DOI: 10.1186/s13058-019-1174-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/22/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Improving breast cancer survival in sub-Saharan Africa (SSA) is urgently needed, requiring early diagnosis and improved access to treatment. However, data on the types of and barriers to receiving breast cancer therapy in this region are limited and have not been compared between different SSA countries and treatment settings. METHODS In different health care settings across Uganda, Nigeria and Namibian sites of the prospective African Breast Cancer - Disparities in Outcomes cohort study, we assessed the percentage of newly diagnosed breast cancer patients who received treatment (systemic, surgery and/or radiotherapy) for cancer and their socio-demographic and clinical determinants. Treatment data were systematically extracted from medical records, as well as self-reported by women during 6-month follow-up interviews, and were used to generate a binary indicator of treatment received within 12 months of diagnosis (yes/no), which was analysed via logistic regression. RESULTS Of 1325 women, cancer treatment had not been initiated treatment within 1 year of diagnosis for 227 (17%) women and 185 (14%) of women with stage I-III disease. Untreated percentages were highest in two Nigerian regional hospitals where 38% of 314 women were not treated (32% among stage I-III). At a national referral hospital in Uganda, 18% of 430 women were not treated (15% among stage I-III). In contrast, at a cancer care centre in Windhoek, Namibia, where treatment is provided free to the patient, all non-black (100%) and almost all (98.7%) black women had initiated treatment. Percentages of untreated women were higher in women from lower socio-economic groups, women who believed in traditional medicine and, in Uganda, in HIV+ women. Self-reported treatment barriers confirmed treatment costs and treatment refusal as contributors to not receiving treatment. CONCLUSIONS Financial support to ensure treatment access and education of treatment benefits are needed to improve treatment access for breast cancer patients across sub-Saharan Africa, especially at regional treatment centres, for lower socio-economic groups, and for the HIV-positive woman with breast cancer.
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Affiliation(s)
- Milena Foerster
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, Lyon, France
| | | | - Fiona McKenzie
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, Lyon, France
| | | | | | - Charles Adisa
- Abia State University Teaching Hospital, Aba, Nigeria
| | | | - Joachim Schuz
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, Lyon, France
| | - Isabel dos Santos Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Valerie McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, Lyon, France
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17
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Foerster M, Zietsman A, Galakunde M, Anele A, Adisa C, Schuz J, Dos Santos Silva I, McCormack V. Abstract P5-13-01: Not presented. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p5-13-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
This abstract was not presented at the conference.
Citation Format: Foerster M, Zietsman A, Galakunde M, Anele A, Adisa C, Schuz J, Dos Santos Silva I, McCormack V. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-01.
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Affiliation(s)
- M Foerster
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
| | - A Zietsman
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
| | - M Galakunde
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
| | - A Anele
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
| | - C Adisa
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
| | - J Schuz
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
| | - I Dos Santos Silva
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
| | - V McCormack
- International Agency for Research on Cancer, Lyon, France; Windhoek Central Hospital, Windhoek, Namibia; Makerere University, Kampala, Uganda; Federal Medical Centre, Owerri, Nigeria; Abia State University Teaching Hospital, Aba, Nigeria; London School of Hygiene, London, United Kingdom
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18
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McKenzie F, Zietsman A, Galukande M, Anele A, Adisa C, Parham G, Pinder L, Dos Santos Silva I, McCormack V. Breast cancer awareness in the sub-Saharan African ABC-DO cohort: African Breast Cancer-Disparities in Outcomes study. Cancer Causes Control 2018; 29:721-730. [PMID: 29980984 DOI: 10.1007/s10552-018-1047-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 06/02/2018] [Indexed: 10/28/2022]
Abstract
A greater understanding of the nature and drivers of poor breast cancer (BC) awareness in sub-Saharan Africa (SSA) will inform much needed awareness programmes. We aimed to assess the level and nature of BC awareness in the multi-country African Breast Cancer-Disparities in Outcome (ABC-DO) cohort of women newly diagnosed with BC during 2014-2017. Awareness indicators were assessed during a baseline interview at/near diagnosis. Logistic/ordinal regression was used to estimate odds ratios (OR) for indicators of BC awareness in relation to woman-level characteristics for individual settings and then meta-analyzed. In the 1,451 women included, almost all Namibian non-black women (n = 104) knew of BC and its curability, while in Namibian black and Zambian women, one in 7 (~ 15%) had not previously heard of BC and 25-40% did not know it was curable. In Uganda and Nigeria awareness was lowest: one in four women had no BC awareness, and 2 in 3 had no knowledge of its cure potential. Low educational level, unskilled employment, low socioeconomic position, rural residence, older age, being unmarried, and in some settings HIV-positivity, were associated with lower BC awareness-e.g., having unskilled employment was associated with not having heard of BC (summary OR 3.37; 95% confidence interval (CI) 2.17-5.23), believing that it is incurable (2.43; 1.81-3.26), and not recognizing a breast lump symptom (1.85; 1.41-2.43) but with between-setting variation (I2 > 68% for all). The findings provide evidence of the level and difference in BC awareness and beliefs across different settings, highlighting the urgent need for context-specific education programmes in the SSA region.
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Affiliation(s)
- Fiona McKenzie
- Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372, Lyon CEDEX 08, France.
| | | | | | | | - Charles Adisa
- Abia State University Teaching Hospital, Aba, Nigeria
| | | | | | - Isabel Dos Santos Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Valerie McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372, Lyon CEDEX 08, France
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19
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Togawa K, McKenzie F, Zietsman A, Silva IDS, McCormack V. Abstract C78: Pre-diagnostic journey of women with breast cancer and disparities in stage at diagnosis in Namibia: The African Breast Cancer–Disparities in Outcomes (ABC-DO) Cohort Study. Cancer Epidemiol Biomarkers Prev 2018. [DOI: 10.1158/1538-7755.disp17-c78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Purpose: Breast cancer survival rates in sub-Saharan Africa (SSA) are low and the reasons therefor partly involve advanced disease at diagnosis. Within the African Breast Cancer – Disparities in Outcomes (ABC-DO) Study, a prospective study of breast cancer survival in multiple SSA settings, we examined spatiotemporal barriers to early presentation and diagnosis related to pre-diagnostic journey of women with breast cancer in the vast Southern African country of Namibia.
Methods: 503 newly diagnosed breast cancer patients who presented at the Windhoek Central Hospital (WCH) in Namibia completed face-to-face interviews between September 2014 and October 2016. Participants were asked about sociodemographic factors, locations of residential home and health care providers, dates of visits to health care providers, and mode of transport. The straight-line distances from home to the first health care provider and the cancer care facility (WCH) were calculated. Clinical data including disease stage were extracted from medical records. Logistic regression models were used to estimate the odds ratios (OR) and corresponding 95% confidence intervals (CI) for late stage disease (stage III or IV) associated with the pre-diagnostic journey of women.
Results: The analytical sample included 498 women, the majority of whom were black (79%), were diagnosed with a late-stage disease (stage III, 41%; stage IV, 15%), and resided outside Windhoek (within Namibia, 70%; outside Namibia, 10%). The mean age at diagnosis was 54 years (standard deviation, 14.7; range, 24–98). The distance from home to the WCH ranged from 0 to 1,643 km (median, 308 km). In unadjusted analyses, a longer distance from home to the WCH was associated with late stage (per 100 km increment: OR, 1.09; 95% CI, 1.04–1.15); however, distance to the first care provider was not statistically significantly associated with disease stage (OR per 100-km increment, 1.06; 95% CI, 0.97–1.17). Unadjusted analyses also showed that being black (vs. non-black: OR, 5.38. 95% CI, 3.30–8.78), longer time taken to travel to the WCH (OR per one-hour increment, 1.06; 95% CI, 1.02–1.10), and travelling by a transport service provided by a cancer association or a hospital (vs. travelling by private cars: OR, 2.71; 95% CI, 1.78–4.11) were associated with late stage whereas age, time interval between the first contact with a health care provider and the first visit to the WCH, and number of health care providers seen before referral to the WCH were not associated with disease stage. In the analysis that adjusted for race/ethnicity, neither travel distance/time from home to the WCH nor transport mode was statistically significantly associated with disease stage.
Conclusions: In the Namibian subset of the ABC-DO Study, the association between a longer travel distance or time to the WCH and late stage of breast cancer at diagnosis appeared to be driven by the association between race/ethnicity and disease stage. The greater odds of late-stage diagnosis associated with the use of patient transport service likely reflect a response to urgent medical needs. The ongoing analysis will further investigate other potential barriers that explain disparities in stage at diagnosis among women in Namibia and other SSA settings.
Citation Format: Kayo Togawa, Fiona McKenzie, Annelle Zietsman, Isabel dos Santos Silva, Valerie McCormack. Pre-diagnostic journey of women with breast cancer and disparities in stage at diagnosis in Namibia: The African Breast Cancer–Disparities in Outcomes (ABC-DO) Cohort Study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C78.
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Affiliation(s)
- Kayo Togawa
- 1International Agency for Research on Cancer, Lyon, France,
| | - Fiona McKenzie
- 1International Agency for Research on Cancer, Lyon, France,
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20
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McKenzie F, Zietsman A, Galukande M, Anele A, Adisa C, Parham G, Pinder L, Cubasch H, Joffe M, Kidaaga F, Lukande R, Offiah AU, Egejuru RO, Shibemba A, Schuz J, Anderson BO, dos Santos Silva I, McCormack V. Drivers of advanced stage at breast cancer diagnosis in the multicountry African breast cancer - disparities in outcomes (ABC-DO) study. Int J Cancer 2018; 142:1568-1579. [PMID: 29197068 PMCID: PMC5838525 DOI: 10.1002/ijc.31187] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
Breast cancer (BC) survival rates in sub-Saharan Africa (SSA) are low in part due to advanced stage at diagnosis. As one component of a study of the entire journey of SSA women with BC, we aimed to identify shared and setting-specific drivers of advanced stage BC. Women newly diagnosed in the multicountry African Breast Cancer-Disparities in Outcomes (ABC-DO) study completed a baseline interview and their stage information was extracted from medical records. Ordinal logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for advanced stage (I, II, III, IV) in relation to individual woman-level, referral and biological factors. A total of 1795 women were included from Nigeria, Uganda, Zambia, and the multiracial populations of Namibia and South Africa, 1091 of whom (61%) were stage III/IV. Stage was lower in women with greater BC knowledge (OR 0.77 (95% CI: 0.70, 0.85) per point on a 6 point scale). More advanced stage was associated with being black (4.00 (2.79, 5.74)), having attended
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Affiliation(s)
- Fiona McKenzie
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
| | | | | | | | | | | | | | - Herbert Cubasch
- University of the Witwatersrand, Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
| | - Maureen Joffe
- University of the Witwatersrand, Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
| | | | | | | | | | | | - Joachim Schuz
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
| | | | - Isabel dos Santos Silva
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Valerie McCormack
- Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
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McKenzie F, Zietsman A, Galukande M, Anele A, Adisa C, Cubasch H, Parham G, Anderson BO, Abedi-Ardekani B, Schuz J, dos Santos Silva I, McCormack V. African Breast Cancer-Disparities in Outcomes (ABC-DO): protocol of a multicountry mobile health prospective study of breast cancer survival in sub-Saharan Africa. BMJ Open 2016; 6:e011390. [PMID: 27554102 PMCID: PMC5013398 DOI: 10.1136/bmjopen-2016-011390] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/07/2016] [Accepted: 05/26/2016] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Sub-Saharan African (SSA) women with breast cancer (BC) have low survival rates from this potentially treatable disease. An understanding of context-specific societal, health-systems and woman-level barriers to BC early detection, diagnosis and treatment are needed. METHODS The African Breast Cancer-Disparities in Outcomes (ABC-DO) is a prospective hospital-based study of overall survival, impact on quality of life (QOL) and delays along the journey to diagnosis and treatment of BC in SSA. ABC-DO is currently recruiting in Namibia, Nigeria, South Africa, Uganda and Zambia. Women aged 18 years or older who present at participating secondary and tertiary hospitals with a new clinical or histocytological diagnosis of primary BC are invited to participate. For consented women, tumour characteristics, specimen and treatment data are obtained. Over a 2-year enrolment period, we aim to recruit 2000 women who, in the first instance, will be followed for between 1 and 3 years. A face-to-face baseline interview obtains information on socioeconomic, cultural and demographic factors, QOL, health and BC attitudes/knowledge, and timing of all prediagnostic contacts with caregivers in orthodox health, traditional and spiritual systems. Responses are immediately captured on mobile devices that are fed into a tailored mobile health (mHealth) study management system. This system implements the study protocol, by prompting study researchers to phone women on her mobile phone every 3 months and, failing to reach her, prompts contact with her next-of-kin. At follow-up calls, women provide updated information on QOL, care received and disease impacts on family and working life; date of death is asked of her next-of-kin when relevant. ETHICS AND DISSEMINATION The study was approved by ethics committees of all involved institutions. All participants provide written informed consent. The findings from the study will be published in peer-reviewed scientific journals, presented to funders and relevant local organisations and at scientific conferences.
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Affiliation(s)
- Fiona McKenzie
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | | | | | | | - Charles Adisa
- Abia State University Teaching Hospital, Aba, Nigeria
| | - Herbert Cubasch
- Department of Surgery, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | | | | | | | - Joachim Schuz
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Isabel dos Santos Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Valerie McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
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Dickens C, Duarte R, Zietsman A, Cubasch H, Kellett P, Schüz J, Kielkowski D, McCormack V. Racial comparison of receptor-defined breast cancer in Southern African women: subtype prevalence and age-incidence analysis of nationwide cancer registry data. Cancer Epidemiol Biomarkers Prev 2014; 23:2311-21. [PMID: 25143359 DOI: 10.1158/1055-9965.epi-14-0603] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Receptor-defined breast cancer proportions vary across Africa. They have important implications for survival prospects and research priorities. METHODS We studied estrogen receptor (ER), progesterone receptor (PR), and HER2 receptor statuses in two multiracial Southern African countries with routine diagnostic immunohistochemistry. A total of 12,361 women with histologically confirmed breast cancer diagnosed at age ≥20 years during (i) 2009-2011 from South Africa's national cancer registry (public sector) and (ii) 2011-2013 from Namibia's only cancer hospital were included. Crude, age, and age + laboratory-adjusted ORs of receptor status were analyzed using logistic regression, and age-incidence curves were analyzed using Poisson regression. RESULTS A total of 10,047 (81%) women had known ER status. Ranking of subtypes was consistent across races: ER(+)/PR(+)HER2(-) was most common (race-specific percentage range, 54.6%-64.8%), followed by triple-negative (17.4%-21.9%), ER(+)/PR(+)HER2(+) (9.6%-13.9%), and ER(-)PR(-)HER2(+) (7.8%-10.9%). Percentages in black versus white women were 33.8% [95% confidence (CI), 32.5-35.0] versus 26.0% (24.0-27.9) ER(-); 20.9% (19.7-22.1) versus 17.5% (15.4-19.6) triple-negative; and 10.7% (9.8-11.6) versus 7.8% (6.3-9.3) ER(-)PR(-)HER2(+). Indian/Asian and mixed-ancestry women had intermediate values. Age-incidence curves had similar shapes across races: rates increased by 12.7% per year (12.2-13.1) across ER subtypes under the age of 50 years, and thereafter slowed for ER(+) (1.95%) and plateaued for ER(-) disease (-0.1%). CONCLUSIONS ER(+) breast cancer dominates in all Southern African races, but black women have a modest excess of aggressive subtypes. IMPACT On the basis of the predominant receptor-defined breast tumors in Southern Africa, improving survival for the growing breast cancer burden should be achievable through earlier diagnosis and appropriate treatment.
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Affiliation(s)
- Caroline Dickens
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France. Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raquel Duarte
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Herbert Cubasch
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Patricia Kellett
- National Cancer Registry of South Africa, National Health and Laboratory Services, Johannesburg, South Africa
| | - Joachim Schüz
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Danuta Kielkowski
- National Cancer Registry of South Africa, National Health and Laboratory Services, Johannesburg, South Africa
| | - Valerie McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France.
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Van Dyk ASB, Small LF, Zietsman A. The pain experience and its management in cancer patients during hospitalisation (in Namibia). Health SA 2000. [DOI: 10.4102/hsag.v5i4.41] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
There is a lack of information on the management of pain in cancer patients in Namibia. For this reason a survey was done to determine the pain experience of cancer patients during hospitalisation and their evaluation of the treatment thereof by nursesOpsommingWeens ‘n gebrek aan inligting oor die hantering van pyn by pasiente met kanker, is 'n opname gedoen na die pyn belewenis van pasiente met karsinoom tydens hospitalisasie.
*Please note: This is a reduced version of the abstract. Please refer to PDF for full text.
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