Trends in the Use of Hypofractionation in Treatment of Breast Cancer in Botswana

PURPOSE/OBJECTIVE(S)

Clinical trials have shown that moderate hypofractionation (HF) is clinically effective as adjuvant treatment to breast conserving surgery or following mastectomy with advanced disease. ASTRO issued updated guidelines in 2018, expanding the population eligible to receive HF to all patients, regardless of age and tumor stage. Use of HF can promote efficient resource utilization for over-burdened health care systems; however, global adoption of HF has been previously only reported via ESTRO survey of individual physicians. These data note that HF following lumpectomy is 40% in Africa vs. >90% in North America, with limited data on the uptake of HF within individual African countries. In this study, we characterize temporal trends and clinical, socio-demographic factors associated with the use of HF in breast cancer in Botswana.

MATERIALS/METHODS

We retrospectively analyzed a cohort of breast cancer patients receiving curative intent radiation between 2015 and 2022 at the only radiation clinic in Botswana. We compared patients' characteristics between those who received HF vs. standard fractionation (SF) and report chi-square statistics when appropriate. We fit a multilevel mixed-effects logistic regression model with a random intercept for district while adjusting for fixed effects such as HIV infection status, laterality, hormone receptor status, and marital status.

RESULTS

A total of 234 patients were prescribed curative intent radiation between 2015 and 2022 in Gaborone, Botswana. Median age at diagnosis was 51 years old, and the majority of patients presented with stage III disease (61.9%, 109/234). 26.9% of this population were women living with HIV (WLWH), and 71% lived >100km from the hospital. HF was utilized overall in 59.4% (139/234) of patients. Most common fractionation patterns included: 4005cGy/15fx and 4267cG/16fx. One patient received ultra-HF (2600cGy/5fx). In unadjusted chi-square analysis, a higher proportion of HF was seen in right vs left-sided breast cancer (65.8% vs. 50.9%, p = 0.02), increasing year of diagnosis from 2015 - 2022 (p<0.001), and among patients >/ = 40 years of age vs. those <40 years of age (62.8% vs 42.1%, p = 0.017). Temporal trends show a significant increase in the utilization of HF starting from 23.8% (5/21) in 2015, to 61.5% (32/52) in 2018, and finally 100% (11/11) of cases in 2022. Our regression analysis shows that there is no statistically significant between-district variance or patient-level factors that associate with the uptake of HF. The overall utilization rate for HF between 2015-2022 was 59.4% (95% CI: 53.0%-65.5%).

CONCLUSION

Based on recent survey results the uptake of HF among African countries is lower than that of North America. To our knowledge, this is the first quantitative analysis of the utilization of HF over 5 years in an African country. Further analysis on factors related to physician prescription of hypofractionation is warranted, including influence of breast laterality, age, and primary surgery type.

Use of Mixed Method Approach on the Norms and Beliefs Related to Cervical Cancer Screening Among Women Aged 25-49 in Botswana: A Pilot Study

Background: A low cervical cancer screening uptake has been reported among women in low middle income countries (Idowu et al, 2016; Ndejjo et al, 2016), including Botswana. An important first step in increasing any health related behavior is to identify factors that affect that behavior. Identifying the norms and beliefs could influence cancer screening among women and would therefore influence the development of interventions to encourage women to screen. Aim: The aim of this exploratory pilot study was to investigate the norms and beliefs related to cancer screening among women aged 25-49 years in Botswana. Methods: The study employs a descriptive cross-sectional mixed-methods design in two purposively selected districts in Botswana. In the first qualitative phase focus group discussions were conducted. Information learned was used to construct a semistructured interview guide for individual interviews. Mixed method allows for triangulation of data as the qualitative data would be mapped with quantitative data to explore emerging norms and beliefs among Batswana women. This research approach was informed by theory of reasoned action, theory of planned behavior and social cognitive theory. Results: Qualitative results revealed that lack of knowledge about cervical cancer, behavioral beliefs, normative beliefs and control beliefs held by Batswana women contributed to their failure to go for cervical cancer screening. Quantitative data are yet to be analyzed. Conclusion: The results will yield information to design and evaluate a series of interventions to maximize the number of women going for cervical screening hence reduce the burden of cervical cancer in Botswana.

Former migrant mineworkers with respiratory disease: the South African compensation system, and implications for neighbouring countries

In the region of Southern Africa, substantial numbers of people, primarily males, have been employed in the South African mining industry. Migrant workers from neighbouring countries have constituted a large part of the work force. Until recently, there has been little or no attention directed toward the state of health of these individuals, despite the fact that their work involves a high health risk, especially in regard to mine-related lung diseases. In addition, the South African workers' compensation programme has seldom been utilised by the migrant worker who is a victim of occupational disease. However, recent experiences from Botswana show that compensation claims can be successfully made from the neighbouring countries where the migrant workers originate. Efforts are being made to address the problem systematically, and the government of Botswana is actively involved. The major occupational lung disorders are described briefly, and differential diagnostic problems with pulmonary TB are discussed. Furthermore, a survey of the compensation system in South Africa is presented, and practical steps for medical examinations involving compensation claims are described.