Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer

Background
There are limited data on breast surgery completion rates and prevalence of care-continuum delays in breast cancer treatment programs in low-income countries.

Methods
This study analyzes treatment data in a retrospective cohort of 312 female patients with non-metastatic breast cancer in Haiti. Descriptive statistics were used to summarize patient characteristics; treatments received; and treatment delays of > 12 weeks. Multivariate logistic regressions were performed to identify factors associated with receiving surgery and with treatment delays. Exploratory multivariate survival analysis examined the association between surgery delays and disease-free survival (DFS).

Results
Of 312 patients, 249 (80%) completed breast surgery. The odds ratio (OR) for surgery completion for urban vs. rural dwellers was 2.15 (95% confidence interval [CI]: 1.19–3.88) and for those with locally advanced vs. early-stage disease was 0.34 (95%CI: 0.16–0.73). Among the 223 patients with evaluable surgery completion timelines, 96 (43%) experienced delays. Of the 221 patients eligible for adjuvant chemotherapy, 141 (64%) received adjuvant chemotherapy, 66 of whom (47%) experienced delays in chemotherapy initiation. Presentation in the later years of the cohort (2015–2016) was associated with lower rates of surgery completion (75% vs. 85%) and with delays in adjuvant chemotherapy initiation (OR [95%CI]: 3.25 [1.50–7.06]). Exploratory analysis revealed no association between surgical delays and DFS.

Conclusion
While majority of patients obtained curative-intent surgery, nearly half experienced delays in surgery and adjuvant chemotherapy initiation. Although our study was not powered to identify an association between surgical delays and DFS, these delays may negatively impact long-term outcomes.

Evaluation of Quality Indicators of Breast Cancer Management at a Tertiary Cancer Center in Nepal

PURPOSE
Breast cancer is the second commonest cancer among female in Nepal. This is our first attempt to audit breast cancer management in our institute and compare with standard quality indicators (QIs) available.

METHODS
The retrospective study included 104 female patients with breast cancer who had taken treatment at Bhaktapur Cancer Hospital in 1 year. Participants were selected on the basis of convenience sampling. Of 33 QIs in breast cancer management according to European Society of Breast Cancer Specialists guidelines, 19 QIs were chosen relevant to our setup. These QIs were calculated for all patients and compared with the European Society of Breast Cancer Specialists standard target. Frequencies and percentages were calculated and presented in tables. Binomial 95% of the rates for QI adherence were also calculated for each QI.

RESULTS
One hundred four patients had a median age of 47.5 years (range 24-70 years). Applicable QIs were in the range of 5-15 with a mean of 9.66 per patient. Of 19 evaluable QIs, very high adherence rates were observed in six QIs, high adherence in three Qis, and low adherences in 10 QIs. High adherence rates were for QI 5 and QI 10a, which were 88.46% and 94.73%, respectively. The low compliance was for QI 1, QI 4a, QI 8, QI 9d, QI 10b, QI 11a, QI 11b, QI 13b, QI 13e, and 14b, which were 53.84%, 78.21%, 0%, 83.16%, 76.92%, 36.0%, 33.33%, 4.76%, 30.55%, and 10.81%, respectively.

CONCLUSION
There are several QIs that have low levels of adherence in our setting and suggest that there is significant room for improvement. We will be continuing auditing these QIs regularly to improve our quality of care.

Current perspectives of oncoplastic breast surgery in Pakistan

Oncoplastic breast surgery is based on the concept of tumour-specific immediate reconstruction. It combines both local and distant techniques to maintain breast texture, symmetry and cosmesis without compromising oncological outcome. The current narrative review was planned to highlight the current state and future of oncoplastic breast surgery in low- and middle-income
countries where its utilisation in surgical practice remains insubstantial because majority of the surgeons who are treating breast cancer are either general surgeons or breast surgeons who do not have expertise in oncoplastic breast surgery or reconstructive surgery. Moreover, scarcity of financial resources, ignorance about oncoplastic breast surgery techniques, disfigurement
distress and cultural taboos coerce women to hide in the shadows with their breast disease. Oncoplastic breast surgery needs more exposure in a developing country like Pakistan.

Analysing the trends in breast surgery practice during COVID-19 pandemic: A comparative study with the Pre-COVID era

The emergence of coronavirus disease 2019 (COVID-19) pandemic has crippled the healthcare systems all over the world. Cancer treatment is indispensable and disruption in its provision can lead to unanticipated consequences. No local data exists that has quantified the impact of COVID-19 pandemic on breast cancer surgery in a lower middle-income country (LMIC), therefore, the present retrospective comparative cohort study is directed to determine the trends in breast surgery operative volumes and its outcomes at our institution in Pakistan.

Materials and methods
Data was collected retrospectively from Pre-COVID-19 and COVID-19 era to determine impact of the current pandemic on breast cancer management practices and outcomes.

Results
Cohort results showed a decline in the number of surgeries during COVID-19 era. A total 149 cases were operated during study period vs. 231 during same Pre-COVID-19 i.e. a 35.5% drop in cancer surgeries. In early COVID-19 time frame, only 4 patients had breast reconstruction, 12 out of 149 (8.05%) surgical candidates were identified having positive COVID-19 status preoperatively and one ASA class 3 patient caught COVID-19 post-surgery and succumbed to virus.

Conclusion
Pandemic has a negative effect on cancer management in a LMIC with compromised access and care of cancer patients.

Drivers of Disparities in Stage at Diagnosis Among Women With Breast Cancer: South African Breast Cancers and HIV Outcomes Cohort

Objective

In low- and middle-income countries (LMICs), advanced stage diagnosis of breast cancer (BC) is common, and this contributes to poor survival. By understanding the determinants of the stage at diagnosis will aid in designing interventions to downstage disease and improve survival from BC in LMICs.

Methods

Within the South African Breast Cancers and HIV Outcomes (SABCHO) cohort, we examined factors affecting the stage at diagnosis of histologically confirmed invasive breast cancer at five tertiary hospitals in South Africa. The stage was assessed clinically. To examine the associations of the health system, socio-economic/household and individual factors, hierarchical multivariate logistic regression with odds of late-stage at diagnosis (stage III-IV), was used.

Results

The majority (59%) of the included 3497 women were diagnosed with late-stage BC disease (59%). The effect of health system-level factors on late-stage BC diagnosis was consistent and significant even when adjusted for both socio-economic- and individual-level factors. Women diagnosed in a tertiary hospital that predominantly serves a rural population were almost 3 times (OR=2.89 (95% CI: 1.40-5.97) likely to be associated with late-stage BC diagnosis when compared to those diagnosed at a hospital that predominantly serves an urban population. Taking more than 3 months from identifying the BC problem to first health system entry (OR=1.66 (95% CI: 1.38–2.00)), and receptor subtypes [luminal B (OR=1.49 (95% CI: 1.19–1.87)), HER2 enriched (OR=1.64 (95% CI: 1.16–2.32))] were associated with a late-stage diagnosis. Whilst having a higher socio-economic level (a wealth index of 5) reduced the probability of late-stage BC, OR=0.64 (95% CI: 0.47 – 0.85).

Conclusion

Advanced stage diagnosis of BC among women in SA who access health services through the public health system was associated with both modifiable health system-level factors and non-modifiable individual-level factors. These may be considered as elements in interventions to reduce the time to diagnosis of breast cancer in women.

Knowledge, awareness, attitudes and screening practices towards breast and cervical cancer among women in Nepal: a scoping review

Aim
Breast and cervical cancers have emerged as major global health challenges and disproportionately affect women in low- and middle-income countries, including Nepal. This scoping review aimed to map the knowledge, attitudes and screening practices for these cancers among Nepali women to improve cancer outcomes and reduce inequality.

Methods
Five electronic databases (CINAHL, Embase, Global Health, PsycINFO and PubMed), grey literature, and reference and citation lists were searched for articles published in English up to June 2021. Articles were screened against inclusion/exclusion criteria, and data from eligible studies were extracted. Results were summarised narratively.

Results
The search yielded 615 articles, 38 of which were included in this scoping review (27 cervical cancer, 10 breast cancer, 1 both cancers). Levels of knowledge regarding breast and cervical varied widely. The main knowledge gaps were misconceptions about symptoms and risk factors, and poor understanding of screening behaviours. Screening practices were mostly inadequate due to socio-cultural, geographical or financial barriers. Positive attitudes towards cervical screening were associated with higher education and increased knowledge of screening modalities. Higher levels of knowledge, (health) literacy and participation in awareness campaigns facilitated breast cancer screening.

Conclusion
Knowledge and screening practices for breast and cervical cancer among Nepali women were poor and highlight the need for awareness and education programmes. Future research should explore community health worker-led awareness and screening interventions for cervical cancer, and programmes to increase the practice of breast self-examination and clinical breast examinations to support early diagnosis of breast cancer.

Profile of patients seen at Pietersburg and Mankweng breast cancer clinics in Limpopo

Background. Breast cancer is the most common cancer diagnosed among women worldwide. It is the most prevalent cancer and leading cause of death among South African (SA) women. The increasing incidence of breast cancer is a major health concern. Until now, the distribution of breast cancer demography, stage at first presentation, and histological characterisation have not been studied in Limpopo Province, SA.

Objectives. To record the demographic profile of breast cancer patients, to report the stage at the time of presentation and to characterise the pattern of malignant disease in Limpopo, SA.

Methods. We conducted a retrospective descriptive review of the records of patients managed at Pietersburg Hospital oncology and Mankweng Hospital breast cancer clinics during the period 1 March 2015 – 28 February 2017. Stata was used to analyse data.

Results. A total of 248 patients with a mean age of 55 years were included for analysis, 7 males (3%) and 241 females (97%). Capricorn and Vhembe districts constituted 32% and 27% respectively. The majority (69%) of patients were diagnosed with disease stage III or IV. The most common histological type was invasive ductal cell carcinoma (IDC) (87%).

Conclusions. More than one-third of patients were younger than 50 years. The majority (69%) had an advanced breast cancer (stage III or IV). We recommend provision of mammography services in regional hospitals

Health-Related Suffering and Palliative Care in Breast Cancer

Purpose of Review
Breast cancer continues to be the most frequently diagnosed cancer in women and the leading cause of cancer death worldwide. By the suffering that it causes in various domains of life, breast cancer seriously impacts the quality of life of affected individuals and causes a major burden of suffering in the community. The objectives of the review were to understand the health-related suffering in patients with breast cancer and to identify the scope of palliative care in improving the quality of life of patients with breast cancer.

Recent Findings
Breast cancer causes suffering in physical, psychological, social, financial, and spiritual domains of the lives of the patient and family. Management of breast cancer with surgery, chemotherapy, and radiation could have adverse effects, such as pain, nausea and vomiting, fatigue, shortness of breath, depression, and constipation. Both cancer and its treatment can impact the psychosocial and spiritual well-being of the patient and family members. Integrating palliative care into existing breast cancer treatment programs seems to be the best approach to diminish these sufferings.

Summary
In addition to pain and other physical symptoms, breast cancer can cause major psychological, social, and spiritual suffering. In the context of developing countries, out-of-pocket expenditure can cause major financial destruction which can impact generations. Integration of palliative care to breast cancer treatment is essential.

Breast Conservative Surgery for Breast Cancer: Indian Surgeon’s Preferences and Factors Influencing Them

Background: It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient’s choice, availability and accessibility of infrastructure and surgeon’s choice. We aimed to elucidate the Indian surgeons’ perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS.

Methods: We conducted a survey-based cross-sectional study over 3 weeks between January-February 2021. Indian surgeons with general surgical or specialised onco-surgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS to an eligible patient.

Results: A total of 347 responses were included. The mean age of the participants was 43(11) years. 63% of the surgeons were in the 25-44 years age group with the majority (80%) being males. 66.4% of surgeons ‘almost always’ offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p<0.01). Surgeons working in hospitals with in-house radiation oncology facilities were 9 times more likely to offer BCS (p<0.05). Surgeons’ years of practice, age, sex and hospital setting did not influence the surgery offered.

Conclusion: Our study found that two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women.

Breast Cancer Patients’ Experience about Involvement in Health Care: A Qualitative Study

Background: Patient involvement in health care is a basic patient’s right. Effective communication between the health care professional and the patient is associated with improved psychological functioning of the patient, adherence to treatment, and higher quality of life. Objective(s): This study aims to explore qualitatively breast cancer patients’ experience and satisfaction with their involvement in cancer care. Methods: This study was carried out among 30 women in different breast cancer care stages through in depth-interviews. The patients were purposively selected from surgery and oncology outpatient clinics and surgery inpatient wards in Medical Research Institute Hospital- Alexandria University, and in Ayadi El-Mostakbal Cancer Care Center – Ayadi El-Mostakbal Charity Foundation, Alexandria, Egypt. Results: Some patients mentioned that they did not know their diagnosis until late, others complained of the harsh non-empathetic way of breaking the news of their disease. Patients, generally, reported a little understanding of their treatment plan, they just followed physician’s instructions without receiving enough explanation. Patients on chemotherapy and radiotherapy expressed their unsatisfied need for information. Patients’ source of information was mainly other patients who suffered from the same disease. Patients, in general, were not familiar with the concept of giving feedback, it was perceived by the majority of them as equivalent to complaining. Some patients believed that complaining could put them in trouble such as receiving harsh blame or even delaying their medication. Conclusion: Patients’ narratives revealed poor involvement in health care and showed dissatisfaction of the majority of patients with their level of involvement.