Breast cancer pathology services in sub-Saharan Africa: a survey within population-based cancer registries

Abstract Background Pathologists face major challenges in breast cancer diagnostics in sub-Saharan Africa (SSA). The major problems identified as impairing the quality of pathology reports are shortcomings of equipment, organization and insufficiently qualified personnel. In addition, in the context of breast cancer, immunohistochemistry (IHC) needs to be available for the evaluation of biomarkers. In the study presented, we aim to describe the current state of breast cancer pathology in order to highlight the unmet needs. Methods We obtained information on breast cancer pathology services within population-based cancer registries in SSA. A survey of 20 participating pathology centres was carried out. These centres represent large, rather well-equipped pathologies. The data obtained were related to the known population and breast cancer incidence of the registry areas. Results The responding pathologists served populations of between 30,000 and 1.8 million and the centres surveyed dealt with 10–386 breast cancer cases per year. Time to fixation and formalin fixation time varied from overnight to more than 72 h. Only five centres processed core needle biopsies as a daily routine. Technical problems were common, with 14 centres reporting temporary power outages and 18 centres claiming to own faulty equipment with no access to technical support. Only half of the centres carried out IHC in their own laboratory. For three centres, IHC was only accessible outside of the country and one centre could not obtain any IHC results. A tumour board was established in 13 centres. Conclusions We conclude that breast cancer pathology services ensuring state-of-the-art therapy are only available in a small fraction of centres in SSA. To overcome these limitations, many of the centres require larger numbers of experienced pathologists and technical staff. Furthermore, equipment maintenance, standardization of processing guidelines and establishment of an IHC service are needed to comply with international standards of breast cancer pathology.

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Breast Cancer Treatment in Sub-Saharan Africa: A Population-Based Registry Study

Journal of Global Oncology ◽

10.1200/jgo.18.10230 ◽

2018 ◽

Vol 4 (Supplement 3) ◽

pp. 20s-20s ◽

Cited By ~ 1

Author(s):

Yvonne W. Joko-Fru ◽

Lucia Haemmerl ◽

Mirko Griesel ◽

Nikolaus Mezger ◽

Tobias Seraphin ◽

...

Keyword(s):

Breast Cancer ◽

Endocrine Therapy ◽

Conflicts Of Interest ◽

Addis Ababa ◽

Cancer Registries ◽

Population Based ◽

Sub Saharan Africa ◽

Case Scenario ◽

Worst Case ◽

Sub Saharan

Purpose Stage at diagnosis and receipt of therapy are the most important determinants of breast cancer (BC) survival in sub-Saharan Africa (SSA). Recently, the National Comprehensive Cancer Network therapy guidelines for SSA were published. Our study aimed to describe the cancer-directed therapy (CDT) received by patients with BC at the population level in SSA. Methods Random samples of patients with BC (≥ 40 cases per registry) who were diagnosed from 2009 to 2015 were drawn from 11 population-based cancer registries—Abidjan, Addis Ababa, Bamako, Brazzaville, Bulawayo, Cotonou, Eldoret, Kampala, Maputo, Namibia and Nairobi—which represented 10 countries in SSA. Active methods were used to update therapy and outcomes of patients with newly diagnosed invasive BC. Results A total of 834 patients were included, with median age at diagnosis of 48 years (range, 20 to 92 years; 16% diagnosed younger than age 35 years). Among patients with known stage (n = 434), 66% were diagnosed at stage III and IV. Eighty-one percent of all cases were morphologically verified. Detailed information on therapy and/or outcome was available for 533 patients (63.9%), and other files not found were assumed without therapy (worst-case scenario). Of the total cohort, 52% of patients had no record of CDT. Of patients without known metastasis (n = 747), 40.6% received surgery (83.1% mastectomy), 33.6% chemotherapy, and 15.5% radiotherapy. Hormone receptor status (HRS) was known for only 16.3%. Of patients with positive or unknown HRS (n = 714), 18.6% received endocrine therapy. Of 299 patients who received chemotherapy, 51.8% received an anthracycline-based regimen and 32.1% received an anthracycline regimen with an additional taxane. For patients in areas with radiotherapy facilities, use ranged from 26% in Addis to 67% in Namibia. Among patients with stage II and III disease (n = 334), 16.5% received surgery only, 8.4% chemotherapy only, 15% received both, 11.1% received both plus endocrine therapy, 5.7% received both plus radiotherapy, and 16.2% received all four modalities. The 5-year overall survival for all patients was 51.1% (95% CI, 44.9% to 56.9%). Conclusion More than one half of patients with BC in SSA had no record of CDT. Our finding of four of five patients without HRS testing suggests high underutilization of affordable and tolerable endocrine therapy. Improving access to care and HRS testing may facilitate adherence to resource-stratified guidelines. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Eva Johanna Kantelhardt Travel, Accommodations, Expenses: Daiichi Sankyo Oncology Europe

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Breast cancer survival in sub‐Saharan Africa by age, stage at diagnosis and human development index: A population‐based registry study

International Journal of Cancer ◽

10.1002/ijc.32406 ◽

2019 ◽

Vol 146 (5) ◽

pp. 1208-1218 ◽

Cited By ~ 15

Author(s):

Walburga Y. Joko‐Fru ◽

Adalberto Miranda‐Filho ◽

Isabelle Soerjomataram ◽

Marcel Egue ◽

Marie‐Therese Akele‐Akpo ◽

...

Keyword(s):

Breast Cancer ◽

Human Development Index ◽

Cancer Survival ◽

Population Based ◽

Breast Cancer Survival ◽

Sub Saharan Africa ◽

Stage At Diagnosis ◽

Registry Study ◽

Sub Saharan ◽

Population Based Registry

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Breast Cancer Diagnostics, Therapy, and Outcomes in Sub-Saharan Africa: A Population-Based Registry Study

Journal of the National Comprehensive Cancer Network ◽

10.6004/jnccn.2021.7011 ◽

2021 ◽

pp. 1-11

Author(s):

Walburga Yvonne Joko-Fru ◽

Mirko Griesel ◽

Nikolaus Christian Simon Mezger ◽

Lucia Hämmerl ◽

Tobias Paul Seraphin ◽

...

Keyword(s):

Breast Cancer ◽

Hormone Receptor ◽

Relative Survival ◽

Population Level ◽

Population Based ◽

Hormone Receptor Status ◽

Sub Saharan Africa ◽

Receptor Status ◽

Sub Saharan ◽

The Impact

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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