medwireNews: A high proportion of women with nonmetastatic breast cancer in sub-Saharan Africa do not initiate or complete treatment, show data from the African Breast Cancer–Disparities in Outcomes (ABC–DO) prospective cohort.
Milena Foerster (International Agency for Research on Cancer, Lyon, France) and colleagues say their findings “highlight the need to improve oncology infrastructure in sub-Saharan Africa, such as radiotherapy and pathology services, to enable guideline-concordant cancer treatment and to ensure that patients and health workers have good understanding of breast cancer and the treatment options.”
The investigators explain that the ABC–DO prospective cohort study recruited women with newly diagnosed invasive breast cancer from eight hospitals across Namibia, Nigeria, Uganda, South Africa, and Zambia.
The current analysis included data for 1716 women whose breast cancer was classified as nonmetastatic at initial presentation between September 2014 and December 2017.
During a median 5.2 years of follow-up, 68% of the women underwent breast cancer surgery.
Foerster et al say that the women who did not receive surgery may have not met the guideline recommendations for this procedure but also note that frailty, comorbidity, cost, reliance on traditional medicine, fear of a mastectomy, and psychological distress could be reasons for not having surgery among the women for whom it was indicated.
Multimodality treatment, that is, surgery plus systemic therapy, in combination with radiotherapy was initiated in 36% of 1028 women with localized tumors versus 23% of 688 women with locally advanced tumors. Multimodality treatment without radiotherapy was initiated in a respective 38% and 24%.
Chemotherapy was indicated in 1530 patients but just 66% initiated treatment with neoadjuvant chemotherapy or surgery within 3 months of baseline. The treatment was adequately completed by 35% of those who initiated it, marginally completed by 28%, abandoned by 20%, and the treatment outcome was unknown in 15%. In addition, 2% of women died within 6–9 months after chemotherapy initiation.
“This finding is worrying, because marginally completed or abandoned chemotherapy will provide the patient with only minimal or no survival benefit, but not without the side-effects of the treatment,” write Foerster and co-authors in The Lancet Oncology.
Endocrine therapy was indicated in 1375 women and initiated in 67%, most commonly with tamoxifen (91%), but just 40% continued treatment for at least 3 years.
The researchers also found that there were “substantial” treatment disparities among the countries for all therapy regimens.
For example, approximately half of women with localized tumors initiated multimodality treatment in Nigeria compared with more than 90% in South Africa and Namibia. Nigeria also had lower rates of chemotherapy initiation, at 39%, compared with other countries where the rates exceeded 60%, as well as the highest rate of chemotherapy abandonment, at 38%. Abandonment rates were 29% in Zambia and 24% among Black women in Namibia, but were as low as 10% in Uganda and 5% among mixed-race women in South Africa.
Finally, the authors point out that immunohistochemistry was not routinely available in the participating hospitals in Nigeria, Zambia, and Uganda, which they say makes “adherence to breast cancer management guidelines unfeasible.” In addition, “radiotherapy facilities are few and overstretched, which substantially hampers treatment quality.”
Foerster and team conclude that their study “quantifies the needs to enhance treatment quality and reduce treatment abandonment in sub-Saharan Africa.”
They add that the data emphasize “the unacceptably high proportion of patients with localised tumours who did not receive surgical tumour resection, or abandoned or did not initiate guideline-concordant systemic therapy, leading to impaired survival chances of a potentially curable cancer.”
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