Breast Cancer Diagnostics, Therapy, and Outcomes in Sub-Saharan Africa: A Population-Based Registry Study
The African Cancer Registry Network, INCTR African Registry Programme, Oxford, United Kingdom;
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Department of Pathology, Faculty of Medicine, Eduardo Mondlane University, Maputo Central Hospital, Maputo, Mozambique;
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The African Cancer Registry Network, INCTR African Registry Programme, Oxford, United Kingdom;
International Agency for Research in Cancer, Lyon, France.
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Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany;
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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.
Submitted August 6, 2020; final revision received January 20, 2021; accepted for publication January 20, 2021. Published online December 29, 2021.
Author contributions: Study concept and design: Joko-Fru, Jemal, Parkin, Kantelhardt. Data acquisition, analysis, or interpretation: All authors. Statistical analysis: Joko-Fru, Kantelhardt. Administrative, technical, or material support: Liu, Jemal, Parkin, Kantelhardt. Study supervision: Jemal, Parkin, Kantelhardt. Writing – original draft: Joko-Fru, Jemal, Parkin, Kantelhardt. Writing – review and editing: Joko-Fru, Griesel, Mezger, Hämmerl, Seraphin, Feuchtner, Nsonde Malanda, Gnangnon, Lorenzoni, Thomssen, McGale, Jemal, Parkin, Kantelhardt. Full access to all data in the study and responsibility for the integrity of data and accuracy of data analysis: Joko-Fru, Kantelhardt.
Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
Funding: Dr. Joko-Fru was the recipient of a 3-month Halle-Oxford exchange fellowship grant within EU/ESF-funded research for the International Research Network Biology of Disease and Molecular Medicine (ZS/2016/08/80642) from Martin-Luther-University Halle-Wittenberg and is a Commonwealth Scholar whose DPhil at the University of Oxford is funded by the UK government. Dr. Mezger was supported by the German Academic Exchange Service (DAAD), financed by the Federal Ministry of Education and Research and the Roland Ernst Stiftung für Gesundheitswesen. Dr. Hämmerl was supported by Bischöfliche Studienförderung Cusanuswerk through her regular scholarship. Dr. Seraphin was supported by Studienstiftung des Deutschen Volkes e.V. through his regular scholarship. Dr. Feuchtner was given a doctorate stipend by Bayer Foundation. Dr. Kantelhardt was supported by intramural funding from the research department of the American Cancer Society (contract number 43359).
Disclaimer: The funders were not involved in the study design, data collection, analyses, interpretation, or write-up of the manuscript. The corresponding author had full access to the data and had the final responsibility for manuscript submission.
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