Invasive breast Cancer treatment in Tanzania: landscape assessment to prepare for implementation of standardized treatment guidelines.

BACKGROUND: Incidence of breast cancer continues to rise in low- and middle-income countries, with data from the East African country of Tanzania predicting an 82% increase in breast cancer from 2017 to 2030. We aimed to characterize treatment pathways, receipt of therapies, and identify high-value interventions to increase concordance with international guidelines and avert unnecessary breast cancer deaths. METHODS: Primary data were extracted from medical charts of patients presenting to Bugando Medical Center, Tanzania, with breast concerns and suspected to have breast cancer. Clinicopathologic features were summarized with descriptive statistics. A Poisson model was utilized to estimate prevalence ratios for variables predicted to affect receipt of life-saving adjuvant therapies and completion of therapies. International and Tanzanian guidelines were compared to current care patterns in the domains of lymph node evaluation, metastases evaluation, histopathological diagnosis, and receptor testing to yield concordance scores and suggest future areas of focus. RESULTS: We identified 164 patients treated for suspected breast cancer from April 2015-January 2019. Women were predominantly post-menopausal (43%) and without documented insurance (70%). Those with a confirmed histopathology diagnosis (69%) were 3 times more likely to receive adjuvant therapy (PrR [95% CI]: 3.0 [1.7-5.4]) and those documented to have insurance were 1.8 times more likely to complete adjuvant therapy (1.8 [1.0-3.2]). Out of 164 patients, 4% (n = 7) received concordant care based on the four evaluated management domains. The first most common reason for non-concordance was lack of hormone receptor testing as 91% (n = 144) of cases did not undergo this testing. The next reason was lack of lymph node evaluation (44% without axillary staging) followed by absence of abdominopelvic imaging in those with symptoms (35%) and lack of histopathological confirmation (31%). CONCLUSIONS: Patient-specific clinical data from Tanzania show limitations of current breast cancer management including axillary staging, receipt of formal diagnosis, lack of predictive biomarker testing, and low rates of adjuvant therapy completion. These findings highlight the need to adapt and adopt interventions to increase concordance with guidelines including improving capacity for pathology, developing complete staging pathways, and ensuring completion of prescribed adjuvant therapies.

Are There Differences in Androgen Receptor Expression in Invasive Breast Cancer in African (Tanzanian) Population in Comparison With the Caucasian (Italian) Population?

PURPOSE: Androgen receptor (AR) has been shown to have prognostic implication on breast cancer (BC). Data on the biological features of African BCs are poor. We decided for the first time to compare AR expression of Tanzanian and Italian BC patients. PATIENTS AND METHODS: Of the 69 consecutive patients seen at the Bugando Medical Center (Mwanza, Tanzania) from 2003 to 2010, who underwent resection of primary BC evaluable for estrogen receptor, progesterone receptor (PgR), and HER2 only 65 were evaluable for AR by immunohistochemistry. Histopathological assessment and biomolecular determinations were performed at the Cancer Institute of Romagna [Istituto Scientifico Romagnolo per lo studio e la cura dei tumori (IRST)-IRCCS, Meldola, Italy]. Caucasian BC patients were selected from an electronic database and matched (1:2 ratio) for year of diagnosis and age at diagnosis. RESULTS: The median age of patients at diagnosis was 51 (range 29-83) years for Tanzanian and 53 (range 26-86) years for Italian patients. Tanzanian patients harbored tumors with lower AR expression than Italian patients according to the median percentage of immunopositive tumor cells (30% versus 80%, p < 0.0001) and staining intensity (p = 0.0003). The proportion of AR negative patients was likewise higher among Tanzanian patients as regards both ≥1% and ≥10% cutoffs. AR-positive BCs were higher in luminal A and B tumors and decreased in triple-negative (TN) and HER2-enriched tumors in Tanzanian population. CONCLUSION: AR loss could represent an unfavorable prognostic marker in the African population. The high frequency of TN tumors with high AR expression could open new perspectives of therapy for population in this low income country.

The Impact of Systematic Point-of-Care Ultrasound on Management of Patients in a Resource-Limited Setting.

Although target point-of-care (POC) ultrasonography has been shown to benefit patients in resource-limited settings, it is not clear whether a systematic POC ultrasound assessment in these settings can also lead to similar changes in patient management. A predefined systematic set of POC ultrasound scans were performed on inpatients at a tertiary referral hospital in Tanzania to see if this resulted in changes to patient management. Of the 55 patients scanned, an abnormality was detected in 75% (N = 41), and a change in patient management was recommended or implemented on the basis of POC ultrasound findings in 53% (N = 29). The main impact was earlier initiation of treatment due to more rapid and accurate diagnosis. Further research is warranted to determine whether systematic POC ultrasonography would result in improved patient outcomes in resource-limited settings.