Epidemiology of Breast Cancer Presentation in Botswana, South Africa, and the United States.

INTRODUCTION: This study sought to compare the clinicopathologic features of women with breast cancer presenting in South Africa, Botswana, and the United States (US). METHODS: Breast cancer samples from Botswana (n = 384, 2011-2015), South Africa (n = 475, 2016-2017), and the US (n = 361,353, 2011-2012) were retrospectively reviewed. RESULTS: The median age of sub-Saharan African women presenting with breast cancer (age 54 in Botswana and South Africa) was younger than that of those in the US (age 61) (P < 0.001). Sub-Saharan women were more likely to present with advanced stage disease than US counterparts (64.7% in Botswana, 63.3% in South Africa, 13% in the US, P < 0.001). Triple negative disease was highest in Botswana (21.3%) compared to South Africa (11.4%) and the US (12.94%) (P < 0.001). Differences in receptor status at presentation among the three cohorts (P < 0.001) were not observed when the cohorts were stratified by ethnicity. Black/multiracial patients in Botswana and the US were the most likely subsets to present with the adverse characteristic of triple negative disease (21.3% and 23.2%, respectively). No correlation was found between HIV and receptor status in the Botswana (P = 0.513) or South African (P = 0.352) cohorts. CONCLUSIONS: Here we report receptor status patterns at presentation in Botswana and South Africa. This study reveals important similarities and differences which may inform policy and provide context for future epidemiologic trends of breast cancer in low- and-middle-income countries particularly in sub-Saharan Africa.

A geospatial analysis of two-hour surgical access to district hospitals in South Africa.

BACKGROUND: In a robust health care system, at least 80% of a country's population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa. METHODS: All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods. RESULTS: Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities. CONCLUSION: Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.

Minimizing Delays in the Breast Cancer Pathway by Integrating Breast Specialty Care Services at the Primary Health Care Level in Zambia.

PURPOSE: In Zambia, more than two-thirds of female patients with breast cancer present with late-stage disease, leading to high mortality rates. Most of the underlying causes are associated with delays in symptom recognition and diagnosis. By implementing breast care specialty services at the primary health care level, we hypothesized that some of the delays could be minimized. METHODS: In March 2018, we established a breast care specialty clinic for women with symptomatic disease within 1 of the 5 district hospitals in Lusaka. The clinic offers breast self-awareness education, clinical breast examination, breast ultrasound, ultrasound-guided breast biopsy, surgery, referral for chemoradiation, follow-up care, and electronic medical records. RESULTS: Between March 2018 and April 2019, of 1,790 symptomatic women who presented to the clinic, 176 (10%) had clinical and/or ultrasound indications for histologic evaluation. Biopsy specimens were obtained using ultrasound-guided core-needle procedures, all of which were performed on the same day as the initial visit. Of the 176 women who underwent biopsy, 112 (64%) had pathologic findings compatible with a primary breast cancer, and of these, 42 (37%) were early-stage (stage I/II) disease. Surgery for early-stage cancers was performed at the district hospital within 2 weeks of the time of definitive pathologic diagnosis. Patients with advanced disease were referred to the national cancer center for multimodality therapy, within a similar time frame. CONCLUSION: Breast care specialty services for symptomatic women were established in a district-level hospital in a resource-constrained setting in Africa. As a result, the following time intervals were minimized: initial presentation and performance of clinical diagnostics; receipt of a definitive pathologic diagnosis and initiation of surgery; receipt of a definitive pathologic diagnosis and referral.

Breast abnormalities in adolescents receiving antiretroviral therapy.

BACKGROUND: Antiretrovirals, particularly efavirenz (EFV), have been shown to cause breast abnormalities in adults. Little is known about the prevalence of these adverse effects among adolescents receiving antiretroviral therapy (ART). OBJECTIVES: The aim of this article was to examine the extent of breast abnormalities in adolescents receiving ART and determine any clinical associations. METHODS: A retrospective record review describing breast conditions in adolescents receiving ART at three facilities in Johannesburg was conducted. Patients aged 10-19 years, who presented from January to December 2014, were included in the study. Analyses were conducted to determine whether EFV was associated with increased breast conditions. RESULTS: Of the 631 patient records reviewed, 37 (6%) had an abnormal breast event documented; with 24/37 (65%) being male patients. Patients with abnormal breast conditions were 1.5 years older than patients with normal breast development (p < 0.0005). Forty-one abnormal breast events were observed in 37 patients, with 20 described as gynaecomastia or lipomastia (49%). Of the 37 patients, 44% (n = 19) had concurrent generalised lipodystrophy. Of those with an abnormal breast event, 71% of patients had CD4 counts > 500 cells/µL and were virologically suppressed (n = 29). Those on EFV had a significantly higher prevalence of breast abnormalities compared to other regimens (p = 0.016). CONCLUSION: Of the studied patients, 6% had an abnormal breast condition. The use of EFV and increased age were associated with breast abnormalities in this population. Further research is needed to better understand the implications of this potential side effect.

Unraveling the South African Breast Cancer Story: The Relationship of Patients, Delay to Diagnosis, and Tumor Biology With Stage at Presentation in an Urban Setting.

BACKGROUND: Adverse outcomes from breast cancer disproportionately affect women in sub-Saharan Africa, with delay the most studied contribution to advanced stage at presentation. However, tumor molecular biology and its contribution to advanced stage are yet to be explored. MATERIALS AND METHODS: Patients newly diagnosed with breast cancer in a South African tertiary breast center completed a questionnaire and file review concerning socioeconomics, delay to care, stage at presentation, and molecular characteristics. Logistic regression was done to determine the relative risk of advanced stage presentation. RESULTS: Advanced stage was present in 70.1% (n = 162) of the 231 participants, with 55.8% stage III (n = 129) and 32% (n = 72) having a T4 tumor. The median age was 56 y with 21.6% (n = 47) aged <45 y. Most common subtype was luminal B (57.7%, n = 128) followed by luminal A (21.6%, n = 48), triple negative (13.9%, n = 31), and HER2 positive (6.7%, n = 15). Lobular cancer (incidence risk ratio [IRR], 1.29; 95% confidence interval [CI], 1.03-1.62), high grade and intermediate grade tumors (IRR, 1.90; 95% CI, 1.15-3.13 and IRR, 1.95; 95% CI, 1.18-3.22, respectively), high Ki67 proliferation index (IRR, 1.30; 95% CI, 1.02-1.66), and HER2 overexpression (IRR, 1.32; 95% CI, 1.12-1.55) were more likely to present with advanced disease, as were luminal B (HER2+) cancers (adjusted IRR [aIRR], 1.46; 95% CI, 1.10-1.95). Although on univariate analysis Black and young participants were both more likely to have advanced stage (IRR, 1.23; 95% CI, 1.01-1.49 and IRR, 1.25; 95% CI, 1.04-1.51, respectively), in multivariate analysis controlling for tumor biology and delay, these were no longer significant (aIRR, 1.12; 95% CI, 0.91-1.37 and aIRR, 1.17; 95% CI, 0.94-1.48, respectively). CONCLUSIONS: Tumor biology has a compelling role in the etiology of advanced-stage disease irrespective of socioeconomic factors. Accurate pathologic assessment is important in planning breast cancer care in Africa.

South African General Surgeon Preparedness for Humanitarian Disasters.

BACKGROUND: Humanitarian medical organizations provide surgical care for a broad range of conditions including general surgical (GS), obstetric and gynecologic (OBGYN), orthopedic (ORTHO), and urologic (URO) conditions in unstable contexts. The most common humanitarian operation is cesarean section. The objective of this study was to identify the proportion of South African general surgeons who had operative experience and current competency in GS, OBGYN, ORTHO, and URO humanitarian operations in order to evaluate their potential for working in humanitarian disasters. METHODS: This was a cross-sectional online survey of South African general surgeons administered from November 2017-July 2018. Rotations in OBGYN, ORTHO, and URO were quantified. Experience and competency in eighteen humanitarian operations were queried. RESULTS: There were 154 SA general surgeon participants. Prior to starting general surgery (GS) residency, 129 (83%) had OBGYN, 125 (81%) ORTHO, and 84 (54%) URO experience. Experience and competency in humanitarian procedures by specialty included: 96% experience and 95% competency for GS, 71% experience and 51% competency for OBGYN, 77% experience and 66% competency for ORTHO, and 86% experience and 81% competency for URO. 82% reported training, and 51% competency in cesarean section. CONCLUSIONS: SA general surgeons are potentially well suited for humanitarian surgery. This study has shown that most SA general surgeons received training in OBGYN, ORTHO, and URO prior to residency and many maintain competence in the corresponding humanitarian operations. Other low- to middle-income countries may also have broad-based surgery training, and the potential for their surgeons to offer humanitarian assistance should be further investigated.

Factors Related to Advanced Stage of Cancer Presentation in Botswana.

PURPOSE: Botswana, a country with a high prevalence of HIV, has an increasing incidence of cancer-related mortality in the post-antiretroviral therapy era. Despite universal access to free health care, the majority of Botswana patients with cancer present at advanced stages. This study was designed to explore the factors related to advanced-stage cancer presentation in Botswana. METHODS: Patients attending an oncology clinic between December 2015 and January 2017 at Princess Marina Hospital in Gaborone, Botswana, completed a questionnaire on sociodemographic and clinical factors as well as cancer-related fears, attitudes, beliefs, and stigma. Odds ratios (ORs) were calculated to identify factors significantly associated with advanced stage (stage III and IV) at diagnosis. RESULTS: Of 214 patients, 18.7% were men and 81.3% were women. The median age at diagnosis was 46 years, with 71.9% of patients older than 40 years. The most commonly represented cancers included cervical (42.3%), breast (16%), and head and neck (15.5%). Cancer stages represented in the study group included 8.4% at stage I, 19.2% at stage II, 24.1% at stage III, 11.9% at stage IV, and 36.4% at an unknown stage. Patients who presented at advanced stages were significantly more likely to not be afraid of having cancer (OR, 3.48; P < .05), believe that their family would not care for them if they needed treatment (OR, 6.35; P = .05), and believe that they could not afford to develop cancer (OR, 2.73; P < .05). The perception that symptoms were less serious was also significantly related to advanced stage ( P < .05). Patients with non-female-specific cancers were more likely to present in advanced stages (OR, 5.67; P < .05). CONCLUSION: Future cancer mortality reduction efforts should emphasize cancer symptom awareness and early detection through routine cancer screening, as well as increasing the acceptability of care-seeking, especially among male patients.

Breast Cancer and HIV in Sub-Saharan Africa: A Complex Relationship.

INTRODUCTION: The number and lifespan of individuals living with HIV have increased significantly with the scale-up of antiretroviral therapy. Furthermore, the incidence of breast cancer in women with HIV is growing, especially in sub-Saharan Africa (SSA). However, the association between HIV infection and breast cancer is not well understood. METHODS: A literature search was performed to identify articles published in journals pertaining to breast cancer and HIV, with an emphasis on SSA. Selected US-based studies were also identified for comparison. RESULTS: Among the 56 studies reviewed, the largest study examined 314 patients with breast cancer and HIV in the United States. There is no consensus on whether HIV infection acts as a pro-oncogenic or antioncogenic factor in breast cancer, and it may have no relation to breast cancer. A higher incidence of breast cancer is reported in high-income countries than in SSA, although breast cancer in SSA presents at a younger age and at a more advanced stage. Some studies show that patients with breast cancer and HIV experience worse chemotherapy toxicity than do patients without HIV. Data on treatment outcomes are limited. The largest study showed worse treatment outcomes in patients with HIV, compared with their counterparts without HIV. CONCLUSION: HIV infection has not been associated with different clinical presentation of breast cancer. However, some evidence suggests that concurrent diagnosis of HIV with breast cancer is associated with increased therapy-related toxicity and worse outcomes. Systematic prospective studies are needed to establish whether there is a specific association between breast cancer and HIV.

Patient Factors Associated With Delays in Obtaining Cancer Care in Botswana.

Purpose Delays in diagnosis and treatment of cancers can lead to poor survival. These delays represent a multifaceted problem attributable to patient, provider, and systemic factors. We aim to quantify intervals from symptom onset to treatment start among patients with cancer in Botswana and to understand potential risk factors for delay. Patients and Methods From December 2015 to January 2017, we surveyed patients seen in an oncology clinic in Botswana. We calculated proportions of patients who experienced delays in appraisal (between detecting symptoms and perceiving a reason to discuss them with provider, defined as > 1 month), help seeking (between discussing symptoms and first consultation with provider, defined as > 1 month), diagnosis (between first consultation and receiving a diagnosis, defined as > 3 months), and treatment (between diagnosis and starting treatment, defined as > 3 months). Results Among 214 patients with cancer who completed the survey, median age at diagnosis was 46 years, and the most common cancer was cancer of the cervix (42.2%). Eighty-one percent of patients were women, 60.7% were HIV infected, and 56.6% presented with advanced cancer (stage III or IV). Twenty-six percent of patients experienced delays in appraisal, 35.5% experienced delays help seeking, 63.1% experienced delays in diagnosis, and 50.4% experienced delays in treatment. Patient income, education, and age were not associated with delays. In univariable analysis, patients living with larger families were less likely to experience a help-seeking delay (odds ratio [OR], 0.31; P = .03), women and patients with perceived very serious symptoms were less likely to experience an appraisal delay (OR, 0.45; P = .032 and OR, 0.14; P = .02, respectively). Conclusion Nearly all patients surveyed experienced a delay in obtaining cancer care. In a setting where care is provided without charge, cancer type and male sex were more important predictors of delays than socioeconomic factors.

A survey of knowledge and attitudes relating to cervical and breast cancer among women in Ethiopia.

BACKGROUND: Breast cancer and cervical cancer are the two leading cancers among women in Ethiopia. This study investigated knowledge and attitudes related to these two types of cancer among women in 4 zones of Ethiopia. This is the first study employing a validated questionnaire to investigate knowledge and attitudes relating to breast and cervical cancer in Ethiopia. METHODS: A community based cross-sectional study was conducted from September to November 2015 in the North Shewa zone (Amhara region), Gamo Gofa zone (Southern Nations, Nationalities and Peoples' region) and zones 1 and 3 (Afar region) of Ethiopia. A total of 799 women aged 18 years and older participated in the survey. Multiple logistic regression analysis was used to investigate the association of possible predictors with breast and cervical cancer knowledge. RESULTS: A total of 799 women aged 18 years and older participated in the survey. Of the women interviewed, 63.0% had heard of breast cancer and 42.2% had heard of cervical cancer. Among those who had heard of breast cancer, 21.3% (107/503) had heard of breast cancer screening and 1.4% of women aged 40 years and older had undergone at least one breast screening examination. Fewer than half of the participants provided the correct response to questions related to risk factors for breast and cervical cancer. Among those who had heard of cervical cancer, 41.5% (140/337) had heard of cervical cancer screening and 3.3% had undergone at least one cervical cancer screening examination. Women with primary and higher levels of education were more likely to have heard of breast cancers (OR = 3.0; 95% CI: 2.1-4.2; p < 0.001) and cervical cancer (OR = 1.9; 95% CI: 1.4-2.6; p < 0.001). From the overall attitude score, the majority of the women were found to have negative attitudes towards breast cancer (67.4%) and cervical cancer (70.6%). CONCLUSIONS: This study found that the overall knowledge of risk factors for breast cancer and cervical cancer among women was low. Lack of cancer awareness, and lack of education in general, are the most potent barriers to access and care, and should be addressed through multi-faceted strategies including peer-education, mass media and other community-based interventions.

The Effect of Access to Information on Beliefs Surrounding Breast Cancer in South Africa.

Breast cancer is the most common cancer affecting women in South Africa. There is little knowledge of beliefs to help identify key areas to improve support and education in this demographically and culturally diverse population. Women with a variety of demographic and socioeconomic characteristics accessing care for breast cancer were asked their agreement to statements of knowledge and beliefs about breast cancer. Of the 259 participants, positive statements of medical cure (87.9%) and family support (90.5%) were most commonly believed. Beliefs in faith-based cure and alternative treatments were also present (79.5 and 24.9%, respectively). Negative beliefs were initially more likely in black patients (RR: 11.57, 95%CI: 1.37-97.69) as was belief of cancer as a punishment (RR: 6.85, 95%CI: 1.41-33.21). However, in multivariate analysis adjusting for age, education and access to information (by newspaper, Internet and confidence in reading and writing), there was no difference between racial groups or hospital attended. Reading a newspaper or accessing the Internet was the most protective against belief that cancer was a punishment or curse (Internet use: aRR: 0.12, 95%CI: 0.02-0.99), belief in alternative methods of cure (newspaper use: aRR: 0.51, 95%CI: 0.27-0.96) and the negative beliefs of death and disfigurement (Internet use: aRR: 0.00, 95%CI: 0.00-0.00). Positive expressions of cure and beating cancer were found equally in all women. Attitudes and beliefs about cancer showed little independent demographic or socioeconomic variance. Negative beliefs were mitigated by access to information and confidence in literacy.

Breast hibernomas: Questioning the embryological origin?

This paper aims to review the concept of hibernomas, with focus on their occurrence, in the breast. It will make reference to a specific case from the Helen Joseph Hospital's Breast Clinic situated in Johannesburg, South Africa. We describe the clinical, radiological and pathological findings in a patient as well as the final diagnosis and treatment (in the form of surgery). This report emphasizes the distinguishable features of hibernomas, and gives guidance as to the surgical approach in large hibernomas stressing the ease of achieving cosmesis without major oncoplastic techniques. More specifically, discussion as whether these rapidly growing, nonrecurring, usually encapsulated growths consisting of brown fat tissue similar to that found in hibernating animals arise from the breast or the underlying muscle is considered.

Usefulness of Organ Electrodermal Diagnostics in Detection of Breast Pathology: A Multicenter, Randomized, Double-Blinded Clinical Study.

Objective: Pathology of an internal organ/body part causes corresponding skin areas-organ projection areas/acupuncture points-to rectify applied electrical currents (a diode phenomenon) once the resistance "breakthrough effect" has been induced in these specific, and sometimes remote, skin zones. The aim of this study was to estimate the diagnostic accuracy-as well as the scope of utilization-for detection of breast pathology of organ electrodermal diagnostics (OED), which utilizes this electrophysiologic phenomenon. Materials and Methods: A multicenter randomized, double-blinded comparative study of OED results and clinical diagnoses, as the criteria standards, was done on 400 female volunteers, with a mean age of 39 (standard deviation: 9 years), at three academic breast clinics. Participants were divided into 7 groups: (1) a control group; (2) a cancer-survivor group; (3) a breast-fibroadenoma group; (4) a mastitis group; (5) a breast-abscess group; (6) a preinvasive breast-cancer group; and (7) an invasive breast-cancer group. Results: The OED overall detection rate was 88.8%, the sensitivity rate was 92.7%, and the specificity rate was 76.5%. The predictive value for positive OED results equaled 92.4% and, for negative OED results, equaled 77.3%. However, both sensitivity and specificity rates varied among specific groups. The highest sensitivity rates were shown by OED in groups with serious pathologies, such as invasive cancer (94.2%), preinvasive cancer (90.0%), breast abscess (94.4%), and mastitis (95.9%). The OED results correlated with the intensity of the pathologic process within breasts but were not affected by either the type or the etiology of the disease. Conclusions: OED appears to be a reliable method for detecting breast pathology; this method might also estimate the intensity of a breast pathologic process but cannot explain the cause of the disease directly.

Setting the research and implementation agenda for equitable access to surgical care in South Africa.

South Africa is an upper-middle-income country with widespread social and geographical inequality of surgical provision. The National Forum on Surgery and Anaesthesia in South Africa brought together various stakeholders, including government, societies, academic clinicians and the biomedical industry, to define the core strategy for a national surgical plan. During the forum, presentations and breakaway workshops explored and reported the challenges and opportunities these stakeholders may have in sustaining and improving surgical provision in South Africa. We present the recommendations of these reports with a literature review and other recent reports from organisations involved in healthcare systems in South Africa. We acknowledge the importance of access to safe and affordable surgery for all as a core component of healthcare provision for South Africa. The proposed core strategies for a South African National Surgical Plan to achieve these goals are the following. First, research will focus on high-quality interdisciplinary collaborative research and audit, which addresses the Global Surgery indices, adopts internationally consistent data points and focuses particularly on maternal mortality and the 'Bellwether procedures'. Second, workforce and training must be tailored to the country's specific surgical needs, based on a primary healthcare and district hospital model, which is supported by government and academic organisations. Third, the surgical infrastructure and service delivery needs to be strengthened by the district hospital. Finally, strong leadership with appropriate financial support by healthcare managers who partner with clinicians both locally and nationally is needed to achieve these objectives.

Indicators of breast cancer in patients undergoing microdochectomy for a pathological nipple discharge in a middle-income country.

BACKGROUND: The management of a pathological nipple discharge often involves surgery for the exclusion of a malignant etiology. This study aimed to determine the prevalence of cancer in patients who had microdochectomy for pathological nipple discharge in a population in South Africa and to evaluate patients' demographics and clinical characteristics as indicators of underlying cancer and make recommendations for their management in resource-limited settings. MATERIALS AND METHODS: Clinical, radiological, and histological data from 153 patients who underwent a microdochectomy for a pathological nipple discharge at two South African breast clinics was collected. RESULTS: Invasive or in situ cancer was found in 12 patients (7.84%), and in all patients, cancer was associated with a bloody nipple discharge. Bloody discharge had a sensitivity of 100% in indicating cancer, specificity of 55.32%, positive predictive value of 16%, and negative predictive value of 100%. Patients with breast cancer were also more likely to be aged 55 y or older (P = 0.04). Preoperative mammogram and ultrasound were poor in detecting cancer (0/12). CONCLUSIONS: In our population, a bloody discharge in women aged 55 years or older should mandate a microdochectomy, with selective surgery for younger women and those with nonbloody discharges. Thorough clinical examination to determine the true color and nature of the discharge is vital in the initial assessment of these patients. Preoperative radiology is not helpful in determining the presence of cancer (in an isolated pathological nipple discharge), and microdochectomy still remains the gold standard in diagnosing cancer in these patients.

Fear of Treatments Surpasses Demographic and Socioeconomic Factors in Affecting Patients With Breast Cancer in Urban South Africa.

PURPOSE: Breast cancer is the most common cause of cancer in women in South Africa, and often patients present late. There is little understanding of the psychosocial stresses affecting women with breast cancer in Africa. METHODS: A questionnaire was distributed to 263 patients with breast cancer at two sites (one government and one private facility) in Johannesburg. Self-reported levels of fear were recorded on summative scales and their relationship to demographic variables assessed through univariable and multivariable modified Poisson regression. RESULTS: Fears related to treatments and prognosis, particularly radiation, loss of hair, and loss of breast, were far stronger than those related to socioeconomic barriers. Relative risk (RR) of most fears was higher in women younger than age 40 years, including treatment affordability (RR, 1.80; 95% CI, 1.26 to 2.56), hair loss (RR, 1.48; 95% CI, 1.12 to 2.95), and surgery (RR, 1.31; 95% CI, 1.02 to 1.68). Difficulty taking time off work predicted fear of job loss (RR, 2.59; 95% CI, 1.59 to 4.21) and missing appointments because of transport (RR, 2.46; 95% CI, 1.52 to 3.96) or family commitments (RR, 2.46; 95% CI, 1.52 to 3.96). Women with dependents and black women were more afraid of dying (RR, 1.73; 95% CI, 1.03 to 2.90; and RR, 1.79; 95% CI, 1.33 to 2.24, respectively); however, socioeconomic status in this sample was a strong confounder of race and explained most of the racial differences in levels of fear. CONCLUSION: The most significant fears around breast cancer were related to treatment modalities and adverse effects rather than transport, financial, or work concerns. Young age and job insecurity were predictive of increased fears. Education about treatments has a key role to play in improving access to breast cancer care in South Africa.

Direct-to-Implant Breast Reconstruction without the Use of an Acellular Dermal Matrix Is Cost Effective and Oncologically Safe.

BACKGROUND: Direct-to-implant breast reconstruction is a predictable, reliable, and cost-effective reconstruction. Most units performing direct-to-implant reconstructions recommend the use of an acellular dermal matrix or a mesh to reinforce the lower pole of the breast reconstruction. METHODS: Two hundred seventy-two consecutive patients with 488 immediate direct-to-implant breast reconstructions performed in a 34-month period are included in this group. Mean follow-up of this group is 35 months. RESULTS: Four hundred eight reconstructions were performed through a lazy-S mastectomy, and 80 were performed through a Wise pattern mastectomy. Two local recurrences occurred. Minor complications accounted for 5.5 percent (n = 27): seromas, 3.4 percent (n = 17); wound healing problems, 0.6 percent (n = 3); and grade 2 capsular contracture, 1.4 percent (n = 7). Major complications accounted for 4.3 percent (n = 21): infection, 0.8 percent (n = 4); prosthetic loss, 0.4 percent (n = 2); hematoma, 0.4 percent (n = 2); and wounds requiring débridement, 2 percent (n = 10). The additional cost of acellular dermal matrix is dependent on manufacturer and size, but increases the cost of the procedure by 35.5 to 47.7 percent. CONCLUSIONS: This reconstruction method compares very favorably with published data from other units as far as early and late complications and cosmetic outcome are concerned. It has a complication rate similar to that of reconstructions using an acellular dermal matrix and is more cost effective. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Characterizing breast conditions at an open-access breast clinic in South Africa: a model that is more than cancer care for a resource-limited setting.

BACKGROUND: While most breast-related research focuses on cancer, presentation of symptomatic persons in non-screened environments requires understanding the spectrum of breast diseases so as to plan services in resource-constrained settings. This study presents the variety of breast disease managed at a government, open-access breast clinic in South Africa. METHODS: We performed a retrospective file review using a systematic random sample of patients 18 years and above presenting for breast care over a 14-month period. We collected demographics, clinical characteristics, management and final diagnoses from the first visit and twelve subsequent months. RESULTS: The final sample contained 365 individuals (97 · 5% women). Most were black, unmarried and South African citizens with a median age of 43 years (IQR 31-55) . Of those reporting their status (24 · 1%) 38 · 6% were HIV-positive. A mass (57 · 0%) and/or pain (28 · 5%) were the most common symptoms. Imaging and breast biopsies were required in 78 and 25% of individuals, respectively. Nearly half of biopsies identified breast cancer (44 · 1% of women ≤40 and 57 · 3% for women >40). Benign conditions (47 · 7%) and no abnormality (18 · 2%) were common final classifications among women. There was no difference between the final classifications of patients who self-referred versus those who were formally referred from another health care provider. Nearly half of the participants (46 · 6%) travelled 20 km or more to attend the clinic. CONCLUSIONS: Benign breast conditions far outweighed cancer diagnoses. As breast cancer awareness increases in resource-limited countries, facilities offering breast care require administrative and clinical preparation to manage a range of non-cancer related conditions.