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

Abstract

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