Breast cancer in Ghana is a growing public health problem with increasing incidence and poor outcomes. Lack of access to comprehensive treatment in Ghana may be a contributing factor to its high ...mortality. The purpose of this study was to evaluate the availability of treatments nationwide and systematically identify high yield areas for targeted expansion. We conducted a cross-sectional, nationwide hospital-based survey from November 2020-October 2021. Surveys were conducted in person with trained research assistants and described hospital availability of all breast cancer treatments and personnel. All individual treatment services were reported, and hospitals were further stratified into levels of multi-modal treatment modeled after the National Comprehensive Cancer Network (NCCN) Framework treatment recommendations for low-resource settings. Level 3 included Tamoxifen and surgery (mastectomy with axillary lymph node sampling); Level 2 included Level 3 plus radiation, aromatase inhibitors, lumpectomy, and sentinel lymph node biopsy; Level 1 included Level 2 plus Her2 therapy and breast reconstruction. Hospitals were identified that could expand to these service levels based on existing services, location and personnel. The distance of the total population from treatment services before and after hypothetical expansion was determined with a geospatial analysis. Of the 328 participating hospitals (95% response rate), 9 hospitals had Level 3 care, 0 had Level 2, and 2 had Level 1. Twelve hospitals could expand to Level 3, 1 could expand to Level 2, and 1 could expand to Level 1. With expansion, the population percentage within 75km of Level 1, 2 and 3 care would increase from 42% to 50%, 0 to 6% and 44% to 67%, respectively. Multi-modal breast cancer treatment is available in Ghana, but it is not accessible to most of the population. Leveraging the knowledge of current resources and population proximity provides an opportunity to identify high-yield areas for targeted expansion.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background
The Gambia has one of the lowest survival rates for breast cancer in Africa. Contributing factors are late presentation, delays within the healthcare system, and decreased ...availability of resources. We aimed to characterize the capacity and geographic location of healthcare facilities in the country and calculate the proportion of the population with access to breast cancer care.
Methods
A facility-based assessment tool was administered to secondary and tertiary healthcare facilities and private medical centers and clinics in The Gambia. GPS coordinates were obtained, and proximity of service availability and population analysis were performed. Distance thresholds of 10, 20, and 45 km were chosen to determine access to screening, pathologic diagnosis, and surgical management. An additional population analysis was performed to observe the potential impact of targeted development of resources for breast cancer care.
Results
All 102 secondary and tertiary healthcare facilities and private medical centers and clinics in The Gambia were included. Breast cancer screening is mainly performed through clinical breast examination and is available in 52 facilities. Seven facilities provide pathologic diagnosis and surgical management of breast cancer. The proportion of the Gambian population with access to screening, pathologic diagnosis, and surgical management is 72, 53, and 62%, respectively. A hypothetical targeted expansion of resources would increase the covered population to 95, 62, and 84%.
Conclusions
Almost half of the Gambian population does not have access to pathologic diagnosis and surgical management of breast cancer within the distance threshold utilized in the study. Mapping and population analysis can identify areas for targeted development of resources to increase access to breast cancer care.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ObjectivesDefine the services available for the care of breast cancer at hospitals in the Eastern Region of Ghana, identify areas of the region with limited access to care through geospatial mapping, ...and test a novel survey instrument in anticipation of a nationwide scale up of the study.DesignA cross-sectional, facility-based survey study.SettingThis study was conducted at 33 of the 34 hospitals in the Eastern Region of Ghana from March 2020 to May 2020.ParticipantsThe 33 hospitals surveyed represented 97% of all hospitals in the region. This included private, government, quasi-government and faith-based organisation owned hospitals.ResultsSixteen hospitals (82%) surveyed provided basic screening services, 11 (33%) provided pathological diagnosis and 3 (9%) provided those services in addition to basic surgical care.53%, 64% and 78% of the population lived within 10 km, 25 km and 45 km of screening, diagnostic and treatment services respectively. Limited chemotherapy was available at two hospitals (6%), endocrine therapy at one hospital (3%) and radiotherapy was not available. Twenty-nine hospitals (88%) employed a general practitioner and 13 (39%) employed a surgeon. Oncology specialists, pathology personnel and a plastic surgeon were only available in one hospital (3%) in the Eastern Region.ConclusionsAlthough 16 hospitals (82%) provided screening, only half the population lived within reasonable distance of these services. Few hospitals offered diagnosis and surgical services, but 64% and 78% of the population lived within a reasonable distance of these hospitals. Geospatial analysis suggested two priorities to cost-effectively expand breast cancer services: (1) increase the number of health facilities providing screening services and (2) centralise basic imaging, pathological and surgical services at targeted hospitals.
Breast cancer is the most frequent cancer and second most common cause of cancer-related death in Ghana. Early detection and access to diagnostic services are vital for early treatment initiation and ...improved survival. This study characterizes the geographic access to hospital-based breast cancer diagnostic services in Ghana as a framework for expansion.
A cross-sectional hospital-based survey was completed in Ghana from November 2020 to October 2021. Early diagnostic services, as defined by the National Comprehensive Cancer Network (NCCN) Framework for Resource Stratification, was assessed at each hospital. Services were characterized as available >80% of the time in the previous year, <80%, or not available. ArcGIS was used to identify the proportion of the population within 20 and 45 km of services.
Most hospitals in Ghana participated in this survey (95%; 328 of 346). Of these, 12 met full NCCN Basic criteria >80% of the time, with 43% of the population living within 45 km. Ten of the 12 met full NCCN Core criteria, and none met full NCCN Enhanced criteria. An additional 12 hospitals were identified that provide the majority of NCCN Basic services but lack select services necessary to meet this criterion. Expansion of services in these hospitals could result in an additional 20% of the population having access to NCCN Basic-level early diagnostic services within 45 km.
Hospital-based services for breast cancer early diagnosis in Ghana are available but sparse. Many hospitals offer fragmented aspects of care, but only a limited number of hospitals offer the full NCCN Basic or Core level of care. Understanding current availability and geographical distribution of services provides a framework for potential targeted expansion of services.
Background Pretreatment with antibiotics is commonly performed before surgical implantation of prosthetic materials. We previously showed that pericardial patches are infiltrated by macrophages and ...arterial stem cells after implantation into an artery. We hypothesized that antibiotic pretreatment would diminish the number of cells infiltrating into the patch, potentially affecting early neointimal formation. Methods Bovine pericardial patches were pretreated with saline, bacitracin (500 U/mL), or cephalexin (10 mg/mL) for 30 minutes before implantation into the Wistar rat infrarenal aorta. Patches were retrieved on day 7 or day 30 and analyzed for histology and cell infiltration. Markers of proliferation, apoptosis, vascular cell identity, and M1 and M2 macrophage subtypes were examined using immunofluorescence and immunohistochemistry. Extracted proteins were analyzed by Western blot. Results At day 7, pericardial patches pretreated with bacitracin or cephalexin showed similar amounts of neointimal thickening ( P = .55) and cellular infiltration ( P = .42) compared with control patches. Patches pretreated with antibiotics showed similar proliferation ( P = .09) and apoptosis ( P = .84) as control patches. The cell composition of the neointima in pretreated patches was similar to control patches, with a thin endothelial layer overlying a thin layer of smooth muscle cells ( P = .45), and containing similar numbers of CD34-positive ( P = .26) and vascular endothelial growth factor receptor 2-positive ( P = .31) cells. Interestingly, within the body of the patch, there were fewer macrophages ( P = .0003) and a trend towards fewer endothelial progenitor cells ( P = .051). No M1 macrophages were found in or around any of the patches. M2 macrophages were present around the patches, and there was no difference in numbers of M2 macrophages surrounding control patches and patches pretreated with antibiotics ( P = .24). There was no difference in neointimal thickness at day 30 between control patches and patches pretreated with antibiotics ( P = .52). Conclusions Pretreatment of bovine pericardial patches with the antibiotics bacitracin or cephalexin has no detrimental effect on early patch healing, with similar neointimal thickness, cellular infiltration, and numbers of M2 macrophages compared with control patches. These results suggest that the host vessel response to patch angioplasty using pericardial patches is adaptive remodeling (eg, arterial healing).
Purpose
The venous limb of arteriovenous fistulae (AVF) adapts to the arterial environment by dilation and wall thickening; however, the temporal regulation of the expression of extracellular matrix ...(ECM) components in the venous limb of the maturing AVF has not been well characterized. We used a murine model of AVF maturation that recapitulates human AVF maturation to determine the temporal pattern of expression of these ECM components.
Methods
Aortocaval fistulae were created in C57BL/6J mice and the venous limb was analyzed on postoperative days 1, 3, 7, 21, and 42. A gene microarray analysis was performed on day 7; results were confirmed by qPCR, histology, and immunohistochemistry. Proteases, protease inhibitors, collagens, glycoproteins, and other non-collagenous proteins were characterized.
Results
The maturing AVF has increased expression of many ECM components, including increased collagen and elastin. Matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinase 1 (TIMP1) showed increased mRNA and protein expression during the first 7 days of maturation. Increased collagen and elastin expression was also significant at day 7. Expression of structural proteins was increased later during AVF maturation. Osteopontin (OPN) expression was increased at day 1 and sustained during AVF maturation.
Conclusions
During AVF maturation, there is significantly increased expression of ECM components, each of which shows distinct temporal patterns during AVF maturation. Increased expression of regulatory proteins such as MMP and TIMP precedes increased expression of structural proteins such as collagen and elastin, potentially mediating a controlled pattern of ECM degradation and vessel remodeling without structural failure.
•93% of patients were Hispanic. 4% had autoimmune diseases.•Aspiration of fluid collections was preferred. Avoid steroids and surgery.•Duration of disease was 19–33.5 weeks. Recurrence rate was 24%.
...Granulomatous lobular mastitis (GLM) is an uncommon benign breast condition characterized by non-caseating Granulomatous inflammation arising from the lobules of the breast. Current therapeutic options include observation, percutaneous aspiration, antibiotics, steroids, methotrexate, and surgical procedures. This study evaluated the effectiveness of therapeutic modalities on the duration of disease and recurrence rate.
A retrospective analysis was performed of clinical, radiographic, and therapeutic data for patients presenting with GLM from January 2008 until October 2018. All patients had a core breast biopsy demonstrating granulomas. Patients with other known sources of granulomas were identified. The use of observation, steroids, methotrexate, abscess aspiration, and surgical procedures was evaluated.
There were 285 female patients, predominantly Hispanic (n = 265, 93%) with mean age of 35.6 ± 8.7 years at time of diagnosis. The majority of patients (n = 213, 75%) presented with a mass, mean size 4.2 ± 2.5 cm. Twelve (4%) patients had coexisting autoimmune diseases. Antibiotics were utilized in 217 (76%) patients for courses that averaged 3.4 ± 2.2 weeks. Glucocorticoids were used in 80 (28%) patients, and methotrexate was used in 16 (5%). Incision and drainage or surgical excision was performed for 76 (27%) of patients. The median duration of disease was 16 (IQR: 7–33) weeks and the overall recurrence rate was 22%. Both duration of disease and recurrence rate were highest amongst patients treated with a surgical intervention.
The self-limited course of disease and relatively low recurrence rate, in addition to longer disease duration and increased recurrence rate noted in patients treated with incision and drainage and/or surgical excision, appears to justify the infrequent use of surgical procedures in the management of GLM.
Breast cancer is the most diagnosed cancer among Mongolian women and mortality rates are high. We describe a virtual multi-institutional and multidisciplinary tumor board (MTB) for breast cancer ...created to assist the National Cancer Center of Mongolia.
A virtual MTB for breast cancer was conducted with participation of two United States and 1 Mongolian cancer centers. A standardized template for presentations was developed. Recommendations were summarized and shared with participants. Collected data included patient demographics, tumor characteristics, stage, imaging and treatments performed, and recommendations. Questions were categorized as treatment, diagnosis, or palliative questions.
Fifteen patients were evaluated. Median age was 39 y. 86.7% of breast cancers were invasive ductal cancers and 13.3% were metaplastic carcinomas. 53.3% were estrogen and progesterone receptor positive (ER+/PR+), 60% were HER2+, 13.3% were triple negative, and 26.7% were recurrent. 40% of patients were evaluated with mammography. 6% received positron emission tomography scans for metastatic evaluation. 66.7% of surgical patients received neoadjuvant chemotherapy. Herceptin was administered to 55.6% of patients with Her2+ cancers. Modified radical mastectomy was most commonly performed and reconstruction was rare. Sentinel lymph node biopsy was not performed. 66.7% of ER+/PR+ patients received endocrine therapy. 6.7% of patients received radiation. 75% of MTB questions pertained to treatment. Recommendations were related to systemic therapy (40%), surgical management (33.3%), pathology (13.3%), and imaging (13.3%).
This study illustrates the development of an international, virtual, multi-institutional breast cancer MTB and provides insight into challenges and potential interventions to improve breast cancer care in Mongolia.
•The study describes the implementation of an international virtual multidisciplinary tumor board for breast cancer care in Mongolia.•Virtual tumor boards are an effective and low-cost mechanism to assist colleagues at low-income and middle-income countries in treatment planning.•Standardized templates are an essential tool to facilitate communication at international multidisciplinary tumor boards.•Formal documentation of recommendations is helpful in dissemination of this information to patients and other care providers, especially in the absence of an electronic medical record.•The patients discussed at this tumor board were predominantly young women presenting with late-stage disease and aggressive breast cancer subtypes. More complete workup with diagnostic mammogram and staging imaging, as well as increased administration of endocrine therapy, Her2 directed therapy, and chemotherapy in the neoadjuvant setting, are needed to improve patient outcomes.
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