Isabel dos Santos Silva

PURPOSE: Detailed understanding of patient pathways and barriers to care is essential in devising context-appropriate cancer care strategies in low-income countries. METHODS: We conducted a mixed-methods study nested within a case-control study among patients newly diagnosed with non-Hodgkin lymphoma (NHL; N = 174) in two referral centers in Ethiopia. Structured interviews and chart reviews were followed by in-depth interviews in a subsample (n = 17). Care intervals were defined via Andersen's model and determinants of delay were assessed with logistic regression; thematic analysis was used for qualitative data. RESULTS: Mean age at diagnosis was 51.4 years (standard deviation, 13.70); 67% had advanced disease. Median patient, primary health care, and tertiary care intervals were 86.5, 15, and 47 days, respectively. Median diagnostic interval was 66.5 days. Delay was associated with lower education (adjusted odds ratio [AOR], 6.3 [95% CI, 1.3 to 25]) and indolent lymphoma (AOR, 2.9 [95% CI, 1.3 to 6.2]). Treatment abandonment was 16.8%, and 9.8% were dead at 3 months. Loss to follow-up (21.8%) was associated with study site (AOR, 6.1 [95% CI, 2.6 to 29.9]) and diagnostic delay >30 days (AOR, 4.8 [95% CI, 1.6 to 14.3]). Qualitative analysis identified symptom misappraisal, misdiagnosis, long waits, high out-of-pocket costs, and long travel distances. CONCLUSION: Delays across Ethiopia's NHL care continuum reflect low health literacy, diagnostic bottlenecks, and persistent financial barriers.

PURPOSE: Breast cancer (BC) is becoming a significant public health issue in Cape Verde. Understanding the profile of BC cases is crucial for improving patient outcomes and guiding public health initiatives. This study aimed to investigate the clinical and pathologic characteristics, treatment approaches, and outcomes of BC cases diagnosed and treated at Agostinho Neto University Hospital between January 2015 and July 2021 following implementation of an international treatment partnership. METHODS: A retrospective analysis was conducted on 158 female patients with BC diagnosed during the study period. Data were collected on patient demographics, tumor characteristics, treatment protocols, and survival outcomes. Immunohistochemistry was performed on a subset of 114 patients to identify molecular subtypes. Descriptive statistics were used to summarize all variables. Overall survival was analyzed, and log-rank tests were performed to formally compare the survival curves and assess the statistical significance of any observed differences. Cox proportional hazard models were used to determine the independent effect of sociodemographic factors and clinical characteristics. RESULTS: The median age at diagnosis was 52.5 years, with patients ranging from 28 to 91 years. Most patients resided on Santiago Island. Invasive ductal carcinoma was the most common type, found in 93% of cases. Over half of the tumors were poorly differentiated, and 57% were diagnosed at advanced stages (III and IV). Subtype distribution mirrored sub-Saharan patterns, with 24% triple negative and 11% human epidermal growth factor receptor 2 positive. Among patients with potentially curable BC, 61.4% received adequate therapy that followed the National Comprehensive Cancer Network (NCCN) Harmonized Guidelines for sub-Saharan Africa (SSA), including radiotherapy treatment, although this was performed abroad. The median follow-up calculated by reverse Kaplan-Meier was 33.7 months (IQR, 20.5-52.8 months). Patients treated according to stage-appropriate and phenotype-specific recommendations achieved better outcomes (79.9% 3-year survival). CONCLUSION: This study emphasizes the importance of early diagnosis and adoption of the NCCN Harmonized Guidelines for SSA. Access to radiotherapy abroad, necessitated by the absence of local radiotherapy facilities, was correlated with improved survival. These findings underscore the feasibility of improving outcomes in low-resource settings through standardized treatment frameworks.

Breast cancer and its treatments impact on women's health‐related quality of life, but few studies have assessed these outcomes among survivors in sub‐Saharan Africa (SSA). We investigated longitudinal changes in Global Health Status (GHS) and their correlates within the African Breast Cancer‐Disparities in Outcomes cohort. Newly diagnosed women (≥18 years) across five SSA countries were recruited in 2014–2017. In four countries, follow‐up interviews were conducted 3‐monthly over 7 years using the European Organisation for Research and Treatment of Cancer Quality of Life 30‐item core questionnaire version 3. Multilevel mixed‐effects models identified correlates of GHS. Overall, 1358 women from Namibia, Nigeria, Uganda and Zambia were included, with a mean age of 50.6 (SD = 13.7) years. Median follow‐up time was 3 (IQR = 2–5) years, with a median of 18 GHS assessments per woman (IQR = 10–23). GHS was lowest in the first 6 months post‐diagnosis but improved gradually thereafter. GHS increased with increasing education ( p ‐value for linear trend [ p _t ] < .0001), breast cancer awareness (adjusted‐odds ratio: 1.32; 95% confidence interval 1.22–1.42), surgical treatment (1.90; 1.53–2.37), family support (1.46; 1.24–1.71) and maintaining pre‐diagnosis employment (1.54; 1.41–1.68). In contrast, GHS decreased with increasing age at diagnosis ( p _t <.0001), rural residence (0.76; 0.70–0.82), advanced tumour stage at diagnosis ( p _t <.0001) and having non‐HIV comorbidities (0.74; 0.60–0.92). GHS was not affected by HIV status, but it was higher during COVID‐19 lockdowns than pre‐/post‐lockdown (1.27; 1.09–1.49). These patterns were similar at young and older ages, and in the short‐ and long‐term. The potentially modifiable factors associated with GHS are known to influence breast cancer survival in SSA. Addressing them could improve survivorship and survival from this cancer in the region.

Supplementary Figure 2 from Regional Variation in the Tumor Microenvironment, Immune Escape and Prognostic Factors in Breast Cancer in Sub-Saharan Africa

Figure S6: Multivariate Cox regression analysis of patient's survival.

Figure S1: Consort diagram of the analyzed samples

Figure S5: MHC I expression in SSA