Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France.
Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France.
Lancet Glob Health. 2020 Sep;8(9):e1203-e1212. doi: 10.1016/S2214-109X(20)30261-8.
Breast cancer is the second leading cause of death from cancer in women in sub-Saharan Africa, yet there are few well characterised large-scale survival studies with complete follow-up data. We aimed to provide robust survival estimates in women in this setting and apportion the survival gaps.
The African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort study was done at eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, South Africa, Uganda, and Zambia). We prospectively recruited women (aged ≥18 years) who attended these hospitals with suspected breast cancer. Women were actively followed up by use of a telephone call once every 3 months, and a mobile health application was used to keep a dynamic record of follow-up calls due. We collected detailed sociodemographic, clinical, and treatment data. The primary outcome was 3-year overall survival, analysed by use of flexible proportional mortality models, and we predicted survival under scenarios of modified distributions of risk factors.
Between Sept 8, 2014, and Dec 31, 2017, 2313 women were recruited from these eight hospitals, of whom 85 did not have breast cancer. Of the remaining 2228 women with breast cancer, 58 women with previous treatment or recurrence, and 14 women from small racial groups (white and Asian women in South Africa), were excluded. Of the 2156 women analysed, 1840 (85%) were histologically confirmed, 129 (6%) were cytologically confirmed, and 187 (9%) were clinically confirmed to have breast cancer. 2156 (97%) women were followed up for up to 3 years or up to Jan 1, 2019, whichever was earlier. Up to this date, 879 (41%) of these women had died, 1118 (52%) were alive, and 159 (7%) were censored early. 3-year overall survival was 50% (95% CI 48-53), but we observed variations in 3-year survival between different races in Namibia (from 90% in white women to 56% in Black women) and in South Africa (from 76% in mixed-race women to 59% in Black women), and between different countries (44-47% in Uganda and Zambia vs 36% in Nigeria). 215 (10%) of all women had died within 6 months of diagnosis, but 3-year overall survival remained low in women who survived to this timepoint (58%). Among survival determinants, improvements in early diagnosis and treatment were predicted to contribute to the largest increases in survival, with a combined absolute increase in survival of up to 22% in Nigeria, Zambia, and Uganda, when compared with the contributions of other factors (such as HIV or aggressive subtypes).
Large variations in breast cancer survival in sub-Saharan African countries indicate that improvements are possible. At least a third of the projected 416 000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable downstaging and improvements in treatment. Improving survival in socially disadvantaged women warrants special attention.
Susan G Komen and the International Agency for Research on Cancer.
在撒哈拉以南非洲地区，乳腺癌是女性癌症死亡的第二大主要原因，但针对这一疾病，仅有少数特征明确、随访数据完整的大规模生存研究。我们旨在为这一人群提供可靠的生存估计，并分析生存差距。
非洲乳腺癌-结局差异（ABC-DO）前瞻性队列研究在撒哈拉以南非洲地区的五个国家（纳米比亚、尼日利亚、南非、乌干达和赞比亚）的八家医院进行。我们前瞻性招募了疑似患有乳腺癌的年龄在 18 岁及以上的女性。通过每 3 个月进行一次电话随访积极对女性进行随访，并使用移动健康应用程序动态记录随访电话。我们收集了详细的社会人口统计学、临床和治疗数据。主要结局是 3 年总生存率，使用灵活的比例死亡率模型进行分析，并预测了在危险因素分布改变情况下的生存率。
2014 年 9 月 8 日至 2017 年 12 月 31 日期间，从这八家医院共招募了 2313 名女性，其中 85 名女性未患有乳腺癌。在剩余的 2228 名患有乳腺癌的女性中，58 名女性之前接受过治疗或复发，14 名女性来自少数种族群体（南非的白人和亚洲人），因此被排除在外。在分析的 2156 名女性中，1840 名（85%）经组织学证实，129 名（6%）经细胞学证实，187 名（9%）经临床证实患有乳腺癌。2156 名（97%）女性接受了长达 3 年或截至 2019 年 1 月 1 日的随访，以先到者为准。截至目前，这些女性中有 879 名（41%）已经死亡，1118 名（52%）存活，159 名（7%）提前被删失。3 年总生存率为 50%（95%CI 48-53），但我们观察到不同种族之间的 3 年生存率存在差异，纳米比亚的白种女性为 90%，黑种女性为 56%，南非的混合种族女性为 76%，黑种女性为 59%，以及不同国家之间的差异（乌干达和赞比亚为 44-47%，尼日利亚为 36%）。所有女性中有 215 名（10%）在诊断后 6 个月内死亡，但在这段时间内存活下来的女性 3 年总生存率仍然较低（58%）。在生存决定因素中，早期诊断和治疗的改善被预测将对生存的最大提升作出贡献，与其他因素（如 HIV 或侵袭性亚型）相比，在尼日利亚、赞比亚和乌干达，这种联合绝对生存率的提升最高可达 22%。
撒哈拉以南非洲国家乳腺癌生存的巨大差异表明，仍有改善空间。在未来十年，该地区预计将有 416000 名女性死于乳腺癌，其中至少有三分之一可以通过分期降级和治疗改善来预防。改善社会弱势群体女性的生存状况值得特别关注。
Susan G Komen 和国际癌症研究机构。
