Treatment outcomes of breast carcinoma in a resource-limited environment
Background. Carcinoma of the breast is the second most common malignancy among South African women, its incidence is rising and the mortality rate is significantly higher than in the developed world. Offering quality treatment in a resource-limited environment with poor patient socioeconomic circumstances is an ongoing challenge. Frail health, lack of support in the event of severe toxicity, and the lack of advanced pharmaceuticals, taxane regimens and biologicals limit treatment options for chemotherapy.
Methods. Records of 250 consecutive female patients newly diagnosed with breast cancer from January to October 2008, were retrieved and analysed. Staging at diagnosis, demographic data, histopathology, treatment given, compliance and outcomes were recorded retrospectively.
Results. Average follow-up time was 36.2 months, the mean age was 56 years, 205 patients underwent surgery, and 84.4% of patients were fully compliant with therapy. Stage I and stage IV overall survival was similar to developed world figures. Combined stage II/III survival was 64.7%, which is significantly lower than survival figures in the developed world (84.6%). A large proportion of patients (15.7%) with stage II and III breast cancer in our series did not receive chemotherapy. For stage III patients, not a single pathologically complete response was recorded; in stage II complete response rate was 10%. Adjuvant chemotherapy was administered to 41 out of 51 patients (80.3%) with node-negative tumours larger than 2 cm and only 3 out of 14 patients (21.4%) with 1 - 2 cm node-negative tumours. Adjuvant radiotherapy was administered to 83.8% node-positive stage II and 88% stage III patients. Hormonal therapy was administered to 90.7% of the oestrogen receptor positive tumours and 64% of these patients were still taking treatment at time of last follow-up.
Conclusion. Combined stage II and III disease-related survival in this series was considerably lower than developed world figures. Adjuvant radiotherapy and hormonal therapy were well applied where indicated. The options of neoadjuvant and adjuvant chemotherapy were underutilised in this series – for a large proportion of these patients (10.7%) the reason remains unknown. Administrative error, patient comorbid conditions and patient refusal also contributed to the underutilisation of chemotherapy. Moreover, tumours showed poor response to chemotherapy regimens administered. The emphasis on the expansion of the services to women with breast cancer should concentrate on the extension of medical oncological services to improve outcomes. Biologicals as well as advanced chemotherapeutic options including taxane regimens should be made available.
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