Comparing the cost of non-metastatic breast cancer care in a low-income vs a high-income country: A plea for an optimal allocation of health resources in Sub-Saharan Africa

Breast cancer incidence is rising in low-income countries, but there is limited information regarding health resource allocation for its care. We assessed the cost of care during the first three years after diagnosis in a low-income country (Mozambique; n = 162 women) and compared it with a high-income country (Portugal, n = 703 women). Local currency prices were converted to 2019 international dollars (Int$). In Mozambique, the median cost was lower than in Portugal (2888 vs 18,533 Int$, respectively) and did not vary across stage or tumor subtype. These findings may help improving resource allocation for breast cancer care in Sub-Saharan Africa, despite reflecting an underfunding of treatment in this setting.The Moza-BC cohort (Mozambique) was funded by the Beginning Investigator Grant for Catalytic Research (BIG Cat) program, an African Organisation for Research and Training in Cancer (AORTIC) program with support from the U.S. National Cancer Institute (grant 59-210-6-004). The NEON-BC cohort (Portugal) was funded by FEDER and by FCT (POCI-01-0145-FEDER-016867; ref. PTDC/DTP-EPI/7183/2014; info:eu-repo/grantAgreement/FCT/6817 - DCRRNI ID/UIDB/04750/2020/PT); by the Chair on Pain Medicine of the Faculty of Medicine, University of Porto and the Grünenthal Foundation, Portugal. SM was also funded by FEDER and FCT (POCI-01-0145-FEDER-032358; ref. PTDC/SAU-EPI/32358/2017). The funding sources had no involvement in the analysis, interpretation of data, writing of the report, or decision to submit this manuscript for publication

Breast cancer subtypes: implications for the treatment and survival of patients in Africa-a prospective cohort study from Mozambique

Background. Data regarding breast cancer epidemiology, treatment and survival in Africa are scarce. We aimed to assess the distribution of breast cancer subtypes in Mozambique and its impact on patients’ treatment and survival. The concordance of biomarker assessment between cytological and histological samples was also evaluated. Methods. Prospective cohort study including 210 patients diagnosed between January 2015 and August 2017, followed to November 2019. Clinicopathological characteristics, treatment, 3-year overall survival (OS) and disease-free survival (DFS) were compared across classic tumour subtypes (oestrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative, HER2-positive and triple-negative breast cancer (TNBC)) and surrogate intrinsic subtypes (St. Gallen classification). Concordance was measured using Cohen’s κ statistics. Results. A total of 51% of patients had ER-positive/HER2-negative tumours, 24% HER2-positive and 25% TNBC. Concordance between cytological and histological samples regarding ER and HER2 status was substantial (κ=0.762 and κ=0.603, respectively). There were no significant differences across subtypes regarding clinical characteristics and treatment, except for HIV positivity and high histological grade (more prevalent among TNBC) or endocrine therapy (higher use among ER-positive/HER2-negative and HER2-positive patients). Three-year OS was 52.5% (95% CI, 44.3% to 60.0%), being higher in ER-positive/HER2-negative (61.1%) compared with HER2-positive (53.2%) and TNBC (31.9%) patients. Adjusted HRs were 1.96 (95% CI, 1.13 to 3.39) among HER2-positive and 3.10 (95% CI, 1.81 to 5.31) among TNBC versus ER-positive/HER2-negative patients. Three-year DFS was 46.6% (95% CI, 38.0% to 54.8%), being lower among TNBC versus ER-positive/HER2-negative patients (HR 2.91; 95% CI, 1.64 to 5.16). Results were similar between surrogate intrinsic subtypes. Conclusion. There was a high proportion of HER2-positive and TNBC among Mozambican patients and their survival was poor compared with ER-positive/HER2-negative patients, partly due to the limited treatment options. A systematic assessment of ER, PR and HER2 status is feasible and may help tailoring and optimise the treatment of patients with breast cancer in low-resource settings, potentially leading to survival gains in this underserved population.We acknowledge the funding support given to the Moza-BC cohort study by the Beginning Investigator Grant for Catalytic Research (BIG Cat) programme, an African Organisation for Research and Training in Cancer (AORTIC) programme with support from the US National Cancer Institute (grant no 59-210-6-004). The funding source had no involvement in the analysis, interpretation of data, writing of the report or decision to submit the manuscript for publication