EDITORIAL COMMENTARY
Year : 2023 | Volume
: 23 | Issue : 1 | Page : 1--4
Saving the breasts of Nigerian breast cancer patients: Prospects of breast-conserving therapy in Nigeria
O Olasehinde
Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
Correspondence Address:
Dr. O Olasehinde
Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State
Nigeria
Abstract
Breast-conserving therapy (BCT) is the most common surgical treatment for breast cancer in high-income countries. In Nigeria and many other low-middle income countries, total mastectomy remains the mainstay. This often results in several women facing numerous psychosocial challenges associated with the removal of their breasts. This paper highlights the limitations and prospects of BCT in Nigeria. Increased community awareness aimed at promoting early presentation, more liberal use of neoadjuvant chemotherapy, introduction of multidisciplinary team meetings, availability of other relevant support services and improved access to radiotherapy are key factors needed to change the current narrative. Nigeria, with its huge population of affected and at-risk women, needs to intensify the drive towards de-escalating breast cancer surgery. These measures have the potential of saving lives and preserving the quality of life of affected women.
How to cite this article:
Olasehinde O. Saving the breasts of Nigerian breast cancer patients: Prospects of breast-conserving therapy in Nigeria.Niger J Health Sci 2023;23:1-4
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How to cite this URL:
Olasehinde O. Saving the breasts of Nigerian breast cancer patients: Prospects of breast-conserving therapy in Nigeria. Niger J Health Sci [serial online] 2023 [cited 2023 Sep 27 ];23:1-4
Available from: http://www.https://chs-journal.com//text.asp?2023/23/1/1/381742 |
Full Text
Introduction
Over the years, breast cancer management has evolved from a radical to a more conservative approach. The initial evidence towards a minimalistic surgical approach to the surgical management of breast cancer came from the NSABP-06 and the Milan trials which showed the safety and efficacy of breast-conserving surgery combined with radiotherapy with equivalent outcomes to mastectomy for early-stage breast cancer.[1],[2] Breast conservation has since become standard of care for early breast cancer in Europe, America and many other parts of the world. The frontiers of breast conserving surgery (BCS) have been pushed further with the advent of potent systemic therapies, resulting in significant downstaging in a proportion of patients with locally advanced cancers, making them eligible for breast conservation.[3]
The narrative is, however, different in many parts of sub-Saharan Africa and Nigeria in particular where mastectomy remains the mainstay with only few patients undergoing breast conservation.[4] This review narrates the problems, prospects and suggestions for achieving increased breast conservation rates in the management of breast cancer in Nigeria.
The Need For Breast Conservation in Nigeria!
The breast is an organ of femininity and beauty. It is therefore not surprising that its removal is often associated with significant psychosocial consequences. This concern is of a greater magnitude in a setting like Nigeria where the majority of affected women are relatively young, predominantly in their forties. The impact of mastectomy is made worse by the lack of routine breast reconstruction. Nigerian women have been shown to have significant psychosocial-, emotional- and stigma-related problems after mastectomy.[5] The majority of these are often not addressed during routine clinical consultations. Some earlier studies in Nigeria have identified the fear of mastectomy as one of the reasons for delayed presentation, given the associated social stigma and the erroneous association of mastectomy with mortality.[6] A breast-conserving approach to breast cancer treatment may therefore provide an incentive for patients to present early for treatment. Ultimately, this has the potential of preventing unnecessary deaths from late presentation in additional to avoiding the psychosocial burden associated with the removal of the breast.
The Pitfalls
While the performance of breast-conserving operation itself poses little or no technical challenge to most surgeon's, other nuances such as patient eligibility, support services and access to radiotherapy are the main hindrances to its routine adoption in the Nigerian context.
Patients who present with advanced disease are traditionally not candidates for breast conservation except if they undergo neoadjuvant chemotherapy (NAC) with good response. The majority of Nigerian breast cancer patients are therefore often not qualified for upfront BCS given that a significant proportion present with locally advanced or metastatic disease, many of whom do not initiate treatment in a timely manner.
Besides the surgeon, the concept of breast-conserving therapy (BCT) requires a great deal of collaboration amongst the various specialties involved in breast cancer care. The radiologist, pathologist, clinical and radiation oncologist all play critical roles. Such collaborations often take place in the form of multidisciplinary team (MDT) meetings. MDTs have not been well established in many Nigerian institutions due to personnel shortages and other system-related factors.
Perhaps one of the greatest limitations to BCT in Nigeria has been the lack of routine access to radiotherapy. For many years, Nigeria witnessed periods of epileptic radiotherapy services. The narrative, however, appears to be changing with increased participation of private players, coupled with some commitment from the government, which has resulted in a few more radiotherapy facilities in the country. While the availability of more radiotherapy services improves geographic access, financial access remains a challenge given that the majority of patients pay for radiotherapy and other cancer care services out of pocket.
Prospects of Breast Conservation in Nigeria
Breast conservation can either be performed upfront in patients presenting with screen-detected/early-stage disease (Stage 0, I and II) or after NAC in patients presenting with larger tumours. In the first category, only about 15%–25% of Nigerian breast cancer patients who present with early-stage disease can be considered eligible.[7],[8] Although much lower, relative to high-income countries, this can be considered a starting point. Over the past few years, there has been increased breast cancer awareness with some slight but noticeable increase in the proportion of patients with early-stage disease.[7] The increased use of screening tools such as mammography which is now more readily available than in the past has also improved the possibilities of detecting breast lesions earlier, thereby making more patients potentially eligible for upfront breast conservation. Surgeons and oncologists should present the option of breast conservation to those who are eligible rather than routinely recommend mastectomy by default.
Patients presenting with locally advanced disease constitute the larger proportion of breast cancer patients in the Nigerian setting. They are candidates for NAC based on contemporary treatment guidelines.[9] In Nigeria, about 50% of patients belong in this category.[7] Those who respond to NAC with a significant downstaging can be considered for de-escalation in favour of a conservative option. It is known that response to NAC is often best amongst patients with triple negative and human epidermal growth factor receptor 2 (HER-2)-positive disease.[10] In Nigeria, triple negative breast cancer is a common subtype,[11],[12],[13] suggesting that with more liberal use of NAC, significant downstaging can be achieved in a sizeable number of patients, thereby increasing the potential for breast conservation. For this to happen, surgeons need to move away from the surgery first approach, to the adoption of NAC as the first line of treatment in patients with locally advanced breast cancer (LABC) in line with treatment guidelines. Apart from the potential for downstaging and subsequent breast conservation, the use of NAC helps to determine the potential benefit of adjuvant chemotherapy based on the initial response in the neoadjuvant setting. Non-adoption of NAC first approach to the management of LABC may be considered non-adherence to guidelines and also a missed opportunity for possible de-escalation. Currently, the use of NAC has expanded to include patients with early tumours with aggressive subtypes (HER-2 positive and triple negative) given the association of pathological complete response with clinical outcomes.[14],[15]
Recommendations
The successful implementation of a breast-conserving approach to managing breast cancer in Nigeria requires the interplay of several factors.
The need for multidisciplinary team management
Cancer management has moved from a physician-led to a MDT-driven approach. Experts in the various fields involved in the overall care of the patient come together to make expert contributions to achieve the best possible outcomes. MDTs have become the standard of care for managing cancer patients in Europe and America with proven benefits.[16] With particular reference to breast-conserving surgery, the success of BCT actually requires proper patient selection which involves surgeons, oncologists and radiologists; treatment planning, which involves multiple specialties (surgeons, clinical oncologists, radiation oncologists, nurse oncologists and pathologists. While a full team may not be readily available in many Nigerian institutions, the availability of a surgeon, radiologist, pathologist and an in-house or a collaborating radiation oncologist from an outside institution can be considered a reasonable benchmark.
Continued advocacy and awareness creation
Early detection has the dual advantage of saving the life as well as the breast of the patient. Patients with early-stage disease are the most suitable candidates for BCT, with good outcomes. This can be achieved through awareness creation and public enlightenment. There needs to be more synergy between clinicians who are primarily involved in the care of breast cancer patients and public health experts who interface with the community.
More liberal use of neoadjuvant chemotherapy
Amongst patients presenting with locally advanced disease, there is a possibility of achieving breast conservation if the benefits of NAC are maximised. Theoretically, the rate of breast conservation can be increased by about 12% following the use of NAC.[3] If Nigerian clinicians will adopt the routine use of NAC for patients with LABC as prescribed by treatment guidelines, it may significantly increase the chances of breast conservation.
The critical role of radiology expertise
Radiology expertise is a necessary requirement for the routine performance of breast-conserving surgery. Besides their role in the performance of image-guided biopsies, radiologists are needed for the localisation of screen detected or small lesions and locally advanced tumours which undergo complete remission after NAC. In these circumstances, radiologists are required to be adept in the placement of clips around lesions and tumour beds at the time of biopsy and in the performance of wire localisation of the lesion or tumour bed before operation. The wire, which serves as a guide for the surgeon to excise the non-palpable lesion or tumour bed, improves the accuracy of the procedure and the overall outcome. Institutions which aim to develop the practice of breast conservation should therefore of a necessity upscale their radiology competencies for effective performance.
Improved access to radiotherapy services
For breast-conserving operation to be successful, it must be followed by radiotherapy which needs to be administered in a timely manner. Although still in short supply and sometimes beyond the reach of the average citizen, Nigeria appears to be gradually moving away from the era of complete non-availability of radiotherapy services, with the increased participation of private players. The challenge however remains that of financial access to the service. While for now, BCT should be offered only to those who can afford radiotherapy, there needs to be strong advocacy for the inclusion of radiotherapy services in the national health insurance package.
Conclusion
There is a need to intensify the drive towards de-escalating breast cancer surgery in Nigeria. If this is executed following sound oncological principles, both the lives and quality of life of affected women can be preserved. Nigeria, with a huge population of affected and at-risk women, should brace up for a new paradigm in the management of breast cancer.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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