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S. F. Oluwole and O. O. Oluwole
cohort study by Kong et al. [15] demonstrates
that the frequency of various histological grades
of breast cancer varied signicantly by race/ethnicity. In Blacks, while the incidences of grade I
and II are lower than in non-Hispanic white
women, grade III incidence is higher. Similarly,
the incidences of grades I and II are signicantly
lower in Asian/Pacic Islander, Hispanic white
women, and American Indian/Alaskan native
women compared with non-Hispanic white
women.
Histologic Types Cancer cells may be in situ or
invasive depending on violation of the basement
membrane. Breast cancer can either be carcinoma in situ when the cancer cells are conned to
the ducts and alveoli or invasive carcinoma when
the malignant cells have violated the basement
membrane and spread to the surrounding stroma.
• Ductal carcinoma in situ (DCIS) was originally termed intraductal carcinoma and was
treated like invasive breast cancer. The widespread use of mammography after 1969 has
led to the diagnosis by mammography in 90%
of DCIS which appear as heterogeneous, faint,
and linear oriented calcications on mammogram (Fig.30.2) and present with a palpable
mass in only 10% of patients. Clustered
microcalcications that suggest malignancy
leads to core needle biopsy and subsequent
treatment with needle localization and excisional biopsy. Currently, treatment for DCIS is
wide local excision with clear margins followed with radiotherapy. After treatment,
there is a 30% risk of developing invasive carcinoma at the site of excision and also a 30%
lifetime risk of bilateral breast invasive
cancer.
• Invasive breast carcinoma can arise from
either the ductal or lobular components of the
breast. Nearly 75% of invasive cancer is of
ductal origin while lobular carcinoma constitutes 10–15%.
• Invasive lobular carcinoma is rarely palpa-
ble and unlikely to be visualized on mammography because it does not form
microcalcications. It has a higher incidence
of bilaterality, multifocality, and multicentricity compared to invasive ductal carcinoma and
has indistinct margins.
• Invasive ductal carcinoma usually presents
as a hard, palpable mass which shows irregular margin on USG (Fig. 30.3c), spiculated
mass or aggregates of micro calcications on
mammography. The other variants of invasive
ductal carcinoma are medullary carcinoma
(4%), tubular carcinoma (2%), mucinous carcinoma (2%), and papillary carcinoma (2%).
Regardless of race/ethnicity, invasive ductal
carcinoma is the most common pathological
pattern found among all patients. NonHispanic white women have a higher proportion of lobular carcinoma and tubular
adenocarcinoma than Black, Asian/Pacic
Islander, Hispanic white, and American
Indian/Alaskan native patience [15].
• Paget’s disease of the nipple is a form of
extensive DCIS which may be associated with
invasive carcinoma. Patient usually presents
with chronic nipple eczema with or without
erosion. Palpation may reveal a mass. The
diagnosis is conrmed on ne needle aspiration (FNA). Treatment necessitates excision
of the nipple-areola complex.
Breast Cancer Staging andSurvival
Staging describes the extent of spread of the disease at time of diagnosis. It is a useful tool in
determining the choice of therapy and in predicting prognosis of the disease. The American Joint
Committee on Cancer (AJCC) TNM Staging is
based on the extent of the primary tumor (T),
absence or presence of regional lymph node
involvement (N), and absence or presence of distant metastasis (M). Once the TNM are determined, a stage of I, II, III, or IV is assigned, with
stage I being early and stage IV being advanced
disease (Table30.3). The overall 5-year survival
rate for women with breast cancer in the USA is
98% for stage I, 92% for stage II, 75% for stage
III, and 27% for stage IV [12]. Unfortunately
many breast cancers in LMICs present late and
are stage IV, sometimes fungating.
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Table 30.3 TNM stage grouping for breast cancer
Breast cancer prognostic factors previously
emphasized primarily the presence or absence of
metastasis in draining axillary lymph nodes.
However, the recent use of immunohistochemical
tests to evaluate tumors has led to the discovery of
tumor characteristics that signicantly correlate
with disease-specic survival. Such characteris-
tics include histologic grade, hormonal receptors,
HER2/Neu, TP53, BRCA, cyclin DI, cyclin D2,
and cyclin E expression [12, 15]. Compared to
post-menopausal women, young breast cancer
patients have tumor characteristics associated
with poor prognosis. Young women with tumors
expressing HR -/HER2+and high cycling level
are associated with aggressive cancer, early
locoregional recurrence, and death [16].
Breast Cancer Treatment
The objective of breast cancer treatment is threefold, namely, eradication of locoregional disease, prevention of locoregional recurrence, and
achievement of disease-free survival. Taking
into account age, tumor size, stage, and other
tumor characteristics (histologic grade, receptor
status, and tumor subtype) as well as patient
preference, treatment may involve lumpectomy
(wide local resection of tumor with clear margin), total mastectomy (surgical removal of all
breast tissue), subcutaneous mastectomy (surgical removal of all breast tissue but preserving the
nipple-areolar complex), and modied radical
mastectomy (surgical removal of the breast combined with axillary lymph nodes dissection).
Treatment may include radiation therapy, chemotherapy (before and/or after surgery), and
hormonal therapy (tamoxifen, aromatase inhibitors), or targeted therapy (like Trastuzumab for
HER2+ tumors). Two or more modalities of
treatments are used in combination. In the USA,
a multidisciplinary approach is used for making
the appropriate decision on the treatment of
choice for all cancer patients and this is encouraged in LMICs whenever possible. Breast cancer
cases are presented at tumor board comprising
surgical, medical, radiation, and nursing oncologists, pathologists, radiologist, psychologist/
psychiatrist, nurse practitioner, tumor registrar,
patient navigator, social worker, and quality
assurance representative. Ideally, such tumor
boards should be organized in many tertiary hospitals in LMICs.
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S. F. Oluwole and O. O. Oluwole
Surgery for early breast cancer aims for
breast-conserving surgery or lumpectomy (wide
local tumor resection with free margin). This is
usually combined with radiation therapy for
stages I and II tumor. Lumpectomy with irradiation has been shown to give similar survival rates
with mastectomy (modied radical mastectomy). The 5-year survival for breast stages I and
II without lymph node involvement is 98% for
either breast conserving-surgery with irradiation
or mastectomy. If the cancer has spread to
regional lymph nodes, the 5-year survival is
84%. 10-year survival for stages I and II tumor is
80% [17].
• Surgical axillary staging for stages I, IIA,
IIB, and IIIA (T3NIM0): Breast-conserving
surgery and irradiation have become the rec-
ommended treatment for stages I and II tumor.
Sentinel lymph node biopsy (SLNB) and
axillary lymph node dissection (ALND)
have been employed to ascertain whether can-
cer has spread beyond breast tissue. Lymph
nodes draining the tumor site are identied by
lymphatic mapping using radioisotope
(Technetium- 99 sulfur colloid) or isosulfan
blue injected intradermally into the subareolar
area in close proximity to the tumor. If cancer
cells are present in the sentinel lymph node,
ALND is performed to determine if cancer
cells are present in the nodes. Indications for
SLNB include (1) men with breast cancer; (2)
multicentric or multifocal disease; (3) patients
undergoing neoadjuvant chemotherapy; (4)
elderly patients; (5) T1-T2 tumors; and (6)
DCIS treated with mastectomy.
Contraindications for SLNB are (1) T4
tumors, (2) clinically and/or FNA positive
lymph node, (3) pregnancy, (4) inammatory
breast cancer, and (5) local recurrence.
• Locoregional Treatment of Clinical Stages
I, IIA, or IIB disease or T3 N1, M0:
Early breast cancer with negative axillary
lymph nodes (AL N) is treated with lumpec-
tomy with surgical axillary staging (SLNB)
combined with whole breast radiation.
Radiation elds are increased for 1–4 or more
positive LN.Additionally, it is recommended
that radiation therapy follow chemotherapy
when chemotherapy is indicated. For large T2
or T3 tumors, it is suggested that patients be
considered for neoadjuvant chemotherapy
prior to breast-conserving surgery or total
mastectomy as indicated. When total mastectomy is the treatment of choice, it is recommended that radiation therapy should include
the chest wall and all the regional LN elds. It
is a common practice that radiotherapy should
follow chemotherapy when chemotherapy is
indicated.
• Systemic adjuvant treatment for pT1, pT2,
pT3, pN0/pN1mi, and HER2+ disease:
Treatment includes lumpectomy and radiation
of whole breast and regional lymph nodes followed by adjuvant hormonal therapy, adjuvant
chemotherapy, and Trastuzumab for women
with T<0.5. However for T>0.6–1.0cm, and
for positive lymph nodes with T > 1.0 cm,
patients should have adjuvant chemotherapy
combined with Trastuzumab followed by hormonal therapy after surgery.
If the cancer is HER2-negative for patients
with pT <0.5 cm, pNO only hormonal therapy
after surgery is used, but those with T>0.5cm
are treated with both adjuvant hormonal therapy
and chemotherapy as are those with positive
nodes.
Stage IV (any T, any N, M1): disease may
not be cured but treatment may prolong life and
improve quality of life if such advanced cancer is
treated with hormonal therapy for HR-positive
tumors and chemotherapy for HR-negative
tumors. In the developing countries where
patients present late with large, fungating, ulcerated, disguring lesions (Fig. 30.5), treatment
with a combination of “toilet” mastectomy followed by radiotherapy, chemotherapy, or hormonal therapy may be benecial.
Factors that Favor Breast-Conserving Surgery
(Lumpectomy) over Mastectomy Include (1)
location and size of tumor favorable for good aesthetic result; (2) unifocal tumors; (3) problems
with general anesthesia; and (4) patient
preference.
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Fig. 30.5 Advanced left
breast carcinoma in a
Nigerian woman
373
Factors Favoring Mastectomy over BreastConserving Surgery for Operable Breast
and exemestane), and targeted agents
(Trastuzumab).
Cancer Include (1) multifocal or multicentric
lesions; (2) inability to achieve negative margins
after reexcision; (3) medical contraindications to
radiation therapy; (4) unfavorable tumor-tobreast ratio; (5) patient preference; (6) anticipated difculty with follow-up especially in
LMICs; (7) previous breast or chest therapeutic
irradiation; and (8) early in pregnancy (rst and
second trimesters).
cer augments disease-free survival after lumpectomy because breast irradiation controls
subclinical residual tumor. Additionally, radiation
to chest wall and regional lymph nodes decreases
locoregional disease recurrence. Indications for
radiation therapy include both post wide excision
for DCIS and post wide excision (lumpectomy)
for early stage invasive cancer, as well as post
mastectomy in high-risk women (T3–4, nodal
Systemic adjuvant chemotherapy is the
administration of cytotoxic agents after primary
surgery for early-stage breast cancer. It is
involvement, high histologic grade, HR-negative,
and HER2/Neu over expression) and especially in
inammatory breast cancer.
designed to eliminate or delay the recurrence of
clinically occult micrometastatic disease that
eventually leads to treatment failure. Details of
management of chemotherapy are beyond the
scope of this book and should be sought in most
recent literature and textbooks on this subject.
Neoadjuvant chemotherapy is being increas-
interferes with estrogen-mediated signaling path-
ways or interrupts the synthesis of estrogen has
become an integral part of the management of
hormone-dependent breast cancer. These include
selective estrogen receptor modulator (SERM)
and aromatase inhibitors (AI).
ingly used in patients with operable breast cancer, either to improve the likelihood of
breast-conserving surgery or to attain pathologic
complete response. Neoadjuvant therapy may
also predict the subsequent response to the same
agent. Agents that have been evaluated in neoadjuvant therapy include taxanes (paclitaxel,
docetaxel), doxorubicin/cyclophosphamide
(AC), aromatase inhibitor (letrozole, anastrozole,
(SERM) commonly used are tamoxifen and ral-
oxifene. Tamoxifen is a compound with both
estrogen-like and anti-estrogen properties
(SERM). It has been demonstrated to reduce the
risk of developing cancer in the contralateral
breast in ER-positive early breast cancer patients
by 45–55% over 10 years after treatment [18].
Additionally, tamoxifen is synergistic with che-
Adjuvant radiotherapy for early breast can-
Adjuvant hormonal therapy that either
Selective estrogen receptor modulators
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S. F. Oluwole and O. O. Oluwole
motherapy in improving disease-free survival
and is effective in treating advanced disease.
Tamoxifen therapy is associated with side effects
that include increased risk of endometrial cancer
and thromboembolism; however its use has also
been shown to improve lipid prole, preserve
mineral bone density, and decrease the incidence
of hip and spine fractures [18]. Tamoxifen is a
rst-line hormonal therapy for premenopausal
women with or without ovarian suppression for
at least 5 years. Following 5years of adjuvant
tamoxifen therapy, a second course of tamoxifen
or aromatic inhibitor is recommended because it
further improves disease-free survival.
Aromatase inhibitors (AI) (anastrozole,
letrozole, and exemestane) block the conversion
of androgens to estrogens in breast tumors, fat,
muscle, and liver. AI reduces the stimulatory
effects of estrogens on breast tumors by suppressing the formation of estrogens in all women,
particularly post-menopausal women who
depend on this source of estrogen. Therefore, AI
has superior outcomes compared to tamoxifen
use in post-menopausal women [18]. It is the recommended hormonal therapy for postmenopausal women with ER-positive breast
cancer. The rst dose is given for 5years and this
is followed by additional 5years which has been
shown to lower risk of relapse and also reduce
cancer-related mortality.
Trastuzumab therapy for HER+ tumors is
used since these are relatively resistant to certain
types of chemotherapy. Trastuzumab improves
the outcome of patients with HER2-positive invasive stage II or III breast carcinoma. It is also efcacious in the treatment of metastatic HER2+
breast cancer when combined with chemotherapy
especially docetaxel. With combined treatment,
women with HER2 overexpressing metastatic
breast cancer showed a 20% decrease in relative
risk of death. Unfortunately Trastuzumab therapy
is associated with 0.5 to 1% cardiac toxicity [19].
Breast Cancer Prevention
The fear of developing breast cancer with its
consequences has raised the question of how
can women with a family history or in the
high-risk group with genetic predisposition
prevent breast cancer. Currently the risk reduction strategies include regular surveillance,
prophylactic mastectomy, oophorectomy or
both, and chemoprevention. The two strategies
that have proven to reduce the risk of breast
cancer in high-risk patients are prophylactic
mastectomy and use of chemopreventive drugs
[18, 20].
Prophylactic mastectomy is indicated in
women with genetic predisposition, women
with one breast cancer, and women with atypia,
LCIS, and DCIS. Prophylactic bilateral total
mastectomy prevents breast cancer in young
women with BRCA1/2 mutations [20]. Since
cancer of the ovary is associated with BRCA
mutation, it is recommended that such patients
should consider simultaneous bilateral mastectomy and oophorectomy. Recently, younger
women under 40 years are more eager to
choose prophylactic mastectomy for reasons
that include their reluctance to undergo radiation therapy, fear of recurrence, and a desire
for aesthetic appearance. It is strongly recommended that all these patients undergo counseling before the surgical procedure.
Consideration for prophylactic mastectomy in
women with unilateral breast cancer includes
(1) genetic predisposition, (2) diffuse microcalcications, (3) LCIS, (4) large breast which
is difcult to evaluate, (5) history of LCIS followed by invasive breast cancer, and (6) atypical hyperplasia.
Chemoprevention drugs such as adjuvant
tamoxifen have been shown to reduce the risk of
new cancer in the contralateral breast by
47–55% in women 49years or younger and by
55% in women age 60 and older [21]. Women
with atypical hyperplasia experienced an 86%
risk reduction. Similarly, raloxifene study in
post-menopausal women with osteoporosis has
shown a 76% reduction in relative risk for invasive breast cancer [21]. The use of tamoxifen
and raloxifene prophylactically showed an equal
(50%) reduction in the risk of developing invasive breast cancer. There is not enough data yet
to support the use of tamoxifen for the prevention of breast cancer in patients with genetic
mutations.
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Racial Disparities inBreast Cancer
Outcomes
In recent years, breast cancer prognosis has
improved. Whereas the incidence of the disease
is higher in whites compared to blacks, the mortality rate is higher in black women than in white
women [12, 16]. This has been attributed to many
factors, primarily in LMICs, that include poverty,
lack of health awareness, later stage at diagnosis,
socioeconomic status, and various barriers to
healthcare. In wealthy countries, there are problems of higher prevalence of obesity and comorbidities, disparity in treatment, type of insurance,
and unfavorable biologic characteristics of the
tumor. More recently, biologic factors have been
shown to inuence the prognostic disparities in
breast cancer [22].
Inuence ofUnfavorable Tumor
Biologic Characteristics onSurvival
It is difcult to compare the disparities from data
in wealthy countries with lack of data from
LMICs. Interestingly, the younger age distribution seen among African American women in the
USA is similar to the nding that 57% of the
women with breast cancer in Nigeria were
younger than 50years at diagnosis [10]. Of note
is the nding that young premenopausal women
develop a more aggressive, larger breast tumor
with higher histologic grade, which are ER negative and have more lymph node metastasis [16].
All these ndings are associated with poor
prognosis.
Another unfavorable factor is the advanced
tumor stage at diagnosis in black women both in
wealthy countries [5] and in LMICs [10]. This
has been shown in the studies from Nigeria where
81% of the patients presented with stages III and
IV disease [10, 23]. Non-Hispanic Black women
have a signicantly higher T4-sized tumors and
stage IV disease than non-Hispanic white women
[15]. These ndings demonstrate that early breast
cancer diagnosis in African American women
lags behind that of white women and that also
appears to be the case in Nigeria and Sub-Saharan
Africa (SSA).
In terms of hormonal markers, African
American women have many more ER-negative
tumors than white women [12], and ER-negative
expression is an adverse prognostic factor that is
associated with poor survival.
Breast cancer subtypes are also strongly
inuenced by race and menopausal status; the
highest prevalence of basal-like and lowest
prevalence of luminal A tumors were observed
among premenopausal African American breast
cancer patients [15]. The basal-like/triple-negative cancers exhibit aggressive features that
include high proliferative index, high histologic
grade, high nuclear grade, and frequent TP53
mutation [16]. Compared to US-born blacks,
the prevalence of the triple-negative tumor is
47% lower in women born in East Africa but
only 8% lower in West Africa-born blacks [12].
Higher incidence of triple- negative cancer is
associated with poor breast cancer survival in
blacks.
By histologic grade, African American women
have most commonly grade 3 breast cancer
(45.2%) while grade 2 is the most frequently seen
breast cancer grade in non-Hispanic white
women (43.3%) [12]. Thus, African American
women have more aggressive tumors associated
with poorer prognosis.
Although BRCA 1&2 identication has contributed greatly to understanding the cause of
hereditary breast cancer risk among white
women, the prevalence of mutations among
African American women and blacks in Africa
has not yet been well studied.
Barriers toHealthcare inAfrican
American andBlacks Worldwide
African American women and black women in
Africa and the Caribbean Islands with breast cancer are more likely to die from the disease than
women of any other race or ethnicity. The higher
breast cancer mortality among black women
compared to non-Hispanic white women in the
USA is due to a myriad sociocultural, economic,
behavioral, environmental, and educational factors. The major healthcare barriers to breast cancer include:
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1. Poverty: Many patients especially the poor
and uninsured meet signicant barriers to
obtaining timely healthcare in medically
underserved communities in the USA [5] and
even more so in LMICs; these barriers include,
but are not limited to, nancial income, communication, and healthcare. Poor people, particularly in LMICs, face substantial obstacles
to obtaining cancer care and often do not seek
care if they cannot pay for it. Poverty is commonly associated with low educational level,
substandard living conditions, inadequate
social support, unemployment, and diminished access to healthcare. Poverty does not
only impede access to the healthcare system,
it is associated with cofactors that can negatively affect outcomes, such as comorbidities,
lack of breast health awareness, and mistrust
and misunderstanding of the system.
2. Breast cancer screening: Randomized con-
trolled trials of mammography screening have
shown that regular screening signicantly
improves breast carcinoma outcome due to
detection of the disease at an early stage [4,
5]). Unfortunately, the vast majority of women
in the developing countries [10, 23] present
with late stage disease compared to nonHispanic white women [24]. The most dramatic effect of mammography screening is
the marked reduction in the size of invasive
tumors associated with an increase in the percentage of breast conserving surgery in
screened patients.
3. Disparities in treatment: Compared to
whites, black women are more likely to have a
delay in recall for abnormal mammography
studies and also for initiating therapy for
breast cancer diagnosis [22]. They also have a
higher incidence of misuse of treatments.
Similarly, African American breast cancer
patients suffer from racial disparity in the
underuse of appropriate adjuvant chemotherapy. And they have less access to timely and
high-quality care and treatment [25]. Data on
this subject for patients in LMICs is scarce
and is urgently needed.
4. Comorbidity: There is a preponderance of
morbidity among African American women
compared to whites. It is unknown whether
this is true for patients in LMICs. The major
problems have been morbid obesity, hypertension, and diabetes mellitus [24]. More women
die of competing comorbidities than of breast
cancer among African Americans and it is
unknown for patients in LMICs.
5. Insurance and cost-related barriers to can-
cer care: Paying for the costs of treatment
should not be a concern with diagnosis of cancer, but for many, it becomes an important
issue. For many cancer patients, nancial barriers delay or limit access to treatment and
supportive services both in the USA and more
so in SSA, and for almost all patients, cancer
treatment presents a signicant burden. Lack
of access to healthcare, regardless of reason,
adversely affects cancer care.
Intervention toCorrect Breast
Cancer Disparities
African American women and women who live
in LMICs are more likely to develop and die from
breast cancer than any other racial and ethnic
groups. This section discusses some of the plans
that can improve or eliminate the observed disparities in breast cancer outcome.
Patient Navigation Program
Patient navigation has evolved as a strategy to
improve outcome in vulnerable populations by
eliminating barriers to timely diagnosis and treatment of cancer patients. The Harlem Hospital
patient navigation model established in 1990,
where this author (S.F.O.) was a former director,
is comprised of a team of lay and professional
patient navigators that collaboratively assist
patients from initial screening through diagnosis,
treatments, and follow-up care [5, 26]. It is a
patient-centered model that provides one-on-one
assistance to any patient with a positive nding in
order to diminish and eliminate barriers to treatment. Additionally, there is an outreach component of the program which promotes cancer
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prevention and encourages appropriate cancer
screening for detection, diagnosis, and treatment.
The program’s intervention is to promote and
support community (and could be country) based
patient navigation particularly among the poor
who experience barriers to breast healthcare. The
Harlem Hospital experience over 10 years
showed improvement in survival rate from 39%
prior to patient navigation to 70% after 10years
of navigation based on earlier detection and earlier intervention [5, 26].
How does the patient navigator help patients?
Through one-on-one contact, the patient navigator has been trained to work with the patients
to help them solve problems and overcome barriers that might keep them from getting the care
they need. A navigator knows the healthcare system and the community of patients served. They
can communicate with the patients and patients’
caregiver(s) while anticipating and solving problems to clear the path from timely diagnosis and
treatment through to resolution. No woman
should present with advanced stage breast cancer
at diagnosis because of barriers to obtaining
prompt medical care, especially those living in
rural areas, as they do now in most LMICs. None
should go untreated, irrespective of their socioeconomic status or should be forced to spend
more time ghting their way through the healthcare system than ghting their disease.
A review of breast cancer in Nigeria suggests
that the patient navigation model described above
that includes both lay and professional navigators
may be optimal to help patients in the LMICs.
Although breast cancer in Nigeria is the most frequently diagnosed cancer in women, 5-year survival for all stages is 10–15% [10, 23] compared
to 87% for American women [12]. This disparity
in survival rates is due to late stage presentation
which is very common in all LMICs. This has
been attributed to poverty, lack of transport, fatalism about cancer, alternate care, communication
and information barriers, and medical system
barriers [27]. In most hospitals in LMICs, there
are no facilities for mammographic screening. It
is inconceivable but true, that other LMICs, like
Nigeria with its manpower and nancial
resources, have not developed a National Health
Policy on prevention, early detection, diagnosis,
and treatment of breast cancer that includes cancer education and outreach programs to ght the
dreadful effects of the disease. This is why a
Patient Navigator System is sorely needed in
most, if not all, LMICs. Such a program will raise
public awareness of early detection, prevention,
and treatment of cancer, coordinate education
and screening programs to increase early detection, develop culturally sensitive outreach programs and educational materials, establish a
Physician education program, including courses
and credits for clinical oncologists as well as
non-cancer clinician, and develop regional and
national tumor boards that hold conferences to
ensure standardized treatment.
Tumor Board andCoordination
ofTreatments
Breast cancer management is a multidisciplinary
team of care providers comprising surgical, medical, and radiation oncologist, oncology nurse,
social worker, psychologist, navigator, and tumor
registrar. Unfortunately, most hospitals in the
rural areas, especially in the LMICs, have no
functioning tumor board. Since the healthcare
delivery system in such hospitals is suboptimal,
breast cancer patients are better referred to tertiary teaching hospitals from the rural district
general hospitals. A way of improving care for all
women, particularly recovering from primary
surgery, is to ensure that triage to medical oncology is successfully accomplished. Reducing such
missed opportunities to facilitate oncology referrals and enabling receipt of appropriate adjuvant
chemotherapy has the potential to reduce racial
disparities in treatment.
Use ofInformation
andCommunication Technology (ICT)
ICT offers a great opportunity to electronic health
records, telemedicine, clinical decision-making,
and links among professionals and between professionals and patients. This is particularly
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important in the developing countries where
communication and information barriers contribute to poor patient outcome. This is discussed in
greater detail in Chaps. 8 and 12. The government can afford to make available to the healthcare providers in rural hospitals the network
facilities for virtual care. Telemedicine will give
healthcare providers in primary care facilities the
opportunity to consult with specialists in tertiary
teaching hospitals either in their home countries
or in specialist hospitals abroad (Europe, the
USA, and Middle East). Virtual consultations/
conferences will improve patient outcomes in
vulnerable communities by integrating ICT with
physician expertise, and collaborating with existing global healthcare.
Breast Cancer During Pregnancy
andLactation
Although breast cancer during pregnancy or lactation is very rare, it is still the most common
malignancy in pregnant women and occurs at a
rate of 1in 3000 pregnancies [28]. It constitutes
0.9–2.8% of all breast carcinomas in white
women [6] compared to 4.3% in Nigerian women
[10]. The mean age of pregnant white women
with breast cancer is 33.4 years compared to
28.8 years in Nigerian women. Again pregnant
women in Nigeria present with late stage disease.
The disease is a challenge to patients and physicians due to difculties encountered with diagnosis and treatment. Breast palpation is difcult
because of breast engorgement. Diagnosis of
breast masses during pregnancy is made with
USG and core needle biopsy since mammography is contraindicated. Treatment is based on
tumor stage and the trimester of pregnancy. The
protocol for management is based on modication of the multidisciplinary management recommended by Keleher etal. [28] and differs for each
trimester of pregnancy. The pregnancy is terminated if axillary nodes are positive in the rst trimester; otherwise the patient is treated with
MRM or breast-conserving surgery for stages I
and II cancer with continuation of pregnancy. In
the second trimester decision is more difcult
and patient has to decide about continuation of
pregnancy as chemotherapy is used for all stages.
In the third trimester, the pregnancy is continued
and standard therapy is used with chemotherapy.
Chemotherapy used in pregnancy that is considered to be relatively safe is a combination of
5-uorouracil, doxorubicin, and cyclophosphamide (FAC).
Male Breast Disease
The male breast is a rudimentary structure composed of small glands with brous tissue and
periductal fat. The common disorders of the male
breast are gynecomastia and carcinoma.
Gynecomastia
Gynecomastia is hypertrophy of the breast due to
excessive development of the male mammary
glands. It can be seen in boys at puberty or in old
men. Gynecomastia can be unilateral but is often
bilateral in most patients. There is also a brous
form which is comprised of dense cellular connective tissue with fewer ducts. Gynecomastia is
usually evaluated with palpation for presence of
masses and ultrasonography for conrmation of a
mass and for FNA. Mammography is recommended when there is suspicion for malignancy.
Causes of gynecomastia include chromosomal
abnormality (Klinefelter’s syndrome), endocrine
dysfunction, or exogenous hormonal use.
Occasionally, gynecomastia may result from use
of exogenous hormones or medications (cimetidine, digoxin, etc.)
Treatment is either surgical or pharmacological. Surgical treatment can be liposuction or subcutaneous mastectomy. Pharmacological
treatment includes endocrine therapy using antiestrogens (tamoxifen, clomiphene, and danazol).
Male Breast Carcinoma
Breast cancer is a rare disease in men and constitutes less than 1% of the total breast cancer cases
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worldwide. Male breast cancer incidence for all
breast cancer cases varies wildly between geographical regions with a 12% incidence in
Uganda compared to 2% in Nigeria and less than
1% in white men in the USA [8]. This geographic
incidence rates are likely partially due to inadequate data collection and to lack of awareness of
the disease in men which leads to diagnosis at a
late stage which adversely affects its prognosis.
The diagnostic work up for male breast cancer
consists of USG, mammography, and FNA
biopsy.
Risk factors for male breast cancer include
age, BRCA 1/2 mutation, PALB2, Klinefelter’s
syndrome, exogenous estrogen or progesterone
use, obesity, and chest wall radiation [29]. In contrast to female breast cancer, males have a much
higher percentage of hormone receptor positive
tumors but signicantly lower HER2 over expression. Staging of male breast carcinoma is the
same as that of women using the TNM system.
More than 40% of men with breast cancer present
with stage III and IV disease [8].
Surgical options for men with early stage
breast cancer are either MRM or breastconserving surgery. Stages l IB, III, and IV are
treated with modied radical mastectomy followed by chemotherapy, radiotherapy, and/or
hormonal therapy for ER-positive tumors like in
women. Men who develop metastatic disease
respond well to endocrine therapy. The overall
survival is worse in men than in women.
Prognosis of male breast cancer in node positive
patients is very poor.
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