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Institute for Global Health & Infectious Diseases

Breast Cancer

Establishment of a novel breast cancer cohort at Kamuzu Central Hospital in Malawi

Summary

(PI, Dr.Tamiwe Tomoka, enrollment paused)

In sub-Saharan Africa, breast cancer is the second most common cancer among women. In 2008 breast cancer was responsible for 64,620 new cases and 35,427 deaths. Breast cancer and cervical cancer comprise one-quarter of all cancers occurring in the region. In addition, the burden of both cancers is expected to increase by 80-90% by the year 2030. Our breast cancer study is one of the first to thoroughly examine the etiology and biology of breast cancer in Malawi, and one of the first such studies in sub-Saharan Africa. Importantly, studying breast cancer in this setting presents several unique opportunities. The high prevalence of potentially genotoxic environmental exposures, such as indoor air pollution from cooking smoke, will enable us to study gene-environment interactions that have not been seen in the U.S [9]. This study will establish procedures and infrastructure for molecular and genomic characterization of tumors, which has not been performed in African populations. Finally, it applies methods from the highly successful Carolina Breast Cancer Study, which will facilitate future cross-national comparisons of breast cancer risk and patient-reported outcomes.

The primary objective of the study is to develop a prospective cohort of Malawian breast cancer patients, who are comprehensively characterized with respect to clinical, laboratory, and histopathologic features, while receiving care according to local standards. Secondary objectives include: to assess if the clinical characteristics of breast cancer at KCH differ by HIV status, to assess the feasibility and acceptability of interviewing patients for risk factors and treatment outcomes, and to evaluate tumor blocks for histologic, molecular, and genomic characterization.

 

Symptom Management and Quality of Life Assessment Through Implementation of the African Palliative Outcome Scale in Breast Cancer Patients at Kamuzu Central Hospital in Lilongwe, Malawi

Summary

(PI, Dr.Tamiwe Tomoka, Dr. Alyssa Tilly, Dr. Shekinah Elmore, Dr. Ryan Wilkins, enrollment complete)

Palliative care is defined as care for life-limiting illness through holistic management of physical, psychosocial, and spiritual suffering.1,2 It is recognized by the World Health Organization (WHO) as a medical necessity and previous studies has shown improved quality of life and length of survival for patients with chronic illness.2-7 However, only 14% of the approximately 40 million people who require palliative care services annually receive it.3 The Palliative Outcome Scale (POS) is a patient and caregiver reported outcome measure and is widely recognized as a useful and valid tool for clinical auditing, training, and research in palliative care.17,18 It was created in the United States and has been largely applied in resource-rich settings, where palliative care services may be well-established. However, over half of the world’s population will live and die in resource-limited settings and may not have access to established palliative care.3 The A-POS seeks to ensure continuous quality palliative care assessment for patients, caregivers, and staff in resource-limited settings. It has been piloted in Malawi as part of the initial pilot study in the development of the tool and validated in South Africa and Uganda, but has not been validated for a Malawian population, where the prevalence for people requiring palliative care services is estimated to exceed 1 million.

This study will establish the validity of the A-POS for palliative care in Malawi and will ensure that the A-POS can be used as a reliable and rigorous continuous outcome measure in this population. It will also allow for comparisons of symptom management and quality of life measurements across cultures and diverse settings. This study will be foundational for the A-POS to be translated, adapted, and validated in other low-resource settings across the continent and to allow for international expansion of qualitative research on palliative care.

Objectives: Primary Objective: To translate and assess the cultural equivalence, face, and content validity of the A-POS for breast cancer patients in Malawi.

  • Objective 1: Translate the A-POS into Chichewa and complete face validation to ensure cultural correlation and understanding.
  • Objective 2: Assess differences in perceptions of symptom management and quality of life between curative- and palliative-intent breast cancer chemotherapy patients through in-depth interviews and analysis using NVivo software.

Barriers to Essential Breast Cancer Treatment Components at Kamuzu Central Hospital in Malawi

Summary

(PI, Dr.Tamiwe Tomoka, Data Analysis)

: Breast cancer in Sub-Saharan Africa (SSA) often remains undetected until advanced stages due to limited awareness and inadequate screening programs. Although curative treatments like chemotherapy, surgery, and endocrine therapy (ET) are increasingly available in Malawi and SSA, recent findings from a prospective cohort at Kamuzu Central Hospital (KCH) revealed poor outcomes and low utilization of recommended breast cancer treatments. This highlights significant gaps in delivering effective treatments, even when they are accessible and recommended by local guidelines. To improve breast cancer outcomes, it is crucial to identify and address barriers to treatment in Malawi and SSA. This study aims to investigate the barriers to initiating and completing curative-intent breast cancer treatments, including chemotherapy, surgery, and ET, at KCH in Lilongwe, Malawi. By employing a cross-sectional qualitative design, semi-structured in-depth interviews will be conducted with breast cancer patients and healthcare providers involved in the KCH breast cancer cohort. Eligible participants will include patients enrolled in the KCH prospective breast cancer cohort, with a confirmed diagnosis of breast cancer, who have been recommended to receive curative-intent treatments, and healthcare providers with prior or ongoing involvement in the KCH breast cancer cohort. This study will contribute to a comprehensive understanding of the patient and provider-level barriers to breast cancer treatment in SSA and facilitate the development of context-specific interventions to improve breast cancer outcomes. Furthermore, the unique aspect of the KCH cohort, with a high prevalence of HIV and worse breast cancer outcomes among HIV-positive patients, necessitates a specific focus on understanding the treatment barriers faced by this population.