There still remains a variance in age of initiation, frequency and termination of screening among different authorities in the US as shown in table 1 (6). In the UK, women aged between 50 and 70 years are invited for breast screening every 3 years (7). Women with a lifetime risk of developing cancer greater than 20%, BRCA 1 or BRCA2 gene mutation, history of chest wall radiation between the ages of 10 and 30 years or those with history of hereditary syndromes that predispose them to breast cancer such as Li-Fraumeni or Cowden are recommended to have screening MRI (8). At present, Kenya does not have a national breast cancer screening program and this could account for the late presentation as seen by Makanga et al. (9). In our setting, long term population studies should be carried out to evaluate the benefit versus the harm of breast cancer screening programs given the cultural variations and healthcare access, among other factors. Only then can we develop evidence-based guidelines on breast cancer screening. Breast cancer is diagnosed through triple assessment: clinical, radiological and pathological. Clinical assessment is vital in establishing the overall performance status of the patient and acts as a guide on the best management modality from local interventions such as surgery and systemic treatments. calcifications in the breast. Secondly, in a patient with a palpable lump, the mammogram offers further assessment of the rest of the breast to determine if the abnormality is multifocal (two or more lesions in the same quadrant) or multicentric (two or more foci in different quadrants of the same breast) as this will have impact on the type of surgery offered. Thirdly, mammogram offers evaluation of the contralateral breast. Ultrasound of the breast can be used in further characterization of a breast mass or a mammographic abnormality as well as in the assessment of the axilla for the presence, and nature, of lymph nodes. Both imaging modalities have been used in guiding biopsy of breast and the axilla. A comprehensive analysis of the utility of radiology in BC is beyond the scope of this editorial. Pathological assessment of the breast is done through cytological or tissue analysis. Fine needle aspirate (FNA) is useful in analysis of suspicious lymph nodes in BC.

However, FNA should not be used independently to obtain a non-operative diagnosis of breast cancer (10). Core biopsy has become the gold standard in assessment of a suspicious breast lesion as it not only offers the morphological classification but also allows for molecular subtyping that guides treatment and prognostication of patients. Open breast biopsies are discouraged as they alter the margins of the tumor and often lead to non-oncologic resection. Two recent studies (5,11) demonstrated that the molecular subtypes in Kenya and Uganda are similar to global trends: majority of cancers were classified as Luminal A, which has the best prognosis. The hormonal and oncogene HER-2 neu expression guides in the choice of optimal management options for BC patients such as response to chemotherapy, hormonal therapy and targeted therapy. This information is crucial from the time of diagnosis through a core biopsy and should be obtained in all patients suspected to have BC. Surgical management of curative breast cancer involves either modified radical mastectomy or lumpectomy plus radiotherapy (breast conserving therapy). The goal of breast conserving therapy (BCT)-the standard of care for early disease- is optimal oncologic control with breast conservation for cosmetic reasons (12, 13). With regards to the management of the axilla, surgery has evolved from Halsted’s axillary clearance through Patey’s level 1 and 2 axillary dissection to sentinel lymph node biopsy (SLNB). SLNB has been practiced in Kenya since 2008. Adjuvant therapy greatly varies from patient to patient depending on several cancer and patient factors after assessment of the histology report. Post treatment follow up is through serial clinical and radiological assessment with the aim of detecting recurrence. The advent of neoadjuvant hormonal and chemotherapy has played a big role in advanced breast cancer, which comprises a significant percentage of the cases seen in the region. This is aptly captured in this collection from the Annals of African Surgery. Neoadjuvant therapy downstages BC and hence prevents extensive surgery for both breast and axillary disease (14, 15). Neoadjuvant endocrine therapy (NET) has been utilized in post-menopausal women who were not initially fit for surgery or chemotherapy due to co-morbidities. With highly effective aromatase inhibitors, the spectrum of NET has expanded in breast surgery (16). Metastatic breast cancer is still sadly diagnosed in a significant proportion of patients (17). The treatment approach to these patients is usually palliative. In conclusion, there is need to have BC patients managed in multidisciplinary teams in order to explore all possible therapeutic options. These teams need to aim for the best treatment in the interest of the patient. Additionally, it is paramount to encourage all BC patients to belong to support groups in order to address other essential needs that may be beyond the clinical realm such as family support, nutrition, spiritual and pain management needs.

Click To View Table 1

References

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3. Otieno ES, Kimende SK, Micheni J. The pattern of breast diseases at Kenyatta National Hospital. 2008; Annals of African surgery 2008; 2:25-9

4. Sayed S,Moloo Z, Wasike R et al. Ethinicity and breast cancer characteristics in Kenya. Breast cancer Res Treat 2018; 167(2):425-37

5. Receptor status and Associated clinic-histopathological charactersitics among women with breast cancer in a Ugandan Tertiary Hospital.

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7. Breast cancer screening- NHS. https://www.nhs.uk/conditions/breast-cancer-screening/

8. Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 2010;7(1):18–27. 


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10. Borelli C, Cohen S, Duncan A et al. NHS screening programme. Clinical guidance for breast cancer screening assessment. 4th Edition, 2016

11. cancer Molecular subtypes and their clinicopathological characteristics amongst patients at the Aga Khan University hospital (Nairobi). Annals of African Surgery. 2010; 5: 19-24

12. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347(16):1233–41. 


13. Litie`re S, Werutsky G, Fentiman IS, et al. Breast conserving therapy versus mastectomy for stage I– II breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial. Lancet Oncol 2012;13(4):412–9. 


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16. Singer CF. Neoadjuvant endocrine therapy in breast cancer. Breast Care 2008;3(5):1508-16

17. Nabawanuka A, Galukande M, Nalwoga et al. Metastatic Breast Cancer and Hormonal Receptor Status among a group of women in sub-Saharan Africa. Annals of African Surgery 2013;10(2):7-11

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