Patient Characteristics and Outcomes of Nonmetastatic Breast Cancer in Haiti: Results from a Retrospective Cohort

Abstract

Background There are few studies on breast cancer outcomes in the Caribbean region. This study identified a retrospective cohort of female patients with nonmetastatic breast cancer in Haiti and conducted survival analyses to identify prognostic factors that may affect patient outcomes. Methods The cohort included 341 patients presenting between June 2012 and December 2016. The primary endpoint was event‐free survival (EFS), defined as time to disease progression, recurrence, or death. Descriptive summaries of patient characteristics and treatments were reported. Survival curves were plotted using Kaplan‐Meier estimation. Multivariate survival analyses were performed using Cox proportional hazards regression. Results Median age at diagnosis was 49 years, with 64.2% being premenopausal. Most patients (55.1%) were staged as locally advanced. One hundred and sixty patients received neoadjuvant therapy: 33.3% of patients with early stage disease and 61.2% of those with locally advanced stage disease. Curative‐intent surgery was performed in 278 (81.5%) patients, and 225 patients received adjuvant therapy. Adjuvant endocrine therapy was used in 82.0% of patients with estrogen receptor–positive disease. During the follow‐up period, 28 patients died, 77 had disease recurrence, and 10 had progressive disease. EFS rates at 2 years and 3 years were 80.9% and 63.4%, respectively. After controlling for multiple confounders, the locally advanced stage group had a statistically significant adjusted hazard ratio for EFS of 3.27 compared with early stage. Conclusion Patients with nonmetastatic breast cancer in Haiti have more advanced disease, poorer prognostic factors, and worse outcomes compared with patients in high‐income countries. Despite several limitations, curative treatment is possible in Haiti. Implications for Practice Patients with breast cancer in Haiti have poor outcomes. Prior studies show that most Haitian patients are diagnosed at later stages. However, there are no rigorous studies describing how late‐stage diagnosis and other prognostic factors affect outcomes in this population. This study presents a detailed analysis of survival outcomes and assessment of prognostic factors in patients with nonmetastatic breast cancer treated in Haiti. In addition to late‐stage diagnosis, other unfavorable prognostic factors identified were young age and estrogen receptor‐negative disease. The study also highlights that the availability of basic breast cancer treatment in Haiti can lead to promising early patient outcomes.

Breast Cancer in the Caribbean

“…DeGennaro et al [ 32 ] reported invasive ductal carcinoma in 87.3% of women, with a prevalence of 51.8% ER+ tumors (supposed overestimation due to over fixation), 19.6% HER2+ tumors, and 38.5% TNBC. The prevalence of 83.9% by late-stage diagnosis mentioned earlier (Patient Demographics) corresponds to Fadelu et al [ 33 ] whose cohort had 53.4% late-stage tumors (given that 23.5% were of an unknown stage). In addition, George et al [ 71 ] found the highest percentage of advanced-stage disease in Haiti in comparison to other Caribbean countries studied, where 64.7% (44 of 68) had stage III/IV BC.…”

“…In Haiti, BC presents at an earlier age and at an advanced stage, predicted anecdotally by DeGennaro et al [ 32 ], and supported by their findings where more than half (53.8%) of the BC cases were in women aged 40-59 years at diagnosis (median 49 years), 49.2% premenopausal women, and 83.9% of cases diagnosed at stage III/IV. Fadelu et al [ 33 ] also observed a median age of diagnosis at 49 years with 64.2% being premenopausal, as with Gomez et al [ 57 ], where the median age at presentation was 48.5 years among their Haitian cohort in contrast to a median of 54 years in their Miami immigrant cohort. DeGennaro et al, (2018) [ 32 ] contend the unavailability of Haitian population data to be able to calculate age-adjusted rates for significant analysis.…”

“…DeGennaro et al [ 32 ] estimated the incidence of BC in Haiti to be 23.9 per 100,000 women with a prevalence of 88.4 per 100,000 women according to GLOBOCAN 2012, and an approximate mortality rate of 45%. In 2018, the estimated number of new BC cases was >1,100, with a mortality-to-incidence ratio of >60% [ 33 ].…”

“…DeGennaro et al [ 115 ] suggested plans to establish a local pathology laboratory to meet the need for immunohistological classification of tumors and a radiotherapy treatment center, both of which were unavailable in Haiti at the time of this study. Fadelu et al [ 33 ] established the continued absence of radiation therapy and therefore unavailability of breast-conserving surgery, as well as the absence of HER2-directed therapy and targeted therapies [ 57 ]. DeGennaro et al [ 32 ] later described a high level of recurrence among Haitian BC patients after treatment (primarily having a mastectomy only) who presented to them for adjuvant chemotherapy and/or hormone therapy.…”

Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018

“…This study extends existing knowledge about breast cancer in low‐ and lower‐middle‐income countries by specifically characterizing disease characteristics, patterns of care and treatment adherence in a center with access to radiotherapy. Parallel to previously published series in the region, most women presented with locally advanced or metastatic disease 3,28‐32 . Also like most countries in the region, Zimbabwe does not currently have a national breast cancer screening program.…”