Short-Term Surgical Mission in Sub-Saharan Country, Experience of a Breast-Dedicated Team: Reviewing the Past and Stepping Toward the Last Mission

PURPOSE

The present article aims to present the data of a Breast Cancer Team Short-Term Surgical Mission in Guinea-Bissau in the setting of the National Bissau Hospital, Hospital Nacional Simão Mendes, level A referral health structure.

PATIENTS AND METHODS

Patients with breast disease have been presented to our team for in loco consultation during the total of three missions in 1 year. We have observed a total of 97 female patients with age ranging from 12 to 70 years. We performed 21 excisional biopsies, five radical surgeries, and 28 needle biopsies.

RESULTS

There have been diagnosed 19 invasive breast cancer cases in stage IV, and in seven patients, the biopsy resulted in malignancy. On the recall consultation of the needle biopsied patients, just two returned and accepted the proposed treatment. Major issue has been the lack of trained pathology technicians for adequate sampling conditioning, a fact that led to a poor quality of 18 samples.

CONCLUSION

Access to surgical care is disparate across the world, and short-term surgical missions are often call-in action to deliver not only patient care but also local staff training. Complex disease management, such as cancer, may create several problems being conditioned by the lack of basic resources required. In Guinea-Bissau, a poor country with very few inhabitants, the need to implement an anticancer national strategy is urgent but seems feasible. Any action should prioritize local team training and enhance specialization. No external intervention can provide any long-term benefit for patients if they are detached from local health workers.

INTRODUCTION

Access to surgical care is disparate across the world, and short-term surgical missions are often call-in actions to deliver not only patient care but also local staff training.¹ Even if in some cases these short-term surgical mission actions can resolve important health issues, such as groin hernias, conditioning the quality of life of a mainly agricultural population, other more complex diseases, such as cancer, may create several problems because of the lack of basic resources required.

CONTEXT

• Key Objective

• To our knowledge, this study provides the first reported data on breast cancer in Guinea‐Bissau.

• Knowledge Generated

• Breast Cancer incidence rises in sub-Saharan countries, especially in very young women. Definition and implementation of screening program must become an urgent issue of public health.

• Relevance

• Data reported can help international community to understand the dimension of the problem and to implement strategies adapted to the local real life needs.

In the present study, we present our 1-year experience, incorporating the Short-Term Medical Mission (ONG SSTENE STMM) in Guinea-Bissau (GB), approaching breast disease in the setting of the National Bissau Hospital, Hospital Nacional Simão Mendes, level A referral health structure. The purpose of this article was to provide insight into a completely unknown reality regarding breast cancer treatment in an extremely low-resource setting.

PATIENTS AND METHODS

The ONG SSTENE has organized various short-term medical and surgical missions since 2018, interrupted during the pandemic and restarted in September 2021. Each mission comprises various specialists and registered nurses (around 30 elements each week of action) that provide health care to those previously identified by local medical staff and patients. The breast-dedicated team participated in three weekly missions: October 2021, January 2022, and August 2022 for a total of 15 working days. Our team comprised a specialized breast surgeon, a breast unit nurse, two general surgeons, and one local surgeon who accompanied outpatient visits and surgical activities.

Patients were previously referred to our team by various attending physicians of the hospital (surgery and gynecology departments) and patients from the emergency department.

During these missions, a total of 97 female patients with age ranging from 12 to 70 years were included. Medical history was collected and registered, an objective examination was performed, and in all cases, a treatment plan was traced/proposed.

The collected data were stored in an ONG database and used to keep a traceable registry of the patients as well as to orient the next missions in terms of individual patient management (for example, in the case of biopsied lesions, the information is sent back to the attending local physician in conjunction with the treatment plan).

The major difficulty faced during the missions has been the lack of complementary examinations and the level of communication with the patients, and even if the official language (Portuguese) has been used, in most cases, the auxilium of a local staff member interpreting the Crioulo dialect and creating confidence bridges with the patients.

RESULTS

A total of 97 female patients with age ranging from 12 to 70 years with an average of 33.9 years have been consulted.

There have been identified nine menopausal women, with the rest being premenopausal.

In two menopausal woman there were reported diabetes mellitus medicated, in five cases hypertension, and in seven premenopausal woman a family history of a first-degree diagnosed breast cancer (all of them younger than 50 years). No HIV case has been reported, even if HIV infection is considered to be the most prevalent health issue in GB.

Seventeen patients had just an echographic breast evaluation with findings in disparity with the in loco clinical evaluation (in terms of regularity of the lesions, dimensions, and localization) and did not meet the international BI-RADS classification criteria. Twelve of the complementary examinations had been performed at least 6 months ago, and 14 cases were executed in a nearby country.

A total of 39 patients presented with complaints of self-detected masses ranging from 20 to 110 mm on palpation. Ten patients presented with locally advanced breast cancer (Fig 2-4). Two patients, one of whom was premenopausal, presented with Paget disease of the nipple (Fig 5), three patients with en cuirasse breast cancer, and four with inflammatory breast cancer. Two premenopausal patients had metastatic breast cancer (MBC), bone, cutaneous, and liver disease (diagnosed by clinical signs such as irregular hepatomegaly, pathologic proximal femoral fracture, and subcutaneous nodules of the trunk).

FIG 2.

Locally advanced breast cancer.

FIG 4.

Locally advanced breast cancer.

FIG 5.

Paget disease of the breast and LABC. LABC, locally advanced breast cancer.

FIG 1.

Age distribution of patients.

FIG 3.

Locally advanced breast cancer.

There have been 26 surgical approaches, 21 excisional and five radical procedures, while 28 Tru-Cut and fine-needle biopsies have been performed, resulting in three benign lesions and seven malignancies; the missing 18 were not properly conditioned to be analyzed by the Portuguese referral laboratory. The biopsy-identified malignancies were as follows: one in situ Ductal Carcinoma ER-positive, one lobular carcinoma, and five ductal carcinomas (three triple-negative, one luminal A-like, and one luminal B-like).

The younger patient diagnosed with carcinoma was age 23 years with triple-negative ductal carcinoma.

In the group younger than 20 years, there have been diagnosed two phyllode border-line tumors and four fibroadenomas.

In the recall consultations, only two of the malignancy-biopsied patients returned while in the cases of refusal of the proposed plan, in the majority, the need to have the husband's, father's, or brother's authorization has been the main reason.

All operated patients provided informed consent, and prosthetic material and bras were offered.

Postoperative patient care was secured with the collaboration of the local staff by means of telemedicine (video-assisted live internet connection).

In Table 1, we summarize the activities of the team, being of special interest the need of the population to elaborate evacuation urgency reports to accelerate the already initiated procedure, that in most of cases presented a delay of almost 17 months. The procedure for evacuation of a suspected breast disease from the GB to Portugal for definitive diagnosis and treatment is particularly moraceous. This procedure starts with the attending physician elaborating a report, clarifying the level of suspicion, and the lack of means to investigate/treat. This report is evaluated by a Commission and then centralized to the Sanitary Authority, where a protocol number is allocated in a communication platform with the Portuguese Central Health Services Direão Geral da Saúde (DGS). Afterward, the DGS distributes the process to the referral Portuguese hospital, which must book a consultation and communicate the date of the booked appointment. The next step is for the Guinee authority to communicate the date to the Portuguese Consulate of GB, and the last step proceeds to the emission of a visa for a specific patient. Consequently, most patients with locally advanced breast cancer and MBC could potentially have been treated according to the international guidelines for breast cancer.

TABLE 1.

Summary of the Activities

During this period, with respect and in partnership with the local physicians, there has been training in all aspects of breast disease, since the patient risk assessment, objective examination, biopsy technique to the surgical technique of modified radical mastectomy, our team was the first to perform this procedure in the Hospital Simão Mendes. Our focus was that both patients and physicians understood the risks, benefits, and limitations of surgery, especially in available care facilities.

DISCUSSION

GB is a small country located on the Atlantic coast in West sub-Saharan Africa, a former Portuguese colony with almost two million inhabitants. The nation achieved its independence in September 1973 but remains one of the 10 most impoverished countries in the world, ranking 175th on the human development index. More than two thirds of the country's population live in poverty.²

GB's GDP per capita is one of the lowest in the world, and its human development index is one of the lowest on Earth.³

According to the 2022 revision of the World Population Prospects, GB's population was 2,060,721 in 2021 compared with 518,000 in 1950. The proportion of the population younger than 15 years in 2010 was 41.3%, 55.4% were age between 15 and 65 years, and 3.3% were age 65 years or older.

Although the only official language of GB since independence, Standard Portuguese is spoken mostly as a second language, with few native speakers, and its use is often confined to intellectual and political elites. Schooling from the primary to tertiary levels is conducted in Portuguese, although only 67% of the children have access to formal education.

The health system of GB is divided into three levels: 11 regions and 114 health districts. It is mainly organized in the public, private, and ONG sectors. This system includes the pharmaceutical sector, which is divided into public and private sectors (for profit and nonprofit).⁴

Trained doctors tend not to stay in the GB for long periods. There are only three pediatricians, four obstetricians, one anesthetist, and 34 midwives in the country.^4,5

Rural populations lack access to health care. Almost 66% of the population live more than 5 km from the nearest health structure.⁴

The treatment of cancer is a rising global health priority, and in 2030, an estimated 22.2 million patients will be newly diagnosed with cancer, and 70% of these cases will occur in low-income countries (LICs).⁵ Mortality is predicted to remain significantly higher in low-income countries (75%), but despite these regions having the highest burden of attributable mortality, only a 5% of global cancer spending occurs in LICs.⁶

Surgery is a major pillar of cancer treatment, serving not only as a curative treatment but also in preventive and palliative roles. By 2030, an estimated 45 million cancer operations will be needed worldwide.⁵ However, five billion people in LICs currently lack access to essential surgical care, and < 5% of patients in low-income settings have access to safe, affordable, and timely cancer surgery. The greatest unmet surgical need exists in Africa and South Asia, but the specific cancer incidence in these regions is largely unknown because of the limited screening and research infrastructure.⁶

In total, 801,392 new cancer cases and 520,158 cancer deaths were estimated to have occurred in sub-Saharan Africa in 2020. Cancers of the breast (129,400 female cases) and cervix (110,300 cases) were responsible for three ten of the cancers diagnosed in both sexes. The disease is among the three leading causes of premature death (at age 30-69 years) in almost all constituent countries and is responsible for one in seven premature deaths overall and one in four deaths from noncommunicable diseases.⁷

In the case of GB, all available data on breast cancer have been extrapolated through neighboring country registries, and no national data on incidence, prevalence, or mortality are known.⁶

Modern breast cancer treatment lies in three major axes: surgery, chemotherapy, and radiotherapy. In order for a patient to be proposed for treatment, in actual practice, always in a multidisciplinary meeting setting, there has to be a histology report.

According to NCCN guidelines for specific basic resources setting, the central component of the treatment of breast cancer is full knowledge of extent of disease and biologic features. These factors contribute to the determination of the stage of disease, assist in the estimation of the risk of recurrence, and provide information that predicts response to therapy (estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2).⁸ This basic facility is not available in GB, a fact that limits every attempt to offer an even suboptimal treatment to the population.

GB has no available pathology laboratory or trained pathology technician, no breast dedicated/trained surgeon, and no medical oncologist, chemotherapy, or radiotherapy facilities. The only anticancer medication that can be found is tamoxifen, which is provided by a pharma ONG, Ayuda, Intercambio y Desarrollo.

According to the WHO, to overcome the cancer treatment challenge, each sub-Saharan African country needs to implement a cancer control program as part of national health planning and have routine surveillance systems capable of monitoring progress in the delivery of specific interventions. The need for the collection and evaluation of population-based indicators is well recognized in the context of global cancer surveillance,⁷ and the urgency of doing so has been further underscored by the inclusion of targets designed to assess the ongoing scale-up of WHO's three signature cancer initiatives on cervical, childhood, and breast cancer.⁷

To be referred that GB makes no part of the African Cancer Registry Network that aims to improve the effectiveness of cancer surveillance in sub-Saharan Africa by providing expert evaluation of current problems and technical support to remedy identified barriers, with long-term goals of strengthening health systems and creating research platforms for the identification of problems, priorities, and targets for intervention.⁹

From our point of view, a starting point to answer the rising issue of breast cancer in GB should be articulated in two phases:

Phase 1: Pilot intervention at 18 months. During this period, trained teams (medical school students and family doctors) will be allocated to the field, door to door, with proximity to the population, urban and rural, and teach all women age older than 16 years how to perform self-breast examination, creating in the same time clinical registries, and performing clinical breast examinations. At the same time, a dedicated senology team must be created in Hospital Simão Mendes, including surgeons, nurses, and technicians of pathology and imaging, to be supported by collaborating breast units via telemedicine and local short medical missions, always with an adequate informatic database registry.

Local organizations such as the Guinea Ligue of Fight Against Cancer and the Ana Pereira Foundation can be of great aid. In the pilot phase, the population adhesion rate and team performance should be evaluated. All detected cases should be promptly evacuated to collaborate with the breast units abroad.

Phase 2: Purchase of a 3D automatic echocardiography system, digital mammography system, and image interpretation via telemedicine connection with referral breast units.

The mass screening to be implemented should start with echography at the age of 16 years and mammography starting at the age of 30 years.

With this approach, detected breast cancer cases can have a prompt and adequate treatment, the population awareness will rise, and there will be given the appropriate time for local health care providers to be trained to perform in a short period of time independently.

In conclusion, breast cancer is a major global issue. In low-income countries, setting is extremely difficult, even for ultraspecialized teams to provide suboptimal treatment because more basic facilities are missing. In GB, a poor country with very few inhabitants, the need to implement an anticancer national strategy is urgent, seems feasible, and surgical oncologists can play a key role. Any action should prioritize local team training and enhance specialization. No external intervention can provide any long-term benefit for patients if they are detached from local health workers.

AUTHOR CONTRIBUTIONS

Conception and design: All authors

Financial support: David Andrade

Administrative support: David Andrade

Provision of study materials or patients: Luís Bicho, David Andrade

Collection and assembly of data: Luís Djedjo, Maria do Céu Oliveira Martins, David Andrade, Zacharoula Sidiropoulou

Data analysis and interpretation: Luís Djedjo, Maria do Céu Oliveira Martins, David Andrade, Zacharoula Sidiropoulou

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/go/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

No potential conflicts of interest were reported.