Comment How advanced is breast cancer in Africa? Breast cancer is a growing problem in low-resource settings According to the GLOBOCAN database,1 an estimated 94 378 new cases of breast cancer are diagnosed in sub-Saharan Africa annually Incidence rates vary considerably between African countries—eg, 38 new cases per 100 000 women per year in Kenya compared with 28 cases per 100 000 women per year in Uganda An average increase in incidence rate of 3·7 cases per 100 000 women per year was seen in the past 20 years in Uganda.2 The Concord study group has published survival data from individual patients from 279 population-based registries in 67 countries worldwide Outcomes vary greatly between regions and improvements in survival were seen over time The outcome was dependent on early diagnosis and access to therapy.3 Findings from hospital-based studies suggest that patients who actually receive therapy can have a good outcome; one such study from Ethiopia4 reported a distant metastasis survival rate of 74% after years Patients with breast cancer in Africa are often thought of as being young and presenting at a late stage of the disease In The Lancet Global Health, Elima Jedy-Agba and colleagues5 present the first comprehensive systematic review and meta-analysis of breast cancer stage at diagnosis in sub-Saharan Africa The authors included 83 studies with 26 788 individuals Most results were from consecutive or convenience case series at tertiary hospitals, an important source of information for health-care planning Notably, the percentage of patients with late-stage (stage III/IV) cancer varied greatly between studies, ranging from 30% in South Africa to nearly 98% in one Nigerian study The metaregression analysis revealed that urban populations and non-black South African populations had lower percentages of patients with late-stage breast cancer at diagnosis than black or mixed ethnic South African patients and those from rural or rural and urban backgrounds Readers might have expected age, region, or type of health facility to affect the percentage of women with late-stage breast cancer, but no differences were seen Information about late-stage breast cancer from a population-based cancer registry would be useful to account for the selection bias of hospitals Population-based data showed that 74% of women in www.thelancet.com/lancetgh Vol December 2016 Côte d’Ivoire and 81% of women in Democratic Republic of the Congo had late-stage breast cancer in 2008–09.6 Jedy-Agba and colleagues also report that the average age at diagnosis in sub-Saharan Africa (35–49 years) is lower than in high-income countries, which is due to the high proportion of young people in these countries Others have shown that age-specific incidence rates in young age groups in Africa not differ when compared with European countries.7 These findings are evidence against the theory of a unique highly aggressive form of breast cancer in Africa However, some differences in tumour biology or genetics have been described in studies comparing African-American patients with white patients, which showed a slightly earlier onset of the disease and adverse outcome in African-American patients after adjusting for known adverse prognostic factors.8 These other known prognostic factors were not presented in most of the African papers and were therefore not reviewed by Jedy-Agba and colleagues A debate about whether the advanced stages are due to a unique aggressive biology of the disease or a delay in presentation is ongoing Jedy-Agba and colleagues found that the average time between self-reported onset of symptoms and time of diagnosis (analysed in 35 studies) was 8–12 months, and was not significantly associated with late-stage disease However, such delays between symptom onset and diagnosis and treatment need to be addressed to improve patient outcome Awareness campaigns can improve health-care seeking behaviour and referral in symptomatic women to some extent, but the long-term effect of early diagnosis on outcome has not been assessed in sub-Saharan Africa Trained volunteers and health-care workers have been shown to be able to simplified screening to find advanced breast cancer at a village level.9,10 The need for patient advocates, such as survivors, and education of health-care workers to correctly help women with symptoms of breast cancer is evident Their success will depend on the assurance of diagnosis and the availability of appropriate treatment Pathology resources have to be sustainably developed across sub-Saharan Africa.11 Palliative care for patients with late-stage breast cancer is much needed because the risk of metastasis in these patients is high The financial burden for the average patient with breast cancer in sub-Saharan Africa should See Articles page e923 e875 Comment also be considered in strategies to improve early diagnosis Jedy-Agba and colleagues found that women in Africa often present with late-stage breast cancer The publications differ greatly in the percentage of patients with late-stage disease, but not according to African regions The percentage of patients with late-stage disease was lower in solely non-black South Africans or patients from non-rural backgrounds than in black or mixed ethnic South Africans or those from rural or rural and urban backgrounds The percentage of patients with late-stage disease reduced over time across all studies These findings might encourage policy makers to design, implement, and monitor adequate cancer control plans Political attention such as the Forum of African First Ladies Against Breast and Cervical Cancer initiative to “Stop Cervical, Breast and Prostate Cancer” will hopefully help to sustain the positive trend already seen We declare no competing interests © The Author(s) Published by Elsevier Ltd This is an Open Access article under the CC BY license 10 11 *Eva Johanna Kantelhardt, Kirstin Grosse Frie Institute of Medical Epidemiology, Biostatistics and Informatics and Department of Gynaecology, Martin Luther University Halle-Wittenberg, 06097 Halle (Saale), Germany Eva.kantelhardt@uk-halle.de e876 International Agency for Research on Cancer GLOBOCAN 2012 http://globocan.iarc.fr/Default.aspx (accessed Sept 25, 2016) Wabinga HR, Nambooze S, Amulen PM, Okello C, Mbus L, Parkin DM Trends in the incidence of cancer in Kampala, Uganda 1991–2010 Int J Cancer 2014; 135: 432–39 Allemani C, Weir HK, Carreira H, et al Global surveillance of cancer survival 1995–2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2) Lancet 2015; 385: 977–1010 Kantelhardt EJ, Zerche P, Mathewos A, et al Breast cancer survival in Ethiopia: a cohort study of 1,070 women Int J Cancer 2014; 135: 702–09 Jedy-Agba E, McCormack V, Adebamowo C, dos-Santos-Silva I Stage at diagnosis of breast cancer in sub-Saharan Africa: a systematic review and meta-analysis Lancet Glob Health 2016; 4: e923–35 Islami F, Lortet-Tieulent J, Okello C, et al Tumor size and stage of breast cancer in Cote d’Ivoire and Republic of Congo—results from populationbased cancer registries Breast 2015; 24: 713–17 Corbex M, Bouzbid S, Boffetta P Features of breast cancer in developing countries, examples from North-Africa Eur J Cancer 2014; 50: 1808–18 Newman LA Breast cancer disparities: high-risk breast cancer and African ancestry Surg Oncol Clin N Am 2014; 23: 579–92 Abuidris DO, Elsheikh A, Ali M, et al Breast-cancer screening with trained volunteers in a rural area of Sudan: a pilot study Lancet Oncol 2013; 14: 363–70 Ngoma T, Mandeli J, Holland JF Downstaging cancer in rural Africa Int J Cancer 2015; 136: 2875–79 Nelson AM, Milner DA, Rebbeck TR, Iliyasu Y Oncologic care and pathology resources in Africa: survey and recommendations J Clin Oncol 2016; 34: 20–26 www.thelancet.com/lancetgh Vol December 2016 ... examples from North -Africa Eur J Cancer 2014; 50: 1808–18 Newman LA Breast cancer disparities: high-risk breast cancer and African ancestry Surg Oncol Clin N Am 2014; 23: 579–92 Abuidris DO, Elsheikh... Breast- cancer screening with trained volunteers in a rural area of Sudan: a pilot study Lancet Oncol 2013; 14: 363–70 Ngoma T, Mandeli J, Holland JF Downstaging cancer in rural Africa Int J Cancer. .. breast cancer in Cote d’Ivoire and Republic of Congo—results from populationbased cancer registries Breast 2015; 24: 713–17 Corbex M, Bouzbid S, Boffetta P Features of breast cancer in developing