Breast cancer is the most common female cancer worldwide and in sub-Saharan Africa (SSA). SSA countries have lower breast cancer incidence rates compared to high income countries (HICs), yet, mortality rates are higher than in HICs owing to a lack of awareness, poor access to care, and long delays to diagnosis and treatment. Stage at diagnosis of breast cancer is one of the most important factors associated with breast cancer survival, yet over 70% of women in SSA persistently present at late stages (III & IV) when treatment outcomes are poor. Poor knowledge, a lack of education and low income are recognized determinants of long delays to presentation and late stage diagnosis in Nigeria. Interventions to promote downstaging (earlier stage at diagnosis) in most settings in SSA where there are no population-based screening programs though crucial, are still lacking. In HICs, such as the United States and the United Kingdom, reductions in mortality from breast cancer prior to the introduction of screening programs suggest that an earlier stage at diagnosis, which can be achieved through clinical downstaging is crucial in obtaining favorable outcomes in the management of breast cancer patients. In settings where breast cancer is diagnosed at early stages and majority of breast cancer patients survive, research emphasis is gradually shifting towards survivorship and managing the long-term effects of a cancer diagnosis. In contrast in SSA, there is still a critical need to improve stage at diagnosis and increase a woman’s chances of survival. Until at least half of late-stage breast cancers in SSA are downstaged to early stages, focus should remain on the timely diagnosis of symptomatic breast cancer rather than on screening for asymptomatic disease. Clinical downstaging should be widely advocated as a priority area for future research in breast cancer in SSA.

OBJECTIVE Data regarding breast (BC) epidemiology, clinical management and survival in Africa are scarce. We aimed to assess the distribution of BC subtypes among patients from Mozambique and their relation with clinical management and survival.
METHODS BC cases consecutively diagnosed at the three Pathology Units of Mozambique were prospectively enrolled from Jan-2015 to Aug-2017. Expression of oestrogen and progesterone receptors, overexpression/amplification of HER2 and Ki67 index were used to classify tumours into surrogate subtypes, according to the St. Gallen classification. Data on demographics, treatment, and survival of patients followed at the Maputo Central Hospital (MCH) were also collected.
RESULTS 212 patients were included: 8% presented Luminal-A, 55% Luminal-B, 13% HER2-enriched, and 25% Basal-like BC. Of these, 174 were followed at MCH: median age was 48 years; 52% were pre-menopausal; 26% HIV-positive; 55% presented with stage III and 18% with stage IV. Regarding treatment, 86% were submitted to surgery, 94% to chemotherapy, 52% to hormone therapy and 5% to radiotherapy. There were no differences in terms of age, education, place of residence, number of gestations, family history of BC, menopausal status, HIV status, histology, or stage among patients within each subtype. A nuclear grade of 3 was more frequent among Basal-like tumours (55%), as compared to the other subtypes (23%-31%). After a median follow-up of 31 months, the 24-month overall survival was 67% among Luminal-A, 75% in Luminal-B, 66% in HER2-enriched and 51% in Basal-like patients. Adjusted hazard ratio was 3.73 (95% confidence interval 1.03-13.45) for Basal-like vs. Luminal-A patients.
Among early BC patients, the 24-month disease-free survival was 60% among Luminal-A, 64% in Luminal-B, 48% in HER2-enriched and 34% in Basal-like patients (p=.321).
CONCLUSIONS Our results show a high proportion of patients with Basal-like BC. Overall, the prognosis is poor, especially among Basal-like BC patients.

INTRODUCTION Breast cancer is a leading cause of cancer morbidity and mortality among African women and presentation at late stage disease is common. Understanding women’s awareness of risk factors and symptoms of breast cancer can inform interventions to improve timely diagnosis. This study describes Ugandan and South African women’s unprompted and prompted awareness and their lay beliefs of breast cancer risk factors and symptoms.
METHODS We conducted the African Women’s Awareness of Cancer (AWACAN) survey study in South Africa and Uganda, from August through December 2018. Data were collected by researchers using interviews conducted with women from urban and rural communities in South Africa (n=873) and Uganda (n=885) to determine awareness of 13 risk factors and 15 symptoms as well as lay beliefs of breast cancer.
RESULTS Recall (unprompted response) of breast cancer risk factors was poor: 8.8% recalled ≥1 risk factor vs. 95.2% who recognized (prompted response) ≥1 risk factors. Symptoms were better known: 78.0% recalled ≥1 symptoms and 99.0% recognized ≥1 symptoms. The most common risk factor recalled was having a family member with breast cancer (3.1% vs. recognized: 49.5%); having had breast cancer previously was the most recognized risk factor (52.9%). For symptom recall, having a lump in the breast was most common (44.9%) vs. recognition (90.8%); bleeding from the nipple was most recognized (91.4%). Recognition of risk factors and symptoms was significantly lower among rural compared to urban communities in South Africa (Wilcoxon rank-sum test: p<0.01, p<0.01, respectively), but not in Uganda (p=0.38, p=0.24, respectively). Overall, multiple lay beliefs were prevalent, more so for risk factors than for symptoms.
CONCLUSON Awareness of risk factors and symptoms is limited in these settings. Public heath interventions for breast cancer control should be widespread and include information on both risk factors and symptoms.

BACKGROUND No known studies have been undertaken in South Africa exploring the contraceptive and fertility needs and preferences of women of reproductive age (18-49) diagnosed with breast cancer.
METHODS Qualitative in-depth interviews were conducted with 24 women diagnosed with breast cancer at a tertiary hospital in Cape Town. We explored responses to a breast cancer diagnosis; the impact of breast cancer on future fertility intentions and contraceptive use; understanding of suitable contraceptive methods during and after treatment and women’s fertility related counseling needs during their continuum of care. Data was analysed using a thematic analysis approach.
RESULTS Women initially found it difficult to talk about future fertility intentions as they were dealing with the aftermath of a breast cancer diagnosis. Since being diagnosed with breast cancer, of those women using a contraceptive method, the non - hormonal intrauterine device was the most commonly used method. However, women reported receiving limited information from health care providers about contraceptive use and future fertility planning post treatment when fertility desires might change. Many women reported limited information received from healthcare providers about the impact of cancer treatment on their future fertility. Most women did not receive information around fertility preservation nor were they familiar with the concept.
CONCLUSIONS Limited contraceptive and future fertility counseling were reported by women despite many women being provided with the non-hormonal IUD. There is a need for improved information and counseling regarding the impact of treatment on contraceptive and fertility options. It is important that cancer care providers provide timely information regarding fertility options and communicate with patients about their fertility concerns prior to treatment and throughout the course of survivorship. The development of evidence-based information tools to enhance patient -provider communication and counseling could address knowledge gaps.