Pathophysiology/ Etiology and Risk Factors
There is a cascade of cellular and molecular events that contribute to breast cancer’s pathogenesis. Genetic mutations occur early on. Breast cancer usually begins with a genetic mutation in the DNA of a breast cell. Increased susceptibility to breast cancer has been linked to mutations in genes like BRCA1 and BRCA2. Estrogen and progesterone are two hormones that have been linked to the development of breast cancer. Hormone receptor positivity indicates that the growth of certain breast tumours requires the presence of specific hormones. The cell cycle becomes unbalanced as a result. Mutations in cell cycle regulatory genes like TP53 and p16 can cause unchecked cell division. Suppose aberrant cells in the breast continue to divide and can evade the body’s regular control mechanisms. In that case, they can eventually form a primary tumour, which manifests as a mass or lump in the breast. It can lead to metastasis, where breast cancer cells enter the bloodstream or lymphatic system and spread to other parts of the body, and invasion, where cancer cells affect nearby tissues. Breast cancer risk factors can be broken down into several categories—a critical factor in the continuing increase in age3. And secondly, gender typically affects females. Another risk factor is family history. The two most significant genes for increased breast cancer risk are BRCA1 and BRCA2. The risk may also be affected by a woman’s reproductive history, namely by the timing of her first child. These include having one’s first menstrual period before the age of 12, having one’s first live birth after the age of 30, having no children, and going through menopause after the age of 55.
The average age of patients at the time of diagnosis was 48 years. In 59.9% of the cases, a significant proportion of the female participants were in the premenopausal stage 1. The prevailing histologic subtype observed in the study was invasive ductal carcinoma, specifically the not otherwise described subtype, accounting for 82% of cases. Tumor grade 2 exhibited a higher prevalence of 55% 1. Out of the total sample size of 302 patients, 169 individuals (56%) exhibited estrogen receptor (ER) expression. In comparison, 154 individuals (49%) had progesterone receptor (PgR) expression. The majority group consisted of ER+PgR+ individuals, comprising 43%. It was followed by 116 instances, accounting for 38% of the population, classified as ER-PgR- 1. The prevalence of patients exhibiting estrogen receptor (ER) expression is higher compared to those demonstrating progesterone receptor (PgR) positivity 1.
The incidence rates of breast cancer have exhibited an upward trend for the majority of the previous decades. Specifically, from 2010 to 2019, the rate was an annual increase of 0.5% 4. This growth can mainly be attributed to cases of localized-stage breast cancer and hormone receptor-positive illness. Although the occurrence of breast cancer is slightly lower in Black women compared to White women (127.8 vs. 133.7 per 100,000), the racial discrepancy in mortality rates for this disease remains consistent 4. Specifically, the overall death rate is 40% higher in Black women (27.6 vs. 19.7 deaths per 100,000 in the period of 2016-2020), and it is twice as high among women under the age of 50 4. Black women have the lowest 5-year relative survival rates across genetic subtypes and disease stages, excluding stage I.
Social Determinants of Health
SDOH in the US is Healthcare Access Disparities. Some Americans are delayed in diagnosis and treatment due to healthcare access and insurance coverage disparities. Uninsured people may not get frequent tests or excellent medical treatment, which might worsen breast cancer outcomes.
Second, socioeconomic disparities. Social factors like income and education affect breast cancer outcomes. Lower socioeconomic status women may have trouble accessing preventive treatments, getting diagnosed, and affording treatment, which increases incidence and worsens outcomes.
Limited Healthcare Infrastructure is a Social Determinant in the Ivory Coast. Ivory Coast’s rural healthcare infrastructure is lacking. A lack of well-equipped healthcare facilities and qualified medical workers can delay breast cancer diagnosis and treatment, increasing prevalence and worsening outcomes.
Second, cultural practices and beliefs. Culture affects health-seeking. In Ivory Coast, cultural stigmas, misinformation, and traditional healing practices may prevent women from seeking early breast cancer treatment. These factors can increase prevalence and worsen outcomes in late-stage presentation.
Similarities and differences and disparities and inequalities
The presence of various disparities and inequities in socioeconomic determinants culminate in a collective adverse health outcome, namely an elevated occurrence and prevalence of advanced-stage breast cancer, resulting in heightened rates of mortality. Various factors, such as delayed access to screenings, limited availability of healthcare resources, and cultural obstacles, frequently contribute to the manifestation of advanced-stage breast cancer. Consequently, these circumstances diminish the efficacy of therapy and jeopardize overall prognoses. In both the United States and Ivory Coast, a correlation exists between lower socioeconomic position and limited availability of healthcare resources. Those above-shared characteristics underscore economic variables’ worldwide influence on health results. Healthcare access disparities, stemming from factors such as inadequate infrastructure in the Ivory Coast or insurance coverage challenges in the United States, have a detrimental impact on the timely identification and treatment of breast cancer, thus resulting in inferior patient outcomes.
Although there are certain shared variables between the two countries, it is essential to note that the particular characteristics of these determinants vary. For example, the United States experiences notable racial inequities, whereas in the Ivory Coast, the focus may be more on the constraints of healthcare infrastructure and cultural attitudes. The influence of artistic ideas and practices is more significant in the Ivory Coast, impacting health-seeking behaviour and perhaps resulting in delays in the diagnosis process. Cultural elements contribute to the United States, but the impact of racial inequities is more prominent.
The efficacy of interventions in both nations is impacted by various factors, encompassing cultural nuances, socioeconomic inequalities, and the broader healthcare infrastructure. According to the guidelines set forth by the US Preventive Services Task Force (USPSTF), it is recommended that women between the ages of 40 and 74 undergo a screening mammography every two years. The United States Preventive Services Task Force (USPSTF) advises that the initiation of mammography screenings before age 40 should be personalized, considering individual circumstances and the potential advantages and disadvantages. These strategies have demonstrated efficacy in enhancing rates of early detection. Nevertheless, there are still obstacles to overcome when it comes to effectively engaging specific demographic segments, including individuals with lower socioeconomic status and restricted healthcare accessibility. Current initiatives are dedicated to enhancing outreach techniques, mitigating access hurdles, and raising awareness to optimize the overall efficacy of mammography access programs.
Non-governmental organizations (NGOs) and foreign organizations frequently engage in collaborative efforts in Ivory Coast to enhance breast cancer outcomes through awareness campaigns and the provision of mobile clinics. The prevalence of HER2 positivity in relatively high-grade breast cancer in young women may be an indicator of the potential aggressiveness of this subtype, according to the study by Aman et al. 5. Patients who test positive for HER2 should see improved survival rates due to targeted therapy. The work presented here highlights the acknowledged prognostic relevance of HER2, which aids in the care of breast cancer patients in the Ivory Coast by a public health professional. The interventions mentioned are specifically aimed at rural areas with poor healthcare infrastructure. They primarily involve providing education regarding early detection, the implementation of screening programs, and the facilitation of effective management strategies. Although much progress has been made in increasing awareness and improving access to healthcare services for marginalized communities, there are still persistent difficulties that need to be addressed and effective management to reduce mortality and morbidity rates. Sustained influence may be impeded by limited resources and inadequate infrastructure in specific places.
Sustainable Development Goal (SDG) 3
The Sustainable Development Goal (SDG) 3 promotes good health and well-being. The initiative’s primary goal is to improve health and well-being for all ages. This initiative addresses breast cancer in the US and Ivory Coast. SDG 3 reduces breast cancer incidence and mortality by promoting prevention, early detection, and high-quality healthcare. The attainment of optimal health and well-being is not solely imperative for individuals but also catalyzes the holistic advancement of society.
Healthy People 2030 Goal
The present objective of Healthy People 2030 pertains to the imperative of augmenting screening rates, a pivotal measure for the timely identification and mitigation of breast cancer. It enhances screening rates to detect breast cancer at earlier stages, which are more amenable to treatment, hence leading to a decrease in mortality rates. This statement underscores the significance of regular screenings as a proactive approach within the comprehensive strategy to address breast cancer following broader public health endeavours in both the United States and the Ivory Coast.
Determinant to improve outcome
Breast cancer (BC) imposes a substantial burden of disease. Enhancing socioeconomic status (SES) is a pivotal upstream factor that has the potential to mitigate the issue of breast cancer substantially. A positive correlation exists between higher socioeconomic status (SES) and improved accessibility to healthcare resources, education, and overall well-being. By effectively examining the underlying factors contributing to socioeconomic disparities, it becomes possible to mitigate obstacles associated with early diagnosis, bolster preventative interventions, and eventually increase the overall outcomes of breast cancer. Public health professionals have a crucial role in the development, execution, and assessment of interventions aimed at addressing social determinants of health, such as socioeconomic status (SES). As a public health nurse, I can engage in policy advocacy. Public health professionals can champion policies that facilitate economic justice, enhance educational accessibility, and foster career advancement. It entails collaborating with policymakers to develop and execute initiatives that effectively target the socioeconomic determinants of health.
Application to professional practice
The acquisition of knowledge derived from this project significantly shapes my approach toward mitigating health disparities, particularly within breast cancer. Significantly, I have learned to appreciate incorporating upstream thinking that helps solve the issue based on the root causes, advocacy for comprehensive policies, and community-centred approaches in different settings. In the realm of public health, the knowledge gained reinforces my commitment to social justice and equity as one of the core values of our university.
- Effi AB, Aman NA, Koui BS, Koffi K, Traoré ZC, Kouyaté M. Immunohistochemical determination of estrogen and progesterone receptors in breast cancer: relationship with clinicopathologic factors in 302 patients in Ivory Coast. BMC Cancer. 2017;17(1). doi:10.1186/s12885-017-3105-z
- Woloshin S, Jørgensen KJ, Hwang S, Welch HG. The New USPSTF Mammography Recommendations — A Dissenting View. The New England Journal of Medicine. 2023;389(12):1061-1064. doi:10.1056/nejmp2307229
- Sun Y, Zhao Z, Zhang Y, et al. Risk factors and preventions of breast cancer. International Journal of Biological Sciences. 2017;13(11):1387-1397. doi:10.7150/ijbs.21635
- Giaquinto AN, Sung H, Miller KD, et al. Breast Cancer Statistics, 2022. CA: A Cancer Journal for Clinicians. 2022;72(6):524-541. doi:10.3322/caac.21754
- Aman NA, Doukouré B, Koffi K, et al. HER2 overexpression and correlation with other significant clinicopathologic parameters in Ivorian breast cancer women. BMC Clinical Pathology. 2019;19(1). doi:10.1186/s12907-018-0081-