Moza-BC: the first cohort of women with breast cancer in Mozambique

It is called Moza-BC, an acronym that results from Mozambican Breast Cancer, and is the first longitudinal study of women with breast cancer in Mozambique. The cohort began in 2015, with the three main central hospitals in Mozambique (Maputo, Beira and Nampula) and in collaboration with the Instituto de Saúde Pública da Universidade do Porto (ISPUP), to help fill the lack of information on the distribution of breast cancer subtypes, treatments available and estimates for disease survival in the country.

Over 260 Mozambican women, diagnosed with breast cancer, between 2015 and 2017, have been followed by the research team. So far, researchers have found, for example, that almost a quarter of women were diagnosed with triple-negative breast cancer (the most aggressive and lethal), many are diagnosed at an advanced stage of the disease and, three years after diagnosis, half of the patients had died.

And, thanks to a project by the Fundação Calouste Gulbenkian, with the support of the Cooperação Portuguesa of the Fundação Millennium BCP and Millennium bim, it was possible to create, for the first time in Mozambique, a multidisciplinary tumor board meeting for breast cancer at the Central Hospital of Maputo, which was found to have a very beneficial impact on the survival of women with breast cancer.

How it all began…

The creation of the cohort dates back to 2014, the year in which ISPUP began a collaboration with the Central Hospital of Maputo to create a hospital-based cancer registry and a population-based cancer registry for the city.

At the time, Carla Carrilho, director of the Anatomic Pathology Service of the Central Hospital of Maputo and responsible for the hospital’s cancer registry, contacted ISPUP, to begin studying breast cancer in depth.

The reason? The existing information about the disease in native African women was very scarce and, through her empirical experience, the doctor was aware that the incidence of breast cancer was increasing among women in Mozambique.

It was in this context that the Moza-BC cohort began in 2015, as a result of a partnership between ISPUP, the three main central hospitals of Mozambique (Maputo, Beira and Nampula) and the Faculty of Medicine of Eduardo Mondlane University, in Maputo.

Between 2015 and 2017, women who were diagnosed with breast cancer in the Anatomic Pathology Services of the three main hospitals in Mozambique were invited to participate in this prospective study. The project was developed with the objective of “knowing the most frequent breast cancer subtypes among women, the treatments available and the disease survival”, explains Mariana Brandão, one of the ISPUP researchers involved in the cohort, with Nuno Lunet.

A total of 262 women were recruited. Information regarding the characteristics of the participants, such as age, number of children, the existence of comorbidities such as HIV, the stage of the disease and the treatments received (e.g., surgery, chemotherapy) was obtained. Data on the survival of these women are collected through the cancer registry at the Central Hospital of Maputo.

Half of the women diagnosed with breast cancer have died

Since about 20 years ago, researchers began to realize that breast cancer should not be considered a “single” disease, but that it is actually composed of several “subtypes” that have different clinical characteristics, and which lead to different survival outcomes. However, most of the knowledge that exists about these subtypes has come from the United States and Europe.

The follow-up of these women allowed the Moza-BC researchers to answer some of the major questions that led to the creation of the cohort: what is the distribution of these breast cancer subtypes in Mozambique, and what is their impact on treatment and patient survival.

The project concluded that there is a high proportion of patients in the country with human epidermal growth factor receptor 2 (HER2)-positive and triple-negative breast cancer tumors (the most aggressive and with the worst prognosis). Specifically, almost half of the patients (49%) were diagnosed with these two subtypes and the other half with tumors that are estrogen receptor (ER)-positive /HER2-negative, whose prognosis is more favorable.

In the three years after the diagnosis of the disease, almost half of the participants in Moza-BC died. In particular, mortality was higher among patients with HER2-positive and triple-negative breast cancer tumors.

The low survival of these women may be explained by the lack of differentiated treatment options, namely, among patients diagnosed with the HER2-positive subtype – a very aggressive type of tumor, but which, thanks to the development of specific drugs, may be more easily treatable.

“In the case of women diagnosed with the HER2-positive subtype, the absence of the drug trastuzumab compromises their survival. For this reason, the prognosis of this breast cancer subtype in Mozambique is quite unfavorable compared to more developed countries, where this drug has been used for several years”, explains Mariana Brandão, first author of the article entitled Breast cancer subtypes: implications for the treatment and survival of patients in Africa — a prospective cohort study from Mozambique, which presents these results.

The need to optimize patient care

To increase patient survival, researchers participating in this prospective study highlight the need to improve the diagnosis and optimize the treatment of these patients in hospitals, something that does not occur in Mozambique.

In the same article, mentioned above, the authors emphasize that breast cancer must no longer be seen by clinicians as a homogeneous disease. It is crucial that doctors understand the importance of determining the breast cancer subtype before recommending treatment to the patient, since each subtype requires a different treatment approach.

The researchers showed that it is possible to determine breast cancer subtypes in hospital centers with low resources, such as those in Mozambique, through an adaptation of the fine needle aspiration technique.“This is an adaptation of a diagnostic method that is perfectly applicable in Mozambican hospitals, but also in other African countries. It is a simple and inexpensive method, in which it is not necessary to have sophisticated equipment, and can contribute to the optimization of treatments and, thus, for the survival of these women”, says the ISPUP researcher.

“Additionally, it would lead to money savings later on in the disease course of these patients, by avoiding, for example, the prescription of hormonal therapy for women who do not need it, or chemotherapy for patients with less aggressive tumors from a biological perspective”.

The creation of a multidisciplinary tumor board for breast cancer

Another one of Moza-BC’s great contributions was helping to create a multidisciplinary tumor board meeting for breast cancer at the Centro Hospitalar de Maputo, in 2016, which is unprecedented in Mozambique.

At that time, a group of health professionals from the Central Hospital of Maputo travelled to Portugal to receive training, under the project “Integrated care for cancer patients”, promoted by the Fundação Calouste Gulbenkian with the Ministry of Health of Mozambique, and co-financing from the Cooperação Portuguesa of the Fundação Millennium BCP and Millennium bim. When they returned, these professionals were able to implement what they learned at the Hospital, with appropriate local adaptations, helping to create the multidisciplinary tumor board meeting that would accompany patients.

This group‘s mission is to bring together members from different clinical areas – surgery, radiology, pathology, radiotherapy and medical oncology – to evaluate each patient individually and to decide which treatment is most appropriate for the patient. The goal? To achieve better guidance for women with breast cancer during the diagnosis and treatment process, and increase their survival.

According to Mariana Brandão, “the Moza-BC cohort and the training program of the Fundação Calouste Gulbenkian raised awareness among Mozambican health professionals that it was necessary to create a multidisciplinary tumor board meeting for breast cancer. This had never been done in the country and, in that sense, we were absolutely innovative. We wanted to see if the introduction of a joint consultation, with members from different clinical areas, would help to achieve better health outcomes in the Mozambican context”.

Gains in survival

And what did the study conclude? That the introduction of a multidisciplinary tumor board in Maputo has achieved effective gains for clinical practice and for the survival of patients with breast cancer.

An article recently published by Moza-BC researchers, entitled Survival impact and cost-effectiveness of a multidisciplinary tumor board for breast cancer in Mozambique, Sub-Saharan Africa, showed that the implementation of the multidisciplinary tumor board led to a 53% reduction in the mortality of women with breast cancer.

Additionally, its implementation is feasible and cost-effective, which is crucial for hospitals where resources are scarce, such as those in Mozambique.

“These results are equally important for the rest of the world, as this is the first time that a multidisciplinary tumor board has been shown to increase the survival of breast cancer patients and is cost-effective in a developing country with low resources. Therefore, it could be a stimulus for the implementation of this model in other African countries and in other regions of the world”, emphasizes the ISPUP researcher.

“Besides, this knowledge can also be useful for developed countries, in which the dissemination of multidisciplinary tumor board meetings is not yet complete, and where one also begins to question their benefit, since they are time consuming and cost money”, she adds.

The success of this project has led to the formal recognition of the multidisciplinary tumor board meeting approach as an essential part of the treatment of oncological disease in the Mozambique Cancer Control Plan 2019-2029 – the first in the country for cancer control – and in the Mozambican Recommendations for the Treatment of Breast Cancer.

Thanks to this first positive experience, other multidisciplinary tumor board meetings have already been created at the Central Hospital of Maputo, namely, for gynecological, head and neck, esophagus, and thoracic cancers.

Implications for breast cancer management in Mozambique

The information produced within the Moza-BC cohort has helped to make up for the lack of data on crucial aspects for the management of breast cancer in Mozambique, which, according to the cancer registry created at the Central Hospital of Maputo in collaboration with ISPUP, is the cancer with the second highest incidence among women in the Mozambican capital.

Through other work carried out within the cohort, the researchers described the risk factors for the development of breast cancer in Mozambique, and assessed the impact of HIV infection on the clinical characteristics and survival of women with breast cancer (available HERE).

The various results achieved thus far are pioneering, and aim to serve as a basis for clinical and political decisions in Mozambique and, eventually, in other African countries as well.

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