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Cancer screening: the collateral damage of the pandemic in Egypt

Cancer screening: the collateral damage of the pandemic in Egypt Eldaly Journal of the Egyptian Public Health Association (2021) 96:14 Journal of the Egyptian https://doi.org/10.1186/s42506-021-00073-2 Public Health Association LETTER TO THE EDITOR Open Access Cancer screening: the collateral damage of the pandemic in Egypt Abdullah S. Eldaly To the Editor, HCC is clinically silent in most patients until late Severe acute respiratory syndrome coronavirus 2 stages and diagnosis could be challenging. Patients with (SARS-CoV-2) pandemic has cast a shadow on all cancer tumors of a size of 2 cm or less could theoretically bene- screening programs; millions of screening appointments fit from all treatment options while those with larger tu- were canceled due to the pandemic and resulting in de- mors or extra-hepatic spread have limited options and priving the population from a vital healthcare service suffer worse prognosis. Screening for HCC in high-risk that could save lives. One study in the USA reported a individuals was started in the 1980s in order to early de- drastic drop in the screenings for breast, colon, and cer- tect the tumor and possibly improve the outcomes [5]. vical cancer by 94%, 86%, and 94% respectively between The most recent screening guidelines recommend that January 2020 and April 2020 [1]. In Japan, hepatocellular all individuals at risk of HCC should undergo an alpha carcinoma (HCC) kept scheduled visits dropped dramat- fetoprotein (AFP) test as well as abdominal ultrasonog- ically from 97% before February 2020 to 49.1% in May raphy at regular 6-month intervals. 2020 according to one study [2]. The consequences of The benefits of HCC surveillance programs were well these canceled or postponed appointments will soon established in 2004 when a randomized clinical trial con- come to the surface and healthcare workers should be ducted in China revealed that biannual screening using prepared for. In Egypt, the relatively weak screening pro- AFP and ultrasonography had reduced HCC mortality grams for liver and breast cancer are expected to be the by 37% [6]. Moreover, the emergence of new effective most severed as a direct result of understaffing, the fear treatments for early HCC in the last two decades has of visiting the screening clinics, as well as turning many most likely increased the benefits from surveillance pro- general hospitals and cancer institutes into SARS-CoV-2 grams. HCC surveillance is now considered a corner- isolation centers. stone of the optimum care to cirrhotic patients and the vast majority of physicians would recommend screening for high-risk patients. 1 HCC screening Although Egypt has a heavy burden of liver cirrhosis Hepatocellular carcinoma (HCC) is the fourth most and HCC, most of the government's attention is directed common cause of cancer-related mortality in the world to HCV screening and eradication; a great success was [1]. The most common cause of HCC is liver cirrhosis of achieved during the national campaign of HCV screen- any etiology. ing and eradication in 2018 and the country is moving Egypt has the second highest incidence rate of HCC in steadily toward the elimination target [7]. However, cir- the world with an age-standardized rate (ASR) of 32.2 rhotic patients remain at risk of developing HCC even [3]. This heavy burden is a direct result of high HCV after HCV eradication which means millions of Egyp- prevalence among Egyptians and is due to the govern- tians are still at risk of developing HCC despite the great ment’s parenteral anti-schistosomal therapy (PAT) mass- success of the HCV eradication campaigns. treatment campaigns that took place between the 1950s In Egypt, the weak HCC surveillance system is ex- and 1980s and lead to transmission of HCV throughout pected to be severed due to the pandemic. Over 300 Egypt [4]. public hospitals were turned into isolation centers for SARS-CoV-2 patients including many tropical medicine Correspondence: abdullaheldali@gmail.com Department of Plastic and Reconstructive Surgery, Tanta University Hospitals, hospitals and some cancer and liver institutes [8]. The Tanta, Egypt © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Eldaly Journal of the Egyptian Public Health Association (2021) 96:14 Page 2 of 3 exact influence of the pandemic on the HCC surveil- developing world. Breast cancer survivors, especially those lance program in Egypt is not exactly known because we who received adjuvant hormonal therapy suffer worsening lack enough data. However, it is not expected to differ financial status even with receiving financial assistance significantly from the worldwide trend which means we [19, 20]. However, this financial burden could be greatly are risking thousands of early HCC cases to pass un- lowered through early detection since the cost of treat- noticed or be discovered when it is too late. ment is inversely related to the stage at presentation. A return-on-investment (ROI) analysis of a breast cancer 2 Breast cancer screening screening program in Egypt found that the average per- With a staggering 200–400% increase in the relative inci- person treatment cost for screened and unscreened pa- dence of breast cancer in Egypt between the years 1990 tients was estimated to be $28,632 and $58,170, respect- and 2017—an increase that was only surpassed by the ively, with a cumulative lifetime risk of 6.36%. Total Kingdom of Saudi Arabia—the deadly cancer has declared screening program cost per person was $112.10. The itself a challenging public health problem that needs ur- study estimated an expected decrease in late-stage breast gent intervention [9]. This is, unfortunately, a part of the cancer diagnosis by 13.7% as a result of the screening pro- bigger picture where the burden of both cases and deaths gram, saving $4049 in treatment costs per individual diag- is shifting steadily toward the less developed world as a nosed. The analysis resulted in a positive ROI of 133% for direct result of urbanization and the resulting obesity and facility-based screening [21]. This is the economic ration- diabetes [10]. The survival depends greatly on the coun- ale of the mass screening campaign for breast cancer that try’s economic status: a study comparing cancer survival is currently running in Egypt. in five continents reported varying 5-year survival rates of Despite the initial success of the national campaign of 80%, 60%, and 40% in high-income, middle-income, and breast cancer screening, the campaign was severed as low-income countries, respectively [11]. the pandemic took over. Many hospitals that were par- In Africa, the continent with the highest breast cancer ticipating in the campaign were turned into isolation mortality rates, the situation is becoming increasingly centers for SARS-CoV-2 patients. Moreover, the under- challenging [12]. The rapid industrialization without an staffing that happened in other non-isolation hospitals equivalent growth in healthcare services and infrastruc- affected the service in the outpatient clinics where ture has left African women with breast cancer more women are supposed to be checked annually for breast vulnerable than their peers in any other part in the cancer. Another important factor that markedly influ- world. The lack of screening, education, and campaign- enced breast cancer screening during the pandemic is ing lead to a great difference in staging at time of pres- the fear of getting infected with SARS-CoV-2 while entation between African and European women: about doing the annual breast check in the hospital. 50–70% of African women with breast cancer present with grade III or IV, while European women tend to 3 What is next? present at stage I and II [13–15]. Ductal carcinoma is There is no doubt Egypt needs to adopt new efficient the most common histological type in Africa as well as strategies for cancer screening, but for now, we should the rest of the world. However, medullary and mucinous aim to restore our pandemic-exhausted system first. The breast carcinomas are more reported in African women; first step toward restoring the normal capacity of the these histological types tend to have poorer prognosis healthcare system is to speed up the vaccination process. than ductal carcinoma. Moreover, the rates of the triple Unfortunately, Egypt has been performing poorly regard- negative breast cancer (TNBC), which has the worst ing the SARS-CoV-2 vaccination with only 164,534 prognosis among other molecular subtypes, are signifi- doses administrated by April 2021 [22]. This weak per- cantly higher in African women [16]; this for sure adds formance will not only lead to more patients with SARS- to the aforementioned problem of late stages at presen- CoV-2 exhausting the healthcare system but also will tation. Women with advanced stages are less likely to affect almost every chronic/high-risk patient including benefit from a breast conserving surgery leaving them to those who undergo regular cancer screening. mastectomy, adjuvant hormonal therapy, chemotherapy, or even palliation. Women with TNBC are unfortunately Abbreviations less likely to respond to adjuvant hormonal therapy and SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; chemotherapy which along with the late stages at pres- HCC: Hepatocellular carcinoma; HCV: Hepatitis C virus; HBV: Hepatitis B virus; DNA: Deoxyribonucleic acid; ASR: Age-standardized rate; PAT: Parenteral anti- entation contributes to the suffering of African women schistosomal therapy; AFP: Alpha fetoprotein; TNBC: Triple negative breast with breast cancer [17]. cancer; ROI: Return-on-investment Breast cancer is the most expensive cancer to treat [18]; this economic burden has important consequences on Acknowledgements both the patients and the weak healthcare systems in the None. Eldaly Journal of the Egyptian Public Health Association (2021) 96:14 Page 3 of 3 Author’s contributions 15. OF I, Kronqvist P, Kuopio T, Ndoma-Egba R, Collan Y. Histopathology of The letter was solely written by the author. The author read and approved breast cancer in different populations: comparative analysis for Finland and the final manuscript. Africa. Electron J Pathol Histol. 2002;8(4):24011–8. 16. Eng A, McCormack V, dos-Santos-Silva I. Receptor-defined subtypes of breast cancer in indigenous populations in Africa: a systematic review and Funding meta-analysis. Plos Med 2014;11(9). Not applicable. 17. Nagini S. Breast cancer: current molecular therapeutic targets and new players. Anticancer Agents Med Chem. 2017;17(2):152–63. Availability of data and materials 18. Diaby V, Tawk R, Sanogo V, Xiao H, Montero AJ. A review of systematic Not applicable. reviews of the cost-effectiveness of hormone therapy, chemotherapy, and targeted therapy for breast cancer. Breast Cancer Research and Treatment. Declarations Springer New York LLC; 2015 ;151:27–40. 19. Semin JN, Palm D, Smith LM, Ruttle S. Understanding breast cancer Ethics approval and consent to participate survivors’ financial burden and distress after financial assistance. Support Not applicable. Care Cancer. 2020;28(9):4241–8. 20. Pezzin LE, O’Niel MB, Nattinger AB. The economic consequences of breast cancer adjuvant hormonal treatments. J Gen Intern Med. 2009 24(SUPPL. 2). Consent for publication 21. Skrundevskiy AN, Omar OS, Kim J, Soliman AS, Korolchuk TA, Wilson FA. Not applicable. Return on investment analysis of breast cancer screening and downstaging in Egypt: implications for developing countries. Value Heal Reg Issues. 2018; Competing interests 16:22–7. The author declares no competing interests. 22. Covid world vaccination tracker - The New York Times. [cited 2021 Apr 13]. Available from: https://www.nytimes.com/interactive/2021/world/covid-va Received: 30 March 2021 Accepted: 6 May 2021 ccinations-tracker.html References Publisher’sNote 1. Cancino RS, Su Z, Mesa R, Tomlinson GE, Wang J. The impact of COVID-19 on Springer Nature remains neutral with regard to jurisdictional claims in cancer screening: challenges and opportunities. JMIR Cancer. 2020:6. [cited published maps and institutional affiliations. 2021 Apr 13]. Available from: https://pubmed.ncbi.nlm.nih.gov/33027039/ 2. Toyoda H, Yasuda S, Kiriyama S, Tanikawa M, Hisanaga Y, Kanamori A, et al. Impact of COVID-19 pandemic on surveillance of hepatocellular carcinoma: a study in patients with chronic hepatitis C after sustained virologic response. GastroHep. 2020;2(5):247–52. 3. McGlynn KA, Petrick JL, London WT. Global epidemiology of hepatocellular carcinoma: an emphasis on demographic and regional variability. Clin Liver Dis. 2015;19:223–38. 4. Frank C, Mohamed MK, Strickland GT, Lavanchy D, Arthur RR, Magder LS, et al. The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet. 2000;355(9207):887–91. 5. Cottone M, Marceno MP, Maringhini A, Rinaldi F, Russo G, Sciarrino E, et al. Ultrasound in the diagnosis of hepatocellular carcinoma associated with cirrhosis. Radiology. 1983;147(2):517–9. 6. Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol. 2004;130(7):417–22. 7. Waked I, Esmat G, Elsharkawy A, El-Serafy M, Abdel-Razek W, Ghalab R, et al. Screening and treatment program to eliminate hepatitis C in Egypt. N Engl J Med. 2020;382(12):1166–74. 8. Mersal: A lifeline for hospital beds in Egypt’s virus fight - politics - Egypt - Ahram Online. [cited 2021 Apr 13]. Available from: https://english.ahram.org. eg/NewsContent/1/64/373511/Egypt/Politics-/Mersal-A-lifeline-for-hospital- beds-in-Egypt’s-vir.aspx 9. Li N, Deng Y, Zhou L, Tian T, Yang S, Wu Y, et al. Global burden of breast cancer and attributable risk factors in 195 countries and territories, from 1990 to 2017: results from the Global Burden of Disease Study 2017. J Hematol Oncol. 2019;12(1). 10. Lukong KE, Ogunbolude Y, Kamdem JP. Breast cancer in Africa: prevalence, treatment options, herbal medicines, and socioeconomic determinants. Breast Cancer Research and Treatment, vol. 166. New York LLC: Springer; 2017. p. 351–65. 11. Coleman MP, Quaresma M, Berrino F, Lutz JM, De Angelis R, Capocaccia R, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol. 2008;9(8):730–56. 12. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359–86. 13. Rambau P, Chalya P, Manyama M, Jackson K. Pathological features of breast cancer seen in northwestern Tanzania: a nine years retrospective study. BMC Res Notes. 2011;4. 14. Boder JME, Abdalla FBE, Elfageih MA, Abusaa A, Buhmeida A, Collan Y. Breast cancer patients in Libya: comparison with European and central African patients. Oncol Lett. 2011;2(2):323–30. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Cancer screening: the collateral damage of the pandemic in Egypt

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Eldaly Journal of the Egyptian Public Health Association (2021) 96:14 Journal of the Egyptian https://doi.org/10.1186/s42506-021-00073-2 Public Health Association LETTER TO THE EDITOR Open Access Cancer screening: the collateral damage of the pandemic in Egypt Abdullah S. Eldaly To the Editor, HCC is clinically silent in most patients until late Severe acute respiratory syndrome coronavirus 2 stages and diagnosis could be challenging. Patients with (SARS-CoV-2) pandemic has cast a shadow on all cancer tumors of a size of 2 cm or less could theoretically bene- screening programs; millions of screening appointments fit from all treatment options while those with larger tu- were canceled due to the pandemic and resulting in de- mors or extra-hepatic spread have limited options and priving the population from a vital healthcare service suffer worse prognosis. Screening for HCC in high-risk that could save lives. One study in the USA reported a individuals was started in the 1980s in order to early de- drastic drop in the screenings for breast, colon, and cer- tect the tumor and possibly improve the outcomes [5]. vical cancer by 94%, 86%, and 94% respectively between The most recent screening guidelines recommend that January 2020 and April 2020 [1]. In Japan, hepatocellular all individuals at risk of HCC should undergo an alpha carcinoma (HCC) kept scheduled visits dropped dramat- fetoprotein (AFP) test as well as abdominal ultrasonog- ically from 97% before February 2020 to 49.1% in May raphy at regular 6-month intervals. 2020 according to one study [2]. The consequences of The benefits of HCC surveillance programs were well these canceled or postponed appointments will soon established in 2004 when a randomized clinical trial con- come to the surface and healthcare workers should be ducted in China revealed that biannual screening using prepared for. In Egypt, the relatively weak screening pro- AFP and ultrasonography had reduced HCC mortality grams for liver and breast cancer are expected to be the by 37% [6]. Moreover, the emergence of new effective most severed as a direct result of understaffing, the fear treatments for early HCC in the last two decades has of visiting the screening clinics, as well as turning many most likely increased the benefits from surveillance pro- general hospitals and cancer institutes into SARS-CoV-2 grams. HCC surveillance is now considered a corner- isolation centers. stone of the optimum care to cirrhotic patients and the vast majority of physicians would recommend screening for high-risk patients. 1 HCC screening Although Egypt has a heavy burden of liver cirrhosis Hepatocellular carcinoma (HCC) is the fourth most and HCC, most of the government's attention is directed common cause of cancer-related mortality in the world to HCV screening and eradication; a great success was [1]. The most common cause of HCC is liver cirrhosis of achieved during the national campaign of HCV screen- any etiology. ing and eradication in 2018 and the country is moving Egypt has the second highest incidence rate of HCC in steadily toward the elimination target [7]. However, cir- the world with an age-standardized rate (ASR) of 32.2 rhotic patients remain at risk of developing HCC even [3]. This heavy burden is a direct result of high HCV after HCV eradication which means millions of Egyp- prevalence among Egyptians and is due to the govern- tians are still at risk of developing HCC despite the great ment’s parenteral anti-schistosomal therapy (PAT) mass- success of the HCV eradication campaigns. treatment campaigns that took place between the 1950s In Egypt, the weak HCC surveillance system is ex- and 1980s and lead to transmission of HCV throughout pected to be severed due to the pandemic. Over 300 Egypt [4]. public hospitals were turned into isolation centers for SARS-CoV-2 patients including many tropical medicine Correspondence: abdullaheldali@gmail.com Department of Plastic and Reconstructive Surgery, Tanta University Hospitals, hospitals and some cancer and liver institutes [8]. The Tanta, Egypt © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Eldaly Journal of the Egyptian Public Health Association (2021) 96:14 Page 2 of 3 exact influence of the pandemic on the HCC surveil- developing world. Breast cancer survivors, especially those lance program in Egypt is not exactly known because we who received adjuvant hormonal therapy suffer worsening lack enough data. However, it is not expected to differ financial status even with receiving financial assistance significantly from the worldwide trend which means we [19, 20]. However, this financial burden could be greatly are risking thousands of early HCC cases to pass un- lowered through early detection since the cost of treat- noticed or be discovered when it is too late. ment is inversely related to the stage at presentation. A return-on-investment (ROI) analysis of a breast cancer 2 Breast cancer screening screening program in Egypt found that the average per- With a staggering 200–400% increase in the relative inci- person treatment cost for screened and unscreened pa- dence of breast cancer in Egypt between the years 1990 tients was estimated to be $28,632 and $58,170, respect- and 2017—an increase that was only surpassed by the ively, with a cumulative lifetime risk of 6.36%. Total Kingdom of Saudi Arabia—the deadly cancer has declared screening program cost per person was $112.10. The itself a challenging public health problem that needs ur- study estimated an expected decrease in late-stage breast gent intervention [9]. This is, unfortunately, a part of the cancer diagnosis by 13.7% as a result of the screening pro- bigger picture where the burden of both cases and deaths gram, saving $4049 in treatment costs per individual diag- is shifting steadily toward the less developed world as a nosed. The analysis resulted in a positive ROI of 133% for direct result of urbanization and the resulting obesity and facility-based screening [21]. This is the economic ration- diabetes [10]. The survival depends greatly on the coun- ale of the mass screening campaign for breast cancer that try’s economic status: a study comparing cancer survival is currently running in Egypt. in five continents reported varying 5-year survival rates of Despite the initial success of the national campaign of 80%, 60%, and 40% in high-income, middle-income, and breast cancer screening, the campaign was severed as low-income countries, respectively [11]. the pandemic took over. Many hospitals that were par- In Africa, the continent with the highest breast cancer ticipating in the campaign were turned into isolation mortality rates, the situation is becoming increasingly centers for SARS-CoV-2 patients. Moreover, the under- challenging [12]. The rapid industrialization without an staffing that happened in other non-isolation hospitals equivalent growth in healthcare services and infrastruc- affected the service in the outpatient clinics where ture has left African women with breast cancer more women are supposed to be checked annually for breast vulnerable than their peers in any other part in the cancer. Another important factor that markedly influ- world. The lack of screening, education, and campaign- enced breast cancer screening during the pandemic is ing lead to a great difference in staging at time of pres- the fear of getting infected with SARS-CoV-2 while entation between African and European women: about doing the annual breast check in the hospital. 50–70% of African women with breast cancer present with grade III or IV, while European women tend to 3 What is next? present at stage I and II [13–15]. Ductal carcinoma is There is no doubt Egypt needs to adopt new efficient the most common histological type in Africa as well as strategies for cancer screening, but for now, we should the rest of the world. However, medullary and mucinous aim to restore our pandemic-exhausted system first. The breast carcinomas are more reported in African women; first step toward restoring the normal capacity of the these histological types tend to have poorer prognosis healthcare system is to speed up the vaccination process. than ductal carcinoma. Moreover, the rates of the triple Unfortunately, Egypt has been performing poorly regard- negative breast cancer (TNBC), which has the worst ing the SARS-CoV-2 vaccination with only 164,534 prognosis among other molecular subtypes, are signifi- doses administrated by April 2021 [22]. This weak per- cantly higher in African women [16]; this for sure adds formance will not only lead to more patients with SARS- to the aforementioned problem of late stages at presen- CoV-2 exhausting the healthcare system but also will tation. Women with advanced stages are less likely to affect almost every chronic/high-risk patient including benefit from a breast conserving surgery leaving them to those who undergo regular cancer screening. mastectomy, adjuvant hormonal therapy, chemotherapy, or even palliation. Women with TNBC are unfortunately Abbreviations less likely to respond to adjuvant hormonal therapy and SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; chemotherapy which along with the late stages at pres- HCC: Hepatocellular carcinoma; HCV: Hepatitis C virus; HBV: Hepatitis B virus; DNA: Deoxyribonucleic acid; ASR: Age-standardized rate; PAT: Parenteral anti- entation contributes to the suffering of African women schistosomal therapy; AFP: Alpha fetoprotein; TNBC: Triple negative breast with breast cancer [17]. cancer; ROI: Return-on-investment Breast cancer is the most expensive cancer to treat [18]; this economic burden has important consequences on Acknowledgements both the patients and the weak healthcare systems in the None. Eldaly Journal of the Egyptian Public Health Association (2021) 96:14 Page 3 of 3 Author’s contributions 15. OF I, Kronqvist P, Kuopio T, Ndoma-Egba R, Collan Y. Histopathology of The letter was solely written by the author. The author read and approved breast cancer in different populations: comparative analysis for Finland and the final manuscript. Africa. Electron J Pathol Histol. 2002;8(4):24011–8. 16. Eng A, McCormack V, dos-Santos-Silva I. Receptor-defined subtypes of breast cancer in indigenous populations in Africa: a systematic review and Funding meta-analysis. Plos Med 2014;11(9). Not applicable. 17. Nagini S. Breast cancer: current molecular therapeutic targets and new players. Anticancer Agents Med Chem. 2017;17(2):152–63. Availability of data and materials 18. Diaby V, Tawk R, Sanogo V, Xiao H, Montero AJ. A review of systematic Not applicable. reviews of the cost-effectiveness of hormone therapy, chemotherapy, and targeted therapy for breast cancer. Breast Cancer Research and Treatment. Declarations Springer New York LLC; 2015 ;151:27–40. 19. Semin JN, Palm D, Smith LM, Ruttle S. Understanding breast cancer Ethics approval and consent to participate survivors’ financial burden and distress after financial assistance. Support Not applicable. Care Cancer. 2020;28(9):4241–8. 20. Pezzin LE, O’Niel MB, Nattinger AB. The economic consequences of breast cancer adjuvant hormonal treatments. J Gen Intern Med. 2009 24(SUPPL. 2). Consent for publication 21. Skrundevskiy AN, Omar OS, Kim J, Soliman AS, Korolchuk TA, Wilson FA. Not applicable. Return on investment analysis of breast cancer screening and downstaging in Egypt: implications for developing countries. Value Heal Reg Issues. 2018; Competing interests 16:22–7. The author declares no competing interests. 22. Covid world vaccination tracker - The New York Times. [cited 2021 Apr 13]. Available from: https://www.nytimes.com/interactive/2021/world/covid-va Received: 30 March 2021 Accepted: 6 May 2021 ccinations-tracker.html References Publisher’sNote 1. Cancino RS, Su Z, Mesa R, Tomlinson GE, Wang J. The impact of COVID-19 on Springer Nature remains neutral with regard to jurisdictional claims in cancer screening: challenges and opportunities. JMIR Cancer. 2020:6. [cited published maps and institutional affiliations. 2021 Apr 13]. Available from: https://pubmed.ncbi.nlm.nih.gov/33027039/ 2. Toyoda H, Yasuda S, Kiriyama S, Tanikawa M, Hisanaga Y, Kanamori A, et al. Impact of COVID-19 pandemic on surveillance of hepatocellular carcinoma: a study in patients with chronic hepatitis C after sustained virologic response. GastroHep. 2020;2(5):247–52. 3. McGlynn KA, Petrick JL, London WT. Global epidemiology of hepatocellular carcinoma: an emphasis on demographic and regional variability. Clin Liver Dis. 2015;19:223–38. 4. Frank C, Mohamed MK, Strickland GT, Lavanchy D, Arthur RR, Magder LS, et al. The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet. 2000;355(9207):887–91. 5. Cottone M, Marceno MP, Maringhini A, Rinaldi F, Russo G, Sciarrino E, et al. Ultrasound in the diagnosis of hepatocellular carcinoma associated with cirrhosis. Radiology. 1983;147(2):517–9. 6. Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol. 2004;130(7):417–22. 7. Waked I, Esmat G, Elsharkawy A, El-Serafy M, Abdel-Razek W, Ghalab R, et al. Screening and treatment program to eliminate hepatitis C in Egypt. N Engl J Med. 2020;382(12):1166–74. 8. Mersal: A lifeline for hospital beds in Egypt’s virus fight - politics - Egypt - Ahram Online. [cited 2021 Apr 13]. Available from: https://english.ahram.org. eg/NewsContent/1/64/373511/Egypt/Politics-/Mersal-A-lifeline-for-hospital- beds-in-Egypt’s-vir.aspx 9. Li N, Deng Y, Zhou L, Tian T, Yang S, Wu Y, et al. Global burden of breast cancer and attributable risk factors in 195 countries and territories, from 1990 to 2017: results from the Global Burden of Disease Study 2017. J Hematol Oncol. 2019;12(1). 10. Lukong KE, Ogunbolude Y, Kamdem JP. Breast cancer in Africa: prevalence, treatment options, herbal medicines, and socioeconomic determinants. Breast Cancer Research and Treatment, vol. 166. New York LLC: Springer; 2017. p. 351–65. 11. Coleman MP, Quaresma M, Berrino F, Lutz JM, De Angelis R, Capocaccia R, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol. 2008;9(8):730–56. 12. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359–86. 13. Rambau P, Chalya P, Manyama M, Jackson K. Pathological features of breast cancer seen in northwestern Tanzania: a nine years retrospective study. BMC Res Notes. 2011;4. 14. Boder JME, Abdalla FBE, Elfageih MA, Abusaa A, Buhmeida A, Collan Y. Breast cancer patients in Libya: comparison with European and central African patients. Oncol Lett. 2011;2(2):323–30.

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Journal of the Egyptian Public Health AssociationSpringer Journals

Published: Jun 2, 2021

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