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    • After the success of the Millennium Development Goals

    2019-06-28

    After the success of the Millennium Development Goals and the reduction in more than 50% of child mortality in children younger than 5 years (Countdown to 2015 report), the survive and thrive motto was given prominence by the Sustainable Development Goals (SDGs). For all children to thrive, we need equitable early development worldwide, entailing that every girl and boy should have the same opportunities to fully develop their potential, which is only achievable if they have good nutrition, good health, and a rich and stimulating home environment. In , Chunling Lu and colleagues have done impressive work updating a head count of children at risk of poor development. With use of the same logic of a previous publication, children in conditions of extreme poverty or stunted were considered to be at risk. Their results show that, between 2004 and 2010, progress was made, and there was a reduction in children at risk, both in relative and absolute terms. Still, the situation is worrying and challenging. In low-income countries, 65% of children younger than 5 years were at risk of poor development. The proportions are less alarming, but still worrying, in middle-income countries. The authors found that, despite the substantial progress, nearly 250 million children in low-and-middle-income countries were still at risk of poor development, 63 million in India alone.
    Breast cancer is a growing problem in low-resource settings. According to the GLOBOCAN database, 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. 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. Findings from hospital-based studies suggest that patients who actually receive therapy can have a good outcome; one such study from Ethiopia reported a distant Doripenem survival rate of 74% after 2 years. Patients with breast cancer in Africa are often thought of as being young and presenting at a late stage of the disease. In , Elima Jedy-Agba and colleagues 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 meta-regression 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 Côte d\'Ivoire and 81% of women in Democratic Republic of the Congo had late-stage breast cancer in 2008–09. 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 do not differ when compared with European countries. 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. These other known prognostic factors were not presented in most of the African papers and were therefore not reviewed by Jedy-Agba and colleagues.