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Reproductive characteristics are known risk factors for breast cancer but, other than recent birth, their role as prognostic factors is less clear, and has not been studied in Sub-Saharan Africa (SSA). In this setting, we examined whether reproductive factors independently influence breast cancer survival in a subset of the African Breast Cancer – Disparities in Outcomes cohort study. In 1485 women with incident breast cancer recruited between 2014 and 2017, we examined birth cohort changes in reproductive factors, and used Cox models to examine whether reproductive characteristics were associated with all-cause mortality after adjusting for confounders (age, stage, treatment, HIV, and social factors). Four years after diagnosis, 822 (56%) women had died. Median parity was 4 (IQR=2, 6) and 209 (28%) of premenopausal women had had a recent birth (less than three years prior to cancer diagnosis). Each pregnancy was associated with a 5% increase (95% CI: 2%, 8%) in mortality rates, which held among postmenopausal women (5%, (1%-9%)). Pre-menopausal women with a recent birth had 52% (20%, 92%) higher mortality rates. Fertility trends by birth cohort showed declining parity, increasing age at first birth and declining age at last birth, however the impact of these population-level changes on future average survival was predicted to be very small (

BACKGROUND: Comprehensive breast cancer management is essential to achieve high breast cancer survival; however, detailed reports of the treatment regimens received by patients are scarce in sub-Saharan Africa where survival is low. We aimed to examine treatment initiation, guideline concordance, and abandonment in patients with non-metastatic breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort. METHODS: The ABC-DO prospective cohort study recruited women (aged ≥18 years) with newly diagnosed invasive breast cancer in eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, Uganda, South Africa, and Zambia). We analysed treatments received by women who were classified as non-metastatic (M0) at the initial presentation. Data on surgery, radiotherapy, and systemic therapies were obtained from medical records and a self-reported follow-up questionnaire at 6 months after the diagnosis, follow-up calls every 3 months, and a baseline questionnaire. Initiation, completion, and abandonment of treatment modalities and combined therapy regimens were examined overall, by country-specific groups, and by clinical factors relevant for guideline-based treatment. FINDINGS: Of 2313 women recruited into the ABC-DO study between Sept 10, 2014, and Dec 31, 2017, 2226 had histologically or clinically confirmed breast cancer. Of these 2226 women, 510 were excluded from the present analysis because 378 had metastatic disease, 37 were prevalent cases (defined as those previously diagnosed with breast cancer >2 years before baseline), 82 had unknown TNM stage, and 13 were White or Asian women in South Africa (number was too small for analysis). After a median follow-up of 5·2 years (IQR 4·6-5·9), 1163 (68%) of 1716 women underwent breast cancer surgery. Surgery and systemic therapy (ie, multimodality treatment) with radiotherapy was initiated in 370 (36%) of 1028 women with localised tumours versus 156 (23%) of 688 women with locally advanced tumours, whereas multimodality treatment without radiotherapy was initiated in 386 (38%) versus 167 (24%) women, respectively. Of 1530 patients requiring chemotherapy (which excludes 105 who died within 6 months after baseline), 1013 (66%) initiated treatment of neoadjuvant chemotherapy or surgery within 3 months after baseline, which was adequately completed by 359 (35%) of 1013 women, marginally completed by 284 (28%), abandoned by 200 (20%), and unknown in 151 (15%). 19 (2%) women died within 6 months after chemotherapy initiation. Of 1375 women in whom endocrine therapy was indicated, this treatment was initiated in 920, and lasted at least 3 years in 367 (40%) women. Treatment disparities between country-specific groups were substantial for all therapy regimens. INTERPRETATION: A high proportion of patients with non-metastatic breast cancer did not initiate, did not fully complete, or abandoned treatment with surgery, systemic therapy, radiotherapy, or an appropriate combination of these, highlighting the need for improved treatment access and completion in sub-Saharan Africa to potentially prevent premature breast cancer deaths. FUNDING: National Institutes of Health (National Cancer Institute), Susan G Komen, and the International Agency for Research on Cancer.

The low overall survival rates of breast cancer (BC) patients in sub-Saharan Africa (SSA) are driven by regionally differing tumor biology, advanced tumor stages at diagnosis and limited access to therapy. However, it is not known whether regional differences in the composition of the tumor microenvironment (TME) exist and affect patients’ prognosis. In this international, multicentre cohort study, 1,237 formalin-fixed, paraffin-embedded BC samples, including samples of the ‘African Breast Cancer-Disparities in Outcomes (ABC-DO) Study’, were analyzed. The immune cell phenotypes, their spatial distribution in the TME and immune escape mechanisms of BC samples from SSA and Germany (n=117) were investigated using histomorphology, conventional and multiplex immunohistochemistry (IHC), and RNA expression analysis. The data revealed no regional differences in the number of tumor-infiltrating lymphocytes (TILs) in the 1,237 SSA BC samples, while the distribution of TILs in different BC IHC subtypes showed regional diversity, particularly when compared to German samples. Higher TIL densities were associated with better survival in the SSA cohort (n=400), but regional differences concerning the predictive value of TILs existed. High numbers of CD163+ macrophages and CD3+CD8+ T cells accompanied by reduced cytotoxicity, altered IL10 and IFNγ levels and downregulation of MHC class I components were predominantly detected in BC samples from Western SSA. Features of non-immunogenic BC phenotypes were associated with reduced patient survival (n=131). We therefore conclude that regional diversity in the distribution of BC subtypes, TME composition and immune escape mechanisms should be considered for therapy decisions in SSA and the design of personalized therapies.

BACKGROUND: Studies have shown increased mortality among women living with HIV diagnosed with breast cancer compared with HIV-negative women with breast cancer. We aimed to examine how this HIV differential varies by patient or breast tumour characteristics. METHODS: The African Breast Cancer-Disparities in Outcomes (ABC-DO) study is a prospective cohort of women (aged ≥18 years) with incident breast cancer recruited consecutively at diagnosis (2014-17) from hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. Detailed clinical and epidemiological data, including self-reported or tested HIV status, were collected at baseline. Participants were actively followed up via telephone calls every 3 months. The primary outcome was all-cause mortality, assessed in all women who had at least one updated vital status after baseline interview. Using Cox regression, we examined differences in overall survival by HIV status in the cohort, and across country and patient subgroups, adjusted for age, tumour grade, and tumour stage at cancer diagnosis. FINDINGS: Between Sept 8, 2014, and Dec 31, 2017, we recruited 2154 women with primary breast cancer, 519 of whom were excluded due to their countries having small numbers of women with HIV for comparison. Among the remaining 1635 women, 313 (19%) were living with HIV, 1184 (72%) were HIV negative, and 138 (9%) had unknown HIV status. At breast cancer diagnosis, women with HIV were younger and had lower body-mass index (BMI) than their HIV-negative counterparts, but had similar tumour stage, grade, and receptor subtypes. At the end of the follow-up (Jan 1, 2019), a higher proportion of women with HIV (137 [44%] of 313) had died than had HIV-negative women (432 [37%] of 1184). Crude 3-year survival was 9% lower for women with HIV (46% [95% CI 40-53]) than for HIV-negative women (55% [52-59]; hazard ratio (HR) 1·41 [1·15-1·74]). The HIV survival differential did not differ by age, BMI, tumour subtype, or tumour grade, but was stronger in women with non-metastatic disease (3-year survival 52% HIV-positive vs 63% HIV-negative women, adjusted HR 1·65 [1·30-2·10]), whereas women with metastatic cancer had low survival, regardless of HIV status. INTERPRETATION: The larger survival deficit among women with HIV with non-metastatic breast cancer calls for a better understanding of the reasons underlying this differential (eg, biological mechanisms, health behaviours, detrimental HIV-breast cancer treatment interactions, or higher HIV background mortality) to inform strategies for reducing mortality among this patient group. FUNDING: Susan G Komen, International Agency for Research on Cancer, National Cancer Institute, and UK-Commonwealth Scholarships.

BACKGROUND The prevalence of decorative tattoos is increasing worldwide. Tattooing is an invasive body art that involves the injection of chemical mixtures into the upper layer of the dermis. Although these mixtures may contain environmental toxins, including known human carcinogens, their long-term health effects are poorly studied. Although epidemiological studies are urgently needed, there is no validated method for assessing tattoo exposure so far. OBJECTIVE To develop and validate a method to assess ink exposure in the tattooed population suitable for application in large cohort studies. METHODS Three preliminary versions of the EpiTAT (Epidemiological Assessment Tool for Tattooing) using the tattoo measurement unit "hand surface", "credit card" or "body schemes", were randomly filled in by tattooed volunteers in Lyon, France. A validation study was conducted with 97 selected respondents to compare the self-assessment with validation measurements of tattoo surface, color and fill made by trained study personnel. Interclass correlation, Kendall's rank correlation and two-tailed Student's t-tests were used to statistically compare tattoo size, color area and tattoo fill. Participants' comments on the questionnaire were also considered. For quality control of validation measures, digital surface analysis of 62 photographs of selected tattoos was performed via Fiji/ImageJ. RESULTS In general, results revealed overestimation of self-assessed compared to validation measures (e.g. mean tattooed body surface 1768 cm2 (SD: 1547) vs. 930 cm2 (SD: 1047; p CONCLUSIONS The final version of EpiTAT contains 21 items and uses the "hand surface" as a visual unit of measurement. Likert scales are used to assess color and filling as a proportion of the total tattoo area. Overestimation of tattoo size by self-reporting must be corrected when calculating exposure.

The presence of preexisting morbidities poses a challenge to cancer patient care. There is little information on the profile and prevalence of multi-morbidities in breast cancer patients across middle income countries (MIC) to lower income countries (LIC) in sub-Saharan Africa (SSA). The African Breast Cancer–Disparities in Outcomes (ABC-DO) breast cancer cohort spans upper MICs South Africa and Namibia, lower MICs Zambia and Nigeria and LIC Uganda. At cancer diagnosis, seven morbidities were assessed: obesity, hypertension, diabetes, asthma/chronic obstructive pulmonary disease, heart disease, tuberculosis and HIV. Logistic regression models were used to assess determinants of morbidities and the influence of morbidities on advanced stage (stage III/IV) breast cancer diagnosis. Among 2189 women, morbidity prevalence was the highest for obesity (35%, country-specific range 15-57%), hypertension (32%, 15-51%) and HIV (16%, 2-26%) then for diabetes (7%, 4%-10%), asthma (4%, 2%-10%), tuberculosis (4%, 0%-8%) and heart disease (3%, 1%-7%). Obesity and hypertension were more common in upper MICs and in higher socioeconomic groups. Overall, 27% of women had at least two preexisting morbidities. Older women were more likely to have obesity (odds ratio: 1.09 per 10 years, 95% CI 1.01-1.18), hypertension (1.98, 1.81-2.17), diabetes (1.51, 1.32-1.74) and heart disease (1.69, 1.37-2.09) and were less likely to be HIV positive (0.64, 0.58-0.71). Multi-morbidity was not associated with stage at diagnosis, with the exception of earlier stage in obese and hypertensive women. Breast cancer patients in higher income countries and higher social groups in SSA face the additional burden of preexisting non-communicable diseases, particularly obesity and hypertension, exacerbated by HIV in Southern/Eastern Africa.

Most breast cancer patients in sub‐Saharan Africa are diagnosed at advanced stages after prolonged symptomatic periods. In the multicountry African Breast Cancer‐Disparities in Outcomes cohort, we dissected the diagnostic journey to inform downstaging interventions. At hospital presentation for breast cancer, women recalled their diagnostic journey, including dates of first noticing symptoms and health‐care provider (HCP) visits. Negative binomial regression models were used to identify correlates of the length of the diagnostic journey. Among 1429 women, the median (inter‐quartile range) length (months) of the diagnostic journey ranged from 11.3 (5.7‐21.2) in Ugandan, 8.2 (3.4‐16.4) in Zambian, 6.5 (2.4‐15.7) in Namibian‐black to 5.6 (2.3‐13.1) in Nigerian and 2.4 (0.6‐5.5) in Namibian‐non‐black women. Time from first HCP contact to diagnosis represented, on average, 58% to 79% of the diagnostic journey in each setting except Nigeria where most women presented directly to the diagnostic hospital with advanced disease. The median number of HCPs visited was 1 to 4 per woman, but time intervals between visits were long. Women who attributed their initial symptoms to cancer had a 4.1 months (absolute) reduced diagnostic journey than those who did not, while less‐educated (none/primary) women had a 3.6 months longer journey than more educated women. In most settings the long journey to breast cancer diagnosis was not primarily due to late first presentation but to prolonged delays after first presentation to diagnosis. Promotion of breast cancer awareness and implementation of accelerated referral pathways for women with suspicious symptoms are vital to downstaging the disease in the region., What's new? In sub‐Saharan Africa, most women with breast cancer are diagnosed long after symptoms first arise. Here, the authors studied the diagnostic journey for breast cancer among the African Breast Cancer‐Disparities in Outcome cohort. This is the largest study to quantify the length of the diagnostic journey across various settings in sub‐Saharan Africa. Time to final diagnosis decreased substantially when a woman recognized her symptoms as cancer. Most delays, they found, were due to extended time between first examination and final diagnosis. Promotion of breast cancer awareness among both women and healthcare providers could help reduce these delays.

Accurate survival estimates are needed for guiding cancer control efforts in sub-Saharan Africa, but previous studies have been hampered by unknown biases due to excessive loss to follow-up (LTFU). In the African Breast Cancer—Disparities in Outcomes Study, a prospective breast cancer cohort study, we implemented active mobile health follow-up, telephoning each woman or her next-of-kin (NOK) trimonthly on her mobile phone to update information on her vital status. Dates of every contact with women/NOK were analyzed from diagnosis in 2014–2017 to the earliest of September 1, 2018, death, or 3 years postdiagnosis. The cumulative incidence of being LTFU was calculated considering deaths as competing events. In all, 1,490 women were followed for a median of 24.2 (interquartile range (IQR), 14.2–34.5) months, corresponding to 8,529 successful contacts (77% of total contacts) with the women/NOK. Median time between successful contacts was 3.0 (IQR, 3.0–3.7) months. In all, 71 women (5.3%) were LTFU at 3 years: 0.8% in Nigeria, 2.2% in Namibia, and 5.6% in Uganda. Because of temporary discontinuity of active follow-up, 20.3% of women were LTFU after 2 years in Zambia. The median time to study notification of a death was 9.1 (IQR, 3.9–14.0) weeks. Although the present study was not a randomized controlled trial, in this cancer cohort with active mobile health follow-up, LTFU was much lower than in previous studies and enabled estimation of up-to-date and reliable cancer survival.

Objectives: Our aim was to derive a short version of the Mobile Phone Problem Use Scale (MPPUS) using data from 412 adolescents of the Swiss HERMES (Health Effects Related to Mobile phonE use in adolescentS) cohort. Methods: A German version of the original MPPUS consisting of 27 items was shortened by principal component analysis (PCA) using baseline data collected in 2012. For confirmation, the PCA was carried out again with follow-up data 1year later. Results: PCA revealed four factors related to symptoms of addiction (Loss of Control, Withdrawal, Negative Life Consequences and Craving) and a fifth factor reflecting the social component of mobile phone use (Peer Dependence). The shortened scale (MPPUS-10) highly reflects the original MPPUS (Kendalls' Tau: 0.80 with 90% concordant pairs). Internal consistency of MPPUS-10 was good with Cronbach's alpha: 0.85. The results were confirmed using the follow-up data. Conclusions: The MPPUS-10 is a suitable instrument for research in adolescents. It will help to further clarify the definition of problematic mobile phone use in adolescents and explore similarities and differences to other technological addictions.

This abstract was not presented at the conference. Citation Format: Foerster M, Zietsman A, Galakunde M, Anele A, Adisa C, Schuz J, Dos Santos Silva I, McCormack V. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-01.

Background: Studies have shown increased mortality among HIV-positive women with breast cancer compared to HIV-negative women with breast cancer, but none has examined how this differential varies by patient or breast tumour characteristics. Methods: ABC-DO study is a prospective cohort of incident breast cancer women recruited at diagnosis (2014-2017) in Namibia, Nigeria, South Africa, Uganda and Zambia. Detailed clinic-epidemiological data were collected at baseline. Participants were actively followed-up via 3-monthly telephone calls. Using Cox regression, we examined differences in overall survival by HIV status in the cohort, and across country and patient subgroups, adjusted for age at cancer diagnosis, tumour grade and stage at cancer diagnosis. Findings: Among 1,635 women, 313 (19%) were HIV-positive, 1,184 (72%) were HIV-negative and 138 (9%) HIV-unknown. At breast cancer diagnosis, HIV-positive women were younger and had lower BMI than their HIV-negative counterparts, but had similar tumour stage, grade and receptor subtypes. At the end of the follow-up (January 1, 2019), a higher proportion of HIV-positive women (137 (44%)) had died compared to HIV-negative women (432 (37%)). Crude three-year survival was 9% lower for HIV-positive women (46% vs. 55% for HIV-negative women, hazard ratio (HR) 1·41; 95% CI: 1·15-1·74). The difference did not differ by age, BMI, tumour subtype or grade but was stronger in women with non-metastatic disease (52% HIV-positive vs. 63% HIV-negative women, adjusted HR 1·65: 1·30-2·10), whilst women with metastatic cancer had low survival regardless of HIV status. Interpretation: The larger survival deficit among WLWH with non-metastatic breast cancer calls for a better understanding of the reasons underlying this differential e.g. biological mechanisms, health behaviours, detrimental HIV-breast cancer treatment interactions or higher HIV background mortality, to inform strategies for reducing mortality among this young patient group. Funding: Susan G Komen, International Agency for Research on Cancer, National Cancer Institute and UK-Commonwealth Scholarships. Declaration of Interest: No declaration of competing interests. Ethical Approval: The ABC-DO study was approved by all institutional ethics committees (List 1 in Supplementary Material), and all women provided written or thumbprint informed consent, witnessed by the study interviewer.

Key Points Question How many maternal orphans resulted from every 100 breast cancer deaths in sub-Saharan African settings in 2014-2019? Findings In the African Breast Cancer–Disparities in Outcomes cohort study of women with breast cancer, there were 964 children (, Importance Low breast cancer survival in sub-Saharan Africa’s young population increases the likelihood that breast cancer deaths result in maternal orphans, ie, children (, This cohort study estimates the number of maternal orphans in 4 sub-Saharan Africa countries when women die of breast cancer.

We examined the geospatial dimension of delays to diagnosis of breast cancer in a prospective study of 1541 women newly diagnosed in the African Breast Cancer—Disparities in Outcomes (ABC‐DO) Study. Women were recruited at cancer treatment facilities in Namibia, Nigeria, Uganda and Zambia. The baseline interview included information used to generate the geospatial features: urban/rural residence, travel mode to treatment facility and straight‐line distances from home to first‐care provider and to diagnostic/treatment facility, categorized into country/ethnicity (population)‐specific quartiles. These factors were investigated in relation to delay in diagnosis (≥3 months since first symptom) and late stage at diagnosis (TNM: III, IV) using logistic regression, adjusted for population group and sociodemographic characteristics. The median (interquartile range) distances to first provider and diagnostic and treatment facilities were 5 (1‐37), 17 (3‐105) and 62 (5‐289) km, respectively. The majority had a delay in diagnosis (74%) and diagnosis at late stage (64%). Distance to first provider was not associated with delay in diagnosis or late stage at diagnosis. Rural residence was associated with delay, but the association did not persist after adjustment for sociodemographic characteristics. Distance to the diagnostic/treatment facility was associated with delay (highest vs lowest quartile: odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.08‐2.27) and late stage (overall: OR = 1.47, CI = 1.05‐2.06; without Nigerian hospitals where mostly local residents were treated: OR = 1.73, CI = 1.18‐2.54). These findings underscore the need for measures addressing the geospatial barriers to early diagnosis in sub‐Saharan African settings, including providing transport or travel allowance and decentralizing diagnostic services., What's new? Survival from breast cancer is poor in sub‐Saharan Africa, due largely to the high proportion of women who are diagnosed at advanced stages. In this study, the authors examined geospatial information to assess women's prediagnostic journey to breast cancer diagnosis, with special attention to delays in diagnosis, in the regions of Namibia, Nigeria, Uganda, and Zambia. Geospatial factors particularly long travel distances to diagnostic and treatment facilities were identified as major barriers to early diagnosis. The findings underscore the need for policies to address these barriers to ensure breast cancer diagnosis at a curable stage.

Summary Background Breast cancer is the second leading cause of death from cancer in women in sub-Saharan Africa, yet there are few well characterised large-scale survival studies with complete follow-up data. We aimed to provide robust survival estimates in women in this setting and apportion the survival gaps. Methods The African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort study was done at eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, South Africa, Uganda, and Zambia). We prospectively recruited women (aged ≥18 years) who attended these hospitals with suspected breast cancer. Women were actively followed up by use of a telephone call once every 3 months, and a mobile health application was used to keep a dynamic record of follow-up calls due. We collected detailed sociodemographic, clinical, and treatment data. The primary outcome was 3-year overall survival, analysed by use of flexible proportional mortality models, and we predicted survival under scenarios of modified distributions of risk factors. Findings Between Sept 8, 2014, and Dec 31, 2017, 2313 women were recruited from these eight hospitals, of whom 85 did not have breast cancer. Of the remaining 2228 women with breast cancer, 58 women with previous treatment or recurrence, and 14 women from small racial groups (white and Asian women in South Africa), were excluded. Of the 2156 women analysed, 1840 (85%) were histologically confirmed, 129 (6%) were cytologically confirmed, and 187 (9%) were clinically confirmed to have breast cancer. 2156 (97%) women were followed up for up to 3 years or up to Jan 1, 2019, whichever was earlier. Up to this date, 879 (41%) of these women had died, 1118 (52%) were alive, and 159 (7%) were censored early. 3-year overall survival was 50% (95% CI 48–53), but we observed variations in 3-year survival between different races in Namibia (from 90% in white women to 56% in Black women) and in South Africa (from 76% in mixed-race women to 59% in Black women), and between different countries (44–47% in Uganda and Zambia vs 36% in Nigeria). 215 (10%) of all women had died within 6 months of diagnosis, but 3-year overall survival remained low in women who survived to this timepoint (58%). Among survival determinants, improvements in early diagnosis and treatment were predicted to contribute to the largest increases in survival, with a combined absolute increase in survival of up to 22% in Nigeria, Zambia, and Uganda, when compared with the contributions of other factors (such as HIV or aggressive subtypes). Interpretation Large variations in breast cancer survival in sub-Saharan African countries indicate that improvements are possible. At least a third of the projected 416 000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable downstaging and improvements in treatment. Improving survival in socially disadvantaged women warrants special attention. Funding Susan G Komen and the International Agency for Research on Cancer.

In order to achieve an integrated radio-frequency electromagnetic fields (RF-EMF) dose assessment, detailed information about source-specific exposure duration and output power is needed. We developed an Integrated Exposure Model (IEM) to combine energy absorbed due to use of and exposure to RF-EMF sources and applied it to a sample of the general population to derive population RF-EMF estimates. The IEM used specific absorption rate transfer algorithms to provide RF-EMF daily dose estimates (mJ/kg/day) using source-specific attributes (e.g. output power, distance), personal characteristics and usage patterns. Information was obtained from an international survey performed in four European countries with 1755 participants. We obtained median whole-body and whole-brain doses of 183.7 and 204.4 mJ/kg/day. Main contributors to whole-brain dose were mobile phone near the head for calling (2G networks) and far-field sources, whereas the latter together with multiple other RF-EMF sources were main contributors for whole-body dose. For other anatomical sites, 2G phone calls, mobile data and far-field exposure were important contributors. The IEM provides insight into main contributors to total RF-EMF dose and, applied to an international survey, provides an estimate of population RF-dose. The IEM can be used in future epidemiological studies, risk assessments and exposure reduction strategies.

Late stage at breast cancer diagnosis is a major contributor to poor survival from breast cancer in many sub-Saharan African countries. Using Ugandan as an example, we discuss barriers along the journey to diagnosis and highlight areas where improvements are needed. In Uganda, the majority of breast cancer patients noticed symptoms of their cancer for at least 9 months prior to diagnosis, which is typical of many African countries. For most women, the health provider delay is extensive, owing to barriers related to cost, transport, stigma, provider knowledge, and difficult-to-navigate referral systems. Downstaging efforts should focus on reducing health system delay and target low community awareness. Implementation research to strengthen women’s breast cancer knowledge, access to breast health services, and referral pathways provide clear opportunities for downstaging.

In order to achieve an integrated radio-frequency electromagnetic fields (RF-EMF) dose assessment, detailed information about source-specific exposure duration and output power is needed. We developed an Integrated Exposure Model (IEM) to combine energy absorbed due to use of and exposure to RF-EMF sources and applied it to a sample of the general population to derive population RF-EMF estimates. The IEM used specific absorption rate transfer algorithms to provide RF-EMF daily dose estimates (mJ/kg/day) using source-specific attributes (e.g. output power, distance), personal characteristics and usage patterns. Information was obtained from an international survey performed in four European countries with 1755 participants. We obtained median whole-body and whole-brain doses of 183.7 and 204.4 mJ/kg/day. Main contributors to whole-brain dose were mobile phone near the head for calling (2G networks) and far-field sources, whereas the latter together with multiple other RF-EMF sources were main contributors for whole-body dose. For other anatomical sites, 2G phone calls, mobile data and far-field exposure were important contributors. The IEM provides insight into main contributors to total RF-EMF dose and, applied to an international survey, provides an estimate of population RF-dose. The IEM can be used in future epidemiological studies, risk assessments and exposure reduction strategies.

Nocturnal media use has been linked to adolescents&rsquo, sleeping problems in cross-sectional studies which do not address reverse causality. To prospectively assess the new occurrence of sleep problems or health symptoms in relation to electronic media use and nocturnal mobile phone use, we used data from the longitudinal Swiss HERMES (Health Effects Related to Mobile phone usE in adolescentS) cohort on 843 children from 7th to 9th grade. Logistic regression models were fitted and adjusted for relevant confounders. Adolescents reporting at baseline and follow-up at least one nocturnal awakenings from their own mobile phone per month were more likely to have developed restless sleep (Odds Ratio (OR): 5.66, 95% Confidence Interval: 2.24&ndash, 14.26) and problems falling asleep (3.51, 1.05&ndash, 11.74) within one year compared to adolescents without nocturnal awakenings. A similar pattern was observed for developing symptoms, although somewhat less pronounced in terms of the magnitude of the odds ratios. With respect to high screen time at baseline and follow-up, associations were observed for falling asleep (2.41, 1.41&ndash, 4.13), exhaustibility (1.76, 1.02&ndash, 3.03), lack of energy (1.76, 1.04&ndash, 2.96) and lack of concentration (2.90, 1.55&ndash, 5.42). Our results suggest a detrimental effect of screen time and mobile phone-related awakenings on sleep problems and related health symptoms. However, the results should be interpreted cautiously with respect to adolescents&rsquo, natural changes in circadian rhythm, which may coincidence with an increase in mobile phone and media use.

Background: Breast cancer is the second leading cause of cancer death in women in sub-Saharan Africa, yet there are few large-scale survival studies with rich clinical and epidemiologic data and few losses to follow-up to inform intervention strategies needed to avert premature deaths. Methods: In the hospital-based African Breast Cancer – Disparities in Outcomes (ABC-DO) cohort, characterized by rich sociodemographic, clinical and treatment data, 2214 women newly diagnosed with breast cancer across five Sub-Saharan African countries were prospectively followed using a trimonthly mobile phone contact protocol. Flexible proportional mortality models were used to estimate observed survival, hazard ratios and predict survival under scenarios of modifying risk factors. Findings: Among 2156 women followed up to three years, 879 (41%) died, 1118 (52%) were alive and 159 (7%) were censored early. Three-year survival was 50% overall, but varied between races in Namibia (90% white, 69% mixed-race and 56% in black women) and South Africa (76% mixed-race, 59% black) and between countries: 44 to 47% in Uganda and Zambia and 36% in Nigeria. Ten percent of all women died within 6 months of diagnosis, but three-year survival remained low (58%) conditional on surviving to this time-point. Among survival determinants, improvements in early diagnosis and treatment were predicted to result in the largest survival gains of up to a combined 22% absolute increase, compared to the contributions of social inequalities (up to 5%), non-receptor positive tumours (up to 4%) and young age or HIV (

Pratiquement tous les jeunes utilisent un telephone mobile quotidiennement. L’etude HERMES avait pour objectif de determiner si l’utilisation d’appareils de communication sans fil et le rayonnement de ces appareils ont un impact sur la qualite de vie associee a la sante, sur le comportement et sur les capacites cognitives des jeunes.

Praktisch alle Jugendlichen nutzen taglich ein Mobiltelefon. Die HERMES Studie hat untersucht, ob die Nutzung und die Strahlung von drahtlosen Kommunikationsgeraten einen Einfluss auf die gesundheitsbezogene Lebensqualitat, das Verhalten und die kognitiven Fahigkeiten von Jugendlichen haben.

Background: The potential impact of microwave radiofrequency electromagnetic fields (RF-EMF) emitted by wireless communication devices on neurocognitive functions of adolescents is controversial. In a previous analysis, we found changes in figural memory scores associated with a higher cumulative RF-EMF brain dose in adolescents. Objective: We aimed to follow-up our previous results using a new study population, dose estimation, and approach to controlling for confounding from media usage itself. Methods: RF-EMF brain dose for each participant was modeled. Multivariable linear regression models were fitted on verbal and figural memory score changes over 1 y and on estimated cumulative brain dose and RF-EMF related and unrelated media usage (n=669–676). Because of the hemispheric lateralization of memory, we conducted a laterality analysis for phone call ear preference. To control for the confounding of media use behaviors, a stratified analysis for different media usage groups was also conducted. Results: We found decreased figural memory scores in association with an interquartile range (IQR) increase in estimated cumulative RF-EMF brain dose scores: −0.22 (95% CI: −0.47, 0.03; IQR: 953 mJ/kg per day) in the whole sample, −0.39 (95% CI: −0.67, −0.10; IQR: 953 mJ/kg per day) in right-side users (n=532), and −0.26 (95% CI: −0.42, −0.10; IQR: 341 mJ/kg per day) when recorded network operator data were used for RF-EMF dose estimation (n=274). Media usage unrelated to RF-EMF did not show significant associations or consistent patterns, with the exception of consistent (nonsignificant) positive associations between data traffic duration and verbal memory. Conclusions: Our findings for a cohort of Swiss adolescents require confirmation in other populations but suggest a potential adverse effect of RF-EMF brain dose on cognitive functions that involve brain regions mostly exposed during mobile phone use. https://doi.org/10.1289/EHP2427

© 2015 Swiss School of Public Health (SSPH+) Objectives: To investigate the associations between problematic mobile phone use and mental health and behavioural problems in 412 Swiss adolescents owning a mobile phone while controlling for amount of mobile phone use. Methods: Problematic mobile phone use was determined by the MPPUS 10 (Mobile Phone Problem Use Scale) and related to health and behavioural problems by means of multivariable regression modelling. Results: MPPUS 10 was 4.7 (95 CI 1.8 7.6) units higher in girls than in boys increased significantly with age and was significantly decreased with increasing educational level of the parents. Furthermore problematic mobile phone use was associated with impaired psychological well being impaired parent and school relationships and more behavioural problems but was not related to peer support and social acceptance. Conclusions: Our study indicates that problematic mobile phone use is associated with external factors such as worse home and school environment and internal factors such as impaired mental health and behavioural problems of the adolescents and thus problematic mobile phone use should be addressed in particular when dealing with adolescents showing behavioural or emotional problems.

Background/Aim: The potential impact of microwave radiofrequency electromagnetic fields (RF-EMF) emitted by wireless communication devices on neurocognitive functions of adolescents is still discus...

The impact of the introduction and advancement in communication technology in recent years on exposure level of the population is largely unknown. The main aim of this study is to systematically review literature on the distribution of radiofrequency electromagnetic field (RF-EMF) exposure in the everyday environment in Europe and summarize key characteristics of various types of RF-EMF studies conducted in the European countries. We systematically searched the ISI Web of Science for relevant literature published between 1 January 2000 and 30 April 2015, which assessed RF-EMF exposure levels by any of the methods: spot measurements, personal measurement with trained researchers and personal measurement with volunteers. Twenty-one published studies met our eligibility criteria of which 10 were spot measurements studies, 5 were personal measurement studies with trained researchers (microenvironmental), 5 were personal measurement studies with volunteers and 1 was a mixed methods study combining data collected by volunteers and trained researchers. RF-EMF data included in the studies were collected between 2005 and 2013. The mean total RF-EMF exposure for spot measurements in European "Homes" and "Outdoor" microenvironments was 0.29 and 0.54 V/m, respectively. In the personal measurements studies with trained researchers, the mean total RF-EMF exposure was 0.24 V/m in "Home" and 0.76 V/m in "Outdoor". In the personal measurement studies with volunteers, the population weighted mean total RF-EMF exposure was 0.16 V/m in "Homes" and 0.20 V/m in "Outdoor". Among all European microenvironments in "Transportation", the highest mean total RF-EMF 1.96 V/m was found in trains of Belgium during 2007 where more than 95% of exposure was contributed by uplink. Typical RF-EMF exposure levels are substantially below regulatory limits. We found considerable differences between studies according to the type of measurements procedures, which precludes cross-country comparison or evaluating temporal trends. A comparable RF-EMF monitoring concept is needed to accurately identify typical RF-EMF exposure levels in the everyday environment.

Spatial and temporal distribution of radiofrequency electromagnetic field (RF-EMF) levels in the environment is highly heterogeneous. It is thus not entirely clear how to monitor spatial variability and temporal trends of RF-EMF exposure levels in the environment in a representative and efficient manner. The aim of this study was to test a monitoring protocol for RF-EMF measurements in public areas using portable devices.Using the ExpoM-RF devices mounted on a backpack, we have conducted RF-EMF measurements by walking through 51 different outdoor microenvironments from 20 different municipalities in Switzerland: 5 different city centers, 5 central residential areas, 5 non-central residential areas, 15 rural residential areas, 15 rural centers and 6 industrial areas. Measurements in public transport (buses, trains, trams) were collected when traveling between the areas. Measurements were conducted between 25th March and 11th July 2014. In order to evaluate spatial representativity within one microenvironment, we measured two crossing paths of about 1km in length in each microenvironment. To evaluate repeatability, measurements in each microenvironment were repeated after two to four months on the same paths.Mean RF-EMF exposure (sum of 15 main frequency bands between 87.5 and 5,875MHz) was 0.53V/m in industrial zones, 0.47V/m in city centers, 0.32V/m in central residential areas, 0.25V/m non-central residential areas, 0.23V/m in rural centers and rural residential areas, 0.69V/m in trams, 0.46V/m in trains and 0.39V/m in buses. Major exposure contribution at outdoor locations was from mobile phone base stations (80% for all outdoor areas with respect to the power density scale). Temporal correlation between first and second measurement of each area was high: 0.89 for total RF-EMF, 0.90 for all five mobile phone downlink bands combined, 0.51 for all five uplink bands combined and 0.79 for broadcasting. Spearman correlation between arithmetic mean values of the first path compared to arithmetic mean of the second path within the same microenvironment was 0.75 for total RF-EMF, 0.76 for all five mobile phone downlink bands combined, 0.55 for all five uplink bands combined and 0.85 for broadcasting (FM and DVB-T).This study demonstrates that microenvironmental surveys using a portable device yields highly repeatable measurements, which allows monitoring time trends of RF-EMF exposure over an extended time period of several years and to compare exposure levels between different types of microenvironments.