The utilisation of endocrine and immunotherapy: Retrospective study at a tertiary hospital in South Africa

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Immunotherapy boosts the immune system against cancer, while endocrine therapy is typically used in cancer patients diagnosed with hormone receptor-positive cancers. Breast and prostate cancers are the most prevalent cancers in which endocrine therapy and immunotherapy are utilised. This study aimed to evaluate the use of endocrine and immunotherapy, and factors associated with their use at a tertiary hospital in Limpopo Province, South Africa. Method A retrospective open cohort, longitudinal, descriptive study design was utilised. The study enrolled 82 (eighty-two) medical records of patients who started cancer treatment from January 2019 to August 2025 at a tertiary hospital in Limpopo Province of South Africa. A Chi-square or ANOVA test was used to examine the association between age, receptor status, and cancer stage at diagnosis with the type of first-line therapy. Data analysis was conducted using R programming software, version 4.5.2. Results Endocrine therapy was used as primary or first- line treatment in 29.3% ( \(n=\) 24) of the patients and was dominantly used as an adjuvant therapy to chemotherapy. The analysis indicated a significant association between age, cancer stage, receptor status, and the use of endocrine therapy as first-line treatment. None of the patients received immunotherapy as first-line treatment at diagnosis. The results further revealed limited use of immunotherapy to a maximum of 5 patients over the study period. Conclusion While endocrine therapy is predominantly used as an adjuvant therapy to chemotherapy, the use of immunotherapy is limited. This reveals that patients who would normally benefit from immunotherapy may not be receiving it. This may be due to the cost implications and budget constraints in the public hospitals. Cancer chemotherapy endocrine therapy immunotherapy Figures Figure 1 Introduction Cancer is a group of diseases that involve the abnormal cell growth in an uncontrollable way, with the potential to invade the surrounding tissues and metastasise to other body parts [ 1 ]. Endocrine therapy is one of the standard treatments to reduce the risk of recurrence and mortality in patients with hormone-receptor sensitive cancers [ 2 ]. Endocrine therapy involves the administration of hormonal agents such as selective estrogen receptor modulators, aromatase inhibitors, and androgen deprivation therapy (ADT) [ 3 ]. Breast and prostate cancers are the most prevalent cancers in which endocrine therapy is utilised. Breast cancer is the most common cancer affecting women globally, while prostate cancer is the leading cancer among men [ 4 ]. In sub-Saharan Africa, breast cancer is the leading cause of cancer deaths, due to resource constraints such as limited access to appropriate cancer therapy, compared to Europe and the United States [ 5 ]. Most breast tumours are hormone receptor-positive in Southern Africa, compared to Eastern Africa, where the triple-negative subtype is more common [ 6 ]; paving the way for the use of endocrine therapy. Endocrine therapy drugs commonly used to treat breast cancer include tamoxifen for premenopausal patients and anastrozole for postmenopausal patients, while goserelin and bicalutamide are used as the primary systemic therapy for regional and advanced prostate cancer disease [ 7 ]. Utilisation of endocrine therapy requires an accurate assessment of hormonal status, while targeted therapy with immunotherapy treatment is mostly unavailable due to costs [ 8 ]. Patients who are hormone receptor negative do not benefit from endocrine therapy, which renders them good candidates for immunotherapy [ 9 ]. Incorporating immunotherapy treatment like trastuzumab into standard cancer treatment regimens provides substantial improvement in patient outcomes [ 10 ]. However, immunotherapy treatment is associated with high costs, which may limit its availability in public institutions. In South Africa’s public healthcare system, cancer treatment is offered for free to unemployed patients and patients without medical insurance coverage. Despite free cancer treatment offered in designated public hospitals, there is limited information regarding the utilisation of endocrine and immunotherapy in South Africa. This study aims to retrospectively evaluate the use of endocrine and immunotherapy and the associated factors at a tertiary hospital in Limpopo Province, South Africa. Materials and methods This study was conducted at a public tertiary hospital located in Limpopo Province of South Africa. This is the only hospital with an oncology unit within the public health facilities in Limpopo Province. This study followed a retrospective open cohort, longitudinal, descriptive study design. Owing to the retrospective design of the study, the requirement for written consent from patients was waived. However, ethical approval was provided by the Turfloop Research Ethics Committee (TREC) at the University of Limpopo and the Limpopo Department of Health. Patients’ information was obtained through a review of existing medical records. The oncology register was used to identify the medical records of eligible patients. The study population consisted of adults older than 18 years diagnosed and treated for cancer using immunotherapy and endocrine therapy. The study enrolled 82 patients’ medical records that met the selection criteria. Medical records with missing treatment information and those that were not retrieved from the record department section due to incorrect file identification numbers were excluded from this research study. Data from January 2019 to August 2025 were obtained from these medical records. Data collected from the medical records included age, gender, race, date of birth, date of diagnosis, type of first-line therapy, type of cancer, category of cancer, stage of cancer at diagnosis, receptor status, occupation, metastasis, district, ECOG level, and clinical outcome. Data analysis Data were analysed using R software, version 4.5.2. Categorical variables were summarized as frequencies and percentages, while continuous variables were reported as means with standard deviations (SD). A chi-square test was performed to determine the relationship between categorical variables. A one-way analysis of variance (ANOVA) was conducted to assess the relationship between the mean age across first-line treatment groups. The level of significance was defined as \(p-value<0.05.\) Study Results Patients' demographics are presented in Table 1 . Out of a total of 82 patients’ medical records enrolled in the study, the majority had breast cancer \((n=72,87.8\%)\) , followed by prostate cancer \((n=8,9.8\%)\) . Melanoma and ovarian cancers were the least common, each accounted for 1.2% ( \(n=\) 1) of cases. The mean age was 55 years (SD=14.45). Females comprised most of the patients ( \(n=\) 73, 89%), while males accounted for 11%( \(n=\) 9). Most patients were from Capricorn ( \(n=\) 24, 29.3%) and Vhembe ( \(n=\) 19, 23.2%) districts, followed by Sekhukhune ( \(n=\) 17, 20.7%), Mopani ( \(n=\) 15, 18.3%), and Waterberg ( \(n=7\) , 8.5%), which contributed the smallest proportion. Employment status analysis showed that most patients were unemployed ( \(n=\) 45, 54.9%), followed by pensioners ( \(n=\) 25, 30.5%). The majority of patients in the study were classified as on ECOG 1 ( \(n=\) 62, 75.6%). Table 1 Patient Characteristics Gender Frequency Percentage Females 73 89% Males 9 11% Mean age in years Standard deviation 55 14.45 Race African 80 97.6% White 1 1.2% Coloured 1 1.2% District of origin Capricorn 24 29.3% Mopani 15 18.3% Sekhukhune 17 20.7% Vhembe 19 23.2% Waterberg 7 8.5% Occupation Employed 12 14.6% Pensioner 25 30.5% Unemployed 45 54.9% Type of cancer Breast Cancer 72 87.8% Prostate Cancer 8 9,8% Ovarian Cancer 1 1,2% Melanoma 1 1.2% Metastasis Unknown 34 41.5 Metastatic 31 37.8 Non-metastatic 17 20.7 Category of cancer Unknown 9 11% Invasive 70 85.4% Non-invasive 3 3.7% Receptor Status Not Indicated 10 12,2% Estrogen +ve 9 11.0% Estrogen +ve, Progesterone +ve 31 37,8% HER2 + ve 4 4,9% Triple +ve 15 18,3% Estrogen +ve, HER2 + ve 7 8,5% Triple -ve 1 1,2% HER2 + ve, Progesterone +ve 2 2,4% Progesterone +ve 3 3,7% Stage of cancer at diagnosis No stage indicated 4 4,9% Stage I 10 12,2% Stage II 7 8,5% Stage III 31 37,8% Stage IV 30 36,6% Type of first-line therapy Chemotherapy 52 63,4% Endocrine therapy 24 29,3% Surgery 3 3,7% Radiation 3 3,7% ECOG level 0 2 2,4% 1 62 75,6% 2 12 14,6% 3 3 3,7% 4 3 3,7% Most patients had no record of metastasis at diagnosis \((41.5\%,n=34)\) . Out of 82 study patients, 37.8% ( \(n=31\) ) recorded metastatic cancer and \(20.7\%(n=17)\) recorded non-metastatic cancer. Most patients were diagnosed at advanced stages (stage III: \(n=31,37.8\%\) ; stage IV: \(n=30,36.6\%\) ). The majority of patients were hormone receptor positive, with about 43 patients (52.5%) having estrogen-positive and/or progesterone-positive (ER+, PR+) status. This was followed by triple positive hormone status (18.3%, \(n=\) 15). Use of endocrine and immunotherapy Endocrine therapy was used as primary or first- line treatment in 29.3% ( \(n=\) 24) of the patients. In most cases ( \(n=\) 52, 63.4%), it was used as an adjuvant therapy to chemotherapy. Endocrine therapy was administered across a wide age range in this study, with patients receiving treatment in their late twenties to mid-eighties. Notably, the use of endocrine therapy was high among older patients (50 years and older), where it accounted for a substantial proportion of first-line treatment. None of the patients received immunotherapy as first-line treatment. However, 6.1% ( \(n=\) 5) of patients received immunotherapy in combination with other chemotherapy drugs post first-line treatment. All patients who received immunotherapy had invasive breast cancer at diagnosis. Among patients who received immunotherapy, two had triple-positive hormonal status, and one was HER2 positive. One patient expressed oestrogen and progesterone positive status, while the other patient had oestrogen positive only. Monoclonal antibody drug (trastuzumab) was the only immunotherapy drug used in this study. It was noted that immunotherapy administration was intermittently affected by stock-outs, resulting in periods when the medication was not available for use. Tamoxifen was the most used endocrine therapy drug at first-line treatment, accounting for 15.9% ( \(n=\) 13), followed by goserelin at 8.5% ( \(n=\) 7) and anastrozole at 3.7% ( \(n=\) 3). The majority of patients received chemotherapy as first-line treatment (combination of cyclophosphamide, doxorubicin or epirubicin, and 5-fluorouracil \(n=\) 34, 41.5%), followed by cyclophosphamide and doxorubicin ( \(n=\) 10, 12.2%). Factors associated with the use of first-line treatment As indicated in Fig. 1 , patients aged 50 years and above with hormone receptor-positive cancers received endocrine therapy as first-line treatment, whereas those younger than 50 years predominantly received chemotherapy. This difference may reflect clinical guidelines that favour endocrine therapy for older patients due to better tolerance and less side effects. A one-way analysis of variance (ANOVA) analysis indicated a significant association between mean age and the use of endocrine therapy as first-line treatment ( \(p-value=0.008\) ). Most patients \((n=42,80.8\%)\) who are on stage III-IV received chemotherapy as first-line treatment, reflecting the preference of chemotherapy in late-stage cancer patients over endocrine therapy. The association was statistically significant, \(({{\chi}^{2}}_{12}=25.43,p-value=0.013)\) indicating that there is a significant relationship between the stage of cancer and the type of cancer treatment at first-line. Patients with hormone receptor-positive cancers without HER2 positivity accounted for most who received endocrine therapy as primary or first-line treatment, including 4 oestrogen-positive cases (16.7%) and 10 estrogen- and progesterone-positive cases (41.7%). Limited use of endocrine therapy was observed in HER2-associated receptor type, with only one estrogen-positive/HER2-positive patient (4.2%) and one triple-positive patient receiving endocrine therapy (4.2%) as first-line treatment. No patient with HER2-positive only or hormone receptor-negative cancers received endocrine therapy as first-line treatment at any point. Chi-square analysis revealed a significant association between endocrine therapy usage at first line and receptor status \(({{\chi}^{2}}_{24}=62.93,p-value<0.001).\) Discussion Endocrine therapy is one of the standard treatments to reduce the risk of recurrence and mortality in patients with hormone receptor-positive cancers [ 2 ]. In this study, the use of endocrine therapy and immunotherapy were investigated by analysing 82 patients’ clinical records. The findings revealed that endocrine therapy was used mainly to treat breast and prostate cancer, while immunotherapy was used in breast cancer only. The use of endocrine therapy to treat breast and prostate cancers is a common phenomenon in cancer therapy and is often regarded as the cornerstone treatment for breast and prostate cancers [ 7 ]. Endocrine therapy may be used as a stand-alone treatment or in combination with surgery, radiotherapy, or chemotherapy. Endocrine therapy was used as first-line therapy in less than one-third of patients. Therefore, it was predominantly used as an adjuvant therapy, as similarly reported in a study conducted by Johnson et al.[ 6 ] in Botswana. The most prevalent associated co-morbidities in this study were hypertension ( \(n=\) 22, 26.8%) and HIV/AIDs ( \(n=\) 7, 8.5%), which aligns with the study findings in India, where hypertension (21.8%) was the most associated comorbidity in a breast cancer study [ 11 ]. None of the patients diagnosed with prostate, melanoma, or ovarian cancer were HIV positive at the time of diagnosis, whereas HIV/AIDS was identified only among patients with breast cancer in this cohort. In South Africa (SA), the majority of patients present with late-stage cancer, which is associated with poor clinical outcomes [ 12 ].The findings by [ 12 ] and [ 5 ] complement the results of this study, where the majority of the patients were diagnosed at advanced stages (stage III ( \(n=\) 31; 37.6%) and stage IV ( \(n=\) 30; 36.6)). While previous studies have indicated the benefits of early endocrine therapy in improving the survival of patients, the late presentation of the patients diminishes this advantage [ 13 ]. Most patients who expressed HR+/HER2– received endocrine therapy as first-line treatment. Similar findings were observed in a study conducted in Sudan, where endocrine therapy was linked to a HR+/HER2– [ 14 ]. The use of endocrine therapy in first-line settings for hormone receptor-positive is in line with the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) [ 15 ]. Accordingly, patients who had triple-positive hormone receptor status or HER2-positive cancers were initiated on chemotherapy. Chemotherapy induction was followed by maintenance with endocrine therapy. The addition of maintenance endocrine therapy to hormone receptor-positive and HER2-positive cancers after chemotherapy induction is associated with improved overall survival [ 16 ]. This indicates the role of the receptor status in determining treatment decisions and underscores the central role of tumour biology in guiding therapeutic decision-making. Furthermore, the clinical stage at diagnosis remains a critical determinant of treatment strategy and an established predictor of overall survival. Endocrine therapy represents a cornerstone of management in both early- and advanced-stage disease [ 17 ]. The lower rate of endocrine therapy in advanced stages may reflect a clinical preference for chemotherapy or other treatment modalities in these patients. Age was one of the determining factors for treatment choice in this study. This study revealed that patients aged 50 years or older with hormone receptor-positive cancer were treated with endocrine therapy compared to younger patients. This finding is supported by a study conducted in the US, where post-menopausal women who expressed hormone receptor-positive tumours and are at low risk of adverse medication effects were treated with endocrine therapy [ 18 ]. According to NCCN guidelines, the preferred endocrine therapy option for postmenopausal patients is an aromatase inhibitor [ 15 ]. Additionally, a study conducted in Italy demonstrated that postmenopausal patients commonly received aromatase inhibitors such as anastrozole, as these agents have been shown to reduce the risk of breast cancer recurrence and mortality more effectively than tamoxifen in this population [ 19 ]. However, tamoxifen was the preferred drug for both pre- and post-menopausal women in this study. Similarly, a study in Nigeria showed that tamoxifen was mostly recommended as an adjunct therapy with a comparable number of pre- and post-menopausal women [ 20 ]. This diversion from the standard guidelines could be due to the inexpensiveness and availability of tamoxifen. While hormone receptor–positive breast cancer is well recognised to respond favourably to endocrine therapy, tumours that overexpress human epidermal growth factor receptor 2 (HER2) may benefit from targeted monoclonal antibody therapy such as trastuzumab [ 21 ]. This study revealed limited use of immunotherapy. This may be due to the limited HER2-positive cancers in this study. Interestingly, the HER2-positivity did not seem to be a determining factor in receiving immunotherapy. The study revealed that only one monoclonal antibody drug (trastuzumab) was available for administration in combination with chemotherapy. In sub-Saharan Africa, the most widely available immunotherapeutic agents are monoclonal antibodies such as trastuzumab. In contrast, in high-income settings, including the United States, additional immunotherapy agents such as pembrolizumab are available for clinical use [ 22 ]. In this study, patients received immunotherapy as an adjuvant treatment. Justly, it is supported by a study conducted in Europe where immunotherapy was first introduced as second line treatment of advanced cancer [ 23 ]. Immunotherapy was not always available for administration, which resulted in treatment alterations. This disparity in available treatments not only affects the choice of therapy but also influences when patients can access immunotherapy during their treatment journey. The high costs of immunotherapy medications decrease their availability and accessibility [ 24 ]. As a result, many patients are unable to benefit from potentially life-extending therapies, which may contribute to poorer survival rates compared to high-income settings. Overall survival in this study was not determined since patients were discharged from the oncology unit and continued with treatment at the primary facilities after completing cancer treatment cycles. These patients were therefore lost to follow-up. Only one death was reported in this study. This may represent a favourable outcome at face value. Study limitations The study was only conducted in one government hospital, and the findings may not be generalised. The final clinical outcomes are not explicitly documented in the files at the last point of the patient’s assessment visit, and most patients continue management at their primary health care facility. It is therefore recommended that further studies should be conducted at the primary sites to determine patients' survival. Conclusion While endocrine therapy is predominantly used as an adjuvant therapy to chemotherapy, the use of immunotherapy is limited. This reveals that patients who would normally benefit from immunotherapy may not be receiving it. This may be due to the cost implications and budget constraints in the public hospitals. It calls for improved budget allocation to enable hospitals to access the life-saving medicines. Abbreviations ADT: Androgen Deprivation Therapy ANOVA: One-Way Analysis of Variance CAF: Cyclophosphamide, Adriamycin(doxorubicin), Fluorouracil CEF: Cyclophosphamide, Epirucibin, Fluorouracil ECOG: Eastern Cooperative Oncology Group ER+: Estrogen Receptor positive HR+/HER2- : Hormone Receptor positive / Human Epidermal Growth Factor 2 Receptor negative HER2: Human Epidermal Growth Factor 2 Receptor HIV/AIDS: Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome HR: Hazard Ratio NCCN: National Comprehensive Cancer Network PR+: Progesterone Receptor positive USA: United States of America SD: Standard Deviations TREC: Turfloop Research Ethics Committee Declarations Ethics approval and consent to participate Ethical approval was obtained from the University of Limpopo, Turfloop Research Ethics Committee (TREC), registration number: REC-0310111-031. The project number for this research study is TREC/598/2025:PG. Approval to conduct the study was granted by the Limpopo Province Department of Health and the Hospital's Chief Executive Officer. Owing to the retrospective design of the study, the researcher requested, as part of the proposal, the waiving of informed consent from the TREC. The requirement for written patient consent was waived. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki Consent for publication Not Applicable Availability of data and materials The dataset used and analysed during the current study is available from the corresponding author on reasonable request. Competing interests The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article Funding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8962788","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612229377,"identity":"2e31ec23-c94b-42a7-ba14-4c714ff1a175","order_by":0,"name":"Kgabo Mashishi","email":"","orcid":"","institution":"University of Limpopo","correspondingAuthor":false,"prefix":"","firstName":"Kgabo","middleName":"","lastName":"Mashishi","suffix":""},{"id":612229378,"identity":"29fd8058-61ab-4d77-a8cd-90a9a1c0d139","order_by":1,"name":"Tebogo Manyama","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYFACHhSeDQMfYQ2oWtIY2EjVcpiwFnv23oMPv1QwRPPP7jH8dKPmfGIbA/PDDwx/7HDbwnMu2VjmDEPujDtnjKVzjt0GamEzlmDgScatRSLHTFqyjSG34UaOgXQOG0gLgxkDgwQzbi3ybyBa5t/IMf6d8+8cUAv7NwYGg3o8tvCYSX4EatlwA2hdbtsBoBYeoC0Jh3FrOZOXbMxwRiJ34420MuvcvmTjNmaeYomEA8dxamFvP3vw4Y8Km9x5N5I33875Zifbz96+8cOHP9U4tYAAMw+DBJDiMIBygTgBrwYGBsYfEAsfEFA3CkbBKBgFIxUAAAu+TVrI+GeTAAAAAElFTkSuQmCC","orcid":"","institution":"University of Limpopo","correspondingAuthor":true,"prefix":"","firstName":"Tebogo","middleName":"","lastName":"Manyama","suffix":""},{"id":612229379,"identity":"43534c9b-beb7-4aab-a4ca-108d5c340530","order_by":2,"name":"Bonelwa Sidumo","email":"","orcid":"","institution":"University of Limpopo","correspondingAuthor":false,"prefix":"","firstName":"Bonelwa","middleName":"","lastName":"Sidumo","suffix":""}],"badges":[],"createdAt":"2026-02-25 03:54:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8962788/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8962788/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105641103,"identity":"41d573b0-2418-4905-bd78-aca1ed64ebdf","added_by":"auto","created_at":"2026-03-28 16:25:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":72191,"visible":true,"origin":"","legend":"\u003cp\u003eAge distribution by type of first-line therapy: 1=Chemotherapy; 2=Endocrine Therapy; 3=Surgery; 4=Radiation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8962788/v1/dd9f5a23668c5e86bf53b355.png"},{"id":105903776,"identity":"f36f5833-1982-4f51-8f1e-a2d2f18dd1d0","added_by":"auto","created_at":"2026-04-01 09:52:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":767687,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8962788/v1/bc8d8b2f-8526-4d9f-993c-7dc33cb9ef35.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The utilisation of endocrine and immunotherapy: Retrospective study at a tertiary hospital in South Africa","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCancer is a group of diseases that involve the abnormal cell growth in an uncontrollable way, with the potential to invade the surrounding tissues and metastasise to other body parts [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Endocrine therapy is one of the standard treatments to reduce the risk of recurrence and mortality in patients with hormone-receptor sensitive cancers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Endocrine therapy involves the administration of hormonal agents such as selective estrogen receptor modulators, aromatase inhibitors, and androgen deprivation therapy (ADT) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBreast and prostate cancers are the most prevalent cancers in which endocrine therapy is utilised. Breast cancer is the most common cancer affecting women globally, while prostate cancer is the leading cancer among men [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In sub-Saharan Africa, breast cancer is the leading cause of cancer deaths, due to resource constraints such as limited access to appropriate cancer therapy, compared to Europe and the United States [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Most breast tumours are hormone receptor-positive in Southern Africa, compared to Eastern Africa, where the triple-negative subtype is more common [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; paving the way for the use of endocrine therapy. Endocrine therapy drugs commonly used to treat breast cancer include tamoxifen for premenopausal patients and anastrozole for postmenopausal patients, while goserelin and bicalutamide are used as the primary systemic therapy for regional and advanced prostate cancer disease [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Utilisation of endocrine therapy requires an accurate assessment of hormonal status, while targeted therapy with immunotherapy treatment is mostly unavailable due to costs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients who are hormone receptor negative do not benefit from endocrine therapy, which renders them good candidates for immunotherapy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Incorporating immunotherapy treatment like trastuzumab into standard cancer treatment regimens provides substantial improvement in patient outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, immunotherapy treatment is associated with high costs, which may limit its availability in public institutions.\u003c/p\u003e \u003cp\u003eIn South Africa\u0026rsquo;s public healthcare system, cancer treatment is offered for free to unemployed patients and patients without medical insurance coverage. Despite free cancer treatment offered in designated public hospitals, there is limited information regarding the utilisation of endocrine and immunotherapy in South Africa. This study aims to retrospectively evaluate the use of endocrine and immunotherapy and the associated factors at a tertiary hospital in Limpopo Province, South Africa.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study was conducted at a public tertiary hospital located in Limpopo Province of South Africa. This is the only hospital with an oncology unit within the public health facilities in Limpopo Province. This study followed a retrospective open cohort, longitudinal, descriptive study design. Owing to the retrospective design of the study, the requirement for written consent from patients was waived. However, ethical approval was provided by the Turfloop Research Ethics Committee (TREC) at the University of Limpopo and the Limpopo Department of Health. Patients\u0026rsquo; information was obtained through a review of existing medical records. The oncology register was used to identify the medical records of eligible patients.\u003c/p\u003e \u003cp\u003eThe study population consisted of adults older than 18 years diagnosed and treated for cancer using immunotherapy and endocrine therapy. The study enrolled 82 patients\u0026rsquo; medical records that met the selection criteria. Medical records with missing treatment information and those that were not retrieved from the record department section due to incorrect file identification numbers were excluded from this research study. Data from January 2019 to August 2025 were obtained from these medical records. Data collected from the medical records included age, gender, race, date of birth, date of diagnosis, type of first-line therapy, type of cancer, category of cancer, stage of cancer at diagnosis, receptor status, occupation, metastasis, district, ECOG level, and clinical outcome.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analysed using R software, version 4.5.2. Categorical variables were summarized as frequencies and percentages, while continuous variables were reported as means with standard deviations (SD). A chi-square test was performed to determine the relationship between categorical variables. A one-way analysis of variance (ANOVA) was conducted to assess the relationship between the mean age across first-line treatment groups. The level of significance was defined as \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(p-value\u0026lt;0.05.\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Results\u003c/h3\u003e\n\u003cp\u003ePatients' demographics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Out of a total of 82 patients\u0026rsquo; medical records enrolled in the study, the majority had breast cancer \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\((n=72,87.8\\%)\\)\u003c/span\u003e\u003c/span\u003e, followed by prostate cancer \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\((n=8,9.8\\%)\\)\u003c/span\u003e\u003c/span\u003e. Melanoma and ovarian cancers were the least common, each accounted for 1.2% ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e1) of cases. The mean age was 55 years (SD=14.45). Females comprised most of the patients ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e73, 89%), while males accounted for 11%( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e 9). Most patients were from Capricorn ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e24, 29.3%) and Vhembe ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e19, 23.2%) districts, followed by Sekhukhune ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e17, 20.7%), Mopani ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e15, 18.3%), and Waterberg ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=7\\)\u003c/span\u003e\u003c/span\u003e, 8.5%), which contributed the smallest proportion. Employment status analysis showed that most patients were unemployed ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e45, 54.9%), followed by pensioners ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e25, 30.5%). The majority of patients in the study were classified as on ECOG 1 ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e62, 75.6%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemales\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean age in years\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eStandard deviation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003e14.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfrican\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColoured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistrict of origin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd 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align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePensioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMelanoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMetastasis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-metastatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCategory of cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvasive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-invasive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReceptor Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12,2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstrogen +ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstrogen +ve, Progesterone +ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37,8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHER2\u0026thinsp;+\u0026thinsp;ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriple +ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18,3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstrogen +ve, HER2\u0026thinsp;+\u0026thinsp;ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriple -ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHER2\u0026thinsp;+\u0026thinsp;ve, Progesterone +ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgesterone +ve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage of cancer at diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo stage indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12,2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37,8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36,6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of first-line therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63,4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndocrine therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29,3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eECOG level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75,6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14,6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost patients had no record of metastasis at diagnosis \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\((41.5\\%,n=34)\\)\u003c/span\u003e\u003c/span\u003e. Out of 82 study patients, 37.8% (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=31\\)\u003c/span\u003e\u003c/span\u003e) recorded metastatic cancer and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(20.7\\%(n=17)\\)\u003c/span\u003e\u003c/span\u003e recorded non-metastatic cancer. Most patients were diagnosed at advanced stages (stage III:\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=31,37.8\\%\\)\u003c/span\u003e\u003c/span\u003e; stage IV: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=30,36.6\\%\\)\u003c/span\u003e\u003c/span\u003e). The majority of patients were hormone receptor positive, with about 43 patients (52.5%) having estrogen-positive and/or progesterone-positive (ER+, PR+) status. This was followed by triple positive hormone status (18.3%, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e15).\u003c/p\u003e\n\u003ch3\u003eUse of endocrine and immunotherapy\u003c/h3\u003e\n\u003cp\u003eEndocrine therapy was used as primary or first- line treatment in 29.3% ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e24) of the patients. In most cases ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e52, 63.4%), it was used as an adjuvant therapy to chemotherapy. Endocrine therapy was administered across a wide age range in this study, with patients receiving treatment in their late twenties to mid-eighties. Notably, the use of endocrine therapy was high among older patients (50 years and older), where it accounted for a substantial proportion of first-line treatment.\u003c/p\u003e \u003cp\u003eNone of the patients received immunotherapy as first-line treatment. However, 6.1% ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e5) of patients received immunotherapy in combination with other chemotherapy drugs post first-line treatment. All patients who received immunotherapy had invasive breast cancer at diagnosis. Among patients who received immunotherapy, two had triple-positive hormonal status, and one was HER2 positive. One patient expressed oestrogen and progesterone positive status, while the other patient had oestrogen positive only. Monoclonal antibody drug (trastuzumab) was the only immunotherapy drug used in this study. It was noted that immunotherapy administration was intermittently affected by stock-outs, resulting in periods when the medication was not available for use.\u003c/p\u003e \u003cp\u003eTamoxifen was the most used endocrine therapy drug at first-line treatment, accounting for 15.9% ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e13), followed by goserelin at 8.5% ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e 7) and anastrozole at 3.7% ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e3). The majority of patients received chemotherapy as first-line treatment (combination of cyclophosphamide, doxorubicin or epirubicin, and 5-fluorouracil \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e34, 41.5%), followed by cyclophosphamide and doxorubicin ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e10, 12.2%).\u003c/p\u003e\n\u003ch3\u003eFactors associated with the use of first-line treatment\u003c/h3\u003e\n\u003cp\u003eAs indicated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, patients aged 50 years and above with hormone receptor-positive cancers received endocrine therapy as first-line treatment, whereas those younger than 50 years predominantly received chemotherapy. This difference may reflect clinical guidelines that favour endocrine therapy for older patients due to better tolerance and less side effects. A one-way analysis of variance (ANOVA) analysis indicated a significant association between mean age and the use of endocrine therapy as first-line treatment (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(p-value=0.008\\)\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMost patients \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\((n=42,80.8\\%)\\)\u003c/span\u003e\u003c/span\u003e who are on stage III-IV received chemotherapy as first-line treatment, reflecting the preference of chemotherapy in late-stage cancer patients over endocrine therapy. The association was statistically significant, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(({{\\chi}^{2}}_{12}=25.43,p-value=0.013)\\)\u003c/span\u003e\u003c/span\u003eindicating that there is a significant relationship between the stage of cancer and the type of cancer treatment at first-line.\u003c/p\u003e \u003cp\u003ePatients with hormone receptor-positive cancers without HER2 positivity accounted for most who received endocrine therapy as primary or first-line treatment, including 4 oestrogen-positive cases (16.7%) and 10 estrogen- and progesterone-positive cases (41.7%). Limited use of endocrine therapy was observed in HER2-associated receptor type, with only one estrogen-positive/HER2-positive patient (4.2%) and one triple-positive patient receiving endocrine therapy (4.2%) as first-line treatment. No patient with HER2-positive only or hormone receptor-negative cancers received endocrine therapy as first-line treatment at any point. Chi-square analysis revealed a significant association between endocrine therapy usage at first line and receptor status \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(({{\\chi}^{2}}_{24}=62.93,p-value\u0026lt;0.001).\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEndocrine therapy is one of the standard treatments to reduce the risk of recurrence and mortality in patients with hormone receptor-positive cancers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In this study, the use of endocrine therapy and immunotherapy were investigated by analysing 82 patients\u0026rsquo; clinical records. The findings revealed that endocrine therapy was used mainly to treat breast and prostate cancer, while immunotherapy was used in breast cancer only. The use of endocrine therapy to treat breast and prostate cancers is a common phenomenon in cancer therapy and is often regarded as the cornerstone treatment for breast and prostate cancers [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Endocrine therapy may be used as a stand-alone treatment or in combination with surgery, radiotherapy, or chemotherapy. Endocrine therapy was used as first-line therapy in less than one-third of patients. Therefore, it was predominantly used as an adjuvant therapy, as similarly reported in a study conducted by Johnson et al.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] in Botswana.\u003c/p\u003e \u003cp\u003eThe most prevalent associated co-morbidities in this study were hypertension ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e22, 26.8%) and HIV/AIDs (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e7, 8.5%), which aligns with the study findings in India, where hypertension (21.8%) was the most associated comorbidity in a breast cancer study [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. None of the patients diagnosed with prostate, melanoma, or ovarian cancer were HIV positive at the time of diagnosis, whereas HIV/AIDS was identified only among patients with breast cancer in this cohort.\u003c/p\u003e \u003cp\u003eIn South Africa (SA), the majority of patients present with late-stage cancer, which is associated with poor clinical outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].The findings by [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] complement the results of this study, where the majority of the patients were diagnosed at advanced stages (stage III ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e31; 37.6%) and stage IV ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e30; 36.6)). While previous studies have indicated the benefits of early endocrine therapy in improving the survival of patients, the late presentation of the patients diminishes this advantage [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost patients who expressed HR+/HER2\u0026ndash; received endocrine therapy as first-line treatment. Similar findings were observed in a study conducted in Sudan, where endocrine therapy was linked to a HR+/HER2\u0026ndash; [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The use of endocrine therapy in first-line settings for hormone receptor-positive is in line with the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Accordingly, patients who had triple-positive hormone receptor status or HER2-positive cancers were initiated on chemotherapy. Chemotherapy induction was followed by maintenance with endocrine therapy. The addition of maintenance endocrine therapy to hormone receptor-positive and HER2-positive cancers after chemotherapy induction is associated with improved overall survival [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This indicates the role of the receptor status in determining treatment decisions and underscores the central role of tumour biology in guiding therapeutic decision-making. Furthermore, the clinical stage at diagnosis remains a critical determinant of treatment strategy and an established predictor of overall survival. Endocrine therapy represents a cornerstone of management in both early- and advanced-stage disease [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The lower rate of endocrine therapy in advanced stages may reflect a clinical preference for chemotherapy or other treatment modalities in these patients.\u003c/p\u003e \u003cp\u003eAge was one of the determining factors for treatment choice in this study. This study revealed that patients aged 50 years or older with hormone receptor-positive cancer were treated with endocrine therapy compared to younger patients. This finding is supported by a study conducted in the US, where post-menopausal women who expressed hormone receptor-positive tumours and are at low risk of adverse medication effects were treated with endocrine therapy [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. According to NCCN guidelines, the preferred endocrine therapy option for postmenopausal patients is an aromatase inhibitor [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, a study conducted in Italy demonstrated that postmenopausal patients commonly received aromatase inhibitors such as anastrozole, as these agents have been shown to reduce the risk of breast cancer recurrence and mortality more effectively than tamoxifen in this population [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, tamoxifen was the preferred drug for both pre- and post-menopausal women in this study. Similarly, a study in Nigeria showed that tamoxifen was mostly recommended as an adjunct therapy with a comparable number of pre- and post-menopausal women [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This diversion from the standard guidelines could be due to the inexpensiveness and availability of tamoxifen.\u003c/p\u003e \u003cp\u003eWhile hormone receptor\u0026ndash;positive breast cancer is well recognised to respond favourably to endocrine therapy, tumours that overexpress human epidermal growth factor receptor 2 (HER2) may benefit from targeted monoclonal antibody therapy such as trastuzumab [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This study revealed limited use of immunotherapy. This may be due to the limited HER2-positive cancers in this study. Interestingly, the HER2-positivity did not seem to be a determining factor in receiving immunotherapy. The study revealed that only one monoclonal antibody drug (trastuzumab) was available for administration in combination with chemotherapy. In sub-Saharan Africa, the most widely available immunotherapeutic agents are monoclonal antibodies such as trastuzumab. In contrast, in high-income settings, including the United States, additional immunotherapy agents such as pembrolizumab are available for clinical use [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In this study, patients received immunotherapy as an adjuvant treatment. Justly, it is supported by a study conducted in Europe where immunotherapy was first introduced as second line treatment of advanced cancer [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Immunotherapy was not always available for administration, which resulted in treatment alterations. This disparity in available treatments not only affects the choice of therapy but also influences when patients can access immunotherapy during their treatment journey. The high costs of immunotherapy medications decrease their availability and accessibility [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. As a result, many patients are unable to benefit from potentially life-extending therapies, which may contribute to poorer survival rates compared to high-income settings.\u003c/p\u003e \u003cp\u003eOverall survival in this study was not determined since patients were discharged from the oncology unit and continued with treatment at the primary facilities after completing cancer treatment cycles. These patients were therefore lost to follow-up. Only one death was reported in this study. This may represent a favourable outcome at face value.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eThe study was only conducted in one government hospital, and the findings may not be generalised. The final clinical outcomes are not explicitly documented in the files at the last point of the patient\u0026rsquo;s assessment visit, and most patients continue management at their primary health care facility. It is therefore recommended that further studies should be conducted at the primary sites to determine patients' survival.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile endocrine therapy is predominantly used as an adjuvant therapy to chemotherapy, the use of immunotherapy is limited. This reveals that patients who would normally benefit from immunotherapy may not be receiving it. This may be due to the cost implications and budget constraints in the public hospitals. It calls for improved budget allocation to enable hospitals to access the life-saving medicines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADT: Androgen Deprivation Therapy\u003c/p\u003e\n\u003cp\u003eANOVA: One-Way Analysis of Variance\u003c/p\u003e\n\u003cp\u003eCAF: Cyclophosphamide, Adriamycin(doxorubicin), Fluorouracil\u003c/p\u003e\n\u003cp\u003eCEF: Cyclophosphamide, Epirucibin, Fluorouracil\u003c/p\u003e\n\u003cp\u003eECOG: Eastern Cooperative Oncology Group\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eER+: Estrogen Receptor positive\u003c/p\u003e\n\u003cp\u003eHR+/HER2- : Hormone Receptor positive / Human Epidermal Growth Factor 2 Receptor negative\u003c/p\u003e\n\u003cp\u003eHER2: Human Epidermal Growth Factor 2 Receptor\u003c/p\u003e\n\u003cp\u003eHIV/AIDS: Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome\u003c/p\u003e\n\u003cp\u003eHR: Hazard Ratio\u003c/p\u003e\n\u003cp\u003eNCCN: National Comprehensive Cancer Network\u003c/p\u003e\n\u003cp\u003ePR+: Progesterone Receptor positive\u003c/p\u003e\n\u003cp\u003eUSA: United States of America\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviations\u003c/p\u003e\n\u003cp\u003eTREC: Turfloop Research Ethics Committee\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Limpopo, Turfloop Research Ethics Committee (TREC), registration number: REC-0310111-031. The project number for this research study is TREC/598/2025:PG. Approval to conduct the study was granted by the Limpopo Province Department of Health and the Hospital's Chief Executive Officer. Owing to the retrospective design of the study, the researcher requested, as part of the proposal, the waiving of informed consent from the TREC. The requirement for written patient consent was waived. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and analysed during the current study is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMKA: Data collection, Data analysis, and Writing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMTL: Conceptualization, Supervision, Writing – Review \u0026amp; Editing, Resources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSB: Statistical analysis, Review \u0026amp; Editing, and Supervision\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are thankful to the University of Limpopo for financial support. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKamal N, Ilowefah MA, Hilles AR, Anua NA, Awin T, Alshwyeh HA, et al. 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Breast Cancer: Targets and Therapy. 2020. 123\u0026ndash;30. https://doi.org/10.2147/BCTT.S266314\u003c/li\u003e\n\u003cli\u003eLin CJ, Jin X, Ma D, Chen C, Ou-Yang Y, Pei YC, et al. Genetic interactions reveal distinct biological and therapeutic implications in breast cancer. Cancer Cell. 2024;42:701-719.e12. https://doi.org/10.1016/j.ccell.2024.03.006\u003c/li\u003e\n\u003cli\u003eOlatunji E, Patel S, Graef K, Joseph A, Lasebikan N, Mallum A, et al. Utilization of cancer immunotherapy in sub-Saharan Africa. Front Oncol. 2023;13:1\u0026ndash;9. https://doi.org/10.3389/fonc.2023.1266514\u003c/li\u003e\n\u003cli\u003ePelicon V, Cufer T, Knez L. Real-world outcomes of immunotherapy with or without chemotherapy in first-line treatment of advanced non-small cell lung cancer. Front Oncol. Frontiers Media SA; 2023;13. https://doi.org/10.3389/fonc.2023.1182748\u003c/li\u003e\n\u003cli\u003eTfayli A, El-Halabi L, Hodroj MH, Rammal F, Ghais A, Tfayli R, et al. Effects of Lack of Access to Immunotherapy Medications on Survival of Lung Cancer Patients. Clin Oncol. 2025;43:103864. https://doi.org/10.1016/j.clon.2025.103864\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cancer, chemotherapy, endocrine therapy, immunotherapy","lastPublishedDoi":"10.21203/rs.3.rs-8962788/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8962788/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCancer remains a major public health concern globally and within sub-Saharan Africa, accounting for a substantial proportion of morbidity and mortality. Immunotherapy boosts the immune system against cancer, while endocrine therapy is typically used in cancer patients diagnosed with hormone receptor-positive cancers. Breast and prostate cancers are the most prevalent cancers in which endocrine therapy and immunotherapy are utilised. This study aimed to evaluate the use of endocrine and immunotherapy, and factors associated with their use at a tertiary hospital in Limpopo Province, South Africa.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA retrospective open cohort, longitudinal, descriptive study design was utilised. The study enrolled 82 (eighty-two) medical records of patients who started cancer treatment from January 2019 to August 2025 at a tertiary hospital in Limpopo Province of South Africa. A Chi-square or ANOVA test was used to examine the association between age, receptor status, and cancer stage at diagnosis with the type of first-line therapy. Data analysis was conducted using R programming software, version 4.5.2.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEndocrine therapy was used as primary or first- line treatment in 29.3% ( \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(n=\\)\u003c/span\u003e\u003c/span\u003e24) of the patients and was dominantly used as an adjuvant therapy to chemotherapy. The analysis indicated a significant association between age, cancer stage, receptor status, and the use of endocrine therapy as first-line treatment. None of the patients received immunotherapy as first-line treatment at diagnosis. The results further revealed limited use of immunotherapy to a maximum of 5 patients over the study period.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhile endocrine therapy is predominantly used as an adjuvant therapy to chemotherapy, the use of immunotherapy is limited. This reveals that patients who would normally benefit from immunotherapy may not be receiving it. This may be due to the cost implications and budget constraints in the public hospitals.\u003c/p\u003e","manuscriptTitle":"The utilisation of endocrine and immunotherapy: Retrospective study at a tertiary hospital in South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-28 16:25:50","doi":"10.21203/rs.3.rs-8962788/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-03T05:26:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172749753403050295015592960021932298527","date":"2026-03-28T18:43:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"135661773008486394409010796093866311286","date":"2026-03-27T13:09:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-25T19:09:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91120563462969103377615124113292475463","date":"2026-03-25T18:35:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-25T11:01:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-23T08:11:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-05T06:52:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-04T13:53:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-03-02T14:32:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b9e13156-30f2-442b-aa27-b65e43a40cc8","owner":[],"postedDate":"March 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-28T16:25:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-28 16:25:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8962788","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8962788","identity":"rs-8962788","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}