Most patients present with advanced tumours which can be treated with local ablative therapies including percutaneous chemoembolisation or ethanol embolisation, radiofrequency ablation or external beam irradiation. As a word of caution, HCC with attendant liver cirrhosis, especially Child-Pugh class C, has poor outcomes whatever the therapeutic intervention.

Various chemotherapeutic agents with modest influence on the course of the disease include doxorubicin, cisplatin, 5-fluorouracil and gemcitabine as single agents or in combination. The benefit versus the toxicity needs to be thoroughly discussed.

Antiangiogenic agent bevacizumab has been used, with mixed and unimpressive results. Multikinase inhibitor, sorafenib, is the current standard of care, but again, its role is not universally accepted as it does not significantly improve disease-free or overall survival.

Controversial reports of hormone receptor positivity rate in Africa are a limitation to the appropriate application of hormonal therapies in breast cancer management. Receptor testing is highly recommended where feasible as it gives important prognostic information. Receptor-positive patients invariably have high clinical response and survival rates with hormone therapies and poor clinical response to chemotherapies in general. Hormonal therapy is recommended as the first-line therapy for strong receptor-positive disease in the absence of severe symptomatic disease and is more acceptable to the patient. Even though hormonal therapy may be detrimental in hormone-negative subtypes, empirical use is unavoidable when patient does not respond to chemotherapy or cannot afford these medications. Aromatase inhibitors are considered more effective compared to tamoxifen in the postmenopausal setting however, without a survival advantage. Recent evidence points to increased efficacy when aromatase inhibitors are combined with ovarian suppression in the premenopausal state compared to tamoxifen with or without ovarian suppression. The high cost of aromatase inhibitors and the associated musculoskeletal side effects make it relatively unattractive leading to high rate of noncompliance. Tamoxifen is indicated in the pre- and postmenopausal woman and is readily available, relatively cheap and therefore highly recommended. Sequential treatment of aromatase inhibitors and tamoxifen may be another means of reducing overall cost without compromising effectiveness compared with tamoxifen alone in the postmenopausal woman.

The choice of chemotherapy depends of tumour biology, comorbidities, prior therapies and most importantly cost and convenience of administration. The cheapest and readily available regimens are the old regimens containing Adriamycin, 5FU, cyclophosphamide and methotrexate. They are still very effective in most breast cancer patients. Additional small but significant benefits are realised when Adriamycin in combination with taxanes is used for more aggressive-type tumours such as node-positive, triple-negative and her2-positive. Neoadjuvant chemotherapy is used frequently due to high representation of locally advanced cancers and long theatre waiting list. To date, there is no overall survival advantage compared to adjuvant therapies, and notably due to cultural influences, patients do not return for mastectomy especially following complete clinical responses. However, neoadjuvant chemotherapy approach may spare patients the use of medications that may not have worked. CMF is less commonly prescribed as it is considered suboptimal for aggressive tumour types. Classical CMF may have less compliance rates due to the multiple clinic visits and poor adherence with oral medication. Newer drugs such as gemcitabine, vinorelbine, capecitabine and epothilones used in combination with other drugs or as single agents have improved response and survival rates for recurrent and metastatic disease but are expensive and not readily available. Problems associated with weekly schedule drugs are neutropenia, cost of granulocyte colony-stimulating factors and inconvenience in administration, and therefore best administered in specialised centres. Triple-negative subgroups may have additional benefit if taxanes and/or platinum are included in first-line or subsequent lines of therapy, but CMF is an option when patient fails initial anthracyclines. Patients with metastatic disease can be managed with single agent sequentially without compromising overall survival which is less toxic, thereby reducing treatment-related morbidity and invariably a cost-saving measure. Clinical exam, tumour markers or radiological test where available should be used to access treatment response every 2–3 cycles and change regimen if there is no significant response.

Advanced techniques for receptor testing are neither readily available nor affordable in low-resource settings. Lack of stringent quality assurance in the few testing laboratories has questioned the relevance of testing in such situations. Nevertheless, if done properly, it guides appropriate care. Her2-targeted therapies are expensive and not covered by national insurance policies. The benefits of her2/neu-targeted therapies where indicated are profound (up to 50 % reduction in recurrence rates and 37 % improvement survival). It is quite unfortunate that 20 % of women with breast cancer who are her2/neu positive in these parts of the world will not realise these benefits. Affordable generic substitutes should be widely available to these populations as a humanitarian gesture. The recommended 1-year duration of treatment is another limiting factor driving most oncologists to prescribe shorter regimes of 9 weeks to 6 months whose benefits even though inferior to longer treatment durations were better compared to those who did not receive her2-targeted therapy at all. Needless to say, second-line and dual targeting is completely beyond the scope of practice in most public institutions. Other therapies are being developed for triple-negative breast cancer but all at prohibitive cost. Tables 3, 4 and 5 summarise some common chemotherapy and hormonal and targeted therapies indicated for breast cancer management.