Factors related to incomplete treatment of breast cancer in Kumasi, Ghana

A cross-sector approach to explore socio-ecological associations with treatment engagement behaviours in Northern Ghana

BACKGROUND

Cancer presents a growing global burden, not least in African countries such as Ghana where high cancer treatment dropouts has been identified due to numerous social, cultural and financial reasons. There is little understanding regarding patterns of treatment access behaviour, especially in Northern Ghana, which this study was designed to explore.

METHODS

Through cross-sector collaboration, we extracted and clinically validated cancer patient records available in the Tamale Teaching Hospital. These were analysed descriptively and through multi-variate logistic regression. A treatment mapping process was also applied to highlight challenges in data collection. Multiple imputation with chained equations was conducted for high levels of missing data. Sensitivity analysis was applied to assess the impact of missing data.

RESULTS

Treatment drop-out was high even when uncertainty due to missing data was accounted for, and only 27 % of patients completely engaged with treatment. High drop-out was found for all cancers including those covered by the Ghana National Health Insurance scheme. Multi-variate logistic regression revealed that social, health condition and systemic factors influence treatment engagement until completion. High missing data was observed for liver, ovarian, colorectal, gastric, bladder, oesophageal and head and neck and skin cancers, and soft tissue sarcomas, which limited model fitting.

CONCLUSION

Treatment drop-out is a critical issue in Northern Ghana. There was high missing data due to the dynamic, complex and decentralised treatment pathway. Future studies are needed to understand the complex challenges in data recording.

POLICY SUMMARY

Treatment drop out is a pertinent issue that policy makers should look to address. Further discussion with stakeholders involved in cancer treatment and data collection is required to better understand challenges to routine data collection in the local setting. This will allow policy to be designed to cater for the impact of multiple intersecting health and social factors on treatment completion.

Mammography and Breast Ultrasonography Services in Ghana, Availability, and Geographic Access

PURPOSE

Breast cancer is the leading type of cancer diagnosed and the second leading cause of cancer-related death in Ghana. Mammography and ultrasound have proven benefits in the early detection of breast cancer. This study evaluates mammography, breast ultrasound, and radiology work force availability throughout Ghana.

METHODS

A survey was administered to all hospitals in Ghana from November 2020 to October 2021. Mammography, breast ultrasound services, and the number of radiologists were assessed. For mammography, the number performed per month, cost incurred by the patient, where images were read, and how long it took to receive reports were also assessed. Health Facilities Regulatory Authority records on diagnostic centers were obtained to identify additional in-country breast imaging services.

RESULTS

Three hundred and twenty-eight of 346 hospitals participated in the survey (95%). Only 21 hospitals reported on-site mammography. One hospital reported performing >100 mammographies per month. The average cost to the patient ranged from 100 to 500 Cedis ($17-87 US dollars [USD]), although three hospitals performed mammography at no cost. An additional 10 mammography machines were identified at diagnostic centers throughout the country, with 41.3% of the female population living within 1 hour of mammography services. There were 135 hospital-based breast ultrasound services identified with 69.5% of the female population living within 1 hour of these services. There were an additional 190 ultrasound machines at diagnostic centers. There were 96 in-country radiologists identified.

CONCLUSION

Although there is limited availability and utilization of mammography in Ghana, there is more readily available ultrasonography. A focus on increasing breast cancer early diagnostic capabilities with breast ultrasound should be prioritized in addition to further expansion of the radiology workforce.

Three-year survival of breast cancer patients attending a one-stop breast care clinic nested within a primary care health facility in sub-Saharan Africa-Zambia

In Zambia, women with breast symptoms travel through multiple levels of the healthcare system before obtaining a definitive diagnosis. To eradicate this critical barrier to care, we nested a novel breast specialty service platform inside a large public-sector primary healthcare facility in Lusaka, Zambia to offer clinical breast examination, breast ultrasound, and ultrasound-guided core needle biopsy in a one-stop format, tightly linked to referral for treatment. The objective of the study was to determine the life expectancy and survival outcomes of a prospective cohort of women diagnosed with breast cancer who were attended to and followed up at the clinic. The effect of breast cancer stage on prognosis was determined by estimating stage-specific crude survival using the Kaplan-Meier method. Survival analysis was used to estimate mean lifespan according to age and stage at diagnosis. We enrolled 302 women with histologically confirmed breast cancer. The overall 3-year survival was 73%. An increase in patients presenting with early breast cancer and improvements in their survival were observed. Women with early-stage breast cancer had a lifespan similar to the general population, while loss of life expectancy was significant at more advanced stages of disease. Our findings suggest that implementing efficient breast care services at the primary care level can avert a substantial proportion of breast cancer-related deaths. The mitigating factor appears to be stage of disease at the time of diagnosis, the cause of which is multifactorial, with the most influential being delays in the referral process.

Quality of life of breast cancer patients in Amhara region, Ethiopia: A cross-sectional study

BACKGROUND

Although breast cancer has a markedly higher incidence in developed countries, seven out of ten deaths occur in developing countries, including Ethiopia. However, there is a limited information on the quality of life (QoL) among breast cancer patients in Ethiopia, notably in the Amhara region. Therefore, this study aimed to assess the QoL and its associated factors among patients with breast cancer in the Amhara Region, Ethiopia.

METHODS

An institutional based cross-sectional study was conducted from 25th March 2019 to 7th July 2019. A systematically selected sample of 256 breast cancer patients were participated in the study. A standardized interviewer-administered Amharic version questionnaire was used to collect the data. We used the European Organization for Research and Treatment of Cancer quality of life questionnaire core 30 (EORTC QLQ C30) and breast cancer supplementary measure (QLQ-BR23) to measure QoL. The data were analyzed by SPSS version 23. A binary logistic regression model was fitted to identify the predictors of QoL. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was reported to show the strength of the association.

RESULTS

Sixty-eight percent of breast cancer patients had poor QoL (68.4%; 95% CI: 62.5-73.8). The mean score of QoL was 70.6 (standard deviation (SD) ±13.9; 95% CI: 69.0-72.4). All functional component scores were less than 75 on the symptom scale. Diarrhea (11.6), constipation (17.5), and dyspnea (24.7) were less noticeable symptoms. Being out of marriage (AOR = 2.59, 95% CI: 1.32-5.07), being poor (AOR = 2.39, 95%CI: 1.32-5.03), being non-housewife (AOR = 3.25, 95% CI: 1.16-7.22), and being complaints of dyspnea (AOR = 3.48, 95% CI: 1.79-6.79), and insomnia (AOR = 2.03, 95% CI: 1.05-3.91) were significantly associated with QoL.

CONCLUSIONS

The proportion of poor QoL among breast cancer patients was high. Health care professionals should give attention to breast cancer patients who are out of marriage, poor and non-housewife while offering the recommended treatment courses.

Designing a virtual breast cancer prevention program for Iranian women: A study protocol

BACKGROUND

The growing number of breast cancer patients in Iran, following the lower referrals of women to screening centers after the outbreak of the COVID-19, suggests the need for designing virtual educational interventions to teach self-care methods to women. The aim of this study is to design a virtual training program for the prevention of breast cancer in women based on the steps of the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) educational design model.

MATERIALS AND METHODS

This developmental study will be conducted based on the steps of the ADDIE model. In the first step (analysis), a qualitative study, literature review, and a panel of experts will be conducted to analyze the situation (learners, content, platforms, and media for the electronic presentation of the program). In the design step, the learning objectives, educational strategies, and the way of program's implementation and evaluation will be specified. In the third step, not only are the content, storyboard, and educational program developed, but the pilot study is also conducted and formative assessment is performed. In the fourth step, the program will be provided to the audience and will be implemented as a preliminary program. In the final step, the final virtual education program for the prevention of breast cancer in women will be presented based on the results of the evaluation.

CONCLUSIONS

Using a comprehensive and systematic educational design model can be a step toward making changes and encouraging innovations in breast cancer prevention education programs in women based on virtual education. Given the existing needs and conditions, this program can promote cancer preventive behaviors as much as possible, reduce the costs imposed on the family and healthcare systems, and lower the complications and mortality rate caused by the delayed diagnosis of the disease.

Medical pluralism, healthcare utilization and patient wellbeing: The case of Akan cancer patients in Ghana

PURPOSE

As cancers increase in Ghana and in many low-and middle-income countries, healthcare utilization has become critical for disease management and patients' wellbeing. There is evidence that medical pluralism is common among cancer patients in Ghana and many other African countries, which results in lack of adherence to and absconding from hospital treatments. The objective of this study was to examine ways in which beliefs in disease causation influence medical pluralism among Akan cancer patients in Ghana.

METHODS

A qualitative research approach was employed in this study. In-depth interviews were conducted for thirty (30) cancer patients who were purposively recruited from Komfo Anokye Teaching Hospital in Ghana. Thematic content analysis was used in analysing data.

RESULTS

Our findings revealed that cancer patients ascribed both physical and spiritual causality to their illness. As such, they combined orthodox treatment with spiritual healing and herbal medicine. Regarding the order of therapeutic search, patients reported to herbal and spiritual centres before going to the hospital, a phenomenon which contributes to the late reporting and diagnosis as well as bad prognosis of cancers in Ghana.

CONCLUSION

The findings of this research elucidate the relationship between culture and health care choices of cancer patients in Ghana. Increased awareness creation is crucial in eradicating myths surrounding cancers in Ghana.

Geospatial availability of breast cancer treatment modalities and hypothetical access improvement in Ghana: A nationwide survey

Breast cancer in Ghana is a growing public health problem with increasing incidence and poor outcomes. Lack of access to comprehensive treatment in Ghana may be a contributing factor to its high mortality. The purpose of this study was to evaluate the availability of treatments nationwide and systematically identify high yield areas for targeted expansion. We conducted a cross-sectional, nationwide hospital-based survey from November 2020-October 2021. Surveys were conducted in person with trained research assistants and described hospital availability of all breast cancer treatments and personnel. All individual treatment services were reported, and hospitals were further stratified into levels of multi-modal treatment modeled after the National Comprehensive Cancer Network (NCCN) Framework treatment recommendations for low-resource settings. Level 3 included Tamoxifen and surgery (mastectomy with axillary lymph node sampling); Level 2 included Level 3 plus radiation, aromatase inhibitors, lumpectomy, and sentinel lymph node biopsy; Level 1 included Level 2 plus Her2 therapy and breast reconstruction. Hospitals were identified that could expand to these service levels based on existing services, location and personnel. The distance of the total population from treatment services before and after hypothetical expansion was determined with a geospatial analysis. Of the 328 participating hospitals (95% response rate), 9 hospitals had Level 3 care, 0 had Level 2, and 2 had Level 1. Twelve hospitals could expand to Level 3, 1 could expand to Level 2, and 1 could expand to Level 1. With expansion, the population percentage within 75km of Level 1, 2 and 3 care would increase from 42% to 50%, 0 to 6% and 44% to 67%, respectively. Multi-modal breast cancer treatment is available in Ghana, but it is not accessible to most of the population. Leveraging the knowledge of current resources and population proximity provides an opportunity to identify high-yield areas for targeted expansion.

Relationship Between Religion/Spirituality and the Aggressiveness of Cancer Care: A Scoping Review

CONTEXT

Religiosity/spirituality/religious-spiritual coping (RS) are resources used by cancer patients with cancer to help cope with the disease and may influence the preference and receipt of end-of-life (EOL) treatment.

OBJECTIVES

To examine the relationship between RS and the EOL care preferred or received by cancer patients.

METHODS

This review protocol is registered on (International Prospective Register of Systematic Review, CRD42021251833) and follows the recommendations of the preferred reporting items for systematic reviews and meta-analyses checklist. Embase, Proquest, PubMed, Scopus, and Web of Science databases were consulted. Google Scholar was consulted for additional publications and gray literature. Quantitative studies including adults with any cancer type/stage were eligible. The paper selection was performed by two independent reviewers; the methodological quality was measured using the Newcastle Ottawa scale.

RESULTS

Seventeen studies were included in the review. In general, RS is related to the preference or receipt of aggressive EOL care and with less advance care planning. Spiritual care by the medical team is related to higher referral to hospice and less aggressive care; in contrast, high spiritual support from religious communities is associated with less hospice and more aggressive care. Religious denominations influenced health care preferences, as Catholics were less likely to sign a do-not-resuscitate order and Buddhists or Taoists received more aggressive interventions at the EOL. Most studies (70%) were of high quality according to the Newcastle Ottawa scale.

CONCLUSION

RS is associated with more aggressive EOL treatments, as well as with lower rates of ACP in cancer patients. On the other hand, spiritual care provided by the medical team seems to be associated with less aggressive EOL care.

Adherence to Oral Anticancer Medications Among Women With Breast Cancer in Africa: A Scoping Review

PURPOSE

Oral anticancer medications (OAMs) improve treatment outcomes and survival in women with breast cancer (BC). However, adherence to OAM therapy remains suboptimal. This scoping review provides evidence of adherence to OAMs among African women with BC.

METHODS

We searched four databases and gray literature, using guidance from the Joanna Briggs Institute. Thirteen studies on adherence rates, determinants, and interventions were included. NVivo 12 software was used to perform thematic analysis of the included studies. The determinants (barriers and facilitators) associated with adherence were analyzed according to the five dimensions of the WHO multidimensional adherence model.

RESULTS

Most studies (n = 11, 85%) focused on endocrine medication. Depending on the definition, measurements, and assessment period, the nonadherence rates ranged from 4.3% to 65.4% for endocrine medications, 80.9% for cytotoxic chemotherapies, and 32.7% for combined medications. The significant barriers associated with adherence include Islamic religion, concurrent comorbidities, mastectomy, anastrozole treatment, side effects, unawareness of treatment insurance coverage, and seeking treatment from traditional healers. Thorough therapeutic communication regarding treatment, neoadjuvant chemotherapy, and adequate social support significantly facilitate adherence. A randomized controlled trial of breast nursing interventions reported improved patient adherence.

CONCLUSION

The evidence mapped from studies that evaluated OAM adherence in women with BC indicates that nonadherence to OAMs is common. Applying context-specific standardized measures to assess adherence and facilitators or strategies targeting the identified barriers can optimize adherence and treatment outcomes. Effective interventions to improve adherence are limited. Therefore, further empirical and interventional studies in Africa are required to enhance the evidence.

What influences cancer treatment service access in Ghana? A critical interpretive synthesis

OBJECTIVES

Multiple social-cultural and contextual factors influence access to and acceptance of cancer treatment in Ghana. The aim of this research was to assess existing literature on how these factors interplay and could be susceptible to local and national policy changes.

DESIGN

This study uses a critical interpretive synthesis approach to review qualitative and quantitative evidence about access to adult cancer treatment services in Ghana, applying the socioecological model and candidacy framework.

RESULTS

Our findings highlighted barriers to accessing cancer services within each level of the socioecological model (intrapersonal, interpersonal community, organisational and policy levels), which are dynamic and interacting, for example, community level factors influenced individual perceptions and how they managed financial barriers. Evidence was lacking in relation to determinants of treatment non-acceptance across all cancers and in the most vulnerable societal groups due to methodological limitations.

CONCLUSIONS

Future policy should prioritise multilevel approaches, for example, improving the quality and affordability of medical care while also providing collaboration with traditional and complementary care systems to refer patients. Research should seek to overcome methodological limitations to understand the determinants of accessing treatment in the most vulnerable populations.

Prevalence of traditional, complementary, and alternative medicine (TCAM) among adult cancer patients in Malawi

PURPOSE

The objective of this study is to document the prevalence of traditional, complementary, and alternative medicine (TCAM) use by adult cancer patients at a national teaching hospital in Malawi. We aim to document the products/therapies used, the reason for use, as well as patient-reported satisfaction with TCAM practitioners and modalities.

METHODS

We conducted investigator-administered interviews with adult cancer patients presenting to the Kamuzu Central Hospital (KCH) Cancer Clinic in Lilongwe, Malawi between January and July 2018. The KCH is a national teaching hospital in the capital of Lilongwe, which serves patients with cancer from the northern half of Malawi. Descriptive statistics were used to describe TCAM use and logistic regression was applied to identify predictors of TCAM.

RESULTS

A total of 263 participants completed the survey, of which 70% (n = 183) were female and average age was 45 (SD 14) years old. The prevalence of overall TCAM use was 84% (n = 222), and 60% (n = 157) of participants reported combining TCAM with conventional cancer treatment. The majority of patients used TCAM to directly treat their cancer versus for symptom management. Patients reported using faith-based healing (64%, n = 168), herbal medicine (56%, n = 148), diet change (46%, n = 120), and vitamins/minerals (23%, n = 61). Participants reported the highest satisfaction for physicians among practitioners and diet change for modalities. Female gender was found to be a predictor of TCAM with conventional treatment use, no other significant predictors were observed.

CONCLUSION

There is a high prevalence of TCAM use among an adult population with cancer in Malawi, and a wide variety in the TCAM modalities used among patients. Additional studies are needed to identify risks and benefits of TCAM use to assist with policy and public health, patient safety, and holistically address the global burden of cancer.

Breast Cancer Screening in Low-Income Countries: A New Program for Downstaging Breast Cancer in Tanzania

Background. Most breast cancer diagnoses in Tanzania are in advanced stages. The Ocean Road Cancer Institute (ORCI) established a new breast cancer screening program in 2014 to reduce advanced-stage diagnoses. This study is aimed at describing the screening program’s referral process and at identifying patient and health system factors that contribute to patients completing diagnostic testing referrals. Methods. Six-hundred and forty patients were included in the study. Testing types, outcomes, and date of diagnostic results were abstracted from records at ORCI and Muhimbili National Hospital (MNH) to determine the proportion of testing completed and the duration between initial referrals and diagnostic tests. Prediction of completion of diagnostic testing was investigated in logistic regression. Results. Of the patients who received referrals for further testing, fifty-two percent completed the recommended ultrasound (USS), mammography (MMG), and fine-needle aspiration cytology (FNAC). Only 33.0% of patients completed the recommended MMG referrals compared to 55.0% for ultrasound and 68.7% for FNAC. The average number of days between initial screening and results was 42 days for MMG, 20 days for USS, and 18 days for FNAC. Significant predictors for completing referrals for USS, FNAC, and MMG included $\text{age}<44$ and >55 years, presenting with symptoms at the initial appointment, and education. The odds of completing an USS was 3.03 (95% CI, 1.65-5.64) for patients 25–34, 2.27 (95% CI, 1.17-4.48) for patients 35–44, and 4.41 (95% CI, 1.66-10.11) for patients older than 55 years compared to the reference group (age 19–24). The presence of symptoms at the initial appointment was a significant predictor of FNAC. The odds of completing an FNAC was 1.55 (95% CI, 1.02-3.72) for symptomatic compared to nonsymptomatic patients. Education was a significant predictor of MMG. The odds of receiving MMG was 4.29 (95% CI, 1.05-21.00) for patients with tertiary education or higher compared to primary education or lower. Possession of health insurance for treatment and living in Dar es Salaam were not significant predictors. Discussion. Future research should focus on patients’ understanding of recommended referrals and factors that influence decision-making. Investigating the cost effectiveness of scaling up screening programs and setting up a patient navigation program that follow patients as they complete the recommended treatment plan will be crucial for Tanzania and other developing countries as they seek to launch and strengthen screening programs.

Association of Health Insurance Literacy with Health Care Utilization: a Systematic Review

BACKGROUND

Given increasing numbers of people experiencing transitions in health insurance due to declines in employer-sponsored insurance and changes in health policy, the understanding and application of health insurance terms and concepts (health insurance literacy) may be important for navigating use of health care. The study objective was to systematically review evidence on the relationship between health insurance literacy and health care utilization.

METHODS

Medline, SCOPUS, Web of Science, CINAHL, PsychInfo, Cochrane Library, and reference lists of published literature were searched in August 2019. Quantitative, qualitative, and intervention studies that assessed the association of health insurance literacy as the exposure and health care utilization as the outcome were identified, without language or date restrictions. Outcomes were independently assessed by 2-3 reviewers.

RESULTS

Twenty-one studies including a total of 62,416 subjects met inclusion criteria: three interventional trials, two mixed-methods studies, and sixteen cross-sectional studies. Ten of thirteen preventive care studies suggested that higher health insurance literacy was associated with greater utilization of primary care and other preventive services. Eight of nine studies of care avoidance demonstrated that individuals with lower health insurance literacy were more likely to delay or avoid care. A few studies had mixed results regarding the utilization of emergency department, inpatient, and surgical care.

DISCUSSION

The emerging literature in this area suggests that health insurance literacy is an important factor that can enable effective utilization of health care, including primary care and preventive services. However, the literature is limited by a paucity of studies using validated tools that broadly measure health insurance literacy (rather than testing knowledge of specific covered services). Improving health insurance literacy of the general public and increasing plain language communication of health insurance plan features at the point of health care navigation may encourage more effective and cost-conscious utilization.

Surveying and mapping breast cancer services in Ghana: a cross-sectional pilot study in the Eastern Region

OBJECTIVES

Define the services available for the care of breast cancer at hospitals in the Eastern Region of Ghana, identify areas of the region with limited access to care through geospatial mapping, and test a novel survey instrument in anticipation of a nationwide scale up of the study.

DESIGN

A cross-sectional, facility-based survey study.

SETTING

This study was conducted at 33 of the 34 hospitals in the Eastern Region of Ghana from March 2020 to May 2020.

PARTICIPANTS

The 33 hospitals surveyed represented 97% of all hospitals in the region. This included private, government, quasi-government and faith-based organisation owned hospitals.

RESULTS

Sixteen hospitals (82%) surveyed provided basic screening services, 11 (33%) provided pathological diagnosis and 3 (9%) provided those services in addition to basic surgical care.53%, 64% and 78% of the population lived within 10 km, 25 km and 45 km of screening, diagnostic and treatment services respectively. Limited chemotherapy was available at two hospitals (6%), endocrine therapy at one hospital (3%) and radiotherapy was not available. Twenty-nine hospitals (88%) employed a general practitioner and 13 (39%) employed a surgeon. Oncology specialists, pathology personnel and a plastic surgeon were only available in one hospital (3%) in the Eastern Region.

CONCLUSIONS

Although 16 hospitals (82%) provided screening, only half the population lived within reasonable distance of these services. Few hospitals offered diagnosis and surgical services, but 64% and 78% of the population lived within a reasonable distance of these hospitals. Geospatial analysis suggested two priorities to cost-effectively expand breast cancer services: (1) increase the number of health facilities providing screening services and (2) centralise basic imaging, pathological and surgical services at targeted hospitals.

Adherence to Newly Implemented Tamoxifen Therapy for Breast Cancer Patients in Rural Western Ethiopia

INTRODUCTION

Endocrine therapy for breast cancer (BC) patients is highly underutilized in rural Ethiopia and other African countries.

OBJECTIVE

This study aims to assess the feasibility of and adherence to tamoxifen therapy in rural Ethiopia.

METHODS

We ascertained the hormone receptor (HR) status in 101 women diagnosed with BC from January 2010 to December 2015 and who had surgery in Aira Hospital, in rural Ethiopia. From 2013, tamoxifen was offered to patients with HR-positive (HR+) tumors. Prescription refill records and a structured questionnaire were used to assess receipt of and adherence to tamoxifen.

RESULTS

Of the 101 BC patients tested for HR status during the study period, 66 (65%) patients were HR+ and were eligible for tamoxifen treatment. However, 15 of the HR+ patients died before tamoxifen became available in 2013. Of the remaining 51 HR+ patients, 26 (51%) initiated tamoxifen but only 9 of them (35%) adhered to therapy (medication possession rate ≥80%, median observation 16.2 months). After 1 year, 52% of the patients were still adherent, and 9 patients had discontinued therapy. The reasons for non-initiation of tamoxifen included patient factors (n = 5), including financial hardship or lack of transportation, and health care provider factors (n = 12).

CONCLUSIONS

Endocrine therapy for BC patients seems feasible in rural Western Ethiopia, although non-adherence due to financial hardship and a less developed health care infrastructure remains a major challenge. We postulate that the implementation of breast nurses could reduce patient and health system barriers and improve initiation of and adherence to endocrine treatment.

Utilization and predictors of postmastectomy radiation receipt in an Oncology Center in Zimbabwe

PURPOSE

Few sub-Saharan African studies have ascertained utilization for postmastectomy radiation (PMRT) for breast cancer, the second most common cancer among African women. We estimated PMRT utilization and identified predictors of PMRT receipt in Zimbabwe.

METHODS

Retrospective patient cohort included non-metastatic breast cancer patients treated from 2014 to 2019. PMRT eligibility was assigned per NCCN guidelines. Patients receiving chemotherapy for non-metastatic disease were also included. The primary endpoint was receipt of PMRT, defined as chest wall with/without regional nodal radiation. Predictors of receiving PMRT were identified using logistic regression. Model performance was evaluated using the c statistic and Hosmer-Lemeshow test for goodness-of-fit.

RESULTS

201 women with localized disease and median follow-up of 11.4 months (IQR 3.3-17.9) were analyzed. PMRT was indicated in 177 women and utilized in 59(33.3%). Insurance coverage, clinical nodal involvement, higher grade, positive margins, and hormone therapy receipt were associated with higher odds of PMRT receipt. In adjusted models, no hormone therapy (aOR 0.12, 95% CI 0.043, 0.35) and missing grade (aOR 0.07, 95% CI 0.01, 0.38) were associated with lower odds of PMRT receipt. The resulting c statistic was 0.84, with Hosmer-Lemeshow p-value of 0.93 indicating good model fit.

CONCLUSION

PMRT was utilized in 33% of those meeting NCCN criteria. Missing grade and no endocrine therapy receipt were associated with reduced likelihood of PMRT utilization. In addition to practice adjustments such as increasing hypofractionation and increasing patient access to standard oncologic testing at diagnosis could increase postmastectomy utilization.

Developing and Maintaining a Global Research Training Infrastructure for Cancer Education

This manuscript illustrates the 20-year process of establishing research sites that have been developed and maintained by the authors in collaboration with oncology colleagues at institutions in low- and middle-income countries. This infrastructure has been created for research training of US public health graduate students over the past 20 years for the Cancer Epidemiology Education in Special Populations (CEESP) Program funded by the US National Cancer Institute (R25 CA112383). We describe the history and resources that were utilized for developing and maintaining the research training infrastructure. We then define the elements needed for selecting and nurturing these global sites for education and research training of students. The elements include data and field resources, patient population, facilities for cancer management, laboratory resources, academic collaborators, and population parameters and cultural characteristics. These elements have also been essential in our US domestic training sites. We then emphasize the strengths and limitations of our global sites. Finally, we elaborate on our learning experience over the past 20 years. We believe that the material provided in this manuscript will serve as a useful toolkit for faculty, mentors, students, and trainees interested developing and/or utilizing research sites for cancer epidemiology and cancer prevention and control research training programs in global settings.

Breast cancer awareness, risk factors and screening practices among future health professionals in Ghana: A cross-sectional study

BACKGROUND

Like many other women in the developing world, the practice of breast cancer screening among Ghanaian women is unsatisfactory. As a result, many cases are diagnosed at advanced stages leading to poor outcomes including mortalities. An understanding of the awareness and predictors of breast examination is an important first step that may guide the design of interventions aimed at raising awareness across the general population. This study aimed to explore the awareness, risk factors, and self-reported screening practices of breast cancer among female undergraduate students at the University of Health and Allied Sciences.

METHODS

This cross-sectional study was conducted among 385 female undergraduate students using a pre-tested questionnaire. Data were analysed using Stata Version 13.1 and presented using descriptive and inferential statistics comprising frequency, percentage, chi-square, and binary logistic regression. Odds ratios and 95% confidence intervals were computed to quantify the association between regular Breast-Self Examination (BSE) and socio-demographic characteristics of respondents.

RESULTS

Seventy-three per cent of the students were aware of breast cancer, with social media being the most important source of information (64.4%). The prevalence of breast cancer risk factors varied from 1% of having a personal history of breast cancer to 14.3% for positive family history of breast cancer. Current use of oral pills/injectable contraceptives was confirmed by 13.2% of participants; 20% were current alcohol users and10.1% were physically inactive. Regarding breast examination, 42.6% performed BSE; 10.1% had Clinical Breast Examination (CBE), while 2.3% had undergone mammography in the three years preceding the study. Women who did not believe to be susceptible to breast cancer (AOR: 0.04; 95%CI: 0.02-0.09) and those who did not know their risk status (AOR: 0.02; 95%CI: 0.005-0.57) were less likely to perform regular BSE compared to those who displayed pessimism. Further, women with no religious affiliation had 0.11 (95%CI: 0.02-0.55) odds of examining their breast regularly compared to Christians.

CONCLUSION

This study demonstrated moderate awareness of the modalities of breast cancer screening and the risk factors of breast cancer among the students. However, there exists a gap between awareness and practice of breast cancer screening, which was influenced by optimism in breast cancer risk perception and religion. Awareness campaigns and education should be intensified in the University to bridge this gap.

Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018

Background

Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub‐Saharan Africa (SSA) with radiotherapy access.

Methods

A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non‐adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease.

Results

In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43–61). Receptor status was missing for 71% (248). 199 (57%) had non‐metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post‐mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study‐defined non‐adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non‐adherence (aOR: 0.18, 95% CI: 0.09, 0.36).

Conclusions

Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient‐level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.

Perceived Breast Cancer Risk among Female Undergraduate Students in Ghana: A Cross-Sectional Study

Background

While breast cancer accounts for the highest mortality among women across the globe, little is known about its perceived risks among them. We examined the perceived risk of breast cancer among undergraduate female university students in Ghana.

Methods

This was a cross-sectional survey of 358 undergraduate female students at the University of Health and Allied Sciences, Ghana. Descriptive and inferential statistics comprising frequencies, percentages, chi-square, and binary logistic regression analyses were used in analysing the data collected. All analyses were done using STATA Version 13.1.

Results

Seventy-three percent were aware of breast cancer and 45.2% out of this did not perceive themselves to be at risk of breast cancer. Academic year (p=0.02), school (p=0.01), knowledge of someone with breast cancer (p < 0.001), family history of breast cancer (p < 0.001), current use of oral pills/injectable contraception (p=0.03), history of breast cancer screening (p < 0.001), and intention to perform breast self-examination (p < 0.001) were the risk factors of breast cancer risk perception. Students without a family history of breast cancer were 90% less likely to perceive breast cancer risk (AOR = 0.10, 95% CI = 0.04-0.29) compared with those having a family history of breast cancer. Students who had never screened for breast cancer were also 62% less likely to perceive that they were at risk of breast cancer (AOR = 0.10, 95% CI = 0.04-0.29) compared with those who had ever screened for breast cancer.

Conclusion

This study showed that female university students tend to estimate their breast cancer risk based on their experience of breast cancer. Students who have ever screened for breast cancer and those with the intention to perform breast self-examination in the future are more likely to perceive themselves as being at risk and thus take action to avoid getting breast cancer.

Developing a Breast Reconstruction Program in a Resource-Constrained Ghanaian Teaching Hospital: Needs Assessment and Implementation

ABSTRACT

As the detection of breast cancer in Ghana improves, the incidence of mastectomy has increased and the outcomes have improved. As a secondary result, the need for breast reconstruction is increasing. The cultural hesitation to undergo a mastectomy and live without a breast can be decreased by making breast reconstruction available, cost-effective, and acceptable. Cultural, economic, and technical factors were considered in choosing the best method of breast reconstruction. Discussions, lectures, and cadaver dissections investigated the various reconstructive options. Operative cases were performed using a latissimus musculocutaneous flap, a lower abdominal transverse rectus abdominis myocutaneous (TRAM) flap, and a midabdominal TRAM flap. The midabdominal TRAM was found to be the best choice at Komfo Anokye Teaching Hospital. It is a reliable, robust, well-perfused, single-stage flap that produced excellent patient satisfaction.

Limited access to care for persons with breast cancer in Africa: A systematic review

PURPOSE

To systematically review the available evidence and examine the factors that may limit patients' access to breast cancer care in Africa.

METHODS

We searched six databases (Google Scholar, Web of Science, PubMed, EMBASE, CINAHL, and Scopus) for studies conducted among breast cancer patients in Africa, highlighting patient challenges and barriers to care or treatment. The search was limited to studies published in the English language and from January 2000 until August 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. There were no limitations to the methodological design of the included studies.

RESULTS

In total, 18,154 articles were retrieved through electronic search; twenty-five were eligible for inclusion after quality appraisal. We analyzed the data using the deductive content analysis approach. Three categories emerged as barriers to breast cancer care: Socio-economic challenges, Institutional shortfalls, and Distinctiveness.

CONCLUSIONS

The findings support that economic hardships, fear, and scarcity of cancer treatments/equipment are critical in limiting access to breast cancer care. Sustainable strategies aimed at scaling-up breast cancer care in the region are necessary. The results also highlight the need for reduced treatment cost and aggressive educational campaigns across healthcare facilities and the local communities.

A scoping review: Facilitators and barriers of cervical cancer screening and early diagnosis of breast cancer in Sub-Saharan African health settings

To address gaps in access to cervical cancer screening and early diagnosis of breast cancer services in Sub-Saharan African (SSA), this scoping review was conducted to explore facilitators and barriers that exist on the patient-, provider-, and system-level. An extensive literature search was conducted in accordance with scoping review methodology and the Cochrane guidelines. Our search criteria were limited to original research studies conducted in community or clinical settings in SSA within the last 10 years (2010-2020). Themes found from this review included patient knowledge and provider education, access to screening services, trust, health-related behaviors, attitudes, values, and practices, community and social values, health infrastructure, resource allocation, and political will. Identified barriers included lack of knowledge about cervical and breast cancer among patients, gaps in education and training among providers, and lack of resources and health infrastructure at the facility level and within the overall health system. Facilitators included perceived risk of cancer, support and encouragement of the provider, and utilization of novel approaches in low-resource settings by health systems. To better address individual-, provider-, and health system and facility-based facilitators and barriers to care, there is a need for political and financial investment and further research on the health service delivery in specific national health systems, especially in the context of the global campaign to eliminate cervical cancer as a public health problem.

Underestimation of hepatocellular carcinoma incidence resulting from a competition between modern and traditional medicine: the case of Gabon

Primary liver cancer, particularly hepatocellular carcinoma (HCC), remains a major killer in sub-Saharan Africa. In this dreadful landscape, West and Central Africas are more particularly affected. However, a small country located on the equator, Gabon, is apparently not concerned by this adverse situation. Despite worrying prevalences of many bona fide risk factors of HCC, including high rates of chronic infections with hepatitis viruses and very high alcohol consumption, Gabon presents theoretically an amazingly low incidence of HCC when compared to other countries of the region. Reports from many places in the world have emphasized the widespread underreporting of HCC cases presumably attributable to the difficulties of proper diagnosis or to a lack of local cancer registry. In Gabon, the remarkably vivid tradition of religious initiation called Bwiti includes some therapeutic rituals exerted by healers or Ngangas. Those treatments are particularly popular in case of severe diseases generally associated with a supernatural etiology. In the present paper, we hypothesize that, in Gabon, the remarkably low incidence of HCC is primarily due to the diversion of patients from the modern medical system due to their preference for Ngangas. Promotion of a form of medical syncretism respecting both systems might be an efficient policy to increase the attractiveness of modern medicine and to ultimately promote public health in Gabon.

Assessment of clinical outcome and health insurance coverage among patients with breast cancer

Breast cancer is a global health concern in terms of morbidity and mortality. Risksharing mechanisms such as health insurance provide resources and promote access to healthcare. The aim of the study was to assess the relationship between health insurance coverage and clinical outcome of breast cancer patients. The study employed retrospective design involving the use of secondary data from the patients diagnosed with breast cancer. Between the period of 2015 to 2019, 250 patients' records were reviewed from a sample size of 300 patients over 5 year patients' follow-up period. A descriptive and Kaplan Meier survival analysis was performed to determine the patients' survival rate. Seventy-two percent of the patients had health insurance cover at the time of diagnosis. Insurance status was found to be significantly associated with survival (p-values= 0.036). Insurance cover had 1.42 hazard ratio (p=0.036, 95% CI: 1.023-1.980). Patients with health insurance coverage at the time of diagnosis had a higher survival rate. No significant association was found among the demographic characteristics and the patients' clinical outcomes.

Health-related quality of life and its predictors among patients with breast cancer at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

Background

Breast cancer is the second most prevalent malignancy in Ethiopia and severely affects patients’ health-related quality of life (HRQOL). We aimed to assess HRQoL, factors influencing HRQoL, and utilities among breast cancer patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods

A hospital-based cross-sectional study was conducted in Tikur Anbessa Specialized Hospital from December 2017 to February, 2018. A total of 404 breast cancer patients were interviewed using the validated Amharic version of the European Organization for Research and Treatment of Cancer module (EORTC QLQ-C30), EORTC QLQ-BR23, and Euro Quality of Life Group’s 5-Domain Questionnaires 5 Levels (EQ-5D-5 L) instruments. Mean scores and mean differences of EORTC- QLQ-C30 and EORTC- QLQ-BR23 were calculated. One-way ANOVA test was employed to determine the significance of mean differences among dependent and independent variables while stepwise multivariate logistic regression was used to identify factors associated with the global quality of life (GQOL). Coefficients and level specific utility values obtained from a hybrid regression model for the Ethiopian population were used to compute utility values of each health state. Data was analyzed using SPSS version 23.

Results

The mean age of patients was 43.94 ± 11.72 years. The mean score for GQoL and visual analog scale was 59.32 ± 22.94 and 69.94 ± 20.36, respectively while the mean utility score was 0.8 ± 0.25. Predictors of GQoL were stage of cancer (AOR = 7.94; 95% CI: 1.83–34.54), cognitive functioning (AOR = 2.38; 95% CI: 1.32–4.31), pain (AOR = 7.99; 95% CI: 4.62–13.83), financial difficulties (AOR = 2.60; 95% CI: 1.56–4.35), and future perspective (AOR = 2.08; 95% CI: 1.24–3.49).

Conclusions

The overall GQoL of breast cancer patients was moderate. Targeted approaches to improve patients’ HRQoL should consider stage of cancer, cognitive functioning, pain, financial status and worries about the patient’s future health. This study also provides estimates of EQ-5D utility scores that can be used in economic evaluations.

Facilitators and barriers to traditional medicine use among cancer patients in Malawi

BACKGROUND

Increasing access to conventional cancer treatment (CT) in low-income countries (LICs) is an important public health initiative to address the global burden of cancer. However, LICs have a high prevalence of use of traditional and complementary medicine (T&CM). It is important to consider the factors that influence a patient's choice to use T&CM, CT, or both for their cancer treatment.

METHODS

We conducted focus groups among adult cancer patients in Lilongwe, Malawi to identify facilitators and barriers of T&CM use. Focus groups were recorded, transcribed, translated, and underwent thematic content analysis.

RESULTS

Cultural norms, T&CM access, T&CM success, and CT failure were all identified as facilitators to T&CM use. CT success and T&CM failure were identified as barriers. Access and norms appear to determine initial treatment selection, while treatment outcomes dictate continued use of T&CM or CT.

CONCLUSION

This study identified a pragmatic and experience-based treatment selection process that aligns with the social cognitive theory of behavior and assists in comprehending the factors that influence T&CM use among cancer patients in a low resource setting.

Sociocultural Barriers Related to Late-Stage Presentation of Breast Cancer in Morocco

Breast cancer is the most prevalent cancer affecting women globally and in Morocco, where more than one fourth of patients are diagnosed at advanced stages. This study aimed to investigate sociocultural barriers that contribute to delayed presentation and diagnosis of breast cancer among women in Marrakesh, Morocco. Qualitative interviews were conducted with 25 breast cancer patients who received care at the CHU Mohammed VI Hospital in Marrakesh to elicit barriers to diagnosis and treatment and ease of access to care. Interviews with breast cancer patients revealed several themes regarding structural and sociocultural barriers to initial diagnosis and treatment. Structural barriers included high treatment-associated costs for patients and their families, burden of transportation to central treatment centers, and limited access to appropriate health care resources. Sociocultural barriers included perceived attack on one's identity associated with breast cancer diagnosis and treatment, influence of the local community, and ideas of faith, spirituality, and conception of death. Findings from this study can help identify areas for improved access and education of patients in order to improve breast cancer diagnostic and treatment efforts and enhance opportunities for early detection.

Integration of breast cancer prevention and early detection into cancer palliative care model

BACKGROUND

Breast cancer is common among Ghanaian women. Late stage presentation has been credited to knowledge deficit and lack of breast cancer prevention and early detection services for women.

OBJECTIVE

This study aimed to develop a model to facilitate the integration of breast cancer prevention and early detection into cancer palliative care.

METHOD

This study used synthesized concepts emerging from a single case study research. The case was a tertiary health care facility, embedded with sub-units of analysis. Mixed-method approach was used to collect data from 102 participants. The study examined the experiences and views of the participants on breast cancer and screening pathways in Ghana. Thematic analysis and descriptive statistics ware used to analyze the qualitative and quantitative data respectively. This was followed with a cross-case analysis across the sub-units of analysis. A theory development approach was further used towards the development of a model, following three steps: concept analysis, statement synthesis and theory synthesis.

RESULTS

Six key concepts synthesized from the data were used to develop the model: initiate and sustain breast cancer prevention and early detection program, collaboration of health professionals, patients, families and micro-communities, conducive environment of the health care facility and needed resources, actions, services, and lastly diffusing innovation into the community through agents.

CONCLUSION

A model has been developed based on the experiences shared by women diagnosed with advanced breast cancer, their first degree relatives, micro-communities as well as clinicians working in a palliative care setting. This model will aid clinicians to provide breast cancer education, teach breast self-examination and offer clinical breast examination to families and micro-communities of advanced breast cancer patients receiving supportive care in a resource-limited setting.

Recognizing and appraising symptoms of breast cancer as a reason for delayed presentation in Ghanaian women: A qualitative study

BACKGROUND

The burden of late presentation is well established in women presenting with advanced breast cancer in Africa. This paper aims to explore the reasons for delayed presentation in Ghanaian women with breast cancer.

METHOD

Eleven (11) women diagnosed with advanced breast cancer were purposively sampled within three years of diagnosis at the palliative care clinic of the Komfo Anokye Teaching Hospital, Ghana. Participation was voluntary. Data was collected through in-depth interviews using a self-devised semi-structured interview guide. The interviews were conducted in "Twi" (local language), audio-tape recorded and covered the women's journey from symptom discovery to their intention to seek help. All audio-taped interviews were transcribed based on the meaning of the respondents' comments. The data was managed using Nvivo version 11 qualitative software. Data was analyzed concurrently with data collection applying the principles of thematic analysis.

KEY FINDINGS

All the women delayed presentation due to overlapping reasons. Symptom appraisal among the women occurred in two main stages: individual understanding of breast symptom and interactive understanding of the breast symptom. These stages were based on cognitive, psycho-cultural and social factors. The five main themes generated from the data were: symptom experience, knowledge of breast cancer, role of social life and network, coping with a breast symptom and lastly intent to seeking health care. A conceptual model was developed to illustrate the relationships among the key factors and concepts emanated from this study.

CONCLUSION

Recognition and appraisal of breast cancer symptom in the eleven (11) Ghanaian women interviewed in this study was poor. For instance, a painless breast lump was considered not serious until a sensory symptom appears. This led women to experience appraisal and time point intervals. To minimize the incidence of late presentation of breast cancer cases in Ghana, adequate educational intervention should be provided for Ghanaian women and their social network, and other stakeholders.

Evidence of promoting prevention and the early detection of breast cancer among women, a hospital-based education and screening interventions in low- and middle-income countries: a systematic review protocol

BACKGROUND

Given the increasing burden of breast cancer in the low- and middle-income countries, cost-effective approaches are needed to improve the early detection of breast cancer in these continents. Global policies and guidelines are now placing much emphasis on promoting early detection of breast cancer through integrated education and screening interventions. The proposed systematic review aims to map evidence on hospital-based breast cancer education, breast self-examination, and clinical breast examination services for women in low- and middle-income countries.

METHODS/DESIGN

We will conduct a systematic review of peer-reviewed studies on hospital-based breast cancer prevention intervention (breast cancer education, breast self-examination, and clinical breast examination) for women in low- and middle-income countries. An electronic search will be conducted in the following electronic databases CINAHL Plus with full text (EBSCOhost), MEDLINE with full-text (EBSCOhost) PsychINFO (EBSCOhost), and PubMed. Articles will also be searched through the "Cited by" search and citations included in the reference list of included articles. A two-stage mapping approach will be conducted. The first stage will involve screening studies through assessing their titles. Also, we will screen abstracts of identified studies descriptively and by focus and methods as dictated by the inclusion and exclusion criteria. The second stage will include extraction of data from eligible studies. A parallel screening and data extraction will be conducted by two reviewers. The quality of included studies will be assessed using the mixed methods appraisal tool (MMAT). A narrative account of the data extracted from the included studies will be analyzed using the thematic analysis.

DISCUSSION

We hope to find relevant studies reporting evidence on promoting prevention and the early detection of breast cancer among women in a hospital-based education and screening interventions in low- and middle-income countries. The evidence obtained from the included studies when summarized will help guide future research. The study results will be disseminated electronically and in print. Also, it will be presented at conferences related to breast cancer.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered with PROSPERO, with registration number CRD42017077818.

Prevalence of traditional, complementary, and alternative medicine use by cancer patients in low income and lower-middle income countries

The use of traditional, complementary, and alternative medicine (TCAM) for cancer may influence the delivery or effectiveness of conventional cancer treatment. In this systematic review, we aimed to (1) summarise the available prevalence data on traditional medicine use by cancer patients in less developed countries (LDCs), and (2) stratify the prevalence data by world region and country income level. A literature search for cancer, TCAM, and low income (LI) and lower-middle income (LMI) countries was conducted across 5 databases. A total of 2,365 publications were reviewed for eligibility, of which 25 studies met inclusion criteria. The combined sample size was 6,878 cancer patients, with a median of 54.5% reporting the use of TCAM for cancer care. Of the studies providing data on the concomitant use of TCAM and conventional cancer treatment (n = 4,872 cancer patients), a median of 26.7% of participants reported combining the two systems of medicine. From the data available, it is apparent that TCAM use among cancer patients in less developed countries is common; however, additional studies are needed to support the safe and effective management of cancer for patients in LI and LMI countries.

A review of the process of knowledge transfer and use of evidence in reproductive and child health in Ghana

Background

The paper carries out a situational analysis to examine the production, dissemination and utilisation of reproductive and child health-related evidence to inform policy formulation in Ghana’s health sector.

Methods

The study used Wald’s model of knowledge production, transfer and utilisation as a conceptual model to collect relevant data via interviews and administration of questionnaire to a network of persons who either previously or currently hold policy-relevant positions in Ghana’s health sector. Additional data was also gathered through a scoping review of the knowledge transfer and research utilisation literature, existing reproductive and child health policies, protocols and guidelines and information available on the websites of relevant institutions in Ghana’s health sector.

Results

The findings of the study suggest that the health sector in Ghana has major strengths (strong knowledge production capacity, a positive environment for the promotion of evidence-informed policy) and opportunities (access to major donors who have the resources to fund good quality research and access to both local and international networks for collaborative research). What remains a challenge, however, is the absence of a robust institutional-wide mechanism for collating research needs and communicating these to researchers, communicating research findings in forms that are friendlier to policy-makers and the inability to incorporate funding for research into the budget of the health sector.

Conclusion

The study concludes, admonishing the Ministry of Health and its agencies to leverage on the existing strengths and opportunities to address the identified challenges.

Family Process with Breast Cancer Patient in Indonesia

Introduction: Breast cancer occupies the first position in Asia’s women cancer cases in recent years. Signs and symptoms experienced by the patient affect the stress condition of the patient as well as the family as a caregiver. The condition changes to deal with problems during patient assistance as a major problem in an outpatient setting. The demands of adaptation to through the needs during the period of assistance by the family is more complex. The study aimed to determine the experience of stress and adaptation of breast cancer patient’s family.Methods: The qualitative method used with in-depth interviews on seven respondents who were the family caregiver of breast cancer patients. Setting carried out at the shelter house in Bandung. The analysis process used thematic analysis based on Braun & Clarke.Results: The results found five main themes are: 1) Stressor on breast cancer patients, 2) Crisis fulfillment of companion needs, 3) Crisis accompaniment, 4) Coping mechanisms of caregiver, and 5) Ability in adaptation.Conclusion: Family experience in assisting breast cancer patients who undergo outpatient also impact families tension who traversed with a subjective effort optimally to adapt in accompanying patients and the needs of other resource support system. Suggestions for future step are early recognition of stress by health workers especially nurses to be able to provide targeted interventions to develop positive adaptation to clients. The development through research is needed in applying family center care both the outpatient and inpatient care in an integrated manner.

Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda

PURPOSE

As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda's first public cancer center.

PATIENTS AND METHODS

We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis.

RESULTS

Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor-positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up.

CONCLUSION

Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival.

Design considerations for identifying breast cancer risk factors in a population-based study in Africa

Although breast cancer is becoming more prevalent in Africa, few epidemiologic studies have been undertaken and appropriate methodologic approaches remain uncertain. We therefore conducted a population-based case-control study in Accra and Kumasi, Ghana, enrolling 2,202 women with lesions suspicious for breast cancer and 2,161 population controls. Biopsy tissue for cases prior to neoadjuvant therapy (if given), blood, saliva and fecal samples were sought for study subjects. Response rates, risk factor prevalences and odds ratios for established breast cancer risk factors were calculated. A total of 54.5% of the recruited cases were diagnosed with malignancies, 36.0% with benign conditions and 9.5% with indeterminate diagnoses. Response rates to interviews were 99.2% in cases and 91.9% in controls, with the vast majority of interviewed subjects providing saliva (97.9% in cases vs. 98.8% in controls) and blood (91.8% vs. 82.5%) samples; lower proportions (58.1% vs. 46.1%) provided fecal samples. While risk factor prevalences were unique as compared to women in other countries (e.g., less education, higher parity), cancer risk factors resembled patterns identified elsewhere (elevated risks associated with higher levels of education, familial histories of breast cancer, low parity and larger body sizes). Subjects with benign conditions were younger and exhibited higher socioeconomic profiles (e.g., higher education and lower parity) than those with malignancies, suggesting selective referral influences. While further defining breast cancer risk factors in Africa, this study showed that successful population-based interdisciplinary studies of cancer in Africa are possible but require close attention to diagnostic referral biases and standardized and documented approaches for high-quality data collection, including biospecimens.

Breast Cancer in Ghana: Demonstrating the Need for Population-Based Cancer Registries in Low- and Middle-Income Countries

Purpose

Breast cancer, the most common cancer worldwide, is the leading cause of cancer mortality in Ghanaian women. Previous studies find Ghanaian women are diagnosed at a younger age and at more advanced stages (III and IV), and have tumors with characteristics similar to African American women. We sought to remedy gaps in knowledge about breast cancer survival in Ghana and its relation to demographic and biologic factors of the tumors at diagnosis to assist in cancer control and registration planning.

Methods

Individuals with a breast cancer diagnosis who sought care at Komfo Anokye Teaching Hospital from 2009 to 2014 were identified via medical records. Follow-up telephone interviews were held to assess survival. Kaplan-Meier plots and Cox proportional hazards models assessed survival associated with clinical and demographic characteristics.

Results

A total of 223 patients completed follow-up and were analyzed. The median survival was 3.8 years. Approximately 50% of patients were diagnosed with grade 3 tumors, which significantly increased the risk of recurrence or death (hazard ratio [HR] for grade 2 versus 1, 2.98; 95% CI, 1.26 to 7.02; HR grade 3 v 1, 2.56; 95% CI, 1.08 to 6.07; P = .04). No other variables were significantly associated with survival.

Conclusion

Higher tumor grade was significantly associated with shorter survival, indicating impact of aggressive biology at diagnosis on higher risk of cancer spread and recurrence. Contrary to prevailing notions, telephone numbers were not reliable for follow-up. Collecting additional contact information will likely contribute to improvements in patient care and tracking. A region-wide population-based active registry is important to implement cancer control programs and improve survival in sub-Saharan Africa.

Factors contributing to delays in diagnosis of breast cancers in Ghana, West Africa

BACKGROUND

Late diagnoses and poor prognoses of breast cancer are common throughout Africa.

METHODS

To identify responsible factors, we utilized data from a population-based case-control study involving 1184 women with breast malignancies conducted in three hospitals in Accra and Kumasi, Ghana. Interviews focused on potential breast cancer risk factors as well as factors that might contribute to presentation delays. We calculated odds ratios (OR) and 95% confidence intervals (CI) comparing malignances with biopsy masses larger than 5 cm. (62.4% of the 1027 cases with measurable lesions) to smaller lesions.

RESULTS

In multivariate analyses, strong predictors of larger masses were limited education (OR 1.96, 95% CI 1.32-2.90 <primary vs. ≥senior secondary school), being separated/divorced or widowed (1.75, 1.18-2.60 and 2.25, 1.43-3.55, respectively, vs. currently married), delay in care seeking after onset of symptoms (2.64, 1.77-3.95 for ≥12 vs. ≤2 months), care having initially been sought from someone other than a doctor/nurse (1.86, 0.85-4.09), and frequent use of herbal medications/treatment (1.51, 0.95-2.43 for ≥3x/day usage vs. none). Particularly high risks associated with these factors were found among less educated women; for example, women with less than junior secondary schooling who delayed seeking care for breast symptoms for 6 months or longer were at nearly 4-times the risk of more educated women who promptly sought assistance.

CONCLUSIONS

Our findings suggest that additional communication, particularly among less educated women, could promote earlier breast cancer diagnoses. Involvement of individuals other than medical practitioners, including traditional healers, may be helpful in this process.

The importance of BRCA1 and BRCA2 genes mutations in breast cancer development

Many factors including genetic, environmental, and acquired are involved in breast cancer development across various societies. Among all of these factors in families with a history of breast cancer throughout several generations, genetics, like predisposing genes to develop this disease, should be considered more. Early detection of mutation carriers in these genes, in turn, can play an important role in its prevention. Because this disease has a high prevalence in half of the global population, female screening of reported mutations in predisposing genes, which have been seen in breast cancer patients, seems necessary. In this review, a number of mutations in two predisposing genes (BRCA1 and BRCA2) that occurred in patients with a family history was investigated. We studied published articles about mutations in genes predisposed to breast cancer between 2000 and 2015. We then summarized and classified reported mutations in these two genes to recommend some exons which have a high potential to mutate. According to previous studies, exons have been reported as most mutated exons presented in this article. Considering the large size and high cost of screening all exons in these two genes in patients with a family history, especially in developing countries, the results of this review article can be beneficial and helpful in the selection of exon to screen for patients with this disease.

A Review on Breast Cancer Care in Africa

BACKGROUND

The global incidence of breast cancer (BC) is rising, especially in low- and middle-income countries. The purpose of this review is to summarize existing publications on BC care in Africa.

PATIENTS AND METHODS

A systematic search in MEDLINE and smaller databases was carried out to identify African studies on BC treatment, and an additional PubMed search was performed for relevant topics on BC care.

RESULTS

A total of 219 publications, mainly from North and West Africa, were found by systematic search. We also selected articles on BC epidemiology, risk factors, clinical presentation, and cancer control in Africa.

CONCLUSIONS

Publications on BC treatment are mostly from hospital case series. Evidence on treatment from prospective randomized trials that address the specific characteristics of African patients is lacking. The epidemiologic data shows rising incidences in Africa. The prevalence of risk factors is changing by age group, geographic region, and over time. The clinical picture of BC differs from that of Western countries due to the high proportion of young patients (on account of the African population with a high proportion of young people) and late presentation. Global collaborative efforts are needed to address the rising need for improved BC care in Africa.