Real-world challenges for patients with breast cancer in sub-Saharan Africa: a retrospective observational study of access to care in Ghana, Kenya and Nigeria

In their voices: Kenyan women's experiences with cancer treatment-related side effects

Objective

This article reports on a secondary analysis of a qualitative study conducted in Nairobi, Kenya that reported several initial themes. In this article, the authors explore the theme of treatment-related side effect management by women receiving treatment for breast or cervical cancer.

Methods

Women were interviewed at three points during their active treatment trajectory. Participants were purposefully selected and saturation was reached when interviews did not yield any new themes. The interviews were transcribed and analyzed for internal consistency, frequency, extensiveness, intensity and specificity. The Nvivo pro 12 software was used in organizing and managing the data to facilitate analysis.

Results

Eighteen women were interviewed. Major side effects reported by participants included fatigue, alopecia, skin and nail changes as well as nausea and vomiting. Women who received information prior to treatment were more comfortable managing side effects. Participants described the impact of side effects on their daily life, body image, and many sought comfort through faith. Some women provided suggestions on strategies for patient education.

Conclusions

This study attempted to capture the cancer treatment-related experiences of Kenyan women in their own voices and present strategies for future intervention and research. The care of individuals receiving treatment can be enhanced through the advancement of health human resources, the development of nationally accessible patient education materials and research on regionally relevant strategies to manage cancer treatment-related side effects.

Factors affecting the economic burden of breast cancer in southern Iran

BACKGROUND

Breast cancer (BC) is the most common cancer in the world, and is associated with significant economic costs for patients and communities. Therefore, the information on the costs of the disease and the identification of its underlying factors will provide insights into designing effective interventions and reducing the costs. Thus, the present study aimed to identify the factors affecting the economic burden of breast cancer from all medical centers providing diagnostic and treatment services in southern Iran.

METHODS

A list of factors affecting the economic burden of breast cancer was obtained based on the effective factors searched in the databases, including PubMed, ProQuest, Scopus, ISI Web of Science, SID, and Magiran, and the opinions of BC cancer specialists. Then, the data on 460 breast cancer patients was collected from March 2020 to March 2022. The relationship between the factors affecting Breast Cancer costs was analyzed using SPSS 13.0 software by the use of multiple regression analysis.

RESULTS

The results of the multiple regression analysis showed that stages (P-value < 0.001), being an extreme user (p = 0.025), type of treatment center (P-value < 0.001), income (P-value < 0.001), chemotherapy side effects (P-value < 0.001), and distance to the nearest health center (P-value < 0.001) were important factors affecting the costs of breast cancer patients.

CONCLUSIONS

According to the results, encouraging people to undergo annual screenings, increasing insurance coverage, assuring the patients about the desirability and adequacy of the provided medical services, deploying specialists in chemotherapy centers (especially nutritionists) to recommend special diets, and establishing cancer diagnostic and treatment centers in high-population cities could help reduce the costs of breast cancer patients.

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.

Population-Level Access to Breast Cancer Early Detection and Diagnosis in Nigeria

PURPOSE

Mammography, breast ultrasound (US), and US-guided breast biopsy are essential services for breast cancer early detection and diagnosis. This study undertook a comprehensive evaluation to determine population-level access to these services for breast cancer early detection and diagnosis in Nigeria using a previously validated geographic information system (GIS) model.

METHODS

A comprehensive list of public and private facilities offering mammography, breast US, and US-guided breast biopsy was compiled using publicly available facility data and a survey administered nationally to Nigerian radiologists. All facilities were geolocated. A cost-distance model using open-source population density (GeoData Institute) and road network data (OpenStreetMap) was used to estimate population-level travel time to the nearest facility for mammography, breast US, and US-guided biopsy using GIS software (ArcMAP).

RESULTS

In total, 1,336 facilities in Nigeria provide breast US, of which 47.8% (639 of 1,336) are public facilities, and 218 provide mammography, of which 45.4% (99 of 218) are public facilities. Of the facilities that provide breast US, only 2.5% (33 of 1,336) also provide US-guided breast biopsy. At the national level, 83.1% have access to either US or mammography and 61.7% have access to US-guided breast biopsy within 120 minutes of a continuous one-way travel. There are differences in access to mammography (64.8% v 80.6% with access at 120 minutes) and US-guided breast biopsy (49.0% v 77.1% with access at 120 minutes) between the northern and southern Nigeria and between geopolitical zones.

CONCLUSION

To our knowledge, this is the first comprehensive evaluation of breast cancer detection and diagnostic services in Nigeria, which demonstrates geospatial inequalities in access to mammography and US-guided biopsy. Targeted investment is needed to improve access to these essential cancer care services in the northern region and the North East geopolitical zone.

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.

Pharmacogenetics of Breast Cancer Treatments: A Sub-Saharan Africa Perspective

Breast cancer is the most frequent cause of cancer death in low- and middle-income countries, in particular among sub-Saharan African women, where response to available anticancer treatment therapy is often limited by the recurrent breast tumours and metastasis, ultimately resulting in decreased overall survival rate. This can also be attributed to African genomes that contain more variation than those from other parts of the world. The purpose of this review is to summarize published evidence on pharmacogenetic and pharmacokinetic aspects related to specific available treatments and the known genetic variabilities associated with metabolism and/or transport of breast cancer drugs, and treatment outcomes when possible. The emphasis is on the African genetic variation and focuses on the genes with the highest strength of evidence, with a close look on CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP3A4/5, CYP19A1, UGT1A4, UGT2B7, UGT2B15, SLC22A16, SLC38A7, FcγR, DPYD, ABCB1, and SULT1A1, which are the genes known to play major roles in the metabolism and/or elimination of the respective anti-breast cancer drugs given to the patients. The genetic variability of their metabolism could be associated with different metabolic phenotypes that may cause reduced patients’ adherence because of toxicity or sub-therapeutic doses. Finally, this knowledge enhances possible personalized treatment approaches, with the possibility of improving survival outcomes in patients with breast cancer.

Assessment of Breast Cancer Management in Sub-Saharan Africa

PURPOSE

To document progress and bottlenecks in breast cancer management in sub-Saharan Africa, subsequent to a 2013 pilot survey conducted through the African Organization for Research and Treatment in Cancer (AORTIC) network.

METHODS

An anonymous survey of breast cancer management was conducted in 2018 among AORTIC members. Results concerning respondent specialty, access to tumor boards, treatment accessibility, diagnostic services, and factors influencing treatment outcomes were compared with the 2013 findings.

RESULTS

Thirty-seven respondents from 30 facilities in 21 sub-Saharan Africa countries responded. The majority (92%) were clinical oncologists. Radiotherapy facilities were available in 70% of facilities. Seventy-eight percent of these had linear accelerators, and 42% had cobalt⁶⁰ machines. Eighty percent of facilities had multidisciplinary tumor boards. Immunohistochemistry was routinely performed in 74% of facilities, computed tomography scan in 90%, bone scan in 16%, and positron emission tomography scans in 5%. Anthracyclines, taxanes, tamoxifen, letrozole, anastrozole, and zoledronic acid were available in the majority; trastuzumab, fertility, and genetic counseling were available in 66%, 58%, and 16%, respectively. There were a 50% increase in oncologist respondents over 2013 and a > 50% increase in radiotherapy facilities, particularly linear accelerators. Availability of trastuzumab, aromatase inhibitors, and taxanes increased. Immunohistochemistry capacity remained the same, whereas facilities harvesting at least 10 axillary lymph nodes increased. Bone scan facilities decreased. Responses suggested improved diagnostic services, systemic therapies, and radiotherapy. Sociocultural and economic barriers, system delays, and advanced stage at presentation remain.

CONCLUSION

Clinicians in sub-Saharan Africa have basic tools to improve breast cancer outcomes, recording positive strides in domains such as radiotherapy and systemic therapy. Socioeconomic and cultural barriers and system delays persist. Workforce expansion must be prioritized to improve quality of care to improve outcomes.

This study highlights the current state of breast cancer management in Sub Saharan Africa, documenting key advancements , challenges and bottlenecks encountered in the sub region. Aside the major aspects of management, pertinent areas such as multidisciplinary tumour board engagements, fertility , genetic counselling and factors affecting outcome were explored. Majority of institutions manage breast cancer patients within a multidisciplinary setting using standard treatment guidelines. The high out of pocket cost of cancer treatment and advanced stage at presentation transcends in many sub Saharan countries negatively impacting outcomes. These results should serve as a benchmark to stakeholders , to guide urgent interventions required to further improve outcomes.

Female breast cancer in sub-Saharan Africa: A PRISMA-S-compliant systematic review of surgery

BACKGROUND

In sub-Saharan countries (SSAs), the advanced stage at diagnosis and the limited surgical interventions of female breast cancer (FBC) lead to poor outcomes. This study assessed current modalities of FBC surgeries.

METHODS

Six literature databases (Medline, Embase, African Journal Online, Google Scholar, Web of Science, Cochrane Library) were searched, plus a manual search, in 2011-2021. We included primary data studies with any setting and presurgeries or postsurgeries treatments, we excluded non-English language studies, editorials, and grey literature.

RESULTS

The search yielded 21 observational studies (16 retrospective, 3 prospective, and 2 case reports). Of the total 6900 patients, 4121 (60%) patients underwent FBC surgical excision only, and 751/2779 (27%) conservative surgery (BCS) or therapy (BCT). All studies reported similar use of mastectomy (>60%), the FBC surgical excision/reconstruction studies displayed more neoadjuvant chemotherapy (536/2779, 19% vs. 215/4121, 5%), and radiotherapy or adjuvant radiotherapy (1461/2779, 52% vs. 411/3921, 4%). Patients' age, histological classification, staging, and follow-up data were often missing.

CONCLUSIONS

The FBC complexity requires structured management by general and plastic surgeons, radiotherapy specialists, and obstetrician-gynecologists through shared guidelines, protocols, and specific programs of public health. In SSAs, FBC surgical strategies should point at decreasing radical mastectomy and increasing BCS/BCT.