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

Breast imaging reporting and data system for sonography: Positive and negative predictive values of sonographic features in Kumasi, Ghana

BACKGROUND

Breast cancer is the most common female cancer globally. The method of choice for screening and diagnosing breast cancer is mammography, which is not widely available in Ghana as compared to ultrasonography. This study aimed to evaluate the sonographic features of solid breast lesions using the new sonographic Breast Imaging- Reporting and Data System (BI-RADS-US) lexicon for malignancy with histopathology as the gold standard.

METHODS

This was a prospective quantitative study that sonographically scanned female patients with breast masses and consecutively selected cases recommended for core biopsy from May 2018 to May 2021. Sixty (60) solid breast masses were described using the sonographic BI-RADS lexicon features. Lesion description and biopsy results from histopathology were compared and analyzed using Pearson's Chi-square test. Odds ratios, sensitivity, specificity, and predictive values were also calculated. Statistical significance level was set at p ≤ 0.05.

RESULTS

Irregular shape (p < 0.0001), spiculated mass margins (p < 0.0001), and not parallel mass orientation (p= 0.0007) were more commonly associated with malignant masses. The sensitivity of breast ultrasound for malignancy was 93.9 % and the specificity was 55.6 % with an overall accuracy rate of 76.6 %. The negative predictive value was 88.7 % and the positive predictive value was 72.1 %. Descriptors like irregular shape, non-parallel orientation, angular and spiculated margins, echogenic halo, and markedly hypoechoic internal content, demonstrated higher odds ratios for malignancy.

CONCLUSIONS

This study adds valuable insights to the diagnosis of breast cancer using the sonographic BI-RADS lexicon features. The results demonstrate that specific sonographic descriptors can effectively differentiate between benign and malignant breast masses.

Availability and Geographic Access to Hospital-Based Breast Cancer Diagnostic Services in Ghana

PURPOSE

Breast cancer is the most frequent cancer and second most common cause of cancer-related death in Ghana. Early detection and access to diagnostic services are vital for early treatment initiation and improved survival. This study characterizes the geographic access to hospital-based breast cancer diagnostic services in Ghana as a framework for expansion.

METHODS

A cross-sectional hospital-based survey was completed in Ghana from November 2020 to October 2021. Early diagnostic services, as defined by the National Comprehensive Cancer Network (NCCN) Framework for Resource Stratification, was assessed at each hospital. Services were characterized as available >80% of the time in the previous year, <80%, or not available. ArcGIS was used to identify the proportion of the population within 20 and 45 km of services.

RESULTS

Most hospitals in Ghana participated in this survey (95%; 328 of 346). Of these, 12 met full NCCN Basic criteria >80% of the time, with 43% of the population living within 45 km. Ten of the 12 met full NCCN Core criteria, and none met full NCCN Enhanced criteria. An additional 12 hospitals were identified that provide the majority of NCCN Basic services but lack select services necessary to meet this criterion. Expansion of services in these hospitals could result in an additional 20% of the population having access to NCCN Basic-level early diagnostic services within 45 km.

CONCLUSION

Hospital-based services for breast cancer early diagnosis in Ghana are available but sparse. Many hospitals offer fragmented aspects of care, but only a limited number of hospitals offer the full NCCN Basic or Core level of care. Understanding current availability and geographical distribution of services provides a framework for potential targeted expansion of services.

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.

Access to Radiation Therapy and Related Clinical Outcomes in Patients With Cervical and Breast Cancer Across Sub-Saharan Africa: A Systematic Review

PURPOSE

To better understand the barriers to accessing standard-of-care radiation therapy (RT) for breast and cervical cancer in sub-Saharan Africa and their impact on outcomes.

METHODS

A comprehensive literature search was completed with a medical librarian. Articles were screened by title, abstract, and full text. Included publications were analyzed for data describing barriers to RT access, available technology, and disease-related outcomes, and further grouped into subcategories and graded according to predefined criteria.

RESULTS

A total of 96 articles were included: 37 discussed breast cancer, 51 discussed cervical cancer, and eight discussed both. Financial access was affected by health care system payment models and combined burdens of treatment-related costs and lost wages. Staffing and technology shortages limit the ability to expand service locations and/or increase capacity within existing centers. Patient factors including use of traditional healers, fear of stigma, and low health literacy decrease the likelihood of early presentation and completion of therapies. Survival outcomes are worse than most high- and middle-income countries and are affected by many factors. Side effects are similar to other regions, but these findings are limited by poor documentation capabilities. Access to palliative RT is more expeditious than definitive management. RT was noted to lead to feelings of burden, lower self-esteem, and worsened quality of life.

CONCLUSION

Sub-Saharan Africa represents a diverse region with barriers to RT that differ on the basis of funding, available technology and staff, and community populations. Although long-term solutions must focus on building capacity by increasing the number of treatment machines and providers, short-term improvements should be implemented, such as interim housing for traveling patients, increased community education to reduce late-stage diagnoses, and use of virtual visits to avoid travel.