Breast Cancer Downstaging Practices and Breast Health Messaging Preferences Among a Community Sample of Urban and Rural Ugandan Women

A model to enhance breast cancer screening among rural women aged 40-75 years in Sub-Saharan Africa (SSA): A scoping review

INTRODUCTION AND BACKGROUND

It is claimed that very little research has been done in Africa on breast cancer screening to identify the best method that can be adopted to have early detection of the malignancy. Breast cancer is a growing burden globally and in Sub-Saharan Africa (SSA). There is a rise in breast cancer mortality in SSA. This is caused by limited breast cancer screening or early detection practices due to limited resources which makes mammography unaffordable by the majority of women. This problem is more prevalent in elderly women living in rural areas where limited or no breast cancer screening is taking place. Downstaging which is context-specific is recommended for African countries but more studies are required to confirm its effectiveness.

OBJECTIVES

This review aims to identify the gaps in the literature focusing on strategies to enhance breast cancer screening among elderly women aged 40-75 years who reside in rural areas.

INCLUSION CRITERIA

The articles to be reviewed should focus on screening for the elderly women population that reside in rural areas and should fall within the age range of 40-75 years. Other phrases that can be included instead of breast cancer screening could be early detection measures, early diagnosis, or downstaging.

METHODOLOGY

The methodology was guided by the published manual for Joana Briggs Institute for scoping reviews. A search of the relevant studies was conducted on 4 October 2022 across PubMed, SCOPUS, Embase, and EBSCO Host databases. The systematic literature search strategy was developed and carried out using the Medical Subject Heading (MeSH) database. The eligibility criteria were developed using the Participants, Concept, and Context framework. Only articles written in English and published between 2010 and 2022 were considered. Removal of duplications was done first, followed by screening using the article title and abstract and then using full-text articles. The results of the search were profiled on the PRISMAScR flow chart diagram. Themes were identified from the conclusions of the reviewed studies.

RESULTS

After searching 78 citations were identified. These were screened and only 8 were left after the different stages of screening. The reviewed articles were published between 2010 and 2020. The majority (75%) of the studies were surveys except for two which were qualitative and all done in Kenya. No mixed methodology study was done. No study focused on developing a model to enhance breast cancer screening among rural women aged 40-75 years although there are very few countries in Africa with established nationwide breast cancer screening guidelines.

CONCLUSION

There are limited studies done on breast cancer screening of elderly rural women in SSA. No study was done to identify a model to enhance breast cancer screening among the rural elderly women population. None of the reviewed studies utilized the mixed methodology design to have an in-depth context-specific understanding to pave the way for the implementation of downstaging which is recommended for countries with limited resources.

CONTRIBUTION

The scoping review indicated the gap in research in terms of breast cancer screening among women aged 40-75 years who reside in rural areas and highlighted the future need for such studies to make downstaging effective.

Barriers and enablers of breast cancer screening among women in East Africa: a systematic review

BACKGROUND

Breast cancer is among the most common cancers globally with a projected increase in incidence and mortality in low- and middle-income countries. The majority of the patients in East Africa present with advanced disease contributing to poor disease outcomes. Breast cancer screening enables earlier detection of the disease and therefore reduces the poor outcomes associated with the disease. This study aims to identify and synthesize the reported barriers and enablers of breast cancer screening among East African women.

METHODS

Medline, Embase, SCOPUS, and Cochrane library were searched for articles published on the subject from start to March 2022 using PRISMA guidelines. Also, forward citation, manual search of references and searching of relevant journals were done. A thematic synthesis was carried out on the "results/findings" sections of the identified qualitative papers followed by a multi-source synthesis with quantitative findings.

RESULTS

Of 4560 records identified, 51 were included in the review (5 qualitative and 46 quantitative), representing 33,523 women. Thematic synthesis identified two major themes - "Should I participate in breast cancer screening?" and "Is breast cancer screening worth it?". Knowledge of breast cancer and breast cancer screening among women was identified as the most influencing factor.

CONCLUSION

This review provides a rich description of factors influencing uptake of breast cancer screening among East African women. Findings from this review suggest that improving knowledge and awareness among both the public and providers may be the most effective strategy to improve breast cancer screening in Eastern Africa.

Determinants of late detection and advanced-stage diagnosis of breast cancer in Nigeria

Late detection of Breast cancer(BC) and progressing with advanced-stage diagnosis after early detection contribute differently to the challenges of managing BC in Africa. Understanding the difference may improve cancer education programs and their effectiveness.

Breast cancer early detection and diagnostic capacity in Uganda

BACKGROUND

Greater than 80% of women presenting for breast cancer treatment in Uganda have late-stage disease, which is attributable to a dysfunctional referral system and a lack of recognition of the early signs and symptoms among primary health care providers, and compounded by the poor infrastructure and inadequate human capacity. Improving the breast health care system requires a systemic approach beginning with situational analysis to identify systematic gaps that prevent sustainable improvements in outcome.

METHODS

The authors performed a situational analysis of the breast health care system using methods developed by the Breast Health Global Initiative. Based on their findings, they developed a series of recommendations for strengthening the health system for the early diagnosis of breast cancer based on clinical detection, referral, tissue sampling, and diagnosis.

RESULTS

Deficits in the recognition of breast cancer signs and symptoms, the underuse of clinical breast examination as a diagnostic and/or screening tool, the centralization of diagnostic tests (radiology and pathology), reliance on excisional biopsies rather than needle biopsies, and a lack of trained professionals and knowledge of the referral system all contribute to significant health system delays.

CONCLUSIONS

To strengthen referral networks and improve the early diagnosis of breast cancer in Uganda, national referral hospitals should provide educational programs to primary health care providers in community health centers (CHCs), at which the majority of women first present with symptoms. At secondary district-level facilities in which imaging and tissue sampling can be performed, the capacity for diagnostic testing could be increased through task shifting of basic interpretation (abnormal vs normal) from specialists to nonspecialists using networking technology to facilitate remote oversight from specialists at the national referral hospitals.

Impact of Community-Based Clinical Breast Examinations in Botswana

PURPOSE

We evaluated a clinical breast examination (CBE) screening program to determine the prevalence of breast abnormalities, number examined per cancer diagnosis, and clinical resources required for these diagnoses in a middle-income African setting.

METHODS

We performed a retrospective review of a CBE screening program (2015-2018) by Journey of Hope Botswana, a Botswana-based nongovernmental organization (NGO). Symptomatic and asymptomatic women were invited to attend. Screening events were held in communities throughout rural and periurban Botswana, with CBEs performed by volunteer nurses. Individuals who screened positive were referred to a private tertiary facility and were followed by the NGO. Data were obtained from NGO records.

RESULTS

Of 6,120 screened women (50 men excluded), 452 (7.4%) presented with a symptom and 357 (5.83%) were referred for further evaluation; 257 ultrasounds, 100 fine-needle aspirations (FNAs), 58 mammograms, and 31 biopsies were performed. In total, 6,031 were exonerated from cancer, 78 were lost to follow-up (67 for ≤ 50 years and 11 for > 50 years), and 11 were diagnosed with cancer (five for 41-50 years and six for > 50 years, 10 presented with symptoms). Overall breast cancer prevalence was calculated to be 18/10,000 (95% CI, 8 to 29/10,000). The number of women examined per breast cancer diagnosis was 237 (95% CI, 126 to 1910) for women of age 41-50 years and 196 (95% CI, 109 to 977) for women of age > 50 years. Median time to diagnosis for all women was 17.5 [1 to 32.5] days. CBE-detected tumors were not different than tumors presenting through standard care.

CONCLUSION

In a previously unscreened population, yield from community-based CBE screening was high, particularly among symptomatic women, and required modest diagnostic resources. This strategy has potential to reduce breast cancer mortality.

A Global Perspective on Screening

Breast cancer is emerging as a major global public health problem. Incidence and mortality continues to rise in low- and middle-income countries (LMICs). A significant and growing disparity exists between high-income countries and LMICs in the availability of screening services and associated preventable mortality. However, population imaging-based screening programs are not appropriate for all settings. Planners should perform a thorough assessment of the target setting prior to implementing any breast cancer detection program, as appropriate guidelines vary according to the resources available. Financial, social, and cultural barriers to breast cancer care need to be addressed to sustainably improve the morbidity and mortality of the populations and make efficient use of available services. Creative approaches, such as mobile and portable imaging and bundling of services, can facilitate the installation of early breast cancer detection programs in LMICs. While image-based screening programs are not initially resource-appropriate in many LMICs, planners can work towards this goal as part of their comprehensive breast cancer detection strategy.

Identifying Barriers and Facilitators to Breast Cancer Early Detection and Subsequent Treatment Engagement in Kenya: A Qualitative Approach

BACKGROUND

Early detection and prompt access to quality treatment and palliative care are critical for good breast cancer outcomes. Interventions require understanding of identified barriers and facilitators to care. A hermeneutic phenomenological approach, whose purpose is to describe feelings and lived experiences of participants, can expand the existing scope of understanding of barriers and facilitators in accessing breast cancer care in Kenya.

METHODS

This is qualitative research applying focus groups and a hermeneutic phenomenological approach to identify barriers and facilitators to breast cancer care from the knowledge, perceptions, and lived experiences of women with and without a diagnosis of breast cancer in Kenya. We conducted four focus group discussions with 6-11 women aged 30-60 years in each. Groups were classified according to breast cancer diagnosis and socioeconomic status. The transcribed discussions were coded independently by two investigators. Together they reviewed the codes and identified themes.

RESULTS

The key barriers were costs, inadequate knowledge, distance to health facilities, communication with health providers, medicines stockouts, long waiting periods, limited or no counseling at diagnosis, patient vulnerability, and limited access to rehabilitation items. Facilitators were dependable social support, periodical access to subsidized awareness, and early detection services and friendly caregivers. We found no marked differences in perceptions between groups by socioeconomic status.

CONCLUSION

There is need for targeted awareness and education for health providers and the public, early detection services with onsite counseling and cost mitigation. Support from the society and religious organizations and persons may be leveraged as adjuncts to conventional management. Further interpretations are encouraged.

IMPLICATIONS FOR PRACTICE

Continuing cancer education for health providers in technical skills for early detection, treatment, and survivorship care, as well as nontechnical skills like communication, and an understanding of their patients' preferences and socioeconomic status may guide individualized management plans and positively affect patient experiences. Patients and the general public also need education on cancer to avoid misconceptions and inaccuracies that perpetuate fear, confusion, delayed presentation for treatment, and stigma. Critical analysis of the cancer care value chain and processes, development, and implementation of interventions to reduce costs while streamlining processes may improve client experiences.

Modifiable patient-related barriers and their association with breast cancer detection practices among Ugandan women without a diagnosis of breast cancer

Most women with breast cancer in sub-Saharan Africa (SSA) are diagnosed with late-staged disease. The current study assesses patient-related barriers among women from a general SSA population to better understand how patient-related barriers contribute to diagnostic delays. Using convenience-based sampling, 401 Ugandan women without breast cancer were surveyed to determine how prior participation in cancer detection practices correlate with patient-related barriers to prompt diagnosis. In a predominantly poor (76%) and rural population (75%), the median age of the participants was 38. Of the women surveyed, 155 (46%) had prior exposure to breast cancer education, 92 (27%) performed breast self-examination (BSE) and 68 (20%) had undergone a recent clinical breast examination (CBE), breast ultrasound or breast biopsy. The most commonly identified barriers to prompt diagnosis were knowledge deficits regarding early diagnosis (79%), economic barriers to accessing care (68%), fear (37%) and poor social support (24%). However, only women who reported knowledge deficits-a modifiable barrier-were less likely to participate in cancer detection practices (p<0.05). Women in urban and rural areas were similarly likely to report economic barriers, knowledge deficits and/or poor social support, but rural women were less likely than urban women to have received breast cancer education and/or perform BSE (p<0.001). Women who have had prior breast cancer education (p<0.001) and/or who perform BSE (p = 0.02) were more likely to know where she can go to receive a diagnostic breast evaluation. These findings suggest that SSA countries developing early breast cancer detection programs should specifically address modifiable knowledge deficits among women less likely to achieve a diagnostic work-up to reduce diagnostic delays and improve breast cancer outcomes.

Role of Family Obligation Stress on Ugandan Women's Participation in Preventive Breast Health

BACKGROUND

The purpose of this study is to determine the role of family obligation stress on Ugandan women's participation in preventive breast health through the receipt of breast cancer education and health check-ups.

MATERIALS AND METHODS

A validated survey was conducted on a community sample of Ugandan women, providing a multi-item scale to assess preventive breast-health-seeking behaviors and measure family obligation stress (FO; range 6-18). Univariate and multivariate linear regression was used to assess associations between sociodemographic factors and FO. Univariate and multivariate linear regression (used in conjunction with the robust sandwich estimator for standard errors) and probability differences (PDs) were used to evaluate associations between preventive breast-health-seeking behaviors, sociodemographic factors, and FO.

RESULTS

A total of 401 Ugandan women ages 25-74 participated in the survey. Most had three or more children in the home (60%) and were employed full time (69%). Higher FO was associated with increasing number of children and/or adults in the household (p < .05), full-time employment (p < .001), and being single (p = .003). Women with higher FO were less likely to participate in breast cancer education (PD = -0.02 per 1-point increase, p = .008) and preventive health check-ups (PD = -0.02, p = .018), associations that persisted on multivariate analysis controlling for sociodemographic factors.

CONCLUSION

Ugandan women with high FO are less likely to participate in preventive breast cancer detection efforts including breast cancer education and preventive health check-ups. Special efforts should be made to reach women with elevated FO, because it may be a risk factor for late-stage presentation among women who develop breast cancer.

IMPLICATIONS FOR PRACTICE

High family obligation stress (FO) significantly reduces women's participation in preventive health check-ups and breast cancer education. These findings support research in U.S. Latinas showing high FO negatively affects women's health, suggesting that FO is an important factor in women's health-seeking behavior in other cultures. Addressing family obligation stress by including family members involved in decision-making is essential for improving breast cancer outcomes in low- and middle-income countries, such as Uganda.

Breast diseases histologically diagnosed at a tertiary facility in Uganda (2005-2014)

BACKGROUND

The prevalence and distribution of histologically diagnosed breast disease are not well documented in low income countries, Uganda inclusive. Although the greater majority of breast lesions globally are benign, breast cancer is the most frequently diagnosed cancer all over the world. We aimed at documenting the prevalence of different breast diseases histologically diagnosed at the histopathology laboratory of the Department of Pathology of the Makerere University College of Health Sciences (MakCHS Lab) over a decade (2005-2014). We also describe the demographic characteristics of the patients in Uganda diagnosed with breast disease at the MakCHS Lab during the same period.

METHODS

This was a 10 year retrospective study of histologically diagnosed breast disease between 2005 and 2014 inclusive at the MakCHS Lab. We extracted information from hard copies of all 2510 histopathology reports retrieved from archives of the Department of Pathology at the MakCHS Lab. 640 records that were either damaged beyond recognition of key details, were duplicated, were implausible or had no conclusive diagnosis made were excluded. Information to be analyzed was then entered into Epidata (version 3.1) on a password protected laptop. Data analysis was done using SPSS software (v16 for Windows × 64).

RESULTS

From the 1870 patients' records eventually analyzed, breast disease was most diagnosed in female patients (97.1%). The overall mean age for breast disease diagnosis was 33 years (S.D ± 16.46) and median age 26 years (IQR: 20-43). Fibroadenoma (40.1%) was the most diagnosed breast disease overall. We noticed steadily increasing frequency of diagnosis of cancerous breast diseases over the last half of the study period. Invasive ductal carcinoma was the most diagnosed breast cancer (326 cases, 55.6%). A high female to male breast cancer ratio of 48:1 was observed. The highest regional breast cancer proportion was from the Western region of the Country.

CONCLUSIONS

There is need for more research into the picture of breast disease in the country, covering various demographic characteristics of the country's population for all regions and informing about its incidence rates and prevalence and also the breast cancer risk estimate for benign breast disease.

Survival of breast cancer patients in rural Ethiopia

PURPOSE

To describe the histopathological characteristics and survival of female breast cancer (BC) patients in a rural setting with limited access to adjuvant treatment.

METHODS

A prospective study of 107 histologically confirmed BC patients treated with surgery from 2010 to 2016 from rural parts of western Ethiopia. Referral pathology was performed, and active follow-up was conducted. Adjusted cox regression analysis (hazard ratio [HR]) was performed.

RESULTS

The median age at diagnosis was 45 (16-83) years; 57% of the patients presented with cT3/4 tumors, 71% with clinically positive lymph nodes, 21% with HER2-overexpression (Dako3+) and 68% with grade 3 tumors. Estrogen and/or progesterone receptor expressions were present in 66% and triple-negative disease in 25%. The estimated 1- and 2-year overall survival probability rates were 78 and 53%, respectively. The 2-year survival for patients with clinically positive lymph nodes was 44% compared to 73% for patients with lymph node-negative disease (HR 2.44; 95% confidence interval [95% CI] 1.19-5.02). The corresponding 2-year survival for patients with cT4 tumors was 25% versus 68% for patients with cT1-2 tumors (cT1-3 vs. cT4 HR 3.86; 95% CI 1.82-13.63). The 2-year survival for patients with hormone receptor-negative disease was 40% compared to 59% for patients with hormone receptor-positive disease (HR 1.92; 95% CI 1.06-3.47).

CONCLUSION

The majority of breast cancer patients treated with surgery in rural parts of western Ethiopia are diagnosed at advanced stage and have hormone receptor-positive disease. Nearly half of the patients die within 2 years. These findings underscore the need for provision of adjuvant hormonal therapy and for the establishment of pathology service including hormone receptor testing.

Differences in Perception of Breast Cancer Among Muslim and Christian Women in Ghana

Purpose

The burden of breast cancer continues to increase in low- and middle-income countries (LMICs), where women present with more advanced disease and have worse outcomes compared with women from high-income countries. In the absence of breast cancer screening in LMICs, patients must rely on self-detection for early breast cancer detection, followed by a prompt clinical diagnostic work-up. Little is known about the influence of religious beliefs on women’s perceptions and practices of breast health.

Methods

A cross-sectional survey was administered to female members of Islamic and Christian organizations in Ghana. Participants were asked about their personal experience with breast concerns, knowledge of breast cancer, performance of breast self-examination, and experience with clinical breast exam.

Results

The survey was administered to 432 Muslim and 339 Christian women. Fewer Muslim women knew someone with breast cancer (31% v 66%; P < .001) or had previously identified a concerning mass in their breast (16% v 65%; P < .001). Both groups believed that new breast masses should be evaluated at clinic (adjusted odds ratio [AOR], 1.08; 95% CI, 0.58 to 2.01), but Muslim women were less likely to know that breast cancer can be effectively treated (AOR, 0.34; 95% CI, 0.23 to 0.50). Muslim women were less likely to have performed breast self-examination (AOR, 0.51; 95% CI, 0.29 to 0.88) or to have undergone clinical breast exam (AOR, 0.48; 95% CI, 0.27 to 0.84).

Conclusion

Muslim women were found to be less likely to participate in breast health activities compared with Christian women, which highlights the need to consider how religious customs within subpopulations might impact a woman’s engagement in breast health activities. As breast awareness initiatives are scaled up in Ghana and other LMICs, it is essential to consider the unique perception and participation deficits of specific groups.

Breast Cancer Beliefs as Potential Targets for Breast Cancer Awareness Efforts to Decrease Late-Stage Presentation in Uganda

Purpose

To assess breast cancer beliefs in Uganda and determine whether these beliefs are associated with factors potentially related to nonparticipation in early detection.

Methods

A survey with open- and close-ended items was conducted in a community sample of Ugandan women to assess their beliefs about breast cancer. Linear regression was used to ascertain associations between breast cancer beliefs and demographic factors potentially associated with early detection, including socioeconomic factors, health care access, prior breast cancer knowledge, and personal detection practices.

Results

Of the 401 Ugandan women surveyed, most had less than a primary school education and received medical care at community health centers. Most women either believed in or were unsure about cultural explanatory models for developing breast cancer (> 82%), and the majority listed these beliefs as the most important causes of breast cancer (69%). By comparison, ≤ 45% of women believed in scientific explanatory risks for developing breast cancer. Although most believed that regular screening and early detection would find breast cancer when it is easy to treat (88% and 80%, respectively), they simultaneously held fatalistic attitudes toward their own detection efforts, including belief or uncertainty that a cure is impossible once they could self-detect a lump (54%). Individual beliefs were largely independent of demographic factors.

Conclusion

Misconceptions about breast cancer risks and benefits of early detection are widespread in Uganda and must be addressed in future breast cancer awareness efforts. Until screening programs exist, most breast cancer will be self-detected. Unless addressed by future awareness efforts, the high frequency of fatalistic attitudes held by women toward their own detection efforts will continue to be deleterious to breast cancer early detection in sub-Saharan countries like Uganda.