Fear of Mastectomy Associated with Delayed Breast Cancer Presentation Among Ghanaian Women

Recurrence and associated factors of breast cancer among women in sub saharan africa, systematic review and meta-analysis

BACKGROUND

Recurrence of breast cancer is a critical indicator of disease progression and survival rates. Therefore, this systematic review and meta-analysis aimed to assess the prevalence of recurrence and associated factors of breast cancer in Sub Saharan Africa.

METHODS

We conducted a thorough search of the following international databases between January 1 and February 7, 2024: PubMed, EMBASE, CINAHL, Google Scholar, Science Direct, and the Cochrane Library. A data extraction format was used by two authors to independently extract all required data. STATA Version 14 was used to evaluate the quantitative data and the Cochrane Q test statistics and I2 test were used to evaluate the heterogeneity among the included studies using a random effects meta-analysis model.

RESULTS

The overall prevalence of breast cancer recurrence is 27.44 % (95%CI: 26.41, 28.46). The highest prevalence was found in Uganda (89.927 % (87.0, 92.851)), followed by Tanzania (82.174 % (77.228, 87.120)). Involved deep surgical margin (OR: 3.62, 95 % CI: 2.11, 5.12), positive lymph node status (OR: 6.85, 95 % CI: 1.42, 12.3)), and histological grade III (OR: 7.43, 95 % CI: 3.56, 11.3)) were all significantly associated factors.

CONCLUSION

The pooled prevalence of breast cancer recurrence in this review was significantly high. Histological grade III, positive lymph node statuses, clinical staging III, and involved deep surgical margin were associated factors. Therefore, frequent monitoring, regular screenings, imaging tests, and consultations with oncologists, take extra care to ensure clear and deep surgical margins using advanced imaging techniques are highly recommended.

Development, acceptability and usability of culturally appropriate survivor narrative videos for breast cancer treatment in Botswana: a pilot study

OBJECTIVES

Narrative communication has demonstrated effectiveness in promoting positive health behaviours, delivering support and coping with complex decision-making. Formal research evaluating this intervention for cancer treatment in Africa is lacking. We aimed to develop, and assess acceptability and usability of survivor video narrative interventions for breast cancer treatment in Botswana.

DESIGN

A pilot study design.

SETTING

Single-centre, tertiary hospital, sub-Saharan Africa.

PARTICIPANTS

Eight women, ≥18 years old, with stages I-III breast cancer were enrolled for the video intervention. 106 women, ≥18 years old, with stages I-IV breast cancer viewed the narrative videos and 98 completed the acceptability and usability surveys.

INTERVENTION

Survivor narrative videos were developed using the theory of planned behaviour and using a purposive sample of Batswana, Setswana-speaking, breast cancer survivors, who had completed systemic treatment and surgery with high rates of adherence to the prescribed treatment plan.

PRIMARY OUTCOMES

We assessed acceptability and usability among prospectively enrolled patients presenting for routine breast cancer care at Princess Marina Hospital in Botswana, using a 13-item survey.

RESULTS

Participants expressed high acceptability and usability of the videos, including 99% (97/98) who strongly agreed/agreed that the video presentations were easy to understand, 92% (90/98) who would recommend to other survivors and 94% (92/98) who wished there were more videos. Additionally, 89% (87/98) agreed or strongly agreed that the one-on-one instruction on how to use the tablet was helpful and 87% (85/98) that the video player was easy to use.

CONCLUSION

Culturally appropriate survivor video narratives have high acceptability and usability among patients with breast cancer in Botswana. There is an opportunity to leverage this intervention in routine breast cancer care for treatment support. Future studies will test the implementation and effectiveness of narrative videos on a wider scale, including for patients being treated for other cancers.

Stigma and Social Determinants of Health Associated With Fidelity to Guideline-Concordant Therapy in Patients With Breast Cancer Living With and Without HIV in Botswana

BACKGROUND

Patients with breast cancer in sub-Saharan Africa (SSA) experience a disproportionate burden of mortality. Fidelity to treatment guidelines, defined as receiving optimal dose and frequency of prescribed treatments, improves survival. We sought to identify patient factors associated with treatment fidelity and how this may differ for people with HIV (PWH) and breast cancer.

METHODS

We conducted a qualitative study of women who initiated outpatient treatment for stages I-III breast cancer in Botswana, with deviance sampling of high- and low-fidelity patients. One-on-one interviews were conducted using semi-structured guides informed by the Theory of Planned Behavior. The sample size was determined by thematic saturation. Transcribed interviews were double coded with an integrated analytic approach.

RESULTS

We enrolled 15 high- and 15 low-fidelity participants from August 25, 2020 to December 15, 2020, including 10 PWH (4 high, 6 low fidelity). Ninety-three percent had stage III disease. Barriers to treatment fidelity included stigma, social determinants of health (SDOH), and health system barriers. Acceptance and de-stigmatization, peer and other social support, increased knowledge and self-efficacy were identified as facilitators. The COVID-19 pandemic amplified existing socioeconomic stressors. Unique barriers and facilitators identified by PWH included intersectional stigma, and HIV and cancer care integration, respectively.

CONCLUSION

We identified multilevel modifiable patient and health system factors associated with fidelity. The facilitators provide opportunities for leveraging existing strengths within the Botswana context to design implementation strategies to increase treatment fidelity to guideline-concordant breast cancer therapy. However, PWH experienced unique barriers, suggesting that interventions to address fidelity may need to be tailored to specific comorbidities.

A critical review and analysis of the context, current burden, and application of policy to improve cancer equity in Ghana

BACKGROUND

Cancer causes a major disease burden worldwide. This is increasingly being realised in low and middle-income countries, which account disproportionately for preventable cancer deaths. Despite the World Health Organization calling for governments to develop policies to address this and alleviate cancer inequality, numerous challenges in executing effective cancer policies remain, which require consideration of the country-specific context. As this has not yet been considered in Ghana, the aim of this review was to bring together and critique the social-environmental, health policy and system factors to identifying opportunities for future health policies to reduce cancer burden in the Ghanian context. A critical policy-focused review was conducted to bring together and critique the current health systems context relating to cancer in Ghana, considering the unmet policy need, health system and social factors contributing to the burden and policy advances related to cancer.

CONCLUSION

The findings highlight the changing burden of cancer in Ghana and the contextual factors within the socio-ecosystem that contribute to this. Policies around expanding access to and coverage of services, as well as the harmonization with medical pluralism have potential to improve outcomes and increase equity but their implementation and robust data to monitor their impact pose significant barriers.

Patients' experiences undergoing breast evaluation in Rwanda's Women's Cancer Early Detection Program

PURPOSE

There is urgent need for interventions to facilitate earlier diagnosis of breast cancer in low- and middle-income countries where mammography screening is not widely available. Understanding patients' experiences with early detection efforts, whether they are ultimately diagnosed with cancer or benign disease, is critical to optimize interventions and maximize community engagement. We sought to understand the experiences of patients undergoing breast evaluation in Rwanda's Women's Cancer Early Detection Program (WCEDP).

METHODS

We conducted in-person semi-structured interviews with 30 patients in two districts of Rwanda participating in the WCEDP. Patients represented a range of ages and both benign and malignant diagnoses. Interviews were recorded, transcribed, translated, and thematically analyzed.

RESULTS

Participants identified facilitators and barriers of timely care along the breast evaluation pathway. Community awareness initiatives were facilitators to care-seeking, while persistent myths and stigma about cancer were barriers. Participants valued clear clinician-patient communication and emotional support from clinicians and peers. Poverty was a major barrier for participants who described difficulty paying for transport, insurance premiums, and other direct and indirect costs of hospital referrals in particular. COVID-19 lockdowns caused delays for referred patients. Although false-positive clinical breast exams conferred financial and emotional burdens, participants nonetheless voiced appreciation for their experience and felt empowered to monitor their own breast health and share knowledge with others.

CONCLUSION

Rwandan women experienced both benefits and burdens as they underwent breast evaluation. Enthusiasm for participation was not reduced by the experience of a false-positive result. Reducing financial, logistical and emotional burdens of the breast diagnostic pathway through patient navigation, peer support and decentralization of diagnostic services could improve patients' experience.

Assessment of Pathological Complete Response Using Vacuum-Assisted Biopsy in Breast Cancer Patients Who Have Clinical and Radiological Complete Response After Neo-Adjuvant Chemotherapy

Background

Any treatment protocol that leads to complete elimination of surgery may lead to a better patient acceptance of breast cancer treatments.

Objectives

We conducted this study to assess the feasibility of preoperative vacuum-assisted biopsies in identifying pathological complete response (pCR) and its accuracy in correlation to final histopathology report (HPR), in an Indian setting.

Methods

This was a prospective study conducted between October 1, 2019, and March 31, 2021. Patients with early breast cancer, estrogen and progesterone receptors negative and either Her2 positive or negative, and who were fit to undergo marker placement at the centre of the tumour and to receive third-generation chemotherapy (4 cycles of 3 weekly doxorubicin and cyclophosphamide followed by 4 cycles of 3 weekly docetaxel) were included in the study. Following the enrolment, a tissue marker was placed at the centre of the tumour and appropriate chemotherapy was started. Patients who achieved clinical complete response were subjected to ultrasound-guided vacuum-assisted biopsy (VAB) from the tumour bed before surgery. Pathology results of the VAB and resected specimen were then compared. Descriptive statistics were used in the study.

Results

Eighteen patients were enrolled in the study, with a mean age of 43.6 ± 9.8 years. However, only 10 were eligible for VAB procedure, and sensitivity and specificity were calculated based on the results of these 10 patients only. Vacuum-assisted biopsy showed sensitivity of 50% and specificity of 100% in identifying pCR. Combination of mammography, ultrasonography, and VAB showed sensitivity of 77.8% and specificity of 66.7% in identifying pCR.

Conclusion

Vacuum-assisted biopsy of tumour bed may not be sensitive enough to eliminate surgery even in patients who have had exceptional response to neo-adjuvant chemotherapy.

Guideline Concordance of Treatment and Outcomes Among Adult Non-Hodgkin Lymphoma Patients in Sub-Saharan Africa: A Multinational, Population-Based Cohort

BACKGROUND

Although non-Hodgkin lymphoma (NHL) is the 6th most common malignancy in Sub-Saharan Africa (SSA), little is known about its management and outcome. Herein, we examined treatment patterns and survival among NHL patients.

METHODS

We obtained a random sample of adult patients diagnosed between 2011 and 2015 from 11 population-based cancer registries in 10 SSA countries. Descriptive statistics for lymphoma-directed therapy (LDT) and degree of concordance with National Comprehensive Cancer Network (NCCN) guidelines were calculated, and survival rates were estimated.

FINDINGS

Of 516 patients included in the study, sub-classification was available for 42.1% (121 high-grade and 64 low-grade B-cell lymphoma, 15 T-cell lymphoma and 17 otherwise sub-classified NHL), whilst the remaining 57.9% were unclassified. Any LDT was identified for 195 of all patients (37.8%). NCCN guideline-recommended treatment was initiated in 21 patients. This corresponds to 4.1% of all 516 patients, and to 11.7% of 180 patients with sub-classified B-cell lymphoma and NCCN guidelines available. Deviations from guideline-recommended treatment were initiated in another 49 (9.5% of 516, 27.2% of 180). By registry, the proportion of all patients receiving guideline-concordant LDT ranged from 30.8% in Namibia to 0% in Maputo and Bamako. Concordance with treatment recommendations was not assessable in 75.1% of patients (records not traced (43.2%), traced but no sub-classification identified (27.8%), traced but no guidelines available (4.1%)). By registry, diagnostic work-up was in part importantly limited, thus impeding guideline evaluation significantly. Overall 1-year survival was 61.2% (95%CI 55.3%-67.1%). Poor ECOG performance status, advanced stage, less than 5 cycles and absence of chemo (immuno-) therapy were associated with unfavorable survival, while HIV status, age, and gender did not impact survival. In diffuse large B-cell lymphoma, initiation of guideline-concordant treatment was associated with favorable survival.

INTERPRETATION

This study shows that a majority of NHL patients in SSA are untreated or undertreated, resulting in unfavorable survival. Investments in enhanced diagnostic services, provision of chemo(immuno-)therapy and supportive care will likely improve outcomes in the region.

A Prospective Evaluation of the Quality of Life and Mental Health Implications of Mastectomy Alone on Women in sub-Saharan Africa

OBJECTIVE

Assess quality of life and mental health implications of mastectomy for breast cancer on sub-Saharan African women.

BACKGROUND

Mortality rates amongst women diagnosed with breast cancer in sub-Saharan Africa (SSA) are high, with disparities in survival relative to women in high income countries partly attributed to advanced disease at presentation. Fears of the sequelae of mastectomy are a prominent reason for presentation delays. There is a critical need to better understand the effects of mastectomy on women in SSA to inform preoperative counseling and education for women with breast cancer.

METHODS

Women with breast cancer in Ghana and Ethiopia undergoing mastectomy were followed prospectively. Breast related quality-of-life and mental health measures were evaluated preoperatively, 3 and 6 months postoperatively, using BREAST-Q, PHQ-9, and GAD-7. Bivariate and logistic regression analyses evaluated changes in these measures for the total cohort and between sites.

RESULTS

A total of 133 women from Ghana and Ethiopia were recruited. The majority of women presented with unilateral disease (99%) and underwent unilateral mastectomy (98%) with axillary lymph node dissection. Radiation was more common in Ghana ( P <0.001). Across most BREAST-Q subscales, women from both countries reported significantly decreased scores at 3 months postoperative. At 6 months, the combined cohort reported decreased scores for breast satisfaction (mean difference, -3.4). Women in both countries reported similar improvements in anxiety and depression scores postoperatively.

CONCLUSIONS

Women from Ghana and Ethiopia who underwent mastectomy experienced a decline in breast-related body image while also experiencing decreased levels of depression and anxiety.

A Narrative Synthesis of Literature on the Barriers to Timely Diagnosis and Treatment of Cancer in Sub-Saharan Africa

Poor cancer survival outcomes in sub-Saharan Africa (SSA) have been linked to delays in diagnosis and treatment. Here we present a detailed overview of the qualitative literature evaluating the barriers to receiving timely diagnosis and treatment of cancer in SSA. The PubMed, EMBASE, CINAHL, PsycINFO databases were searched to identify qualitative studies reporting on barriers to timely diagnosis of cancer in SSA published between 1995 and 2020. A systematic review methodology was applied, including quality assessment and narrative data synthesis. We identified 39 studies, of which 24 focused on breast or cervical cancer. Only one study focused on prostate cancer and one on lung cancer. When exploring factors contributing to delays, six key themes emerged from the data. The first theme was health service barriers, which included: (i) inadequate numbers of trained specialists; (ii) limited knowledge of cancer among healthcare providers; (iii) poor co-ordination of care; (iv) inadequately resourced health facilities; (v) negative attitudes of healthcare providers towards patients; (vi) high cost of diagnostic and treatment services. The second key theme was patient preference for complementary and alternative medicine; the third was the limited understanding of cancer among the population. The fourth barrier was a patient's personal and family obligations; the fifth was the perceived impact of cancer and its treatment on sexuality, body image and relationships. Finally, the sixth was the stigma and discrimination faced by patients following a diagnosis of cancer. In conclusion, health system, patient level and societal factors all influence the likelihood of timely diagnosis and treatment for cancer in SSA. The results provide a focus for targeting health system interventions, particular with regards to awareness and understanding of cancer in the region.

Locally advanced breast cancer (LABC) and delayed care: a qualitative analysis of psychosocial factors

The literature has extensively documented how delayed access to health care services in the context of cancer can result from subjective characteristics, dysfunctional coping styles, barriers to care, or procrastination. However, limited research has investigated the psychosocial experience of women diagnosed with Locally Advanced Breast Cancer (LABC). This qualitative study aimed at understanding cognitive, emotional and relational factors associated with delayed access to care and treatment decision-making. In-depth interviews with 14 Italian women were conducted. A thematic analysis of elementary contexts using T-LAB was used to identify the association between emerging clusters and participants' coping styles as measured by the Mini-MAC. Five clusters were identified: 'relationships', 'ineluctability', 'disease', 'surgery', and 'diagnosis'. The 'relationships' cluster was characterized by elevated rates of Fighting Spirit (p < 0.01) while Anxious Preoccupation was associated with 'surgery' (p < 0.01). Findings contribute to explain individual and relational variables related to delay seeking care of LABC patients by illustrating the interplay of personal motivations and social networks' characteristics. Evidence from this work expands current understanding of the interplay of factors contributing to delays in seeking medical attention and may be utilized to inform strategies to timely identify women at greater risk.

A nationwide pilot study on breast cancer screening in Peru

Introduction

A high prevalence of advanced breast cancer (BC) is a common scenario in Latin America. In Peru, the frequency of BC at Stages III/IV is ≈50% despite implementation of a programme for breast cancer screening (BCS) along the country. We carried out a study to assess the feasibility and develop an instrument to evaluate the knowledge, barriers and perception about BCS in a nationwide pilot study in Peru among candidates for BCS.

Methods

We conducted a systematic review of 2,558 reports indexed in PubMed, Scopus, Web of Science, Medline-Ovid and EMBASE, regarding to our study theme. In total, 111 were selected and a 51-items survey was developed (eight items about sociodemographic characteristics). Patients were recruited in public hospitals or private clinics, in rural and urban areas of nine departments of Peru.

Results

We surveyed 488 women from: Lima (150), Cajamarca (93), Ica (59), Arequipa (56), Loreto (48), Ancash (38), Junín (15), Puerto Maldonado (15) and Huancavelica (14); 27.9% of them were from rural areas. The mean of age was 53.3 years (standard deviation ± 9.1). Regarding education level, 29.8% had primary, 33.2% secondary and 37.0% higher education. In total, 28.7% of women did not know the term 'mammogram' and 47.1% reported never receiving a BCS (36.9% from urban and 73.5% from rural population). In women that underwent BCS, only 67% knew it is for healthy women. In total, 54.1% of patients had low levels of knowledge about risk factors for BC (i.e. 87.5% of women respond that injuries in the breast produce cancer). Cultural, economic and geographic barriers were significantly associated with having a mammogram where 56.9% of participants considered a cost ≤ 7 USD as appropriate. Mammogram was perceived as too painful for 54.9% of women. In addition, women with a self-perception of low-risk for BC and a fatalistic perception of cancer were less likely to have a BCS.

Conclusion

We found that it is feasible to conduct a large-scale study in Peru. The results of this pilot study highlight an urgent need of extensive education and awareness about BCS in Peru.

Delayed diagnostic evaluation of symptomatic breast cancer in sub-Saharan Africa: A qualitative study of Tanzanian women

Background

Women with breast cancer in sub-Saharan Africa are commonly diagnosed at advanced stages. In Tanzania, more than 80% of women are diagnosed with stage III or IV disease, and mortality rates are high. This study explored factors contributing to delayed diagnostic evaluation among women with breast cancer in Tanzania.

Methods

A qualitative study was performed at Muhimbili National Hospital in Dar es Salaam, Tanzania. Twelve women with symptomatic pathologically proven breast cancer were recruited. In-depth, semi-structured interviews were conducted in Swahili. Interviews explored the women’s journey from symptom recognition to diagnosis, including the influence of breast cancer knowledge and pre-conceptions, health seeking behaviors, psychosocial factors, preference for alternative treatments, and the contribution of culture and norms. Audio-recorded interviews were transcribed and translated into English. Thematic analysis was facilitated by a cloud-based qualitative analysis software.

Results

All women reported that their first breast symptom was a self-identified lump or swelling. Major themes for factors contributing to delayed diagnostic presentation of breast cancer included lack of basic knowledge and awareness of breast cancer and misconceptions about the disease. Participants faced barriers with their local primary healthcare providers, including symptom mismanagement and delayed referrals for diagnostic evaluation. Other barriers included financial hardships, fear and stigma of cancer, and use of traditional medicine. The advice and influence of family members and friends played key roles in healthcare-seeking behaviors, serving as both facilitators and barriers.

Conclusion

Lack of basic knowledge and awareness of breast cancer, stigma, financial barriers, and local healthcare system barriers were common factors contributing to delayed diagnostic presentation of breast cancer. The influence of friends and family also played key roles as both facilitators and barriers. This information will inform the development of educational intervention strategies to address these barriers and improve earlier diagnosis of symptomatic breast cancer in Tanzania.

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.

Healthcare providers’ perspectives of the supportive care needs of women with advanced breast cancer in Ghana

Background

The study sought to understand the supportive care needs of women with advanced breast cancer from the perspectives of healthcare professionals (HCPs) and key informants of charitable/non-governmental organisations (NGOs), that provide supportive care services to women with advanced breast cancer, in Ghana.

Methods

A qualitative descriptive approach was employed via one-to-one semi-structured interviews with 13 HCPs and key informants of charitable/NGOs in Ghana that provide supportive care services to women with advanced breast cancer. The study was underpinned by Bradshaw’s taxonomy of social needs and Fitch’s supportive care framework. The data were analysed using a deductive content analysis approach.

Results

Healthcare providers and key informants perceived that women with advanced breast cancer in Ghana have numerous and complex supportive care needs in key areas that align with Fitch’s supportive care framework, including informational, psychological, emotional, physical, practical, social, sexuality and spiritual needs.

Conclusion

Participants perceived that women who have advanced breast cancer in Ghana require ongoing information about their condition, treatments and related effects, as well as spiritual support and guidance particularly due to the fatalistic beliefs they often associate with the condition. Tailored supportive care interventions and services, which address the unique sociocultural circumstances for this cohort, are required. Additional research is needed to explore how multidisciplinary teams can work collaboratively to provide comprehensive support to women in addressing their needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01931-7.

Breast reconstruction following mastectomy in Indian women: a neglected entity

Phyllodes tumour is a rapidly growing neoplasm with a propensity to involve the entire breast tissue. In large tumours, the treatment comprises a wide local excision or a mastectomy. A woman in her 20s from rural India presented with complaints of a recurrent left breast lump. The lump progressed to a large size, limiting her social activities and causing depression. On examination, she had a mass occupying almost the entire left breast, with stretched skin, dilated veins and pressure necrosis. There were no palpable axillary nodes. She was offered a wide local excision and reconstruction with a latissimus dorsi pedicled flap. After much discussion and clarification of some misconceptions around breast reconstruction, she underwent the planned surgery. This was followed by adjuvant radiation therapy as the histopathology was consistent with a complex phyllodes tumour with close margins. She was well at 1-year follow-up and led a good family and social life. Breast conservation and reconstruction are seldom offered as part of cancer treatment in India. All women should be offered surgical options that are oncologically safe while preserving body image, and hence healthcare providers must work towards breaking the barriers that prevent breast reconstruction.

Treatment guideline concordance, initiation, and abandonment in patients with non-metastatic breast cancer from the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort in sub-Saharan Africa: a prospective cohort study

BACKGROUND

Comprehensive breast cancer management is essential to achieve high breast cancer survival; however, detailed reports of the treatment regimens received by patients are scarce in sub-Saharan Africa where survival is low. We aimed to examine treatment initiation, guideline concordance, and abandonment in patients with non-metastatic breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort.

METHODS

The ABC-DO prospective cohort study recruited women (aged ≥18 years) with newly diagnosed invasive breast cancer in eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, Uganda, South Africa, and Zambia). We analysed treatments received by women who were classified as non-metastatic (M0) at the initial presentation. Data on surgery, radiotherapy, and systemic therapies were obtained from medical records and a self-reported follow-up questionnaire at 6 months after the diagnosis, follow-up calls every 3 months, and a baseline questionnaire. Initiation, completion, and abandonment of treatment modalities and combined therapy regimens were examined overall, by country-specific groups, and by clinical factors relevant for guideline-based treatment.

FINDINGS

Of 2313 women recruited into the ABC-DO study between Sept 10, 2014, and Dec 31, 2017, 2226 had histologically or clinically confirmed breast cancer. Of these 2226 women, 510 were excluded from the present analysis because 378 had metastatic disease, 37 were prevalent cases (defined as those previously diagnosed with breast cancer >2 years before baseline), 82 had unknown TNM stage, and 13 were White or Asian women in South Africa (number was too small for analysis). After a median follow-up of 5·2 years (IQR 4·6-5·9), 1163 (68%) of 1716 women underwent breast cancer surgery. Surgery and systemic therapy (ie, multimodality treatment) with radiotherapy was initiated in 370 (36%) of 1028 women with localised tumours versus 156 (23%) of 688 women with locally advanced tumours, whereas multimodality treatment without radiotherapy was initiated in 386 (38%) versus 167 (24%) women, respectively. Of 1530 patients requiring chemotherapy (which excludes 105 who died within 6 months after baseline), 1013 (66%) initiated treatment of neoadjuvant chemotherapy or surgery within 3 months after baseline, which was adequately completed by 359 (35%) of 1013 women, marginally completed by 284 (28%), abandoned by 200 (20%), and unknown in 151 (15%). 19 (2%) women died within 6 months after chemotherapy initiation. Of 1375 women in whom endocrine therapy was indicated, this treatment was initiated in 920, and lasted at least 3 years in 367 (40%) women. Treatment disparities between country-specific groups were substantial for all therapy regimens.

INTERPRETATION

A high proportion of patients with non-metastatic breast cancer did not initiate, did not fully complete, or abandoned treatment with surgery, systemic therapy, radiotherapy, or an appropriate combination of these, highlighting the need for improved treatment access and completion in sub-Saharan Africa to potentially prevent premature breast cancer deaths.

FUNDING

National Institutes of Health (National Cancer Institute), Susan G Komen, and the International Agency for Research on Cancer.

Burden of cancer in the general surgical population in the eastern region of Ghana

OBJECTIVE

To estimate the surgical burden of malignant disease in the Eastern Region of Ghana.

DESIGN

Descriptive cross-sectional study.

SETTING

Regional hospital in the eastern region of Ghana.

PARTICIPANTS

Patients treated by the surgery department at Eastern Regional Hospital in Koforidua, Ghana.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was incidence of malignancy and secondary outcome descriptive differences between patients who had a benign indication for surgery compared with those with a malignant indication for surgery.

RESULTS

A total of 1943 inpatient surgical procedures were performed from 2015 to 2017 with 13.4% (261) of all procedures ultimately performed for malignancy. Of all breast procedures performed, 95.2% of procedures resulted in a malignant diagnosis. The remaining subtypes of procedures had rates ranging from <1% to 41.2% of procedures performed for malignant disease. Additionally, this study found over 13% of patients admitted to the surgical service for breast cancer ultimately did not undergo a surgical procedure.

CONCLUSION

This is the first study investigating the burden of malignant disease in the Eastern Region of Ghana. We found a substantial prevalence of malignant disease in the surgical population in this region. This information can be used to aid in future medical resource planning in this region.

Competencies for Nurses Regarding Psychosocial Care of Patients With Cancer in Africa: An Imperative for Action

Psychosocial care is considered an important component of quality cancer care. Individuals treated for cancer can experience biologic or physical, emotional, spiritual, and practical consequences (eg, financial), which have an impact on their quality of living. With the establishment of cancer centers in Africa, there is growing advocacy regarding the need for psychosocial care, given the level of unmet supportive care needs and high emotional distress reported for patients. Nurses are in an ideal position to provide psychosocial care to patients with cancer and their families but must possess relevant knowledge and skills to do so. Across Africa, nurses are challenged in gaining the necessary education for psychosocial cancer care as programs vary in the amount of psychosocial content offered. This perspective article presents competencies regarding psychosocial care for nurses caring for patients with cancer in Africa. The competencies were adapted by expert consensus from existing evidenced-based competencies for oncology nurses. They are offered as a potential basis for educational program planning and curriculum development for cancer nursing in Africa. Recommendations are offered regarding use of these competencies by nursing and cancer program leaders to enhance the quality of care for African patients with cancer and their family members. The strategies emphasize building capacity of nurses to engage in effective delivery of psychosocial care for individuals with cancer and their family members.

Palliative Care Needs in Breast Cancer Patients Entering Inpatient Hospice in Western Kenya

CONTEXT

Breast cancer in Kenya is associated with a high mortality due to late stage disease at presentation and limited access to specialty care.

OBJECTIVES

To understand the symptom burden in breast cancer patients entering hospice in Western Kenya and utilize the data to meet the growing need for palliative care and hospice services.

METHODS

We conducted a quality improvement exercise to assess the needs of Kenyan women admitted to inpatient hospice with the diagnosis of breast cancer. A retrospective chart review was undertaken to collect and collate demographic, physical and symptom data from a standardized admission form and the medical record.

RESULTS

Between 2011-2019, 62 women with breast cancer were admitted for care. The median age was 50.0 years (range 23-86) and the median time from diagnosis to admission one year (range 0-4). Only 20% had received surgical treatment for breast cancer. Pain was the predominant symptom on admission (98%) and breast wounds were the most common physical finding. Approximately 50% voiced worry, depression, and stress with <10% voicing spiritual distress. The mean length of stay was 42.6 days (median 10, range 1-1185). While over 70% died in hospice, 27% were discharged home.

CONCLUSIONS

The low rate of surgical intervention leads to painful breast wounds that were a major factor for many women seeking hospice admission. The findings challenge our team to maintain expertise in pain and wound management but to also include breast cancer awareness in our rural outreach services.

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

BACKGROUND

Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

METHODS

PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization's six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

RESULTS

From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

CONCLUSION

The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

Stigma and its influencing factors among breast cancer survivors in China: A cross-sectional study

PURPOSE

Although stigma has attracted considerable scholarly attention, few studies have focused on its influencing factors among discharged breast cancer survivors, especially in a Chinese cultural context. The present study therefore explores stigma and its influencing factors among breast cancer survivors in China.

METHOD

Between December 2017 and May 2018, 103 breast cancer survivors at the outpatient clinic of a tertiary cancer center in southern China were enrolled in a cross-sectional study. The research instruments comprised the Social Impact Scale (SIS), the General Self-Efficacy Scale (GSES), the Medical Coping Modes Questionnaire (MCMQ), and sociodemographic and disease-related questionnaires. Descriptive statistics, univariate analysis, and multivariable linear regression were used to explore the current status of stigma and to identify influencing factors.

RESULTS

Of the respondents, 76.7% and 8.7%, respectively, reported moderate and high levels of stigma. The mean SIS score was 55.20 ± 12.15 (moderate), and the SIS subscale with the highest average score was financial insecurity. The results of a multivariable linear regression showed that body image (β = 0.32, P＜0.001), spousal support (β = -0.47, P < 0.001), personal acceptance of the disease (β = -0.22, P＜0.001), coping modes (resignation) (β = 0.14, P < 0.001), support from medical staff (β = -0.23, P < 0.001) and self-efficacy (β = -0.10, P = 0.037) were the main factors influencing stigma among breast cancer survivors (R² = 0.83).

CONCLUSIONS

Stigma, among breast cancer survivors, which is influenced by various sociocultural factors, is a neglected issue requiring attention. Healthcare professionals should therefore formulate effective measures for alleviating stigma in this group by improving their self-efficacy and acceptance of the disease, reducing their poor body image and negative coping mode, and eliciting more support from their spouses and medical staff.

Fears and barriers: problems in breast cancer diagnosis and treatment in Pakistan

Background

Women in Pakistan lack appropriate awareness about diagnosis and treatment for breast cancer due to a range of multifaceted barriers. There is a dearth of literature examining the socio-cultural factors that inhibit women from breast cancer screening, diagnosis and treatment in Punjab, Pakistan. Addressing this gap, this qualitative study sought to identify and explore the barriers that hinder women from seeking timely screening and treatment.

Methods

In this process 45 women (age = 18–50 years) with breast cancer were purposively sampled and interviewed from the Punjab Institute of Nuclear Medicine (PINUM) hospital, Faisalabad, Pakistan.

Results

An inductive approach was used to analyze the data which resulted in the emergence of eight subthemes under the umbrella of three major themes that delineate individual, socio-cultural and structural barriers to seek screening and treatment of breast cancer in Punjab. Individual barriers included lack of awareness, hesitance in accepting social support, and spiritual healing. The identified socio-cultural factors included feminine sensitivity, stigmatization, and aversion to male doctors. Lack of financial resources and apathetic medical services were structural barriers that hinder screening and treatment.

Conclusions

These barriers can be addressed through raising awareness and community mobilization about breast-self exam and treatment. The healthcare system should also pay attention to socio-psychological and cultural factors impeding women's access to available health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01293-6.

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.

Patient Characteristics and Outcomes of Nonmetastatic Breast Cancer in Haiti: Results from a Retrospective Cohort

BACKGROUND

There are few studies on breast cancer outcomes in the Caribbean region. This study identified a retrospective cohort of female patients with nonmetastatic breast cancer in Haiti and conducted survival analyses to identify prognostic factors that may affect patient outcomes.

METHODS

The cohort included 341 patients presenting between June 2012 and December 2016. The primary endpoint was event-free survival (EFS), defined as time to disease progression, recurrence, or death. Descriptive summaries of patient characteristics and treatments were reported. Survival curves were plotted using Kaplan-Meier estimation. Multivariate survival analyses were performed using Cox proportional hazards regression.

RESULTS

Median age at diagnosis was 49 years, with 64.2% being premenopausal. Most patients (55.1%) were staged as locally advanced. One hundred and sixty patients received neoadjuvant therapy: 33.3% of patients with early stage disease and 61.2% of those with locally advanced stage disease. Curative-intent surgery was performed in 278 (81.5%) patients, and 225 patients received adjuvant therapy. Adjuvant endocrine therapy was used in 82.0% of patients with estrogen receptor-positive disease. During the follow-up period, 28 patients died, 77 had disease recurrence, and 10 had progressive disease. EFS rates at 2 years and 3 years were 80.9% and 63.4%, respectively. After controlling for multiple confounders, the locally advanced stage group had a statistically significant adjusted hazard ratio for EFS of 3.27 compared with early stage.

CONCLUSION

Patients with nonmetastatic breast cancer in Haiti have more advanced disease, poorer prognostic factors, and worse outcomes compared with patients in high-income countries. Despite several limitations, curative treatment is possible in Haiti.

IMPLICATIONS FOR PRACTICE

Patients with breast cancer in Haiti have poor outcomes. Prior studies show that most Haitian patients are diagnosed at later stages. However, there are no rigorous studies describing how late-stage diagnosis and other prognostic factors affect outcomes in this population. This study presents a detailed analysis of survival outcomes and assessment of prognostic factors in patients with nonmetastatic breast cancer treated in Haiti. In addition to late-stage diagnosis, other unfavorable prognostic factors identified were young age and estrogen receptor-negative disease. The study also highlights that the availability of basic breast cancer treatment in Haiti can lead to promising early patient outcomes.

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.