Developing a Breast Cancer Screening Program in Nigeria: Evaluating Current Practices, Perceptions, and Possible Barriers

Improving access to breast cancer screening and treatment in Nigeria: The triple mobile assessment and patient navigation model (NCT05321823): A study protocol

BACKGROUND

In Nigeria, breast cancer incidence is rising, late presentation is common, and outcomes are poor. Patient-related factors such as lack of awareness and misperceptions in addition to health system deficiencies such as lack of a clearly defined framework for breast cancer screening and referral are some of the major drivers of this poor outlook. Guidelines for breast cancer screening in high-income countries have limited applicability in low-middle-income countries, hence the need for innovative, resource-compatible strategies to combat the negative trend. This manuscript presents our study protocol which aims to evaluate the impact of a novel breast cancer early detection program developed to address delayed presentation and lack of access to diagnostic and treatment facilities in South-West Nigeria. This entails the use of mobile technology (innovative handheld iBreast Exam [iBE] device, mobile breast ultrasound, and mobile mammography) and patient navigation as interventions at the community level.

METHODS

The study (ClinicalTrials.gov identifier: NCT05321823) will adopt a randomized two group clinical trial design with one local government area (LGA) serving as an intervention arm and another serving as the control. Both LGAs will receive breast cancer awareness education but only one will receive the interventions. In the intervention arm, asymptomatic (40-70 years) and symptomatic (30-70 years) women will be invited for breast evaluation which will be performed by trained Community Health Nurses using Clinical Breast Exam (CBE), and iBE. Those with positive findings will proceed to imaging using mobile mammography and ultrasound brought to the LGA every month. Symptomatic women with negative findings on CBE and iBE will be scheduled for repeat clinical evaluation on a short-term basis (one month). The Radiologist will obtain core needle biopsies as indicated and transfer them for prompt pathological assessment. Women presenting to the Primary Healthcare Centers in the control LGA will be referred directly to Obafemi Awolowo University Teaching Hospitals Complex as per the current standard of care. Records of all breast cancer cases seen in the two LGAs during the study period will be obtained. The program metrics will include screening participation rate, cancer detection rate, stage at diagnosis, and timeline from detection to initiation of treatment. The stage at diagnosis and timeline from detection to treatment compared between the two LGAs will be used to assess the impact of the intervention. The study is proposed for 2 years; however, a descriptive analysis will be carried out at 1.5 years to evaluate the retention of the study participants.

STUDY SIGNIFICANCE

It is anticipated that this study will provide vital data to support wider breast cancer screening efforts in Nigeria.

Implementing Patient-Directed Cancer Education Materials Across Nigeria

As access to cancer care expands in low-income countries, developing tools to educate patients is paramount. We took a picture booklet, which was initially developed by the nonprofit Global Oncology for Malawi and Rwanda, and adapted it for use in Nigeria. The primary goal was to assess acceptability and provide education. The secondary goals were (1) to describe the collaboration, (2) to assess knowledge gained from the intervention, (3) to assess patient understanding of their therapy intent, and (4) to explore patient's experiences via qualitative analysis.

In this cross-continent collaboration supported by @StanfordCIGH, low literacy-friendly cancer education booklets developed by @GlobalOnc increased awareness and knowledge about cancer treatment in 4 diverse sites in Nigeria.

Contemporary management of breast cancer in Nigeria: Insights from an institutional database

High-quality data are needed to guide interventions aimed at improving breast cancer outcomes in sub-Saharan Africa. We present data from an institutional breast cancer database to create a framework for cancer policy and development in Nigeria. An institutional database was queried for consecutive patients diagnosed with breast cancer between January 2010 and December 2018. Sociodemographic, diagnostic, histopathologic, treatment and outcome variables were analyzed. Of 607 patients, there were 597 females with a mean age of 49.8 ± 12.2 years. Most patients presented with a palpable mass (97%) and advanced disease (80.2% ≥ Stage III). Immunohistochemistry was performed on 21.6% (131/607) of specimens. Forty percent were estrogen receptor positive, 32.8% were positive for HER-2 and 43.5% were triple negative. Surgery was performed on 49.9% (303/607) of patients, while 72% received chemotherapy and 7.9% had radiotherapy. At a median follow-up period of 20.5 months, the overall survival was 43.6% (95% CI -37.7 to 49.5). Among patients with resectable disease, 18.8% (57/303) experienced a recurrence. Survival was significantly better for early-stage disease (I and II) compared to late-stage disease (III or IV) (78.6% vs 33.3%, P < .001). Receipt of adjuvant radiotherapy after systemic chemotherapy was associated with improved survival in patients with locally advanced disease (68.5%, CI -46.3 to 86 vs 51%, CI 38.6 to 61.9, P < .001). This large cohort highlights the dual burden of advanced disease and inadequate access to comprehensive breast cancer care in Nigeria. There is a significant potential for improving outcomes by promoting early diagnosis and facilitating access to multimodality treatment.

Geospatial access predicts cancer stage at presentation and outcomes for patients with breast cancer in southwest Nigeria: A population-based study

BACKGROUND

The majority of women in Nigeria present with advanced-stage breast cancer. To address the role of geospatial access, we constructed a geographic information-system-based model to evaluate the relationship between modeled travel time, stage at presentation, and overall survival among patients with breast cancer in Nigeria.

METHODS

Consecutive patients were identified from a single-institution, prospective breast cancer database (May 2009-January 2019). Patients were geographically located, and travel time to the hospital was generated using a cost-distance model that utilized open-source data. The relationships between travel time, stage at presentation, and overall survival were evaluated with logistic regression and survival analyses. Models were adjusted for age, level of education, and socioeconomic status.

RESULTS

From 635 patients, 609 were successfully geographically located. The median age of the cohort was 49 years (interquartile range [IQR], 40-58 years); 84% presented with ≥stage III disease. Overall, 46.5% underwent surgery; 70.8% received systemic chemotherapy. The median estimated travel time for the cohort was 45 minutes (IQR, 7.9-79.3 minutes). Patients in the highest travel-time quintile had a 2.8-fold increase in the odds of presenting with stage III or IV disease relative to patients in the lowest travel-time quintile (P = .006). Travel time ≥30 minutes was associated with an increased risk of death (HR, 1.65; P = .004).

CONCLUSIONS

Geospatial access to a tertiary care facility is independently associated with stage at presentation and overall survival among patients with breast cancer in Nigeria. Addressing disparities in access will be essential to ensure the development of an equitable health policy.

Presentation intervals and the impact of delay on breast cancer progression in a black African population

Background

The help-seeking interval and primary-care interval are points of delays in breast cancer presentation. To inform future intervention targeting early diagnosis of breast cancer, we described the contribution of each interval to the delay and the impact of delay on tumor progression.

Method

We conducted a multicentered survey from June 2017 to May 2018 hypothesizing that most patients visited the first healthcare provider within 60 days of tumor detection. Inferential statistics were by t-test, chi-square test, and Wilcoxon-Signed Rank test at p-value 0.05 or 95% confidence limits. Time-to-event was by survival method. Multivariate analysis was by logistic regression.

Results

Respondents were females between 24 and 95 years (n = 420). Most respondents visited FHP within 60 days of detecting symptoms (230 (60, 95% CI 53–63). Most had long primary-care (237 of 377 (64 95% CI 59–68) and detection-to-specialist (293 (73% (95% CI 68–77)) intervals. The primary care interval (median 106 days, IQR 13–337) was longer than the help-seeking interval (median 42 days, IQR 7–150) Wilcoxon signed-rank test p = 0.001. There was a strong correlation between the length of primary care interval and the detection-to-specialist interval (r = 0.9, 95% CI 0.88–0.92). Patronizing the hospital, receiving the correct advice, and having a big tumor (> 5 cm) were associated with short intervals.

Tumors were detected early, but most became advanced before arriving at the specialist clinic. The difference in tumor size between detection and arriving at a specialist clinic was 5.0 ± 4.9 cm (95% CI 4.0–5.0). The hazard of progressing from early to locally advanced disease was least in the first 30 days (3%). The hazard was 31% in 90 days.

Conclusion

Most respondents presented early to the first healthcare provider, but most arrived late at a specialist clinic. The primary care interval was longer than the help-seeking interval. Most tumors were early at detection but locally advanced before arriving in a specialist clinic. Interventions aiming to shorten the primary care interval will have the most impact on time to breast cancer presentation for specialist oncology care in Nigeria.

Academic Partnerships in Global Surgery: An Overview American Surgical Association Working Group on Academic Global Surgery

: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.

Prevention of cervical and breast cancer mortality in low- and middle-income countries: a window of opportunity

Breast and cervical cancer are the two most common women’s cancers worldwide. Countries have invested for decades in early detection programs for breast and cervical cancer through screening, community education, and opportunistic case detection by health professionals. However, effectiveness in low- and middle-income countries (LMICs) has been limited due to low coverage, insufficient laboratory capacities for diagnosis, health information systems (HIS) that are not designed to track patients or monitor program performance, barriers that inhibit women’s uptake of services, and inadequate treatment options. Even where some screening activities exist, there has not been sufficient attention to ensuring completion of appropriate diagnosis and treatment after women receive a positive screening test result or report symptoms suggesting cervical or breast cancer. Because of this failure to provide adequate follow-up care, these women miss the potential benefit from early detection and have a higher than average risk to develop cancer or progress to more advanced cancer stages that could have been avoided. There are several critical steps in a woman’s journey from good health to elevated cancer risk, then to cancer prevention or diagnosis, and finally to treatment. There is a window of opportunity that extends from the time a positive finding is identified—by a cervical or breast screening test or recognition of a breast abnormality—to the point when cervical precancer treatment is delivered or a treatment plan for diagnosed breast cancer is initiated. Building on existing health systems and adapting measurable, affordable, and culturally acceptable interventions can achieve a lasting impact. If women can successfully navigate this window of opportunity, they can avoid progression to cervical cancer or greatly reduce the need for invasive treatments for breast cancer and improve their chances for survival and improved quality of life. We propose several actions that can lead us on the path towards reduction of this cancer burden.

Transforming Screening Uptake in Low-resource and Underinformed Populations: A Preliminary Study of Factors Influencing Women's Decisions to Uptake Screening

OBJECTIVES

The objective of this study was to assess the factors influencing women's decision to uptake screening mammography in an underinformed population.

STUDY DESIGN

The study is a cross-sectional survey of factors influencing screening uptake.

METHODS

A modified breast cancer awareness measure was used to assess women's knowledge of breast cancer, mammography, and factors that influence screening uptake. A second questionnaire investigated health professionals' (HPs') attitude to screening and the criteria for screening recommendation. Descriptive statistics were used to assess women's breast cancer awareness, factors that influence screening uptake, and HPs' attitude to breast cancer education and mammography recommendation. We ranked HPs' responses pertaining to criteria for screening recommendation using a Kendall's W test.

RESULTS

Sixty-nine percent (n = 180) of women were aware of breast cancer, and half of them had performed breast self-examination (n = 131). About 53% (n = 138) of women were not aware of mammography, and only 15.4% (n = 40) of them have had a screening mammogram. Women's awareness of breast cancer risk factors and symptoms was poor. Many women would consider having a screening mammogram if instructed to do so by their husbands (87.7%; n = 228), HPs (96.2%; n = 250), and if government-funded screening programmes are available (90%; n = 234). Less than 40% (n = 21) of HPs had referred at least one woman for screening mammography within the last 6 months. Family history, age, and reproductive factors ranked as the highest criteria for screening recommendation.

CONCLUSIONS

Spouses and HPs may be crucial to changing the current status quo around screening utilisation and government-funded screening programmes may increase screening uptake.

Knowledge and Attitudes about Breast Cancer among Women: A Wake-Up Call in Nigeria

BACKGROUND:

Preventable deaths resulting from the scourge of breast cancer has become alarming and worrisome in many societies in developing countries, including Nigeria. Of much concern is the fact that breast cancer has continued to claim the precious lives of young, middle-aged, old, educated and non-educated women irrespective of their religion, socio-economic background and socio-demographic characteristics.

AIM:

This study attempts to ascertain the knowledge and attitudes of women to breast cancer in Ogun State, Nigeria.

METHODS:

The study adopts both primary and secondary data sources to examine the level of knowledge and attitude of women towards breast cancer with the view of suggesting probable solutions and recommendations for policy.

RESULTS:

The result indicates that the awareness about breast cancer is overwhelming but only few women know about mammography; women in older age are 0.193 times less likely to attend breast cancer screening (p=0.000). Older women with secondary education that are either self-employed outside the home or full-time housewives are unfavourably disposed to breast cancer screening.

CONCLUSION:

The authors recommend that concerned stakeholders in the health sector and policy decision makers should intensify action on cancer programmes and campaigns that could target older women especially housewives and women in middle level education.