Perspectives of patients, family members, and health care providers on late diagnosis of breast cancer in Ethiopia: A qualitative study

Willingness and ability to pay for breast cancer treatment among patients from Addis Ababa, Ethiopia: A cross-sectional study

INTRODUCTION

Breast cancer (BC) is the most common malignant neoplasm among women in Addis Ababa, Ethiopia. The willingness and ability to pay (WATP) for treatment is a contributing factor in the utilization of health care services. The World Health Organization Breast Cancer Initiative calls for 80% of patients to complete multimodality treatment and indicates payment as central factor to improve BC outcome. The objectives of this study are to identify how much female BC patients paid in Addis Ababa for BC treatment, their WATP for BC treatment, and the factors that affect WATP.

METHODS

The researchers collected data from 204 randomly selected BC patients who were treated in one of four different health facilities (one public and three private) between September 2018 and May 2019. A structured questionnaire was used to assess their WATP for BC treatment and multivariable regression to investigate factors associated with patients' WATP.

RESULTS

Of interviewed patients, 146 (72%) were at reproductive age. Patients' median expenditure for all BC treatment services was 336 US dollars (USD) in a public cancer center and 926 USD in privately owned health facilities. These amounts are in contrast with a reported WATP of 50 USD and 149 USD. WATP increased with increasing expenditure (OR 1.43; 95% CI 1.09 to 1.89 per 100 US), educational level (OR 1.37; 95% CI 1.02 to 1.85) and service quality (OR 1.34; 95% CI 1.04 to 1.72). In contrast, a monthly income increase by 100 USD corresponds to a 17% decrease of WATP (OR 0.83; 95% CI 0.70 to 0.99).

CONCLUSIONS

We demonstrated that BC treatment was very expensive for patients, and the cost was much higher than their WATP. Thus, we suggest that BC should be included in both social and community-based health insurance plans and treatment fees should consider patients' WATP.

A Qualitative Study on Psychosocial Challenges of Patients With Cancer in Ethiopia Using the Social-Ecological Model

Cancer diagnosis and treatment can be physically arduous, disrupting patients' social and work lives. Understanding the extent of these problems is key to addressing patients' needs, but specific psychosocial challenges have not yet been well studied in resource-limited settings. A qualitative study was conducted in the capital and two regions of Ethiopia with the aim of exploring psychosocial challenges among cancer patients. A total of 14 in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were done with cancer patients, health professionals, community representatives, and religious leaders. Four separate interview guides were used to facilitate the interviews and discussions. All transcribed documents, field notes, and reflexive memos were entered into NVivo 12 software, and deductive thematic analysis using the social-ecological model was applied to summarize the main findings. At an individual level, emotional distress, suicidal risk, denial, and refusal of treatment were identified immediately after diagnosis while hopelessness, feeling depressed, and fear of death were commonly reported psychosocial challenges during the course of treatment. Involvement of family members in major treatment decisions was recognized at an interpersonal level. Our result also revealed that cancer patients had strong social support from family members and close friends. In the community, traditional medicine and religious rituals were considered an alternative treatment for cancer. The findings indicate that counselling and psychoeducation are crucial for cancer patients, family members, and close friends. Awareness creation programmes should be delivered through collaboration with religious leaders and traditional healers.

"How can a woman live without having a breast?": challenges related to mastectomy in Ethiopia

BACKGROUND

Although mastectomy is the standard treatment modality for breast cancer patients in Ethiopia, our previous study revealed that one in five patients do not receive the recommended procedure, half due to patient refusal or lack of returning to the hospital. Therefore, this study aimed to explore reasons for refusing mastectomy and identify challenges among breast cancer patients in Ethiopia.

METHODS

An explorative qualitative study was conducted in four hospitals located in the towns of Woliso, Butajira, Hossana, and Assela. A total of 14 in-depth interviews (IDIs) and eight focus group discussions (FGDs) were held with breast cancer patients, patient relatives, and health professionals. Four semi-structured interview guides were used to facilitate the IDIs and FDGs. All recorded IDIs and FGDs were transcribed and translated verbatim and entered in NVivo 12 software. Emerging ideas were categorised and explained using an inductive content analysis approach.

RESULTS

Our participants reported that particularly elderly and very young women refuse to have mastectomy. The main reasons identified in this study were summarised into six themes: (i) fear of the surgical procedure, (ii) religious beliefs and practice, (iii) utilisation of traditional treatments, (iv) in relation to having a baby and breastfeeding their children (young patients often request to remove only the lump, leaving their breast tissue intact), (v) lack of awareness about the disease, and (vi) sociocultural factors and advice from the community that influence women, since breasts are considered an attribute of femininity, beauty, and motherhood. In addition, knowing someone who died after mastectomy emerged as a main reason for not having breast cancer surgery.

CONCLUSIONS

High refusal rate for mastectomy has direct implication on increased breast cancer mortality. Hence, expansion of radiotherapy service is instrumental to initiate breast-conserving surgery as an alternative surgical procedure, especially for young women with early-stage breast cancer. Involving religious leaders, traditional healers, and breast cancer survivors could be an effective strategy to persuade newly diagnosed breast cancer patients. Addressing individual patient psychosocial needs and preferences may substantially improve retention of breast cancer patients in the health system.

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.

Exploring Challenges Related to Breast Cancer to Identify Opportunities for Advocacy in Hawassa City, Southern Ethiopia: A Community-Based, Qualitative Study

PURPOSE

The aim of this study was to explore breast cancer (BC) challenges to identify opportunities for advocacy in southern Ethiopia in 2022.

METHODS

Twenty-five participants from four local districts (kebeles) in Hawassa City were selected as key contributors to future work. Semistructured in-depth interviews were held for two clinicians, two local health bureau managers, two media managers, and three religious leaders. Two focus group discussions were conducted: one included six BC survivors and a caregiver; the other included two health extension workers, three members of the Women's Development Group, two community volunteers, one kebele leader, and one traditional healer.

RESULTS

To our knowledge, our study was the first time that most participants had assembled. Many referred to patients as victims and BC as a killer disease or curse. Community and religious leaders were concerned about challenges and willing to collaborate. Survivors, providers, and religious leaders were identified as key sources of information, positive messages, and leadership.

CONCLUSION

Recommendations for advocacy work in Hawassa include lobbying for BC as a health priority; including BC within the health extension package; initiating programs for earlier detection; educating the community to remove stigmas of the disease and treatments; working with media to disseminate messages that are inclusive of people in remote areas and speaking different languages; improving availability, affordability, and access to care; and assisting patients with psychosocial support. A strategic collaboration between religious leaders and health care providers was identified to increase community awareness and support advocacy for patients.

Misconceptions About Female Cancers Contributing to Late Presentation to Health Facilities in Ethiopia: A Qualitative Study

Introduction

Morbidity and mortality from female cancers is a major public health problem in low- and middle-income countries, including Ethiopia. More than three quarters of women visiting health facilities are diagnosed with late-stage cervical and breast cancer. Evidence reveals that misconception affects timely health seeking behavior which could have averted expensive treatment and poor survival. This study aimed to explore misconceptions about female cancers that may have contributed to late presentation of the problem to health facilities in Sidama region, Ethiopia.

Methods

A descriptive qualitative study was carried out in June 2021. Nine focus group discussions (six with women and three with men) and 14 key informants were conducted. Data were collected using interview guide until all information get saturated. Data were inductively coded and qualitative content analysis was applied.

Results

A total of 63 (24 men and 39 women) people participated in this study. Nearly all (12) key informant interviewees have awareness about cervical and breast cancer, yet reported that their community members clearly lack awareness and they are working to improve misconceptions regarding cervical and breast cancer. The focus group discussion participants (15 men and 36 women) reported lack of detailed information related to cervical and breast cancer. Women believe that cervical and breast cancer mainly resulted from poor hygiene, trauma, having multiple sexual partners, early marriage, breast exposure to heat, not breast feeding, birth complication, urinating in the sun, hereditary, devil's intrusion and God's punishment.

Conclusion

There were misconceptions among the community on what cervical and breast cancer mean, how they could happen, what the symptoms are, why and when to screen, when to seek health care and how to use modern treatment options. Therefore, we recommended the design of social and behavioral change strategies to address the misconceptions among different population groups.

Applications of different machine learning approaches in prediction of breast cancer diagnosis delay

Background

The increasing rate of breast cancer (BC) incidence and mortality in Iran has turned this disease into a challenge. A delay in diagnosis leads to more advanced stages of BC and a lower chance of survival, which makes this cancer even more fatal.

Objectives

The present study was aimed at identifying the predicting factors for delayed BC diagnosis in women in Iran.

Methods

In this study, four machine learning methods, including extreme gradient boosting (XGBoost), random forest (RF), neural networks (NNs), and logistic regression (LR), were applied to analyze the data of 630 women with confirmed BC. Also, different statistical methods, including chi-square, p-value, sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC), were utilized in different steps of the survey.

Results

Thirty percent of patients had a delayed BC diagnosis. Of all the patients with delayed diagnoses, 88.5% were married, 72.1% had an urban residency, and 84.8% had health insurance. The top three important factors in the RF model were urban residency (12.04), breast disease history (11.58), and other comorbidities (10.72). In the XGBoost, urban residency (17.54), having other comorbidities (17.14), and age at first childbirth (>30) (13.13) were the top factors; in the LR model, having other comorbidities (49.41), older age at first childbirth (82.57), and being nulliparous (44.19) were the top factors. Finally, in the NN, it was found that being married (50.05), having a marriage age above 30 (18.03), and having other breast disease history (15.83) were the main predicting factors for a delayed BC diagnosis.

Conclusion

Machine learning techniques suggest that women with an urban residency who got married or had their first child at an age older than 30 and those without children are at a higher risk of diagnosis delay. It is necessary to educate them about BC risk factors, symptoms, and self-breast examination to shorten the delay in diagnosis.

Communicating bad news to patients and families in African oncology settings

AIMS

To assess clinicians' self-reported knowledge of current policies in African oncology settings, of their personal communication practices around sharing bad news with patients, and to identify barriers to the sharing of serious news in these settings.

METHODS

A cross-sectional study of cancer care providers in African oncology settings (N = 125) was conducted. Factor analysis was used to assess cross-cultural adaptation and uptake of an evidence-based protocol for disclosing bad news to patients with cancer and of providers' perceived barriers to disclosing bad news to patients with cancer. Analysis of Various (ANOVA) was used to assess strength of association with each dimension of these two measurement models by various categorical variables.

RESULTS

Providers from Nigeria, Kenya, Ghana, and Rwanda represented 85% of survey respondents. Two independent, psychometrically reliable, multi-dimensional measurement models were derived to assess providers' personal communication practices and providers' perceived barriers to disclosing a cancer diagnosis. Forty percent (40%) of respondent nurses but only 20% of respondent physicians had had formal communications skills training. Approximately 20%-25% of respondent physicians and nurses reported having a consistent plan or strategy for communicating bad news to their cancer patients.

CONCLUSIONS

Results show that effective communication about cancer diagnosis and prognosis requires an appreciation and clinical skill set that blends an understanding of cancer-related internalized stigmas harbored by patient and family, dilemmas posed by treatment affordability, and the need to navigate family wishes about cancer-related diagnoses in the context of African oncology settings. Findings underscore the need for culturally grounded communications research and program design.

Kusankha Pamodzi: Health Care Decision-Making Preferences Among Patients with Cancer in Malawi

Background

Oncology teams are encouraged to include patient preferences and goals of care in determining appropriate treatment courses. There are no existing data from Malawi exploring decision-making preferences among cancer patients.

Methods

In the oncology clinic in Lilongwe, Malawi, 50 patients were surveyed for decision making.

Results

Most participants (70%, n = 35) preferred to engage in shared decision making regarding cancer treatment. About half (52%, n = 24) did not feel that their medical team involved them in decision making and 64% (n = 32) felt that they were never or only sometimes listened to by the medical team. Nearly all (94%, n = 47) preferred to have their medical team inform them how likely treatments are to lead to cure.

Conclusions

Shared decision making was the preferred mode of treatment decision making by the majority of the surveyed cancer patients in Malawi. Cancer patients in Malawi may have similar preferences to cancer patients in other low-resource settings regarding decision making and communication.

Experience of patients with breast cancer with traditional treatment and healers' understanding of causes and manifestations of breast cancer in North Shewa zone, Ethiopia: a phenomenological study

OBJECTIVES

Despite a high number of traditional healers (THs) who treat patients with cancer in Ethiopia, there is limited evidence that explored the lived experience of patients with breast cancer (BC) with traditional treatment and healers' understanding of the causes and manifestations of BC.

DESIGN

A phenomenological study design was employed.

SETTING

This study was conducted in the North Shewa zone in Ethiopia.

PARTICIPANTS

Eight in-depth interviews were conducted; four of which were with patients with BC and four with THs. Semistructured interviewing techniques were used to collect data from the two groups of respondents. All interviews were audio-recorded. The recorded data were transcribed verbatim. Coding and marking were then performed to make the raw data sortable. The marked codes were then summarised and categorised into themes.

RESULTS

In this study, some of THs were unaware of the main risk factors or causes of BC. They did not mention the lifestyle risk factors of BC such as smoking cigarettes, consuming alcohol and eating habits. The most common clinical manifestations noted by THs were lumps at the breast, discharge from the nipples and weakness. All of the THs got their knowledge of BC treatment from their families and through experience. Regarding the lived experience of treatment, some patients with BC perceived that traditional medicines were safer and more effective than modern treatments and they eventually referred themselves to the THs.

CONCLUSIONS

Although THs were unaware of the causes of BC, they were familiar with basic signs and symptoms of the disease. Patients with BC referred themselves to the THs because they preferred traditional therapies to modern ones. In order to better satisfy the unmet needs of Ethiopian women with BC, due consideration should be given to traditional treatments.

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.

Burden of Cancer and Utilization of Local Surgical Treatment Services in Rural Hospitals of Ethiopia: A Retrospective Assessment from 2014 to 2019

BACKGROUND

Global cancer estimations for Ethiopia announced 77 352 new cases in 2020 based on the only population-based registry in Addis Ababa. This study characterizes cancer patients in rural Ethiopia at 8 primary and secondary hospitals between 2014 and 2019.

PATIENTS AND METHODS

All clinically or pathologically confirmed cancer cases that were diagnosed between 1 May 2014 and 29 April 2019 were included. A structured data extraction tool was used to retrospectively review patients' charts and descriptive analysis was done.

RESULTS

A total of 1298 cancer cases were identified, of which three-fourths were females with a median age of 42 years. Breast (38%) and cervical (29%) cancers were the most common among females, while prostate (19%) and oesophageal cancers (16%) were the most common among males. Only 39% of tumors were pathologically confirmed. Nearly two-thirds of the cases were diagnosed at an advanced stage. Surgery was the only accessible treatment option for more than half of the cancer patients, and systemic treatment (except endocrine) was rarely available. One in 5 patients did not receive the recommended surgical procedure, half due to patient refusal or lack of the patient returning to the hospital.

CONCLUSION

The pattern of cancer diagnoses in rural hospitals shows an exceptionally high burden in women in their middle-ages due to breast and cervical cancers. Advanced stage presentation, lack of pathology services, and unavailability of most systemic treatment options were common. The surgery was offered to nearly 60% of the patients, showing the significant efforts of health workers to reduce sufferings.

Enablers and hindrances to health promotion and disease prevention practices among healthcare workers in Nelson Mandela Bay Municipality, South Africa

Health promotion (HP) and disease prevention (DP) practices among healthcare workers (HCWs) are key to achieving universal health coverage. This study identified HP and DP enablers and hindrances and compared them at different healthcare levels in Nelson Mandela Bay Municipality, South Africa. An exploratory cross-sectional study using a structured questionnaire was conducted among HCWs (n = 501) from 23 hospitals. Bivariate and multinomial regression were used to analyze the data. The highest number of participants (70.46%; n = 353) were from tertiary hospitals. Thirteen and Eight categories of enablers and hindrances respectively were identified. Of these, eleven enablers and six hindrances of HP and DP were associated with tertiary hospitals; no enabler was identified at both primary and secondary while one hindrance was associated with primary level of health care. Collaboration among disciplines and organizations (Coeff: 2.16, 95% CI: 1.28-3.66) and programme planning (Coeff: 0.375, 95% CI: 0.23-0.62) were the predictors of HP and DP among medical doctors, while staff induction training (Coeff: 0.62, 95% CI: 0.40-0.95) and performance appraisal (Coeff: 1.86, 95% CI: 1.16-2.98) were the enablers among allied health workers. On the other hand, 'facility promoting treatment more than prevention' (Coeff: 2.03, 95% CI: 1.30-3.14) and 'practice guidelines incorporating HP' (Coeff: 2.79, 95% CI: 1.66-4.70) were the predictors of HP and DP hindrances among medical doctors and allied health workers respectively. Our work indicates the need for an operational strategy designed considering enabling and hindering factors to HP and DP practices for empowering HCWs and enhancing health outcomes.

From their own perspectives: a qualitative study exploring the perceptions of traditional health practitioners in northern Uganda regarding cancers, their causes and treatments

Background

Many cancer patients in the low- and middle-income countries seek care with traditional health practitioners (THPs) and use traditional and complementary medicines (T&CMs) for treatment of cancers. Little is known about the perceptions and influence of THPs on cancer patients’ help-seeking and treatment decisions. We aimed to explore perceptions of THPs regarding cancers, cancer causes, and preferred treatments for cancers, in order to identify aspects that can inform interventions to improve cancer outcomes in Uganda.

Methods

We conducted this ethnographic study in northern Uganda. In-depth interviews were conducted at the respondents’ homes in quiet, open places, and in the absence of none- respondents. Interviews were audio-recorded and transcribed verbatim within a week of the interviews. Thematic qualitative analysis approaches were used to identify themes and subthemes.

Results

We included 21 respondents in the study; most were male (16/21), married, with median age of 59 years (range 39 – 80). Most respondents perceived cancer as a new and challenging disease, while one respondent thought of cancer as a result of an imbalance within the body. Most confessed unawareness of the causes of cancers, but believed that cancer could result from the interplay of a number of factors including poor diets, ingestions of chemical agents, and assaults by the spirits of the dead. Some reported that cancers (especially of women’s genital tracts) were sexually transmitted, or caused by accumulation of dirt. Only few healers treated cancers. Most respondents reported that they referred cancer patients to biomedical facilities, sometimes after they have first used their medicines. Most respondents hoped that collaborative research with scientists could help them identify potent T&CMs that cure cancers.

Conclusion

Traditional health practitioners require training on cancer causes, symptoms and signs, and the necessity for prompt initiation of effective treatments in order to improve cancer outcomes. The predisposition of the majority of respondents to refer cancer patients to biomedical services sets a fertile ground for meaningful cooperation between biomedical and traditional health practices. The national health system in the low- and middle-income countries could formally recognize traditional health practices as a component of the national healthcare system, and encourage the two to practice side by side.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01505-w.

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.

Factors associated with advanced-stage diagnosis of breast cancer in north-west Ethiopia: a cross-sectional study

Background

Breast cancer tumours are the most common malignant tumours among women in Ethiopia. Although advanced-stage diagnosis of breast cancer is a common problem, evidence-based information is lacking about the magnitude and determinants of advanced-stage presentation in north-west Ethiopia.

Methods

An institution-based, cross-sectional study was conducted at the oncology units of the University of Gondar and Felege Hiwot specialised hospitals. Stages III and IV were considered advanced stage, whereas stages I and II were considered early stages. Data were collected prospectively on newly diagnosed breast cancer patients and entered using the EPI Info version 7.2 and analysed using Statistical Package for the Social Sciences version 23. Multivariable logistic regression was used to identify the determinants of advanced-stage diagnosis of breast cancer. A p-value < 0.05 was used as the cut-off point to select the determinants of the advanced stage.

Result

About 71.2% of breast cancer patients presented with advanced-stage disease. The median age of patients was 40 years. Rural residence (adjusted odds ratio (AOR) = 1.7; 95% confidence interval (CI): 1.02, 2.96), painless breast lump/wound (AOR = 2.5; 95% CI: 1.45, 4.13), travel distance ≥5 km (AOR = 3.2; 95% CI: 1.72, 5.29), not practising breast self-examination (BSE) (AOR = 2.9; 95% CI: 1.30, 6.52), time to presentation ≥3 months (AOR = 1.4; 95% CI: 1.02, 2.37) and misdiagnosed at first visit (AOR = 1.9; 95% CI: 1.09, 3.59) were determinants of advanced-stage breast cancer.

Conclusion

Nearly three-quarters of the patients were diagnosed with advanced-stage breast cancer. Not practising BSE, travel distance ≥5 km, rural residence, painless breast wound/lump and being misdiagnosed at first visit were important determinants of advanced-stage diagnosis of breast cancer. Focused awareness creation programmes for the public and increasing cancer diagnostic centres in the country are crucial to downstage breast cancer at presentation.

Factors Associated with Delay in Breast Cancer Presentation at the Only Oncology Center in North East Ethiopia: A Cross-Sectional Study

BACKGROUND

Female breast cancer is becoming an emerging public health problem which accounts for 33% of all cancers in women and 23% of all cancer cases in Ethiopia. The majority of women with breast cancer are diagnosed at later stages due to delayed presentation to seek treatment.

OBJECTIVE

To determine the prevalence and factors associated with patient delay at presentation among breast cancer patients at Dessie Referral Hospital, the only oncology center in North East Ethiopia.

METHODS

We conducted an institution-based cross-sectional study among 204 female patients with pathology-confirmed breast cancer at the only oncology center of North East Ethiopia from January to June 2020. An interviewer administered questionnaire and a medical record data extraction tool were used to address the objective of the study. Patients were said to be delayed for diagnosis if the time duration between first clinical presentations to first clinical consultation was more than 3 months. Then, bivariable and multivariable logistic regression was employed to analyze the association between dependent and independent variables.

RESULTS

Among a total of 209 eligible participants, 5 refused to participate with a response rate of 97.6%. The proportion of patients with delayed presentation was 103 (50.5%), with the median time taken to visit a healthcare provider after recognition of the first symptom was 4 months. Age above 40 years (AOR=4.81; 95% CI=1.26-18.65) P<0.024, college and above educational status (AOR=0.05; 95% CI=0.01-0.77) p<0.036, government employee (AOR=0.19, 95% CI=0.03-0.91) P<0.002, urban residence (AOR= 0.21; 95% CI=0.01-0.82) p<0.001, visit traditional healer (AOR=0.38; 95% CI=0.2-0.69) P<0.0037, and no lump in under armpit (AOR= 9.05; 95% CI=1.14-22.69) P<0.002 were associated with delayed presentation.

CONCLUSION

Delays to seek treatment is generally high in our study. Age, educational status, occupation, residence, visiting traditional healer, and absence of lump in under armpit were significant factors for delayed presentation. Intervention programs focusing on reducing delayed presentation should be employed.

Factors affecting medical healthcare-seeking behaviours of female patients according to their stage of being diagnosed with breast cancer

OBJECTIVE

The aim of study was to determine factors affecting the medical healthcare-seeking behaviours of female patients according to their stage of being diagnosed with breast cancer.

METHODS

This descriptive and correlational study was carried out with 150 women. The data were collected by a survey form, the Body Perception Scale, the Rosenberg Self-Esteem Scale and the Social Appearance Anxiety Scale.

RESULTS

About 54% of the women were diagnosed with early-stage breast cancer, 68.7% had high self-esteem, and 80% had positive body perceptions, while their social appearance anxiety levels were moderate. The patients with breast cancer at the 4th stage had a high body perception score of 174.00 ± 23.34. Self-esteem was the highest in the patients with stage 2B breast cancer with a value of 0.61 ± 0.91. The highest social anxiety mean score was found in the patients with stage 2A breast cancer as 31.65 ± 12.50. There was no statistically significant difference in the women's sociodemographic characteristics, health and breast cancer history, self-esteem, body perception and social appearance anxiety based on their stages of cancer (p > 0.05).

CONCLUSION

Nurses' identification of risky individuals in early diagnosis, information for the individual / family and society by planning trainings and raising awareness will contribute positively to the patients' medical health-seeking behaviours.

Information Needs of Breast Cancer Patients Attending Care at Tikur Anbessa Specialized Hospital: A Descriptive Study

PURPOSE

The purpose of this study was to assess the information needs of women with breast cancer attending care at a major hospital in Ethiopia. It also aimed at describing the association of information needs with sociodemographic and clinical variables, preferred sources of information, and time to have it.

PATIENTS AND METHODS

A hospital-based cross-sectional study was conducted on 375 women with breast cancer at Tikur Anbessa Specialized Hospital. Data were collected by interview and Toronto information needs questionnaire for breast cancer which contains 52 items categorized under five domains was pretested, adopted, and used to address the information needs of patients. One way ANOVA was done to get an association of sociodemographic and clinical variables with information needs. All statistical analysis was performed using STATA (Version 14), and statistical significance was set at P ≤ 0.05.

RESULTS

The total mean score for overall information needs among breast cancer patients was 238.7 (22.5) with a range scale of 156-260. Among the five subscales information on disease and information on treatment were the most highly needed areas with a mean percentage of 94.8 and 93.7, respectively; and 254 (67%) of them preferred the information to come from health professionals. Diagnosing as stage IV (p=0.0005) and urban residence (0.02) was associated with less and high information needs, respectively.

CONCLUSION

The information needs of breast cancer patients were high. Determining what the patient's needs are an important aspect of providing health care especially in cancer care. The healthcare system should include a way of information provision system for breast cancer patients based on their needs.

Ascertaining breast cancer patient experiences through a journey map: A qualitative study protocol

BACKGROUND

The current cancer care system must be improved if we are to have in-depth knowledge about breast cancer patients' experiences throughout all the stages of their disease.

AIM

This study seeks to describe breast cancer patients' experience over the course of the various stages of illness by means of a journey model.

METHODS

This is a qualitative descriptive study. Individual, semi-structured interviews will be administered to women with breast cancer and breast cancer survivors. Patients will be recruited from nine large hospitals in Spain and intentional sampling will be used. Data will be collected by means of a semi-structured interview that was elaborated with the help of medical oncologists, nurses, and psycho-oncologists. Data will be processed adopting a thematic analysis approach.

DISCUSSION

The outcomes of this study will afford new insights into breast cancer patients' experiences, providing guidance to improve the care given to these individuals. This protocol aims to describe the journey of patients with breast cancer through the healthcare system to establish baseline data that will serve as the basis for the development and implementation of a patient-centered, evidence-based clinical pathway.

Why women with breast cancer presented late to health care facility in North-west Ethiopia? A qualitative study

BACKGROUND

Although early diagnosis is a key determinant factor for breast cancer survival, delay in presentation and advanced stage diagnosis are common challenges in low and middle income countries including Ethiopia. Long patient delays in presentation to health facility and advanced stage diagnosis are common features in breast cancer care in Ethiopia but the reasons for patient delays are not well explored in the country. Therefore we aimed to explore the reasons for patient delay in seeking early medical care for breast cancer in North-west Ethiopia.

METHODS

A qualitative study was conducted from November to December 2019 using in-depth interviews from newly diagnosed breast cancer patients in the two comprehensive specialized hospitals in North West Ethiopia. Verbal informed consent was taken from each participant before interviews. A thematic content analysis was performed using Open Code software version 4.02.

RESULTS

Lack of knowledge and awareness about breast cancer, cultural and religious beliefs, economic hardships, lack of health care and transportation access, fear of surgical procedures and lack of trusts on medical care were the major reasons for late presentation of breast cancer identified from the patient's narratives.

CONCLUSIONS

The reasons for late presentation of patients to seek early medical care for breast cancer had multidimensional nature in Northwest Ethiopia. Health education and promotion programs about breast cancer should be designed to increase public awareness to facilitate early detection of cases before advancement on the existing health care delivery system.

Delays Experienced by Patients With Pediatric Cancer During the Health Facility Referral Process: A Study in Northern Tanzania

PURPOSE

It is estimated that 50%-80% of patients with pediatric cancer in sub-Saharan Africa present at an advanced stage. Delays can occur at any time during the care-seeking process from symptom onset to treatment initiation. Referral delay, the time from first presentation at a health facility to oncologist evaluation, is a key component of total delay that has not been evaluated in sub-Saharan Africa.

METHODS

Over a 3-month period, caregivers of children diagnosed with cancer at a regional cancer center (Bugando Medical Centre [BMC]) in Tanzania were consecutively surveyed to determine the number and type of health facilities visited before presentation, interventions received, and transportation used to reach each facility.

RESULTS

Forty-nine caregivers were consented and included in the review. A total of 124 facilities were visited before BMC, with 31% of visits (n = 38) resulting in a referral. The median referral delay was 89 days (mean, 122 days), with a median of two facilities (mean, 2.5 facilities) visited before presentation to BMC. Visiting a traditional healer first significantly increased the time taken to reach BMC compared with starting at a health center/dispensary (103 v 236 days; P = .02). Facility visits in which a patient received a referral to a higher-level facility led to significantly decreased time to reach BMC (P < .0001). Only 36% of visits to district hospitals and 20.6% of visits to health centers/dispensaries yielded a referral, however.

CONCLUSION

The majority of patients were delayed during the referral process, but receipt of a referral to a higher-level facility significantly shortened delay time. Referral delay for pediatric patients with cancer could be decreased by raising awareness of cancer and strengthening the referral process from lower-level to higher-level facilities.

Factors associated with late-stage diagnosis of breast cancer among women in Addis Ababa, Ethiopia

PURPOSE

Stage at diagnosis is a key determinant of breast cancer prognosis. In this study, we characterize stage at diagnosis and determine factors associated with advanced stage at diagnosis among women diagnosed with invasive breast cancer in Addis Ababa, capital city of Ethiopia.

METHODS

Stage information was collected from medical records of 441 women with invasive breast cancer seen in seven major health facilities in Addis Ababa, from January 2017 to June 2018; these seven facilities capture 90% of all incident breast cancer cases in the city. We used multivariable Poisson regression model with robust variance to determine factors associated with advanced stage at diagnosis.

RESULTS

The predominant tumor histology was ductal carcinoma (83.7%). More than half of the tumors' grade was moderately or poorly differentiated. The median tumor size at presentation was 4 cm. Sixty-four percent of the patients were diagnosed at advanced stage of the disease (44% stage III and 20% stage IV), with 36% of the patients diagnosed at early-stage (5% stage I and 31% stage II). The prevalence of advanced stage disease was significantly higher among women who used traditional medicine before diagnostic confirmation (adjusted prevalence ratio [aPR] = 1.31; p = 0.001), had patient delay of >  3 months (aPR = 1.16; p = 0.042) and diagnosis delay of > 2 months (aPR = 1.24; p = 0.004). But it was lower among women who had history of breast self-examination (aPR = 0.77; p = 0.021).

CONCLUSIONS

Advanced stage at diagnosis of breast cancer among women in Addis Ababa is strongly associated with use of traditional medicine and with prolonged time interval between symptom recognition and disease confirmation. Community- and health systems-level interventions are needed to enhance knowledge about breast cancer and facilitate timely diagnoses.

Person and Family Centeredness in Ethiopian Cancer Care: Proposal for a Project for Improving Communication, Ethics, Decision Making, and Health

Background

Cancer is a major burden in Ethiopia. The Oncology Department of Tikur Anbessa (Black Lion) Specialized Hospital in Addis Ababa is the sole specialist unit for cancer care in the country. With only a handful of oncologists, a lack of resources, and a huge patient load, the work is challenging, especially in terms of achieving effective and ethical patient consultations. Patients, usually accompanied by family members, often wait for a long time to receive medical attention and frequently depart without treatment. Handling consultations effectively is essential to help patients as much as possible within such limitations.

Objective

The project has the following three main aims: (1) to enhance and expand the understanding of communicative and associated ethical challenges in Ethiopian cancer care; (2) to enhance and expand the understanding of the implications and use of person- and family-centered solutions to address such communicative challenges in practice; and (3) to plan and evaluate interventions in this area.

Methods

This project develops and consolidates a research collaboration to better understand and mitigate the communicative challenges in Ethiopian cancer care, with a focus on the handling and sharing of decision making and ethical tension among patients, staff, and family. Using theoretical models from linguistics, health communication, and health care ethics, multiple sources of data will be analyzed. Data sources currently include semistructured interviews with Ethiopian staff (n= 16), patients (n= 54), and family caregivers (n= 22); survey data on cancer awareness (n=150) and attitudes toward breaking bad news (n=450); and video recordings of medical consultations (n=45). In addition, we will develop clinical and methodological solutions to formulate educational interventions.

Results

The project was awarded funding by the Swedish Research Council in December 2017 for the period 2018 to 2021. The research ethics boards in Sweden and Ethiopia approved the project in May 2018. The results of the studies will be published in 2020 and 2021.

Conclusions

The project is the first step toward providing unique and seminal knowledge for the specific context of Ethiopia in the areas of physician-patient communication research and ethics. It contributes to the understanding of the complexity of the role of family and ethical challenges in relation to patient involvement and decision making in Ethiopia. Improved knowledge in this area can provide a fundamental model for ways to improve cancer care in many other low-resource settings in Africa and the Middle East, which share central cultural prerequisites, such as a strong patriarchal family structure, along with strong and devout religiosity. The project will also serve to develop greater understanding about the current challenges in Western health systems associated with greater family and patient participation in decision making. In addition, the project will contribute to improving the education of Ethiopian health professionals working in cancer care by developing a training program to help them better understand and respond to identified challenges associated with communication.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16493

Communicative challenges among physicians, patients, and family caregivers in cancer care: An exploratory qualitative study in Ethiopia

Background

Cancer is a growing concern in Ethiopia. Though communication is essential for the treatment process, few studies have looked at communication in Ethiopian cancer care. Due to the large number of patients and scarcity of resources, it is vital to understand how to manage consultations in order to effectively help as many patients as possible in this challenging work environment. Thus, research is needed to analyze and understand the communicative challenges experienced by physicians, patients, and family caregivers, in order to successfully handle patient care in practice.

Objective

We explore communication in Ethiopian cancer care and present the main challenges faced by physicians, patients, and family caregivers.

Methods

This explorative qualitative study was conducted at the Oncology Department of the Tikur Anbessa (Black Lion) Specialized Teaching Hospital (TASH) in Addis Ababa, Ethiopia. A triangulation of data collection methods was used: 91 audio-recorded, semi-structured interviews and 21 video-recordings of authentic interactions during hospital rounds. The aim was to obtain as complete a picture as possible of communication from the perspectives of physicians, patients, and family caregivers. The interviews were analyzed using thematic content analysis and the identified themes were supported by excerpts from the transcribed recordings.

Results

Eight themes emerged from the data. Workload and time pressure, in combination with restricted space for privacy, limited the possibilities for physicians to deliver detailed information and provide emotional support. Furthermore, patient literacy levels, in combination with no or little cancer awareness, financial problems, reliance on traditional and religious treatments, the stigma of cancer, and a fatalistic attitude, resulted in delays in patients seeking care and participating in positive health behaviors, and, subsequently, often resulted in an unwillingness to openly discuss problems with physicians and adhere to treatment. The study also illustrates the paramount role of family in physician-patient communication in Ethiopia. Though family caregivers provide a valuable interpreting support when patients have limited language skills, they can also prevent patients from sharing information with physicians. Another important finding is that family caregivers were often responsible for making decisions about treatment and avoided telling patients about a poor prognosis, believing that conveying bad news may upset them. All of these themes have important implications for the role of ethically acceptable communication in patient-centered care.

Conclusions

This study has identified a number of serious challenges for successful and ethically acceptable health communication in Ethiopian cancer care. The study contributes to our understanding of the complexity around the role of family, combined with patients’ dependency on family members for communication, support, and access to care, which creates particular ethical dilemmas for the medical staff. The questions raised by this study concern how to organize consultations to achieve patient-centered health communication, while maintaining a constructive alliance with the family and not jeopardizing the patient’s continued access to care. The integration of communication training for medical students in Ethiopia, with a focus on ethical guidelines for family-centered patient consultation suitable for these circumstances, would be an essential step.

Time intervals experienced between first symptom recognition and pathologic diagnosis of breast cancer in Addis Ababa, Ethiopia: a cross-sectional study

OBJECTIVES

This study aimed to estimate the magnitude of patient and diagnostic delays and associated factors among women with breast cancer in Addis Ababa.

DESIGN

This is a cross-sectional study.

SETTINGS AND PARTICIPANTS

All women newly diagnosed with breast cancer in seven major healthcare facilities in Addis Ababa (n=441) were included in the study.

MAIN OUTCOMES AND MEASURES

Patient interval (time from recognition of first symptom to medical consultation) and diagnostic interval (time from first consultation to diagnosis). Patient intervals >90 days and diagnostic intervals >30 days were considered delays, and associated factors were determined using multivariable Poisson regressions with robust variance.

RESULTS

Thirty-six percent (95% CI [31.1%, 40.3%]) of the patients had patient intervals of >90 days, and 69% (95% CI [64.6%, 73.3%]) of the patients had diagnostic intervals of >30 days. Diagnostic interval exceeded 1 year for 18% of patients. Ninety-five percent of the patients detected the first symptoms of breast cancer by themselves, with breast lump (78.0%) as the most common first symptom. Only 8.0% were concerned about cancer initially, with most attributing their symptoms to other factors. In the multivariable analysis, using traditional medicine before consultation was significantly associated with increased prevalence of patient delay (adjusted prevalence ratio (PR) = 2.13, 95% CI [1.68, 2.71]). First consultation at health centres (adjusted PR = 1.19, 95% CI [1.02, 1.39]) and visiting ≥4 facilities (adjusted PR = 1.24, 95% CI [1.10, 1.40]) were associated with higher prevalence of diagnostic delay. However, progression of symptoms before consultation (adjusted PR = 0.73, 95% CI [0.60, 0.90]) was associated with decreased prevalence of diagnostic delay.

CONCLUSIONS

Patients with breast cancer in Addis Ababa have prolonged patient and diagnostic intervals. These underscore the need for public health programme to increase knowledge about breast cancer symptoms and the importance of early presentation and early diagnosis among the general public and healthcare providers.