Determinants of Delayed Presentation and Advanced-Stage Diagnosis of Breast Cancer in Africa: A Systematic Review and Meta-Analysis

Experiences of cancer-related stigma in Africa: A scoping review

Cancer is a major health issue, particularly in low- and middle-income countries where 70% of cancer deaths occur. Stigma and barriers to screening and treatment lead to poor outcomes. We conducted structured searches of PubMed, Embase, MEDLINE, CINAHL, and CABI Global Health databases according to PRISMA-ScR guidelines. Searches used keywords related to (1) Africa, (2) cancer, and (3) stigma. We then screened to finalize a list of research manuscripts, dissertations, theses, and conference abstracts using quantitative, qualitative, or mixed methods to explore cancer stigma in Africa. This review focused on non-cervical cancers. Breast and cervical cancers have distinct stigma-related experiences due to awareness, screening, and sociocultural perceptions. Including cervical cancer risks dilutes the specificity and depth of findings. The review included 53 studies that linked stigma and cancer in Africa to physical symptoms, appearance changes, misconceptions, and emotional challenges, hindering care and worsening treatment outcomes. Cancer-related stigma negatively impacts screening and treatment engagement in Africa. The lack of intervention studies underscores the need for evidence-based strategies to reduce stigma. Future efforts should reduce barriers to cancer care, enhance public awareness, and implement policy changes to improve outcomes.

Assessing Breast Cancer Diagnosis and Management in Ghana per the Global Breast Cancer Initiative Key Performance Indicators

PURPOSE

The WHO's Global Breast Cancer Initiative (GBCI) described three key performance indicators (KPIs) to reduce breast cancer deaths worldwide. We assessed the management of breast cancer in Ghana against the GBCI KPIs to inform necessary steps for system-wide improvement.

METHODS

We reviewed patients diagnosed with breast cancer in 2021 calendar year at Ghana's second largest tertiary hospital. Relevant data were extracted from the electronic medical records to determine the stage of breast cancer at diagnosis, duration to confirm diagnosis from initial presentation, and proportion of patients completing recommended treatment without abandonment. Data were presented as descriptive statistics and compared with GBCI KPI benchmarks.

RESULTS

Of 319 patients undergoing biopsy of suspicious breast lesions, 243 were diagnosed with breast cancer. Most (98.7%) were female, with a median age of 49 years and median symptom duration of 24 weeks. Diagnosis was confirmed for all patients within 31 days of initial presentation. Only 22 of 214 patients (10.3%) undergoing staging were diagnosed as early breast cancer (stage I or II), 50% at stage III, and 39.3% at stage IV. Forty-five of 139 patients (32.4%) initiating recommended treatment completed without abandonment, and 45 of 243 patients (18.5%) with a confirmed breast cancer completed recommended treatment without abandonment.

CONCLUSION

Ghana met the GBCI KPI for timely diagnosis (<60 days of presentation) but fell short in early detection (≥60% early breast cancer) and treatment completion without abandonment (>80%). Our findings provide baseline data for planning system-wide improvements toward the GBCI's goal of reducing breast cancer mortality by 2.5% annually.

Predictors of survival among breast cancer patients in Ethiopia: a systematic review and meta-analysis

Introduction

Breast cancer remains a significant public health issue, with delayed medical attention often leading to advanced stages and poorer survival rates. In East Africa, evidence on the prevalence and factors contributing to the delayed presentation of breast cancer is limited. As a result, this study aims to assess the pooled prevalence of delayed breast cancer presentation and identify contributing factors in East Africa.

Methods

We conducted a systematic review of observational studies from East Africa using PubMed, Google Scholar, Embase, Cochrane Library, Hinari, and Mednar databases. The Newcastle Ottawa 2016 Critical Appraisal Checklist assessed methodological quality. Publication bias was evaluated using a funnel plot and Egger's test, and heterogeneity was examined with the I-squared test. Data were extracted with Microsoft Excel and analyzed using Stata 11.

Results

The pooled prevalence of delayed presentation among breast cancer patients in East Africa was 61.85% (95% confidence interval, 48.83%-74.88%). Significant factors contributing to delayed presentation included visiting traditional healers (adjusted odds ratio, 3.52; 95% CI, 1.43-5.59), low educational levels (adjusted odds ratio, 3.61; 95% CI, 2.39-4.82), age > 40 years (adjusted odds ratio, 1.87; 1.03, 2.71), absence of breast pain (adjusted odds ratio, 2.42; 1.09, 3.74), distance >5 km away from home to health institution (adjusted odds ratio, 2.89; 1.54, 4.24), and rural residence (adjusted odds ratio, 3.33; 95% CI, 2.16-4.49).

Conclusion

This meta-analysis' findings demonstrated that over half of breast cancer patients in East Africa delayed detection. Significant factors associated with delayed presentation include age over 40 years, illiteracy, rural residence, use of traditional healers, distance >5 km from a health facility, and absence of breast pain. Healthcare stakeholders and policymakers must be focused on raising awareness and educating people to encourage early detection and prompt therapy.

Diagnostic delay in women with cancer: What do we know and which factors contribute?

Timely cancer diagnosis is important, but delays are common, also among women. This study reviews recent literature on diagnostic delays in women with breast cancer, focusing on individual-level factors and their interaction with micro, meso, exo, and macrosystem factors. Following PRISMA-ScR guidelines, we conducted a scoping review on diagnostic delays in cancer among women, including qualitative and quantitative studies with oncological patients or healthcare professionals. We searched PubMed/MEDLINE and Scopus for publications from 2018 to November 28, 2023, excluding studies not meeting the inclusion criteria, not in English or Dutch, or focused solely on cancer screening. Titles and full texts were screened, with disagreements resolved through discussion. Two reviewers independently extracted study details, population characteristics, study design, and factors contributing to diagnostic delays. Initially, 9699 records were retrieved, resulting in 129 relevant studies after exclusions. We focused on women's health and breast cancer, narrowing our scope to 22 studies in high-income countries. Studies explored diagnostic delays and factors at various levels: microsystem (demographics, health behaviours, psychology, healthcare interactions), mesosystem (schedules, peer and support networks), exosystem (social, cultural, environmental, accessibility factors), and macrosystem (broader cultural, societal contexts, healthcare policies). In high-income countries, diagnostic delays in breast cancer care involve factors across various systems, affecting individuals, peers, healthcare, and policies. Enhancing awareness, communication, and access is important, requiring targeted campaigns and infrastructure upgrades. The Bronfenbrenner's ecological model effectively addresses the multifaceted factors influencing diagnostic delays. Future research can benefit from applying this model to various cancers and income settings.

Delayed presentation of breast cancer patients and contributing factors in East Africa: Systematic review and meta-analysis

INTRODUCTION

Breast cancer remains a significant public health issue, with delayed medical attention often leading to advanced stages and poorer survival rates. In East Africa, evidence on the prevalence and factors contributing to the delayed presentation of breast cancer is limited. As a result, this study aims to assess the pooled prevalence of delayed breast cancer presentation and identify contributing factors in East Africa.

METHODS

We conducted a systematic review of observational studies from East Africa using PubMed, Google Scholar, Embase, Cochrane Library, Hinari, and Mednar databases. The Newcastle Ottawa 2016 Critical Appraisal Checklist assessed methodological quality. Publication bias was evaluated using a funnel plot and Egger's test, and heterogeneity was examined with the I-squared test. Data were extracted with Microsoft Excel and analyzed using Stata 11.

RESULTS

The pooled prevalence of delayed presentation among breast cancer patients in East Africa was 61.85% (95% Confidence Interval: 48.83%-74.88%). Significant factors contributing to delayed presentation included visiting traditional healers (Adjusted Odds Ratio: 3.52; 95% CI: 1.43-5.59), low educational levels (Adjusted Odds Ratio: 3.61; 95% CI: 2.39-4.82), age>40 years (Adjusted Odds Ratio 1.87; 1.03, 2.71), absence of breast pain (Adjusted Odds Ratio 2.42; 1.09, 3.74), distance >5km away from home to health institution (Adjusted Odds Ratio 2.89; 1.54, 4.24), and rural residence (Adjusted Odds Ratio: 3.33; 95% CI: 2.16-4.49).

CONCLUSION

This meta-analysis's findings demonstrated that over half of breast cancer patients in East Africa delayed detection. Significant factors associated with delayed presentation include age over 40 years, illiteracy, rural residence, use of traditional healers, distance greater than 5 km from a health facility, and absence of breast pain. Healthcare stakeholders and policymakers must be focused on raising awareness and educating people to encourage early detection and prompt therapy.

Timeliness of Breast Cancer Patients' Presentation to Health Care Facilities in Ethiopia: A Systematic Review and Meta-Analysis

PURPOSE

Low breast cancer survival rates are often linked to late-stage diagnosis. The patient interval, the time between symptom detection and the first health care visit, is a key indicator of early diagnosis. This study aimed to assess the prevalence of patient delay and its associated factors in Ethiopia.

METHODS

This systematic review used a combined approach of meta-analysis and meta-synthesis of quantitative and qualitative data, respectively. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

RESULTS

Eleven studies that satisfied the eligibility criteria were included in the review. More than half (58.48%) of the patients with breast cancer delayed seeking medical help at health facilities, with a median delay time of 120 days. Presence of a painful breast ulcer/wounded mass (odds ratio [OR], 0.23 [95% CI, 0.09 to 0.58]), having swelling or a lump in the armpit (OR, 0.27 [95% CI, 0.15 to 0.46]), residing in urban area (OR, 0.27 [95% CI, 0.15 to 0.49]), and having a secondary school education or higher (OR, 0.28 [95% CI, 0.12 to 0.64]) were less likely to delay in seeking formal health care. However, patients who travel more than 5 km (OR, 6.33 [95% CI, 4.10 to 9.75]) were more likely to delay in our meta-analysis. Moreover, the meta-synthesis showed that the nature and progression of symptoms, symptom disclosure, social support, emotional responses, use of alternative therapies, misconceptions about breast cancer, financial limitations, accessibility issues, and other personal-environmental factors were associated with patient delay.

CONCLUSION

Nearly three fifths of patients with breast cancer delayed seeking health care at health facilities. Inaccessibility, low awareness, cultural beliefs, and socioeconomic factors contributed to these delays. Increasing public awareness, especially in rural areas, and improving health care access could encourage earlier presentation.

The Social Reality of Meaning Making: The Dichotomy in the Illness Narratives of Women With Breast Cancer and Biomedical Practitioners in Nigeria

BACKGROUND

Despite the increasing burden of breast cancer in the developing world, there is a misunderstanding of the complex and multifaceted relationship between culture and cancer, particularly breast cancer. Hence, a dichotomy of illness narratives exists due to differential meaning making concerning breast cancer. While clinicians always recommend biomedical treatment, women with breast cancer often seek alternative treatment pathways.

AIMS

To explore the experiences of women with breast cancer and clinicians in Nigeria on the dichotomy in the illness narratives.

METHODS

This qualitative study used in-depth interviews and focus group discussion to explore the experiences of 22 women with breast cancer and 7 clinicians in Nigeria on the dichotomy in the illness narratives using grounded theory method analysis.

RESULTS

This study revealed that many women living with breast cancer (WLBC) hold health beliefs that are contradictory to the biomedical norm. They mostly sought treatment based on the perceived aetiology of breast cancer. The treatment pathway follows faith and traditional healing as alternatives or sometimes in combination with biomedicine. WLBC reported a constant fear of biomedical treatment, perceived to be harmful to women's sexuality, fertility and body image. Hence, after perceived treatment failure from alternative care, biomedical care becomes the last resort, usually at an advanced stage of breast cancer, often responsible for poor prognosis.

CONCLUSION

There is a dichotomy of illness construction between sufferers and health practitioners. To guide women with breast cancer on the path of care, modern care practitioners should consider some cultural norms and practices without compromising professional ethos.

Availability and geographic access to breast cancer pathology services in Ghana

INTRODUCTION

Breast cancer poses a significant health challenge in Sub-Saharan Africa, particularly in Ghana, where late-stage diagnoses and limited healthcare access contribute to elevated mortality rates. This study focuses on the crucial role of pathology and laboratory medical (PALM) services in the timely diagnosis of breast cancer within Ghana.

METHODS

A cross-sectional survey of hospitals was completed from November 2020 to October 2021, with 94.8% of identified in-country hospitals participating. Pathology service-related parameters assessed included whether pathology was available for the diagnosis of breast cancer on-site or via external referral, the number of pathology personnel, additional breast cancer diagnostic capabilities including estrogen and progesterone and/or HER2 testing, and the time from biopsy to patients receiving their results. Geospatial mapping was used to identify areas of limited access.

RESULTS

Of the 328 participating hospitals, 136 (41%) reported breast cancer pathology services, with only 6 having on-site capabilities. Pathology personnel, comprising 15 consultants and 15 specialists, were concentrated in major referral centers, particularly in Greater Accra and Kumasi. An assessment of referral patterns suggested that 75% of the population reside within an hour of breast cancer pathology services. Among the 136 hospitals with access to breast cancer pathology, only a limited number reported that results included ER/PR (38%) and HER2 testing (33%).

CONCLUSION

Ghana has been able to ensure significant pathology service availability through robust referral pathways with centralized labs. Despite this, difficulties persist with the majority of pathology results not including hormone receptor testing which is important in providing tumor specific treatment.

"Let him die. He caused it": A qualitative study on cancer stigma in Tanzania

Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation and poor cancer outcomes worldwide. The burden of cancer in Tanzania is on the rise, with cancer being the third-leading cause of death in the country. Despite rising incidence and poor outcomes of cancer, cancer-related stigma interventions have received low prioritization. There is a need for sound research that focuses on understanding attitudes driving stigma, its impact on care-seeking and treatment adherence, and intervention models to reduce stigma. We used a cross-sectional qualitative study design. We administered three open-ended qualitative questions to 140 adults newly diagnosed with cancer in Moshi, Tanzania. The questions explored common attitudes toward people with cancer, the perceived impact of cancer-related stigma on care engagement, and ideas for reducing cancer stigma. Patients were recruited during routine appointments at the Cancer Center at Kilimanjaro Christian Medical Center. Data were analyzed using a team-based, applied thematic approach and NVivo 12 software. All participants described stigma as a significant challenge for treatment and receiving support from their social networks. Perceptions of financial burden, misconceptions about cancer, such as the belief that it is contagious, and fear of death, were common attitudes driving cancer stigma. Most participants feared that symptoms would prevent them from being able to work and that the cost of cancer care would drive away loved ones. Stigma was not a ubiquitous response, as some participants reported increased care and social support from family members after a cancer diagnosis. Experiences of stigma contributed to feelings of shame, fear of burdening the family, reduced resources to access treatment, and disengagement from care. Common substitutes to medical therapies included religious interventions and traditional medicine, perceived as less expensive and less stigmatizing. Many participants felt they would benefit from improved financial support, professional counseling, and education for families and communities to reduce stigmatizing attitudes and enhance social support. There is a need for intervention studies focused on improving cancer literacy, community advocacy to reduce cancer stigma, and increasing emotional and practical support for people with cancer and their families. There is also a clear need for policy efforts to make cancer care more affordable and accessible to reduce the financial burden on patients and families.

From Incidence to Intervention: A Comprehensive Look at Breast Cancer in South Africa

The formidable impact of breast cancer extends globally, with South Africa facing pronounced challenges, including significant disparities in breast cancer screening, treatment and survival along ethnic and socioeconomic lines. Over the last two decades, breast cancer incidence has increased and now accounts for a substantial portion of cancers in women. Ethnic disparities in terms of screening, incidence and survival exacerbate the issue, leading to delayed diagnosis among Black patients and highlighting healthcare inequities. These concerning trends underscore the urgency of enhancing breast cancer screening while mitigating treatment delays, although obstacles within the healthcare system impede progress. The intersection of breast cancer and human immunodeficiency virus (HIV) further complicates matters and particularly affects the Black population. Tackling the aforementioned disparities in breast cancer in South Africa mandates a multifaceted strategy. Robust screening efforts, particularly those targeting marginalised communities, are crucial for early detection. Concurrently, expedited treatment initiation is imperative. Addressing HIV-related complexities requires tailored interventions to ensure effective care. These multifaceted disparities require pan African research and cooperation as well as tailored interventions to enhance breast cancer care within the African region.

Comparative analysis of breast cancer characteristics in young premenopausal and postmenopausal women in Ghana

Breast cancer is increasingly common among young women in Ghana. BCa is heterogeneous with unique traits that impact causes, prognostic, and predictive outcomes of patients before and after menopause. However, limited evidence exists on differences between young premenopausal (YPM) and postmenopausal cases in Ghana. This study compared breast tumour characteristics between YPM women (under 35 years) and postmenopausal women. We conducted a prospective cross-sectional study involving 140 BCa-diagnosed women at the Breast Care Clinic of Komfo Anokye Teaching Hospital (KATH), Kumasi from November 2019 to June 2021. Thirty-one (22.1%) of participants were YPM and 109 (77.9%) were postmenopausal. The median ages for YPM and postmenopausal were 32.0 (range: 25.0-35.0) and 57.0 (48.0-86.0) respectively. Invasive carcinoma was the most common histological type (97.1%). Left tumour location was the most frequent in both groups (51.6% for YPM and 51.8% for postmenopausal). Lumps detected were frequently in the outer upper quadrant in both groups (61.3% and 56.0%). The majority of the YPM women (80.7%) and postmenopausal women (87.0%) had stage III and IV diseases. Most YPM (64.5%) and postmenopausal women (64.4%) exhibited triple-negative breast cancer (TNBC). Both YPM 13 (56.6%) and postmenopausal participants 40 (56.3%) exhibited a predominantly partial response to neo-adjuvant chemotherapy but YPM women (21.7%) experienced disease progression than the postmenopausal women (12.7%). The study highlights consistent tumour characteristics and advanced clinical stages at diagnosis in both groups with a higher prevalence of TNBC. TNBC and HER2+ subtypes respond better to Anthracycline-based neoadjuvant chemotherapy. Establishing Breast Care Clinics in district and regional hospitals for early detection is crucial and further studies are warranted to understand the higher TNBC prevalence in black Africans and re-evaluate breast education programs to address the persistently late presentations.

Factors associated with late diagnosis of breast cancer in women in Togo, Sub-Saharan Africa

BACKGROUND

Breast cancer is the most frequently diagnosed cancer in women worldwide. The objective of this study was to identify factors associated with late diagnosis of breast cancer in Togolese women.

METHODS

We conducted a prospective cross-sectional study with descriptive and analytical purposes on cases of breast cancer in women in 2021, in Togo. The patients included in this study were women followed in the gynecology department for stages III and IV breast cancer.

RESULTS

We included 62 cases of breast cancer. The average age of the patients was 38.6 ± 12.5 years with extremes of 17 and 76 years. The breast nodule was the most common reason for consultation in 75.8% of cases. The histological types diagnosed were invasive carcinoma of non-specific type (58; 93.55%), mucinous carcinoma (3; 4.84%) and lobular carcinoma (1; 1.61%). For the stage of the cancer, 43 patients were stage III (69.4%) and 19 stage IV (30.6%). In multivariate analysis, the factors associated with late diagnosis of breast cancer were: fear of diagnosis (aOR = 1.29; p = 0.0014), long delay in diagnosis (aOR = 2.62; p = 0.0001) and failure to perform breast self-examination (aOR = 1.68; p = 0.0022).

CONCLUSION

The fear of the diagnosis, the absence of self-examination of the breasts and the use of traditional treatment and self-medication in first intention constituted the essential factors of the late diagnosis of breast cancer. Strategies should be put in place at the national level to impact on these factors for an early diagnosis of breast cancer.

Drivers of disparities in stage at diagnosis among women with breast cancer: South African breast cancers and HIV outcomes cohort

OBJECTIVE

In low- and middle-income countries (LMICs), advanced-stage diagnosis of breast cancer (BC) is common, and this contributes to poor survival. Understanding the determinants of the stage at diagnosis will aid in designing interventions to downstage disease and improve survival from BC in LMICs.

METHODS

Within the South African Breast Cancers and HIV Outcomes (SABCHO) cohort, we examined factors affecting the stage at diagnosis of histologically confirmed invasive breast cancer at five tertiary hospitals in South Africa (SA). The stage was assessed clinically. To examine the associations of the modifiable health system, socio-economic/household and non-modifiable individual factors, hierarchical multivariable logistic regression with odds of late-stage at diagnosis (stage III-IV), was used.

RESULTS

The majority (59%) of the included 3497 women were diagnosed with late-stage BC disease. The effect of health system-level factors on late-stage BC diagnosis was consistent and significant even when adjusted for both socio-economic- and individual-level factors. Women diagnosed in a tertiary hospital that predominantly serves a rural population were 3 times (OR = 2.89 (95% CI: 1.40-5.97) as likely to be associated with late-stage BC diagnosis when compared to those diagnosed at a hospital that predominantly serves an urban population. Taking more than 3 months from identifying the BC problem to the first health system entry (OR = 1.66 (95% CI: 1.38-2.00)), and having luminal B (OR = 1.49 (95% CI: 1.19-1.87)) or HER2-enriched (OR = 1.64 (95% CI: 1.16-2.32)) molecular subtype as compared to luminal A, were associated with a late-stage diagnosis. Whilst having a higher socio-economic level (a wealth index of 5) reduced the probability of late-stage BC at diagnosis, (OR = 0.64 (95% CI: 0.47-0.85)).

CONCLUSION

Advanced-stage diagnosis of BC among women in SA who access health services through the public health system was associated with both modifiable health system-level factors and non-modifiable individual-level factors. These may be considered as elements in interventions to reduce the time to diagnosis of breast cancer in women.

Ethnobotanical Survey of Medicinal Plants Used in Breast Cancer Treatment by Traditional Health Practitioners in Central Uganda

Purpose

The study aimed to document the existing knowledge and practices related to breast cancer recognition and treatment using medicinal plants by traditional health practitioners in Central Uganda.

Methods

This cross-sectional exploratory survey, conducted between February and August 2020, applied a mixed methods research approach. A semi-structured questionnaire was administered to 119 traditional health practitioners (THPs) in Kampala, Wakiso and Mukono. Content analysis of qualitative data was done. Quantitative ethnobotanical survey indices, namely user reports (Nur), percentage of respondents with knowledge (PRK), informant consensus factor (Fic), fidelity level (FL), preference ranks (PR) and direct matrix ranking (DMR) were determined.

Results

Most THPs recognized breast cancer by breast swelling (n=74, 62.2%) and breast pain (n=29, 24.4%). They cited 30 plants from 30 genera in 23 families (Fic 0.75 on breast cancer). Asteraceae, Apocynaceae, Euphorbiaceae, Fabaceae, Lamiaceae and Rutaceae were the predominant families. The ten most cited plants were Annona muricata L. (Nur=24), Rhoicissus tridentata (L.f.) Wild & R.B.Drumm (Nur =19), Erythrococca bongensis Pax (Nur=11), Ficus sp. (Nur=10), Cannabis sativa L. (Nur=8), Ipomoea wightii (Wall.) Choisy (Nur=7), Erythrina abyssinica DC. (Nur=5), Leucas martinicensis (Jacq.) R.Br. (Nur=4), Abelmoschus esculentus (L.) Moench (Nur=4) and Zanthoxylum chalybeum Engl. (Nur=3). Annona muricata L. was highly preferred by THPs (PR 1), Ficus sp. had highest fidelity level (FL=77%) and Zanthoxylum chalybeum Engl. ranked as the highest multipurpose plant (DMR 1). Herbs (n=14, 47%) were the most commonly used life forms besides trees (n=11, 37%) and shrubs (n=5, 16%). THPs mostly used leaves (46%), prepared decoctions (82%) and applied residues on the breast.

Conclusion

THPs in Central Uganda recognized breast cancer by symptoms. Medicinal plants applied in its folk treatment have been documented and the claims of cure by THPs merit further investigation.