Drivers of advanced stage at breast cancer diagnosis in the multicountryAfrican breast cancer – disparities in outcomes (ABC‐DO) study

Abstract

Breast cancer (BC) survival rates in sub‐Saharan Africa (SSA) are low in part due to advanced stage at diagnosis. As one component of a study of the entire journey of SSA women with BC, we aimed to identify shared and setting‐specific drivers of advanced stage BC. Women newly diagnosed in the multicountry African Breast Cancer–Disparities in Outcomes (ABC‐DO) study completed a baseline interview and their stage information was extracted from medical records. Ordinal logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for advanced stage (I, II, III, IV) in relation to individual woman‐level, referral and biological factors. A total of 1795 women were included from Nigeria, Uganda, Zambia, and the multiracial populations of Namibia and South Africa, 1091 of whom (61%) were stage III/IV. Stage was lower in women with greater BC knowledge (OR 0.77 (95% CI: 0.70, 0.85) per point on a 6 point scale). More advanced stage was associated with being black (4.00 (2.79, 5.74)), having attended <secondary education (1.75 (1.42, 2.16)), having never heard of BC (1.64 (1.31, 2.06)), an unskilled job (1.77 (1.43, 2.20)) and pregnancy in the past 3 years (30% of ≤45 year olds) (1.63 (1.15, 2.31)), and were mediated through delays to diagnosis: symptom duration of ≥ 1 year (OR 2.47 (1.93, 3.15)). These findings provide further evidence that late‐stage BC in SSA is largely attributed to modifiable factors and strategies to improve BC education and awareness in women and the health system should be intensified.

Breast cancer survival in sub‐Saharan Africa by age, stage at diagnosis and human development index: A population‐based registry study

“…Some reasons for late presentation in SSA include low breast cancer awareness, difficult access to healthcare (both physical and economic), fear, distrust of conventional medicine and belief in alternative sources of healing . Additionally, pathways within the healthcare system often hinder early diagnosis . Unfavorable tumor biology such as triple‐negative disease or the luminal‐B‐like phenotype may also be associated with late stage presentation, as these tumors generally grow faster leading to late stage at diagnosis.…”

“…23,30 Additionally, pathways within the healthcare system often hinder early diagnosis. 31,32 Unfavorable tumor biology such as triplenegative disease or the luminal-B-like phenotype may also be associated with late stage presentation, 33 as these tumors generally grow faster leading to late stage at diagnosis. Furthermore, the possibility of underestimation of Stage IV disease due to the paucity of facilities for accurate staging needs to be considered in SSA.…”

Breast cancer in women living with HIV: A first global estimate

“…Where the majority of this patient population occurs, in sub‐Saharan Africa, breast cancer is typified by an advanced stage distribution at diagnosis and poor survival . Prolonged intervals to diagnosis are a major contributor to late stage, but for WLWHA, their established contact with the health system for HAART medication offers an opportunity to educate about breast and other cancers, to encourage early presentation, and ensure referral, diagnosis and treatment not only of AIDS‐associated malignancies, but also of other common cancers. Similar to the integration of cervical cancer screening into HIV clinics, this contact provides a valuable opportunity for breast health awareness, education and early presentation in order to minimize delays to diagnosis, achieve early stage diagnosis and ultimately improve survival, should breast cancer arise.…”

“…In the Uganda Cancer Cohort, 24 HIV‐positive women with breast cancer had two‐fold increased mortality rates (hazard ratio 2.04; 95% CI 0.76–5.47) compared to HIV‐negative breast cancer women, while in 88 HIV‐positive breast cancer patients in Soweto, a non‐significant increased mortality rate was seen (hazard ratio 1.4) relative to their HIV‐negative counterparts . In addition to further survival studies, research needs to address side‐effects and survivorship, with relevant studies currently underway . Clinically, concerns have been raised related to delays in initiating primary or adjuvant chemotherapy in highly immuno‐suppressed patients, HAART‐chemotherapy interactions, and a higher incidence of intolerance to, and side‐effects of, chemotherapy, including chemotherapy‐induced neutropenia, which are often exacerbated in the HIV‐positive cancer patient .…”

Early detection and treatment strategies for breast cancer in low-income and upper middle-income countries: a modelling study

“…20 The underlying causes include patient delays in seeking care and inability of primary care health-care providers to recognise early stage tumours; more than 40% of cases in the East African region have delayed diagnosis (>12 months from symptomatic presentation to diagnosis). 21 Although patients with cancer undergo surgical resection, standard drug therapy (endocrine or chemotherapy) is not consistently available.…”