Inequities in breast cancer treatment in sub-Saharan Africa: findings from a prospective multi-country observational study

Milena Foerster,Moses Galukande,Fiona Mckenzie,Isabel Dos Santos Silva,Annelle Zietsman,Benjamin O Anderson,Angelica Anele,Charles Adisa,Joachim Schuz,Valerie Mccormack

doi:10.1186/s13058-019-1174-4

Abstract

BackgroundImproving breast cancer survival in sub-Saharan Africa (SSA) is urgently needed, requiring early diagnosis and improved access to treatment. However, data on the types of and barriers to receiving breast cancer therapy in this region are limited and have not been compared between different SSA countries and treatment settings.MethodsIn different health care settings across Uganda, Nigeria and Namibian sites of the prospective African Breast Cancer - Disparities in Outcomes cohort study, we assessed the percentage of newly diagnosed breast cancer patients who received treatment (systemic, surgery and/or radiotherapy) for cancer and their socio-demographic and clinical determinants. Treatment data were systematically extracted from medical records, as well as self-reported by women during 6-month follow-up interviews, and were used to generate a binary indicator of treatment received within 12 months of diagnosis (yes/no), which was analysed via logistic regression.ResultsOf 1325 women, cancer treatment had not been initiated treatment within 1 year of diagnosis for 227 (17%) women and 185 (14%) of women with stage I–III disease. Untreated percentages were highest in two Nigerian regional hospitals where 38% of 314 women were not treated (32% among stage I–III). At a national referral hospital in Uganda, 18% of 430 women were not treated (15% among stage I–III). In contrast, at a cancer care centre in Windhoek, Namibia, where treatment is provided free to the patient, all non-black (100%) and almost all (98.7%) black women had initiated treatment. Percentages of untreated women were higher in women from lower socio-economic groups, women who believed in traditional medicine and, in Uganda, in HIV+ women. Self-reported treatment barriers confirmed treatment costs and treatment refusal as contributors to not receiving treatment.ConclusionsFinancial support to ensure treatment access and education of treatment benefits are needed to improve treatment access for breast cancer patients across sub-Saharan Africa, especially at regional treatment centres, for lower socio-economic groups, and for the HIV-positive woman with breast cancer.

Highlights

Improving breast cancer survival in sub-Saharan Africa (SSA) is urgently needed, requiring early diagnosis and improved access to treatment
Standardised breast cancer treatment guidelines tailor therapy to key tumour features: stage at diagnosis, and expression of oestrogen, progesterone and Human epidermal growth factor receptor 2 (HER2) receptors, for which curative treatment involves some combination of surgery, radiotherapy and systemic therapies
Most women had unskilled jobs (n = 923; 70%), and other than in Uganda, where 74% (n = 320) of women lived in rural areas, the majority resided in urban areas

Summary

Introduction

Improving breast cancer survival in sub-Saharan Africa (SSA) is urgently needed, requiring early diagnosis and improved access to treatment. Data on the types of and barriers to receiving breast cancer therapy in this region are limited and have not been compared between different SSA countries and treatment settings. As per the Breast Health Global Initiative’s recommended phased implementation approach, SSA countries need to develop and strengthen programs to ensure the early diagnosis of symptomatic breast cancer, in parallel with improvements in timely access to appropriate treatment. Whilst there are several studies on the predominantly advanced stage at breast cancer diagnosis in SSA [3], there are limited data on breast cancer treatment gaps from this region. The influence of traditional and spiritual healers on receipt of conventional cancer care has not been quantified, and in HIV-endemic regions of SSA, the evidence base on management of the HIV-positive woman with breast cancer is very limited [10]

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Conclusion