Patient Characteristics and Predictors of Advanced Breast Cancer Stage at a Public Referral Hospital in a Middle-Income Sub-Saharan African Country

Abstract

Background: Breast cancer is the second leading cause of death in women in Botswana, a middle-income country in sub-Saharan Africa where cancer treatment is free to all citizens. While treatment is accessible, treatment outcomes may be limited by delayed diagnosis and or suboptimal treatment. Aim: As a preliminary step to understanding ways to improve early diagnosis of breast cancer in Botswana, we aimed to describe sociodemographic and clinical characteristics of breast cancer patients receiving specialized oncology care. Methods: Retrospective review of electronic data of patients enrolled in Thabatse Cancer Cohort study, including female patients diagnosed with breast cancer between October 2010 and July 2017 was conducted. Patient sociodemographic and clinical characteristics were described. We used univariate and multivariable logistic regression to explore predictors of advanced stage (III or IV) at presentation. Patients without known cancer stage were excluded. All factors significant in univariate analysis ( P < 0.05) were included in final multivariable model. Statistical analyses were performed using R on an EZR platform. Results: A total of 481 female breast cancer patients were included in our analysis, with median age of 52.4 (IQR 44.0- 64.4) years. Majority of patients were not married (61%), nearly half (48%) had primary school or less education, 54% had income of less than $50 per month, and 30% were HIV positive. Overall, 260 (54%) were diagnosed with advanced cancer stage, 144 (30%) had early-stage cancer, and 77 (16%) had unknown cancer stage. Compared with early-stage cancer; income of less than $50 per month (odds ratio [OR] 1.58, 95% CI 1.03-2.44) and not having an indoor toilet (OR 0.56, 95% CI 0.36-0.87) were significantly associated with advanced cancer. Importantly, no significant association was detected for HIV infection (OR 1.29, 95% CI 0.79-2.13), education (OR 1.19, 95% CI 0.77-1.83) and electricity at home (OR 0.97, 95% CI 0.56-1.64). In the adjusted model only income of less than $50 per month was significantly associated with advanced cancer (adjusted OR 1.85, 95% CI 1.17-2.93). Conclusion: Our findings indicate that a high proportion of breast cancer cases receiving specialized oncology care were diagnosed at an advanced stage. While patients from lower socioeconomic seem to be at higher risk, these data suggest that broad sectorial interventions are needed to reduce cancer stage at presentation rather than targeted programs focused on individual populations or barriers.