Audit of delayed presentation in breast cancer from a tertiary centre in the Niger Delta, Nigeria.
Lucy O. Eriba1 and Peter I. Agbonrofo2
Context: Breast cancer is the most common cause of cancer-related morbidity and mortality in women in developing countries, compounded by delayed presentation. Determining the contemporary reasons for delayed presentation in our environment, is necessary to properly guide enlightenment campaigns, enhance their effectiveness and improve patient survival.
Subjects and Methods: A 1-year audit of consecutive histologically-confirmed breast cancer patients presenting to University of Benin Teaching Hospital was done. Socio-demographic data, time to presentation with reasons, stage at presentation were obtained in a proforma and analyzed.
Results: 92% of patients had delayed presentation. 270 patients with complete records were included in the study. Mean age of patients was 47.6±11.0years, most were between 40 – 49 years (32.2%). Most patients in the study were married (75.6%), of lower class (52.2%) and had tertiary education (55.9%). Delay of 12 – 15months occurred most (54.8%) with advanced stage disease (Stages 3/4; 73%). Use of alternative medicine accounted for most of the delay (48.9%) while fear of mastectomy (30.4%), financial (6.7%) and referral problems (6.7%) were other common reasons.
Conclusion: Delay in presentation is common in our breast cancer patients. Use of alternative medicine, fear of mastectomy, financial issues were common reasons for delay. There should be proper regulation of alternative medical practice to forestall bogus claims of cancer treatment. More affordable and accessible screening centres, insurance coverage of cancer care, alongside enlightenment about effect of delayed presentation and appropriate cancer care in religious houses, amongst traditional rulers and other custodians of cultural practices are required to help mitigate negative beliefs resulting in delayed presentation.
Keywords: Breast cancer, Delayed presentation, advanced stage, reasons for delayed presentation.
Breast cancer is the most common cancer in women worldwide.1 It constituted 25% of diagnosed cancer cases worldwide in women, in 2012 and 53% of these newly diagnosed cancer cases were from developing countries.1 It is the most common cause of cancer-related morbidity and mortality in women in developing countries.1,2 Women in developing countries present late, unlike those in the developed world who tend to present earlier.1,3-6 The disease is usually more aggressive amongst blacks.7-12 This poor prognosis is further compounded by the late/delayed presentation in sub-Saharan Africa, which is directly linked to poor survival.1,5,13-16 Despite recent health campaigns, patients still present with late stage disease in the University of Benin Teaching Hospital (UBTH), Benin City, Nigeria.3,17 Therefore, it is pertinent to determine the contemporary reasons for delayed presentation in our environment, to properly guide enlightenment campaigns and enhance their effectiveness. This could go a long way in improving breast cancer survival in our environment.
Objective of the study
To determine the reasons for delayed presentation amongst breast cancer patients in UBTH over a one-year period.
Subjects and method
A 1-year audit of consecutive histologically-confirmed breast cancer patients presenting to Surgery and Radio-oncology departments of University of Benin Teaching Hospital (a tertiary/referral health facility in the Niger Delta, Nigeria) from July 2018 to June 2019 was carried out. Information concerning socio-demographics, duration of symptoms/time to presentation, reasons for time to presentation, stage at presentation were obtained using a proforma. Prolonged time interval from discovery of initial symptom to presentation to an appropriate health care provider of greater than 12weeks (3 months/90days) was considered to be delayed presentation (longer periods than this have been linked to reduced survival).18 American Joint Committee on Cancer Staging System for breast cancer Stage 3 and 4 disease were considered as late stage disease.19,20 Patients with incomplete data were excluded from the study. Data obtained were analyzed with IBM Statistical Package for Social Sciences software version 21. The study was carried out in conformity with the World Medical Association Helsinki declaration.
In the 1-year study period, a total of 299 breast cancer patients were seen. Of these, 275 (92%) patients had delayed presentation. However, 5 patients with delayed presentation had incomplete records and were excluded from the study. Thus, 270 patients with delayed presentation were further analyzed.
Age range was 20 – 79 years, with most patients (32.2%) between 40 – 49 years. Mean age of patients was 47.6±11.0years, 99.6% were females
Most patients (75.6%) in the study were married, of lower socio-economic class (52.2%) and had tertiary level of education (55.9%) (Table 1).
The highest proportion of patients (54.8%) delayed for 12 – 15months before presenting followed by delays of 8 – 11months (15.6%) (Figure 1).
Advanced disease was the most common stage at presentation with 37.4% and 35.6% of patients in Stage 3 and Stage 4 respectively (Figure 2).
Use of alternative medicine accounted for most of the delay in presentation (48.9%) while fear of mastectomy (30.4%), financial (6.7%) and referral problems (6.7%) were other common reasons for delayed presentation (Figure 3).
Many cancers are curable with early presentation and treatment, but delayed presentation of patients with diagnosis of cancer is a common phenomenon in developing countries leading to poor outcome and survival.21 The reasons for delayed presentation vary.
Most of the patients (32.2%) in this study were between the ages of 40-49 years with mean age of 47.6±11.0 years, this is similar to other studies were many of the patients presenting with breast cancer are tending towards a lower age.3,22,23
This study showed that majority (92%) of the patients with breast cancer had a delay of more than three months before presenting to a health professional with most patients (54.8%) presenting between 12-15 months after onset of symptoms. A large proportion of patients presented in advanced stage III and IV (37.4% and 35.6% respectively). This finding is comparable with reports of other studies which found that over 50% of patients diagnosed with breast cancer in most African countries present late and report to the hospital with advanced stage III and IV disease, a major reason for the poor survival rate.3,23-25
One hundred and forty one patients (52.2%) were of lower socio-economic status. Lower socio-economic status has been shown to limit patients’ access to effective breast cancer care26,27 and could be a contributory factor to the high incidence of delayed presentation in this study.
Majority of the patients (48.9%) in this study, sought alternative care with unorthodox or traditional healthcare systems, consisting of herbal medicines, rituals, occultism and many others. They considered this a major option for their treatment as they believe it is an avenue to their quick recovery.
West Africa has been shown to have the highest use of alternative medicine; Ibrahim and Oludara reported that 61.6% of the participants studied relied mainly on alternative medicine for the treatment of their disease,28 Ezeome and Anarado noted 65% alternative medicine use in Enugu,29 while a similar finding was made by Clegg-Lamptey et al in Ghana30 and in Kaduna, Nigeria, 38.4 % of breast cancer patients sought alternative care before presenting for medical consultation.31 However, in East Africa, Otieno et al. reported 9.6% of breast cancer patients in Kenya relied on alternative medicine,32 similar to a study done in Enugu, Nigeria were 17.5% of patients first sought aid from traditional healers.33
Almost 80% of Africans use unorthodox healthcare,34 probably because unorthodox medical services are easily accessible to all, including the poor and vulnerable. It is therefore not surprising, that many women with breast cancer present late and only come to the hospital when their symptoms worsen like intractable pains, ulceration, fungation and sometimes imminent death from complications of their disease.
Other identified causes of delayed presentation include fear of mastectomy. From this study, 30.4% of patients delayed because of fear of surgery. This is similar to the report by A.T Ajekigbe, where fear of mastectomy was the major cause of delayed presentation and this was neither affected by age or educational background.35
The authors believe that the fear of mastectomy could contribute to the high proportion of patients with tertiary level of education (55.9%) and also increased use of unorthodox therapy found in this study.
Fear as the major contributing factor causing late presentation or delayed diagnosis of breast cancer in Africa has been documented.36 Individuals were afraid that mastectomy would leave a dreadful cosmetic deformity, lymphedema, arm pain, chest tightness, financial burden, and sexuality issues (women expressed very passionately that the diminished sexuality a woman experiences after mastectomy was the biggest fear associated with a mastectomy), this could result in divorce and embarrassment.37-39 It is the authors’ opinion that the high proportion of married patients (75.6%) with delayed presentation in this study, could be as a result of this fear of possible marital issues from mastectomy.
However, studies from Europe have shown that divorce is not associated with breast cancer diagnosis but rather the patients experienced increased intimacy and support.40,41 This is in contrast to what pertains in Africa.39,42
Finances and problem in referral system accounted for 6.7% each in delayed presentation in this study. In most African countries, healthcare is expensive and individuals are required to pay out of pocket.27,43 Therefore, financial barriers prevent the poor in the society from seeking medical help while some may sometimes have to travel long distance to access healthcare facility. Geographical inequalities in healthcare service provision and utilization is a major concern in Africa.27,44 Longer travel time deters patients from seeking medical help as at when due.
Nine Patients (3.3%) delayed in presenting due to Self-denial. The “it is not my portion syndrome”, borne out of spiritual belief, has kept patients in a denial phase while cultural practices and negative cultural beliefs has led to refusal of treatment hence resulting to worsening of symptoms and presentation in advanced stages.27,42
About 2.6% of patients in our study, noted their pregnancy status prevented them from presenting early and seeking medical care; symptoms of pregnancy can mask breast cancer and this can lead to delayed presentation.45,46 In developing countries, the reported frequency of diagnosis delay of >3 months was 72.6% of patients with Breast cancer.45 The delays are mainly caused by an underestimation of Breast Cancer symptoms during pregnancy and lactation. Therefore, an increased awareness of clinicians may help reduce the delay in the diagnosis of women with Pregnancy Associated Breast Cancer.
About 1.5% went to prayer houses, considering the fact that our society in Africa is very religious, some women diagnosed with breast cancer felt confident in discussing their diagnosis with church affiliates to get “spiritual covering” rather than presenting to the hospital and this has led to delayed presentation and poor outcome and survival.27,35,11,13
More than 90% of breast cancer patients in our experience delay in presenting to appropriate health care facility with associated advanced stage disease. Use of alternative medicine, fear of mastectomy, financial and referral issues were common reasons for delay. Proper legislation/regulation of alternative medical practice to forestall bogus claims of effective cancer treatment. More enlightenment about effect of delayed/late presentation and appropriate cancer care should be carried out in religious houses, amongst traditional rulers and other custodians of cultural practices to help mitigate some of the negative beliefs which lead to delayed presentation. More affordable and accessible screening centres, with greater health insurance coverage of cancer care will attenuate the financial burden of patients.
The contributions of Stanley Okugbo and Kester Okoduwa in the preparation of this manuscript are acknowledged.
- American Cancer Society. Global Cancer Facts & Figures. 3rd ed. Atlanta: American Cancer Society; 2015: 1 – 51.
- Badoe EA, Baako BN, Clegg-Lamptey JN. The Breast. In: Badoe EA, Achampong EQ, da Rocha-Afodu JT, eds. Principles and Practice of Surgery including Pathology in the Tropics. 4th ed. Accra: Ghana Publishing Cooperation; 2008:488 – 519.
- Momoh MI, Agbonrofo PI. Stage at Presentation of Breast Cancer in the Second Decade of the 21st Century in Benin City. Annals of Medical and Surgical Practice June 2016; 1(1):6-10.
- Unger-Saldana K. Challenges to the early diagnosis and treatment of breast cancer in developing countries. World J Clin Oncol 2014; 5(3): 465 – 477.
- Kene TS, Odigie VI, Yusufu LMD et al. Pattern of Presentation and Survival of Breast Cancer in a Teaching Hospital in North Western Nigeria. Oman Med. J. 2010; 25(2): 104-107.
- Jha AK, Hamal PK, Jha J et al. Pattern of breast cancer in a Tertiary Care Center. J Nepal Med Assoc 2010; 49(177):1-5.
- Warner ET, Tamimi RM, Hughes ME et al. Racial and Ethnic Differences in Breast Cancer Survival: Mediating Effect of Tumor Characteristics and Sociodemographic and Treatment Factors J Clin Oncol 2015; 33(20):2254-2261.
- Parise CA, Bauer KR, Caggiano V: Variation in breast cancer subtypes with age and race/ethnicity. Crit Rev Oncol Hematol 76:44-52, 2010.
- Keenan T, Moy B, Mroz E et al. Comparison of the Genomic Landscape between Primary Breast Cancer in African American versus White Women and the Association of Racial Differences with Tumor Recurrence. J Clin Oncol 2015; 33(31):3621-3627.
- Baquet CR, Mishra SI, Commiskey P et al. Breast Cancer Epidemiology in Blacks and Whites: Disparities in Incidence, Mortality, Survival Rates and Histology. J Natl Med Assoc. 2008; 100(5): 480–488.
- Troester MA, Sun X, Allott EH et al. Racial Differences in PAM50 Subtypes in the Carolina Breast Cancer Study. JNCI J Natl Cancer Inst (2018) 110(2): djx135. doi: 10.1093/jnci/djx135.
- Gukas ID, Jennings BA, Mandong BM et al. Clinicopathological features and molecular markers of breast cancer in Jos, Nigeria. West Afr J Med. 2005; 24(3):209-13.
- Hunt KK, Robertson JF, Bland KI. The Breast. In: Brunicardi F, Andersen D, Billiar T, Dunn D, Hunter J, Matthews J, Pollock R, eds. Schwartz’s Principles of Surgery. 10th ed. New York: McGraw Hill education, 2015: 497 – 564
- Popoola AO, Ogunleye OO, Ibrahim NA et al. Five Year Survival of Patients with Breast Cancer at the Lagos State University Teaching Hospital, Nigeria. Online Journal of Medicine and Medical Science Research 2012; 1(2):24-31.
- Neave LM, Mason BH, Kay RG. Does delay in diagnosis of breast cancer affect survival? Breast Cancer Res Treat 1990, 15(2):103-108.
- Afzelius P, Zedeler K, Sommer H et al. Patient’s and doctor’s delay in primary breast cancer. Prognostic implications. Acta Oncol 1994, 33(4):345-351.
- Momoh MI, Ohanaka CE. Factors associated with Delay in Presentation of Breast Cancer in Benin. Port Harcourt Med J 2008; 2: 97 – 102.
- Ramirez AJ, Westcombe AM, Burgess CC et al. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. The Lancet 1999; 353(9159):1127–1131.
- Breast. In: Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds American Joint Committee on Cancer: AJCC Cancer Staging Manual, 7th ed. New York: Springer-Verlag 2010: 358-361.
- Hunt KK, Robertson JF, Bland KI. The Breast. In: Brunicardi F, Andersen D, Billiar T, Dunn D, Hunter J, Matthews J, Pollock R, eds. Schwartz’s Principles of Surgery. 10th ed. New York: McGraw Hill education, 2015: 497 – 564.
- Ekanem VJ, Aligbe JU: Histopathological types of breast cancer in Nigerian women: A 12-year review (1993-2004). Afr J Reprod Health 2006; 10:71-75.
- Galukande M, Mirembe F, Wabinga H. Patient Delay in Accessing Breast Cancer Care in a Sub Saharan African Country: Uganda. Br J Med Med Res. 2014; 4(13): 2599–2610.
- Odongo J, Makumbi T, Kalungi S, Galukande M. Patient delay factors in women presenting with breast cancer in a low income country BMC Res Notes. 2015; 8: 467. doi: 10.1186/s13104-015-1438-8.
- Montazeri A, Ebrahimi M, Mehrdad N et al. Delayed presentation in breast cancer: a study in Iranian women. BMC Women’s Health 2003; 3, 4 doi: 10.1186/1472-6874-3-4.
- Donkor A. Factors Contributing to Late Presentation of Breast Cancer in Africa: A Systematic Literature Review. Arch Med. 2015, 8:2.
- Dreyer MS, Nattinger AB, McGinley EL, Pezzin LE. Socioeconomic status and breast cancer treatment. Breast Cancer Res Treat. 2018; 167(1):1-8. doi: 10.1007/s10549-017-4490-3.
- Foerster M, Anderson B, McKenzie F et al. Inequities in breast cancer treatment in sub-Saharan Africa: findings from a prospective multi-country observational study. Breast Cancer Res 2019; 21:93
- Ibrahim NA, Oludara MA. Socio-demographic factors and reasons associated with delay in breast cancer presentation: a study in Nigerian women. Breast 2012; 21: 416-418.
- Ezeome ER, Anarado AN. Use of complementary and alternative medicine by cancer patients at the University of Nigeria Teaching Hospital, Enugu, Nigeria. BMC Complement Altern Med. 2007; 7: 28. doi: 10.1186/1472-6882-7-28.
- Clegg-Lamptey J, Dakubo J, Attobra YN. Why do breast cancer patients report late or abscond during treatment in Ghana? A pilot study. Ghana Medical Journal 2009; 43(3):127–131.
- Ukwenya AY, Yusufu LD, Nmadu PD et al. Delayed treatment of symptomatic breast cancer: the experience from Kaduna, Nigeria. South African Journal of Surgery 2008; 46(4)106 – 110.
- Otieno ES, Micheni JN, Kimende SK, Mutai KK. Delayed presentation of breast cancer patients. East African Medical Journal. 2010; 87(4): 147-150.
- Ezeome ER. Delays in presentation and treatment of breast cancer in Enugu, Nigeria. Nigerian Journal of Clinical Practice 2010; 13(3):311–316.
- Elujoba AA, Odeleye OM, Ogunyemi CM. Traditional medicine development for medical and dental primary health care delivery system in Africa. Afr. J. Trad. Comp. Alt. Med 2005; 2(1):46 – 61.
- Ajekigbe AT. Fear of Mastectomy: The Most Common Factor Responsible for Late Presentation of Carcinoma of the Breast in Nigeria. Clinical Oncology (Royal College of Radiologists (Great Britain)) 1991; 3(2):78-80.
- Smith LK, Pope C, Botha JL. Patients’ help-seeking experiences and delay in cancer presentation: a qualitative synthesis. Lancet 2005; 366: 825-831.
- Brandberg Y, Sandelin K, Erikson S et al. Psychological reactions, quality of life, and body image after bilateral prophylactic mastectomy in women at high risk for breast cancer: a prospective 1-year follow-up study. J Clin Oncol. 2008; 26(24):3943-3949.
- Alzahrani SM, Albalawi AA, Alshehri AR, Al-Jifree HM. Divorce Rates among Cancer Patients – A Saudi Arabian Study. The Egyptian Journal of Hospital Medicine 2018; 70 (7):1196-1200.
- Odigie VI, Tanaka R, Yusufu LM et al. Psychosocial effects of mastectomy on married African women in Northwestern Nigeria. Psycho-oncology 2009; 19(8):893-897.
- Cassileth BR, Deng G. Complementary and alternative therapies for cancer. Oncologist 2004; 9:80-89.
- Dorval M, Maunsell E, Taylor-Brown J, Kilpatrick M. Marital stability after breast cancer. J Natl Cancer Inst 1999; 91: 54-59.
- Opoku SY, Benwell M, Yarney J. Knowledge, attitudes, beliefs, behaviour and breast cancer screening practices in Ghana, West Africa. Pan African Medical Journal. 2012; 11:28 – 37.
- Tanser F, Gijsbertsen B, Herbst K. Modelling and understanding primary health care accessibility and utilization in rural South Africa: an exploration using a geographical information system. Social Science and Medicine 2006; 63: 691-705.
- Sharma K, Costas A, Shulman LN, Meara JG. A Systematic Review of Barriers to Breast Cancer Care in Developing Countries Resulting in Delayed Patient Presentation. J Oncol. 2012: 121873. doi: 10.1155/2012/121873.
- Norsa’adah B, Rampal KG, Rahmah MA et al. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer. 2011; 11:141.
- Woo JC, Yu T, Hurd TC. Breast cancer in pregnancy: a literature review. Arch Surg. 2003; 138:91- 98.