Audit of delayed presentation in breast cancer from a tertiary centre in the Niger Delta

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.


Introduction
Breast cancer is the most common cancer in 1 women worldwide.It constituted 25% of diagnosed cancer cases worldwide in women, in 2012 and 53% of these newly diagnosed cancer 1 cases were from developing countries.It is the most common cause of cancer-related morbidity and mortality in women in 1, 2 developing countries.Women in developing countries present late, unlike those in the 1, 3 -6 developed world who tend to present earlier.The disease is usually more aggressive amongst 7 -12 blacks.
This poor prognosis is further compounded by the late/delayed presentation in sub-Saharan Africa, which is directly linked to 1, 5, 13 -16 poor survival.
Despite recent health campaigns, patients still present with late stage disease in the University of Benin Teaching  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 oneyear period.

Results
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).for the poor survival rate.
One hundred and forty one patients (52.2%) were of lower socio-economic status.Lower socioeconomic status has been shown to limit patients' 26,27 access to effective breast cancer care 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 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 Africa has been documented.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 37 -39 embarrassment.
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 40,41 increased intimacy and support.This is in 39,42 contrast to what pertains in Africa.
Finances and problem in referral system accounted for 6.7% each in delayed presentation in this study.
In most African countries, healthcare is expensive 27,43 and individuals are required to pay out of pocket.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 27,44 major concern in Africa.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 27,42 presentation in advanced stages.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 45,46 to delayed presentation.In developing countries, the reported frequency of diagnosis delay of >3 45 months was 72.6% of patients with Breast cancer.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 11, 13 27, 35 and poor outcome and survival.

Conclusion
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.

Figure 1 :
Figure 1: Time interval before presentation