Late diagnosis of breast cancer in a hospital setting in Ouagadougou in 2024: patient characteristics and associated factors

INTRODUCTION

Of all cancers, breast cancer is the most common in women, with very high morbidity and mortality rates.¹ It represents a major public health problem, often regarded as a life-changing event.² Its prediction is strongly linked to the stage at which the diagnosis is made.³ Although the disease is more common in people over 50, younger women are also affected; they are affected by more aggressive, rapidly growing forms.⁴

Every year, there are over 1.7 million cases of breast cancer and almost 627,000 deaths worldwide.⁵ In 2020, 1,109,209 cases were recorded in Africa.⁵ Of these, 49,339 were recorded in West Africa, with 25,626 deaths.^2,5 These incidence and mortality rates will continue to rise unless effective prevention and management strategies are put in place.^6,7

Generally speaking, deaths from breast cancer occur most frequently in underdeveloped countries, where diagnosis is very late due to a number of factors.² These include lack of financial resources, sociocultural barriers, previous diagnostic errors, the inflammatory nature of cancers, fear of diagnosis, lack of breast self-examination, and reliance on traditional treatment and self-medication as first-line treatment.^8,9 This is a disease for which the means of diagnosis not only make it possible to identify the sociodemographic, clinical, and paraclinical characteristics.⁷ It helps to detect its manifestations at an early stage and also to assess the stages of progression in order to propose the most effective treatment protocols.⁷

There are four main stages of breast cancer, ranging from early stage to more advanced, numbered I to IV. The higher the stage, the more aggressive the disease. Stage I corresponds to a small, localized tumor. This is early-stage breast cancer. At this stage, there is no lymph node invasion or distant metastases. The prognosis is good.¹⁰ Stage II is characterized by a larger or slightly more invasive tumor. Limited involvement of nearby lymph nodes may be present, but no distant metastases. In stage III, the tumor is even larger. There is significant involvement of regional lymph nodes, but no distant metastases. Stage IV corresponds to metastatic cancer. The tumor can be of any size, with or without lymph node involvement.¹⁰ The main feature is the presence of distant metastases. Each stage requires specific management, adapted to the extent of the cancer and the patient’s general condition.⁷ Diagnosis is said to be late when it is made at advanced stages (III and IV), reducing the chances of survival and limiting treatment options.¹¹

In Burkina Faso, breast cancer ranks first among female cancers and is the second most deadly after cervical cancer.¹² According to data from the statistical yearbook of the Burkina Faso Ministry of Health, in 2023 there were 2,571 cases of breast cancer, with 111 deaths.¹³ Of the cases diagnosed in the country, 45.7% were at stage III of the International Union Against Cancer’s tumor nodes metastasis classification and 41% at stage IV.¹⁴ Faced with this situation, the government of Burkina Faso has put in place several strategies to promote early detection and reduce the incidence of the disease, including free screening and treatment of gynecological and breast cancers in the various public health facilities.^15,16 Despite the country’s best efforts, delayed diagnosis remains a problem.¹⁴ This delay results in complex and costly management, as well as reduced survival rates. The aim of the present study was to investigate late diagnosis of breast cancer, looking at the main characteristics of women affected, the state of late diagnosis, and the factors associated with it.

METHODS

Type and site of study

This was an analytical cross-sectional study. It took place in the university hospitals (CHU) of the city of Ouagadougou, from February 2 to July 31, 2024.

Study population

The study population consisted of all women with breast cancer (stage I to IV) who consulted one of the relevant departments during the study period.

Inclusion criteria

Included in the study were patients with histologically confirmed breast cancer fulfilling stage I, II, III and IV criteria and who had consulted or been hospitalized in one of the departments concerned during the study period.

Exclusion criteria

Patients whose general condition did not allow them to participate in the study were excluded.

Sampling and sampling

This was a non-probability, convenience (accidental) sample. We recruited patients who met our selection criteria in hospital, in the chemotherapy room, and then in the consultation room.

Dependent variable

The dependent variable was the time to diagnosis of breast cancer. It had two modalities: early and late. Late diagnosis was defined as advanced or immediately metastatic, i.e., stage III and IV according to the tumor nodes metastasis classification of the International Union Against Cancer. Conversely, early diagnosis was defined as diagnosis at a less advanced stage, corresponding to stages I and II of the same classification.

Explanatory variables

We grouped independent variables into sociodemographic, clinical and paraclinical variables; variables related to breast cancer knowledge and awareness; and variables related to access to screening services and sociocultural characteristics.^8,9

Sociodemographic variables were age, level of education, marital status, area of residence of women, income, health insurance.

Clinical variables were inaugural symptom, first recourse, reasons for delay in medical consultation, reason for consultation with conventional medicine, symptoms experienced, time to diagnosis, main reasons for delay in diagnosis

Paraclinical variables were health system delay.

Analytical methods

To meet the study’s objectives, we adopted a three-stage analytical approach: descriptive analysis, bivariate analysis, and multivariate analysis. We used descriptive analysis to characterize the individuals and variables studied. For quantitative variables, we calculated means and standard deviations, while for qualitative variables, we presented numbers and proportions (%). We performed a bivariate analysis to compare the relationship between late diagnosis (dependent variable) and each independent variable. We retained variables with a p value less than or equal to 20% for multivariate analysis. Finally, we used logistic regression to identify factors independently associated with late diagnosis. We expressed the results of this multivariate analysis in terms of adjusted odds ratios (OR), with their 95% confidence intervals. A p value of less than 5% was considered statistically significant.

Ethical and deontological aspects

The study protocol was submitted to registered under number 2023-11271 with the Health Research Ethics Committee for advice and approval. The agreement of the competent administrative authorities of the different hospitals was obtained before data collection. First, we obtained informed consent from patients who met our inclusion criteria and then we administered the questionnaire. We collected data under the responsibility of a physician who specializes in oncology. We respected confidentiality and restricted access to the digital database to the research team.

RESULTS

Characteristics of women with cancer

We analyzed 226 women. The 40-49 age group was most represented (39.3%). In addition, 33.63% had a secondary education level. More than half of the population (79.65%) lived in urban areas. Fewer than half (42.48%) had an income of over $300,000, and more than half (93.81%) did not have health insurance (Table 1).

Clinical and paraclinical characteristics of women

The majority of women (91.15%) included in this study were in conventional medicine. Of these, 97.33% had consulted a health-care professional after experiencing symptoms. The breast nodule was the main inaugural symptom of breast cancer for 64.16%. The lack of awareness of symptoms, mentioned by 56.05% of patients, was the main cause of delay in diagnosis, with a diagnostic time of less than 6 months in 50.44% of patients (Table 2). The mean time between first symptom and histological confirmation was 150 days, with a standard deviation of 217 days, and extreme values ranging from 27 to 771 days. The mean time between first consultation and biopsy was 80 days, with a standard deviation of 136 days and extreme values ranging from zero to 518 days. The time between biopsy and histological confirmation was 101 days, with a standard deviation of 123 days, and extreme values ranging from 2 to 511 days.

Bivariate analysis

Among the study variables, the following factors were significant with a p less than or equal to 0.2%. These were the level of study (p=0.086), the environment of residence (p=0.06), the inaugural symptom (more precisely, the mammary discharge) (p=0.17), the first recourse (more precisely, traditional medicine) (p<0.001). Also significant were symptoms (mainly ulceration) (p=0.092), lack of sensitization to symptoms (p=0.060), delay between biopsy and histological confirmation (p<0.001), as well as delay between first symptom and histological confirmation (p=0.085) (Table 3).

Frequency of late diagnosis

Among the 226 women with breast cancer, 74 were diagnosed late [32.74% IC95% (0.674-0.914)].

Factors associated with late diagnosis

The final logistic regression model showed that the following were significantly associated with late diagnosis of breast cancer (Table 4): residential environment (OR=0.08; p=0.001); the first treatment, including traditional medicine (OR=106; p<0.001); and insufficient awareness of symptoms (OR=4.63; p=0.001).

DISCUSSION

Study boundary

The main limitation of our study, which was conducted exclusively in a hospital setting, is that the results obtained are not generalizable to the entire female population.

Typical profile of women with breast cancer

A typical patient is a woman of a least 40 years of age, with a secondary education and living in an urban area (Table 1). Women in this age group may interpret some symptoms, such as pain or changes in the breasts, as hormonal manifestations related to menopause.¹⁷ They underestimate the risk of breast cancer, believing that the disease mainly affects older women.¹⁷ Also, in some cultures, decisions about health may be made by the spouse. This joint, mainly financial dependence could delay or limit their access to paid medical consultations or examinations.¹⁸

Frequency of late diagnosis of breast cancer

The frequency of late diagnosis of breast cancer in this study was 32.74%. Late diagnosis represents a major public health problem in terms of financial and emotional costs for the patients and the system of care delivery. Similar studies were conducted in Benin, in which the frequency of late diagnosis of breast cancer in hospitals was 62.1% in 2023.¹⁹ This frequency was higher than ours and could be explained by several reasons, such as differences in the quality and availability of health care, as well as the performance of the respective health systems.²⁰ This difference in frequency may also reflect differences in the level of effectiveness of disease awareness among the population.²⁰

The respondents alleged various reasons for the delay in curative consultation (Table 2). These include neglect, financial hardship, and fear of a positive outcome. Breast cancer is most common in women, with symptoms ranging from a lump in the breast to changes in skin texture.^19,21 These symptoms are not always perceived as serious.²² Many women have a limited understanding of the disease and are not familiar with screening methods.²³ They may not know that a nodule in the breast or a change in skin texture is a reason for consultation.²² They may underestimate the severity of these symptoms, attributing them to infection or hormonal changes.¹⁷ They may be reluctant to see a doctor or specialist, when they feel severe pain, usually in an advanced stage of the disease.^24,25 The high frequency of late breast diagnosis may be explained by a lack of awareness of early signs of breast cancer. This highlights the need to increase awareness of early signs of disease in order to reduce cancer-related mortality.²⁶

Factors associated with late diagnosis of breast cancer

Factors included in the logistics model are rural residence, first use of traditional medicine, and lack of awareness of symptom recognition. Being a rural resident deprives people of regular and easy access to communication channels about breast cancer. Rural populations have less access to information.²⁷ This inequality is explained in particular by the fact that radio and television infrastructures are most often grouped in cities.²⁸ Their transmission range remains small, reducing coverage and accessibility in rural areas.²⁷ Efforts by health professionals to make breast cancer information available to rural populations are mainly based on specific programs, such as organized awareness campaigns.¹⁶ These programs, although important, are not always sufficient to bridge the information gap, particularly with regard to the frequency and relevance of messages disseminated.^16,29 These deficiencies are even more pronounced for breast cancer, due to sociocultural taboos and geographic isolation that make it difficult to participate in screening and educational activities.³⁰

The use of traditional medicine is more systematic in rural than in urban areas.^31,32 Indeed, this recourse is often seen as an essential alternative to modern medicine, especially in contexts where modern health services are not easily accessible.^33,34 Traditional medicine is integrated with the sociocultural values and local practices of rural populations.^35,36 It often meets the immediate needs of people, at affordable costs and in a familiar setting.³¹ In addition, self-medication, which involves the use of home remedies or prescription-free medicines, is also a common alternative in rural areas, exacerbated by the lack of health professionals in those areas.³⁶

Lack of awareness about the recognition of breast cancer symptoms is also more common in rural than in urban areas. Awareness campaigns play a key role in the early detection of cancer.²⁷ They inform women about the early signs of the disease, encouraging them to consult a professional promptly when suspicious symptoms appear.²⁷ Insufficient awareness campaigns contribute to the neglect of early symptoms and delay medical consultation.³⁰ Although in our study the media accounted for more than three-quarters of all information sources (Table 3), they are still under-exploited in some low-income countries.²⁷ In these situations, prevention messages do not reach a broad audience, contributing to delayed cancer detection.^27,29

It is important to consider the three factors discussed in adherence strategies for early breast cancer screening.^27,30,33 This would also reduce inequalities in breast cancer management and improve the chances of recovery, especially for those living in rural areas.³⁷ More than three-quarters of our respondents were from urban areas (Table 1). An integrated approach that respects cultural beliefs is essential.³⁸ This could be achieved through a constructive dialogue between traditional and modern medicine, training traditional practitioners in detecting the early signs of breast cancer and encouraging them to refer patients for specialized care when in doubt.³¹ It would also be beneficial to strengthen the skills of modern medical professionals in breast cancer diagnosis and plan integrated active case research at the peripheral level.^2,5 By bringing together all the actors, diagnosis would be facilitated and knowledge enhanced on both sides.^2,5

CONCLUSION

The typical profile of women with breast cancer in our study was 40 years and older, secondary school educated, and living in urban areas. Rural residency, primary use of traditional medicine, and lack of awareness of symptom recognition are the model for interacting factors influencing the frequency of late diagnosis of breast cancer. These three factors should be considered in mitigation strategies for late breast cancer screening. A constructive dialogue between traditional and modern medicine would enable traditional practitioners to be trained in the recognition of breast cancer warning signs and the prompt referral of patients to appropriate health centers for treatment. It would also be interesting to bring together all the actors involved in the journey of women with cancer to facilitate diagnosis and strengthen their skills.

ACKNOWLEDGEMENTS

We thank all colleagues who provided advice and technical support in the writing of this manuscript.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Federal Office of Public Health. Noncommunicable diseases: a challenge. The national strategy for the prevention of non-communicable diseases (NCD strategy). 2020. Available from: https://www.iccp-portal.org/system/files/plans/CHE_B3_Les%20maladies%20non%20transmissibles%20un%20defi.pdf. Accessed on 2 November 2024.
2. 2. Aloulou S, Mahfoudi AE, Omrani AE, Khouchani M. Factors linked to late diagnosis of breast cancer: experience of the Mohammed VI Marrakech University Hospital. Pan Afr Med J. 2015;21:162.
3. 3. Miles R, Nicolae A, Ravi A. Routine breast cancer screening in average-risk women younger than 50 years: current paradigms based on National Guidelines. Oncology (08909091). 2021;35(6).
4. 4. National League Against Cancer. Cancers in French-speaking Africa. 2017. Available from: https://www.iccp-portal.org/system/files/resources/LivreCancer.pdf. Accessed on 2 November 2024.
5. 5. Cissé K, Adjadé G, Fadli ME, Essadi I, Belbaraka R. Factors linked to the late diagnosis of breast cancer and the initiation of treatment. Pan Afr Med J. 2024;47:207.
6. 6. Arnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. Breast Edinb Scotl. 2022;66:15‑23.
7. 7. Lopez A. Chapter 17. The treatment of the different stages of the method. Hors Collection. 2013:319-82.
8. 8. Toure M, Nguessan E, Bambara AT, Kouassi YKK, Dia JML, Adoubi I. Factors linked to late diagnosis in breast cancer in Sub-Saharan Africa: case of Côte d’Ivoire. Gynecol Obstet Fertil. 2013;41:696‑700.
9. 9. Darré T, Tchandikou L, Simgban P, Bombone M, Djiwa T, N’Timon B, et al. Factors associated with late diagnosis of breast cancer in women in Togo, Sub-Saharan Africa. BMC Womens Health. 2023;23:106.
10. 10. Masataka S, Hiroji I, Tadahiko S. TNM classification of malignant tumors (Breast Cancer Study Group). ResearchGate. 2019;49(3):228‑31.
11. 11. Breast diagnostic and therapeutic reference. Breast cancers and pathologies diagnostic and therapeutic attitudes, treatment protocols 2021-2022. 2021. Available from: https://www.gustaveroussy.fr/sites/default/files/referentiel-senorif-2021-2022.pdf. Accessed on 2 November 2024.
12. 12. Zongo N, Millogo-Traore TFD, Bagre SC, Bagué A-H, Ouangre E, Zida M, et al. Role of surgery in the management of breast cancer in women at the Yalgado Ouedraogo University Hospital Center: about 81 cases. Pan Afr Med J. 2015;22(117):1-4.
13. 13. General Directorate of Sectoral Studies and Statistics. Statistical yearbook 2023. 2024. Available from: http://cns.bf/IMG/pdf/annuaire_2023_mshp_signe_020824.pdf. Accessed on 2 November 2024.
14. 14. Somé OR, Bagué AH, Konkobo D, Hien D, Dembélé A, Bélemlilga GH, et al. Breast cancer in Bobo-Dioulasso, Burkina Faso: results of management. Oncology. 2022;24:173‑84.
15. 15. World Health Organization. In Burkina Faso, improve screening and prevention of cervical cancer. WHO. Regional Office for Africa. 2021. Available from: https://www.afro.who.int/fr/news/au-burkina-faso-ameliorer-le-depistage-et-la-prevention-du-cancer-du-col-de-luterus. Accessed on 2 November 2024.
16. 16. Ministry of Health. National strategy to combat cancer 2021-2025. 2020. Available from: https://www.iccp-portal.org/system/files/plans/BFA_B5_Strat%C3%A9gie%20nationale%20de%20lutte%20contre%20le%20cancer%202021-2025_VF%2022-10-2020.pdf. Accessed on 2 November 2024.
17. 17. Kim JHJ, Drake BL, Accortt EE, Pollin IS, Bairey Merz CN, Stanton AL. Younger women living with chronic disease: comparative challenges, resiliencies, and needs in heart disease and breast cancer. J Womens Health. 2021;30:1288‑302.
18. 18. Mseke P, Jessup B, Barnett T. Impact of distance and/or travel time on healthcare service access in rural and remote areas: A scoping review. J Transp Health. 2024;37:101819.
19. 19. Gnangnon F, Gbessi D, Kiki-Migan Y, Attolou S, Imorou Souaibou Y, Denakpo J, et al. Study of survival and prognostic factors for breast cancer in women in two reference hospitals in southern Benin. Rev DEPedemiology Public Health. 2021;69:S69‑70.
20. 20. The American College of Obstetrician and Gynecologists. Health Disparities in Rural Women. 2014. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/02/health-disparities-in-rural-women. Accessed on 2 November 2024.
21. 21. The League Against Cancer. Breast cancers. 2018. Available from: https://www.ligue-cancer.net/sites/default/files/media/downloadable-files/2023-09/les_cancers_du_sein.pdf. Accessed on 2 November 2024.
22. 22. Aloulou S, Mahfoudi AE, Omrani AE, Khouchani M. Factors linked to late diagnosis of breast cancer: experience of the Mohammed VI Marrakech University Hospital. Pan Afr Med J. 2015;21:162.
23. 23. Green SMC, Lloyd KE, Smith SG. Awareness of symptoms, anticipated barriers and delays to help-seeking among women at higher risk of breast cancer: a UK multicentre study. Prev Med Rep. 2023;34:1-8.
24. 24. Tagne Simo R, Baiguerel EM, Nwabo Kamdje AH, Seke Etet PF, Ahmadou M, Nangue C, et al. Awareness of Breast Cancer Screening among the Medical and General Population of the North Region of Cameroon. Int J Breast Cancer. 2021;2021:1-7.
25. 25. Lu Y, Hajjar A, Cryns VL, Trentham‐Dietz A, Gangnon RE, Heckman‐Stoddard BM, et al. Breast cancer risk for women with diabetes and the impact of metformin: a meta‐analysis. Cancer Med. 2022;12:11703‑18.
26. 26. Cherny NI, Paluch-Shimon S, Berner-Wygoda Y. Palliative care: needs of advanced breast cancer patients. Breast Cancer Targets Ther. 2018;10:231‑43.
27. 27. Chen X, Orom H, Hay JL, Waters EA, Schofield E, Li Y, et al. Differences in Rural and Urban Health Information Access and Use. J Rural Health. 2019;35:405‑17.
28. 28. Yeo H, Kra KJ, Koffi LF. Transport infrastructure and geographic accessibility of rural populations to urban health facilities in the dense area of Korhogo (northern Ivory Coast). Population and society space. Space Popul Soc. 2016;(2016/2).
29. 29. Afaya A, Ramazanu S, Bolarinwa OA, Yakong VN, Afaya RA, Aboagye RG, et al. Health system barriers influencing timely breast cancer diagnosis and treatment among women in low and middle-income Asian countries: evidence from a mixed-methods systematic review. BMC Health Serv Res. 2022;22:1601.
30. 30. Sarwar H. Navigating Breast Cancer in South Asia: Interconnected Challenges and Collaborative Solutions. J Cancer Ther Res. 2024;4. Disponible sur : https://www.genesispub.org/navigating-breast-cancer-in-south-asia-interconnected-challenges-and-collaborative-solutions
31. 31. Alemu Anteneh T, Aklilu Solomon A, Tagele Tamiru A, Solomon Tibebu N, Nigatu Alemu H, Yibeltal Desalegn S, et al. Knowledge and Attitude of Women Towards Herbal Medicine Usage During Pregnancy and Associated Factors Among Mothers Who Gave Birth in the Last Twelve Months in Dega Damot District, Northwest Ethiopia. Drug Healthc Patient Saf. 2022;14:37‑49.
32. 32. Shewamene Z, Dune T, Smith CA. The use of traditional medicine in maternity care among African women in Africa and the diaspora: a systematic review. BMC Complement Altern Med. 2017;17:382.
33. 33. Li S, Odedina S, Agwai I, Ojengbede O, Huo D, Olopade OI. Traditional medicine usage among adult women in Ibadan, Nigeria: a cross-sectional study. BMC Complement Med Ther. 2020;20:93.
34. 34. Ministère de l’économie, et du développement. Accès des pauvres aux services de base. 2002;1-85.
35. 35. Ouoba K, Bonkoungou WH, Semdé R. Traditional Medicine’s Contribution to Health Care Access in Burkina Faso. Glob Adv Integr Med Health. 2024;13:1-2.
36. 36. Madi H. Meeting: traditional medicine and western medicine in healthcare in Mayotte. 2023;1‑97
37. 37. Haddad S, Nougtara A, Ridde V. Inequalities in access to health services and their determinants in Burkina Faso. Health Soc Solidar. 2004;3:199‑210.
38. 38. West African Health Organization. Traditional medicine practices and promotion of medicines from traditional pharmacopoeia in ECOWAS member states. 2013. Available at: https://www.wahooas.org/web-ooas/sites/default/files/publications/2186/pratiques-de-la-medecine-traditionnelleok.pdf. Accessed on 2 November 2024.