In this prospective, descriptive study of 47 hospitals equipped for the management of breast cancer patients in sub-Saharan Africa, differences in the ability of these facilities to provide a quality continuum of care for breast cancer patients were found.
Sub-Saharan Africa
SSA is, etymologically, the area of the African continent that lies south of the Sahara. According to the United Nations Population Division, the population is expected to grow rapidly by an annual average rate of 2.7% to reach 2.2 billion by 2050 [16].
Hospital size and coverage in SSA
More than one-third of the hospitals included in our study covered a population greater than two million people, and the majority were referral hospitals. These figures indicate that access to care is particularly difficult for cancer patients in SSA. A study reported that more than one-sixth of the population in SSA lives more than two hours away from a public hospital [16].
Availability and access to breast cancer surgery in SSA
Our results indicate that surgeons are the most accessible specialists involved in breast cancer management in SSA. In most low-income countries, surgeons are often the only available specialists in cancer care and are responsible not only for diagnosis and surgical management but also for nonsurgical treatment (chemotherapy) as well as palliative care [17].
To improve the technical capacities of hospitals providing cancer care in SSA, there is clearly a need to train surgeons in a number of cancer surgical procedures [17]. In the US, the subspecialization of breast surgical oncology has resulted in more favorable outcomes and higher patient satisfaction [18].
Access to breast cancer imaging in SSA
Unlike CT, ultrasound was available in the majority of SSA hospitals covered by our study. The accuracy of ultrasonography in the preoperative assessment of breast cancer is necessary to provide accurate loco-regional pretreatment planning [19], but CT is essential for disease staging and the extension workout. In most SSA countries, clinical examination, chest radiography, and ultrasound are often the only available resources for staging a patient [17].
Access to pathology in SSA
Only half of the hospitals in this study had a functional full-time pathology department. Breast cancer management is based on pathology and immunohistochemistry findings [20]. In most low-resource settings, such as SSA, patients with breast cancer rarely obtain a histological diagnosis; therefore, many receive inappropriate treatment [17]. The greatest challenge in most LMICs is the lack of human resources [17, 20]. In SSA, for instance, there are less than 80 pathologists for every 1 million population (60 times less than recommended) [17].
Access to radiotherapy
Access to radiotherapy is probably the most challenging aspect of breast cancer management in SSA. In fact, SSA is the region of the world with the most limited radiotherapy services [21]. In 2017, twenty-nine African countries out of fifty-four reported having no access to radiation services [5]. In our study, radiotherapy was one of the least available therapies. The 2020 WHO World Cancer Report highlighted data showing the significant relationship between the number of available radiotherapy machines and cancer mortality [22]. The limited access to radiotherapy could explain, in part, the excess mortality from breast cancer in SSA for several reasons. First, the majority (up to 90% in some countries) of breast cancers are diagnosed at a late stage in SSA [5], and radiotherapy is a pivotal treatment for the control of locally advanced breast cancers. Radiotherapy can also have an impact on the acceptability of care. Indeed, in a study conducted in Nigeria [23], fear of mastectomy was the primary cause of delay in the management of women with breast cancer. African series are characterized by a high rate of mastectomy compared to Western series due, among other things, to the absence of radiotherapy, which is the standard of postsurgical care in cases of breast-conserving surgery.
Even when radiotherapy was available, the devices sometimes do not comply with international recommendations (half of the hospitals in our study still use a cobalt accelerator, which is considered to be less appropriate than a linear accelerator). Cobalt accelerators are suboptimal for radiotherapy treatment, particularly in SSA, for many reasons. First, cobalt's decaying dose rate and its more significantly reported grade 3 to 5 toxicities limit its use in clinical situations compared with linear accelerators. Moreover, there are security concerns with that active source, which always produces radiation, has a high potential for harm and requires specific security measures for source transfers, disposal and the vault that hosts the unit [24].
Another issue is the fact that the devices sometimes fail, resulting in dramatic situations. In a previous study, the radiotherapy machine at one of Uganda’s main cancer centers was down for 18 months; therefore, only 15% of patients with breast cancer had access to radiotherapy [4].
Access to chemotherapy and systemic therapies
Breast cancer in Africa is thought to be a more aggressive disease occurring in younger women with poor hormone receptor staining, which may require the use of many lines of chemotherapy [5]. Moreover, with most breast cancer patients presenting at late stages in SSA, the role of surgery as a curative measure is reduced [6].
In our study, only half of the hospitals (n = 25, 53.1%) had chemotherapy drugs available on site. Unfortunately, even when chemotherapy is offered, experience has shown that the limited availability and cost of treatment lead to high rates of interruption and premature termination of cycles [6]. In Eritrea, in 2013, more than 97% of patients received surgical intervention as their only treatment because there were no chemotherapy or radiotherapy options available nationally [6, 25].
Nevertheless, chemotherapy is cost prohibitive for most patients on the African continent [5]. The discovery of HER 2-targeted therapy, such as trastuzumab or pertuzumab, and more recently immunotherapy, such as pembrolizumab, has revolutionized the management of certain subtypes of breast cancer. However, despite the inclusion of some of those systemic therapies in the World Health Organization (WHO) essential drug list, the cost of these life-saving drugs remains, unfortunately, high [5] and therefore inaccessible for most patients in SSA. Tamoxifen, a very low-cost hormonal therapy sometimes available free of charge, is one of the most accessible treatment options even in poorer countries of SSA. Unfortunately, in black women, the most common type of breast cancer seems to be triple-negative breast cancer, which is known to be much more aggressive and less sensitive to hormonal therapies [26].
MDT
Our study found that MDTs are not available in most hospitals treating breast cancers in SSA. Moreover, even when MDTs were available, only a limited proportion of patients, which varies greatly from one hospital to another, were discussed. This could partially explain the excess breast cancer mortality in SSA. In some settings, MDT care was reported to intercept 98.8% of all medication errors and improve the quality of care [27]. In the United Kingdom, for example, the introduction of MDTs and the resulting improvement of processes and treatment pathways has reduced breast cancer mortality by 18.0% [8].
One of the most important aspects of MDT care is the quality and variety of team members. In breast cancer services in the UK, at a minimum, the MDT core members for breast cancer care include clinical and medical oncologists, breast surgeons, radiologists, pathologists and breast care nurse specialists [27]. In our study, the most frequently missing practitioners at MDTs were nurse oncology specialists. In a previous report, MDT members identified specialist oncology nurses as “the glue of the team” [28].
Access to palliative care and opiate prescriptions
According to our study, access to opiate pain medication seems to be low. It is astonishing that such a relatively inexpensive, essential medicine is inaccessible to the world's poorest region[29]. According to a scoping review of palliative care in Africa [30], the limited availability of opioids in Africa is because some countries have strict regulations on opioid use and prescription, while others require specific licenses to prescribe or administer morphine. At a hospital level, training in pain management and the presence of a palliative care team could improve morphine prescription [31].
Pathway and financial access to care
The pathways that patients take to breast cancer treatment in SSA are numerous and littered with obstacles because of both patient- and system-related factors. In addition to diagnostic delays that we have already discussed, there are further delays between confirmation of diagnosis and onset and completion of therapy [2, 32]. Understanding these barriers would support global and country-level decision-makers in planning and programmes for improvements [33].
Limitations of the study
Although we examined 47 hospitals from 15 countries, we cannot ensure that our sample is representative of all hospitals treating breast cancer in SSA. However, this work produces estimates of the availability and quality of breast cancer treatment that were not previously estimated from SSA to the best of our knowledge. Our study produces estimates from data collected in the field and could be used to inform public health authorities on breast cancer management in SSA and to improve models for access to breast cancer treatment in SSA.