USAfrica: Tackling inequities in Breast Cancer treatment in Africa

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Dr. Miriam Mutebi is a breast cancer surgeont and Assistant Professor in the Department of Surgery at the Aga Khan University Hospital in Nairobi. She was appointed to the board of directors of the Union for International Cancer Control (UICC). Dr. Mutebi, a , clinical epidemiologist and alumni of AKU is the first African oncologist to sit on the board.
WHO. July 13, 2022: In sub-Saharan Africa, preventing and treating breast cancer is a pressing public health issue. Breast cancer survival rates five years after diagnosis stand at a dismal 40% in sub-Saharan Africa — as compared to over 90% in most high-income countries.

In countries showing successful reductions in breast cancer mortality rates, most breast cancer patients are diagnosed at an early stage, when the disease is more likely curable. In sub-Saharan Africa, late-stage diagnosis and inadequate access to quality breast cancer care lead to high death rates. Most women are diagnosed at advanced stages when treatment is difficult, costly and less likely to achieve a cure.

Addressing barriers to early diagnosis

Illustrating the many barriers to accessing quality breast cancer treatment in sub-Saharan Africa, Dr. Miriam Mutebi, a breast surgical oncologist in Nairobi reports, “A few years back, a patient of mine was diagnosed with breast cancer and had begun her chemotherapy treatment, when she suddenly disappeared. She came back to me after six months overjoyed that she had finally saved up enough money for the remaining treatment. The local National Hospital Insurance Fund (NHIF) has helped considerably to increase the number of patients completing care, but more needs to be done to provide comprehensive coverage.” Paying out of pocket to access care routinely results in catastrophic health costs and financial hardship for families—leading to treatment delays that make treatment less effective.

Socio-cultural barriers further limit access to cancer treatment in sub-Saharan Africa: Women often lack agency to seek healthcare on their own. This situation is worsened by cancer myths and widespread stigma. “A number of  cancer patients are abandoned by their partners or families after receiving a cancer diagnosis because of stigma,” said Dr Mutebi. “Cancers related to a woman’s reproductive system are often erroneously linked to sexual promiscuity or equated with failure to fulfil one’s role as a caregiver—resulting in abandonment.”  These misconceptions amplify the socio-cultural barriers that deter women from cancer screening or completing their treatment once diagnosed.

The WHO Global Breast Cancer Initiative (GBCI) strives to address barriers in early cancer diagnosis through its first pillar: health promotion and early detection. This first pillar in the initiative’s three-pronged approach aims to reduce stigma associated with breast health and improve public awareness of the signs and symptoms of breast cancer.

Closing the gap between diagnosis and treatment

The initiative’s second pillar is to ensure timely diagnosis. Dr Mutebi explains how health provider diagnostic delays promote late-stage diagnosis: “a patient of mine, who also happened to be HIV-positive, came to me with stage four breast cancer. She had been attending an external facility for anti-retroviral treatment for eight years with monthly visits to the institution and yet no one had ever discussed with her or screened her for breast or even cervical cancer for which she was at higher risk.” Health provider delays contribute to poor prognoses for women with breast cancer in sub-Saharan Africa.

To ensure timely referrals for diagnosis, health workers must be trained to identify the signs and symptoms of early breast cancer. Dr Mutebi reports, “data shows that many patients in sub-Saharan Africa will on average see three or four health providers, before receiving a definitive cancer diagnosis”. She shares another example of a patient: “a lactating mother was treated with antibiotics for months on end, for a worsening lump labelled as an ‘unresolving mastitis’, while being falsely reassured that since she was breastfeeding, it  was nothing to worry about!” By the time the patient reached Dr Mutebi’s team, the tumour had progressed considerably.

Every patient who visits a clinic provides an opportunity to engage in prevention education and timely interventions for cancer management. GBCI strives to minimize delays between the time a breast cancer patient first interacts with the health system and when treatment starts. Through the initiative, countries will receive an evidence-based technical package that incorporates existing WHO cancer tools and products to strengthen health systems.

Employing a multidisciplinary approach to cancer care

Relaying the importance of GBCI’s third pillar—comprehensive breast cancer management—Dr Mutebi shares how the kind of care patients received might depend on the type of clinician they first encounter: “If you saw a surgeon first, you would blink twice and find yourself in the operating theatre. If you saw the oncologist, you were likely to receive chemotherapy first”.

Cancer treatment requires the collaboration of multiple specialities to provide surgery, chemotherapy and radiotherapy in the correct sequence, as well as rehabilitation for women after treatment with palliative services to reduce pain and discomfort.

Fortunately, Dr Mutebi sees growing recognition in the region regarding the need for multidisciplinary approaches to cancer management based on the concept of “personalised care where treatment is tailored to each patient”. There has been an encouraging increase in the number of countries with national cancer control programs in SSA, that emphasize these important pillars of breast cancer care. More in-country investment in systems and health workforce is still needed to improve access to these services for our patients.

WHO supports governments to provide centralized services for breast cancer with the aim of ensuring that 80% of breast cancer patients undergo full-course multimodality treatment. Through GBCI’s three pillars—health promotion and early detection, timely diagnosis, and comprehensive breast cancer management—WHO aims to reduce global breast cancer mortality by 2.5% per year by 2040.

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