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Macedonian Journal of Medical Sciences. 2011 Dec
15;
4(4):388-392.
http://dx.doi.org/10.3889/MJMS.1957-5773.2011.0187
Clinical Science
Breast Cancer among Urban Nigerian Women: Appraising Presentation and the Quality of Care
Nasiru Akanmu Ibrahim1, Abiodun O Popoola2, Mobolaji A
Oludara1, Foluso O Omodele1, Idowu Olesegun Fadeyibi1
1Department of Surgery, Lagos State University College of
Medicine and Lagos State University Teaching Hospital, Ikeja-Lagos, Nigeria;
2Department of Radiology, Lagos State University College of
Medicine and Lagos State University Teaching Hospital, Ikeja-Lagos, Nigeria
Introduction: Late presentation is the hallmark of breast cancer
among Nigerians. Awareness of the disease is low and care of this condition
has not received adequate attention from Government. Health education to
improve awareness was intensified in the last 2 decades. This study aims to
assess the current state of care and presentation of breast cancer in Lagos,
Nigeria.
Patients and Methods: A prospective study of 350 breast cancer
patients seen over a period of four years at a General Surgical unit
out-patient clinic of LASUTH was carried out. Data on patient
characteristics, presentation, diagnosis and treatment were obtained and
analyzed.
Results: Average duration of symptoms was 46.48 weeks. One fifth
presented within 3 months while 17% presented after 1 year. Lumps were
self-detected in 96% and 287 (82%) presented with advanced disease (stages
III & IV). Two hundred and thirty seven patients (67%) received treatment
and 175 (74%) among them had mastectomy. None had breast conservation
surgery. One hundred and fourteen patients (48%) absconded and did complete
treatment.
Conclusion: The trend of late presentation has not changed with
current efforts to improve breast cancer awareness. Quality of care for our
breast cancer patients is not satisfactory and needs improvement.
...................
Citation: Ibrahim NA, Popoola AO, Oludara MA,, Omodele FO, Fadeyibi
IO. Breast Cancer among Urban Nigerian Women: Appraising Presentation and
the Quality of Care. Maced J Med Sci. 2011 Dec 15; 4(4):388-392.
http://dx.doi.org/10.3889/MJMS.1957-5773.2011.0187.
Key words: Breast cancer; awareness; quality of care; presentation;
treatment.
Correspondence: Dr. Nasiru Akanmu Ibrahim. Lagos State University,
College of Medicine, Dept of Surgery, Ikeja, Lagos100247, Nigeria. E-Mail:
ibrahimakanmu@yahoo.com
Received: 16-Jun-2011; Revised: 17-Aug-2011; Accepted: 01-Sep-2011; Online
first: 04-Oct-2011
Copyright: © 2011 Ibrahim NA. This is an open access article
distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
Competing Interests: The authors have declared that no competing
interests exist.
Breast cancer is the most common female malignancy worldwide and a leading
cause of cancer deaths [1]. In Nigeria, it has become the most common female
cancer, taking over from cervical cancer [2]. Current estimates put the
prevalence of this condition in Nigeria at 116 cases per 100,000 women/year
[2]. This rate is higher than 33.6/100,000 women reported less than 2
decades ago [3]. In advanced countries, majority among breast cancer
patients present with early stages due to better awareness and adoption of
breast cancer screening methods [1]. In contrast, more than two-third among
breast cancer patients in Nigeria and many developing nations present late
when the disease is already advanced [2, 4, 5]. Breast cancer patients in
Nigeria are younger; presenting a decade earlier than their Caucasian
counterparts [2]. In addition, studies on biological characteristics of
breast cancer showed that it tends to be more aggressive in black women [6].
These features portray poor prognosis for this condition in Nigerian women
with breast malignancy.
Currently, facilities for breast cancer screening and treatment in Nigeria
are grossly inadequate and resources available to government are used
largely to tackle the challenges of communicable diseases such as HIV/AIDS,
Tuberculosis, Malaria and reduction in maternal mortality. Following the
establishment of Nigeria cancer society in 1968, other non–governmental
organizations like the breast cancer association of Nigeria (BRECAN), the
bloom Cancer and Support Centre and Princess Nikky breast cancer foundation
were formed to promote breast cancer awareness and offer support to victims
of the disease in the country. In addition, regular mass screening of women
in their places of work, markets and worship centres employing clinical
breast examination (CBE) was commenced by Lagos State government about a
decade ago.
We therefore prospectively studied the characteristics, presentation and
quality of care of breast cancer patients seen at the out-patient clinic of
a single general surgical unit of the Lagos State University Teaching
Hospital (LASUTH), Ikeja-Lagos, Nigeria between January 2006 and December
2009. The objective is to assess the current state of breast cancer care and
presentation in Lagos, a highly urbanized State in Nigeria. This may assist
in defining the gaps in breast cancer detection and treatment in our
community. It may also help in identifying areas where improvement are
needed.
All patients with breast cancer presenting to
one of LASUTH, General Surgical Clinics between January 2006 and December
2009 were prospectively studied. Informed consent was obtained and the
hospital Research and Ethics committee approved the conduct of the study.
Information obtained included age, sex, marital status, occupation, level of
education, reproductive and social histories of the patients. Presenting
complaint(s), duration of symptoms, mode of lump detection, history of past
breast lesions and family history of breast disease were also documented.
Tumours were clinically assessed and biopsies
were taken for either histological or cytological diagnosis. Assessment of
metastases was done by chest X-ray and abdominal ultrasonography and where
indicated, skeletal X-ray and CT scan. Staging was done using the American
Joint Committee on Cancer (AJCC) method [7]. Patients whose lesions were
amenable to surgery were offered simple mastectomy and level II axillary
clearance after which they were all sent to the Oncology Unit for adjuvant
chemotherapy and radiotherapy. Those with advanced diseases that were not
suitable for immediate surgical intervention were referred to the Oncologist
after diagnosis for neo-adjuvant chemotherapy. Radiotherapy was recommended
for patients with T4 lesions, N2 or N3 nodal stage, primary tumour of 5cm or
more with positive axillary lymph node, axillary lymph node of >2.5 cm in
diameter and Pectoralis muscle Fascia involvement. Patients were referred to
another centre for radiotherapy because the facility was not available in
our hospital. They were followed up at the oncology clinic and outcomes of
treatment were documented. Data was analyzed using SPSS version 15.0.
Frequency tables were drawn; means and proportions were also calculated.
Characteristics of Breast Cancer Patients
A total of 350 new cases of primary breast
cancer were seen during the study period. Age ranged from 23 to 104 years
with a mean of 48.93 years (SD ± 13.365). Table 1 shows socio-demographic
features of the patients.
Table 1:
Characteristics of breast cancer patients in LASUTH (n = 350).
Clinical Presentation
Three hundred and forty eight patients (99.5%)
presented with breast lumps. Lumps were detected by the patients in 95%
cases. In 11 patients (3%), lumps were detected by the doctor during
examination for other complaints while in 4 patients (1%), they were
detected by the husband. Lumps in 4 patients (1%) were discovered through
clinical breast examination during government sponsored mass screening
exercises. Other associated presentations include breast ulceration in 18%,
breast pain in 5%, nipple retraction in 3%, bloody nipple discharge in 2%
and axillary mass in 0.5%.
Table 2:
Distribution of symptoms duration.
Duration of symptoms among patients ranged from
3 weeks to 6 ½ years. Average duration of symptoms was 46.48 weeks (SD ±
51.97). One-fifth presented within 3 months while 17% presented after 1 year
(Table 2). Right breast alone was affected in 157 patients (45%) and left
breast alone in 144 patients (41%). In 49 patients (14%), both breasts were
affected at presentation. Stage of tumour at presentation is shown in Table
3.
Table 3:
Clinical stage of tumours at presentation.
Pathology
Histological diagnosis was made in 296 patients
(85%) while the rest (15%) had cytological diagnosis by Fine Needle
Aspiration Cytology (FNAC). Invasive ductal carcinoma was the most common
histological type accounting for 93% followed by invasive lobular carcinoma
seen in 3%.
Treatment
Two hundred and thirty seven patients (67%)
received treatment in our hospital while 113 patients (33%) did not report
for treatment after diagnosis. Among those that were treated, 175 (74%) had
simple mastectomy and axillary clearance. All of them commenced adjuvant
chemotherapy after surgery. Sixty two patients (26%) whose lesions were not
suitable for surgery had neo-adjuvant chemotherapy. Adriamycin and
cyclophosphamide combination was used in 72% of cases while 22% had
cyclophosphamide, methotrexate and 5 fluorouracil (CMF) combination. All
patients that received treatment were placed on oral tamoxifen empirically
because our centre lacks facilities to assess hormone receptor status. One
hundred and eight patients (46%) were referred for radiotherapy following
completion of chemotherapy. A total of 114 patients (48%) among those that
commenced therapy did not complete treatment. Forty five out of the 114
patients (39%) defaulted during the course of chemotherapy while the
remaining 69 patients (61%) were not seen again at the clinic after referral
for radiotherapy.
Outcome
Among 123 patients who did not default, 8 (6.5%)
died before completion of treatment and only 115 (93.5) completed prescribed
therapy. Another thirty patients (24%) died after completion of treatment;
making a total of 38 deaths during the study period. Sixty seven patients
(54.5%) are still alive and attending clinic while 18 (15%) stopped
attending clinic. Reasons for stopping clinic attendance could not be
ascertained.
Painless breast lump is the dominant presenting complaint in our patients
and they were self-detected in nearly all cases. Substantial proportion of
breast cancer is detected by mammography screening in communities with high
level of awareness. In Singapore, for example, 13.4% of breast cancers were
screen detected [8]. In this study, only 4 patients (1%) were found to have
breast cancer through mass screening employing CBE. Less than half among the
patients presented within 6 months. Earlier study conducted in Lagos more
than a decade ago showed that 36% reported within 6 months after observing
breast cancer symptoms [9]. Late presentation is a notable feature in breast
cancer patients in developing countries [4, 5]. This has been a persistent
feature of breast cancer presentation in Nigeria over the past 4 decades [2,
3, 10]. Studies have shown that fear of mastectomy, ignorance of the
seriousness of painless breast lump, preference for traditional treatment,
belief in spiritual healing and economic reasons are the main cause of late
presentation of breast cancer patients in Nigeria and Ghana [11, 12]. Eighty
two percent among breast cancer patients in our centre presented with
advanced disease (Stages III & IV). This figure is higher than what was
reported more than a decade ago when 77% among breast cancer patients in
Lagos presented in late stages [9]. Reports from other centres in Nigeria
over the years showed that majority, ranging from 64% to 95% presented with
late stages of the disease [2, 3, 10, 13]. Fourteen percent had bilateral
breast involvement at presentation in this study. Involvement of both
breasts at presentation ranged from 1% to 9% in previous studies among
breast cancer patients in Nigeria [3, 9, 10, 13].
Breast cancer awareness remains low among Nigerian women [14]. Patients
continue to present late even when lesions are discovered early. Efforts by
government and non-governmental agencies towards raising awareness and
encouraging early presentation of the disease appear ineffective so far.
Observed increase in the proportion of bilateral breast cancer at
presentation in this study further reinforces this belief. Lagos has the
largest concentration of both print and electronic media outfits used in
breast cancer information dissemination in Nigeria. Furthermore, majority of
the patients in the study are literate. All these do not appear to have made
positive impact regarding breast cancer awareness. Communities have adopted
different types of approaches towards achieving increased awareness about
breast cancer. Individual–level interventions by written information,
telephone counselling or interactive computer programme were tried but found
to promote cancer awareness over short term only. There was no evidence that
they promote early presentation with cancer symptoms [15]. However,
community–level intervention through small group educational programmes,
health promotion programmes in work places, health clubs and leisure centres
was found to promote cancer awareness and presentation at an early stage
[15]. There is need for studies aimed at identifying effective ways to
achieve better awareness and early presentation of breast cancer patients in
our community.
Two-third among those diagnosed as having breast cancer eventually received
treatment in our hospital. Simple mastectomy and level II axillary clearance
were offered to those whose lesions were still operable. None had breast
conservation surgery. This is a reflection of the advanced nature of breast
cancer in our patients. Few that presented with early stages were not
considered for conservation surgery largely because of non-availability of
radiotherapy facilities in our centre. Breast conservation surgery is
currently the most popular treatment for breast cancer, representing 75 –
80% of all operations [16]. In patients presenting with large primary
tumours, primary chemotherapy has been utilized to reduce the size of the
tumour and make the lesion suitable for breast conservation surgery [16].
Unfortunately, advanced stages at presentation and poor infrastructure for
treatment of breast cancer have made this mode of surgical treatment less
popular in many developing countries. None of the patients was offered
plastic surgery for breast reconstruction following mastectomy due to late
presentation and the necessity for prolonged follow-up before the
reconstructive procedure. Breast reconstruction after mastectomy for breast
cancer has become a standard procedure. In a report, 42% among patients
undergoing mastectomy had breast reconstruction with 95% being performed at
the time of mastectomy [17]. Awareness about the availability of expertise
and facilities for immediate breast reconstruction after mastectomy may
encourage early presentation for treatment among our patients.
All patients presenting for treatment had combination chemotherapy. This is
an important component of breast cancer treatment and it is widely used in
centres across Nigeria. One fifth among those offered chemotherapy defaulted
and did not complete the course. Non adherence to chemotherapy is a major
challenge in breast cancer treatment especially in resource poor settings.
Reasons for non-adherence include financial difficulty, relatively feeling
well after commencement of chemotherapy, resorting to alternative treatment
and drug side effects [18]. Only one-third among patients who were referred
to the Radiotherapist reported to the oncology clinic after completion of
radiotherapy. Access to radiotherapy is a serious handicap to breast cancer
treatment in developing countries. In Nigeria, a country with over 140
million inhabitants, there are only 5 functional radiotherapy centres. The
high cost of this mode of treatment which is beyond what an average breast
cancer patient can afford might have contributed to the non-compliance.
Generally, high default rate was observed in this study. Thirty-three
percent did not present for treatment after diagnosis was made while 48%
among those that commenced treatment did not complete therapy. Default after
diagnosis and during treatment for breast cancer is common among patients in
Nigeria. In an earlier study in Lagos, one-third among breast cancer
patients was lost to follow-up [9]. Similarly high rate of default was
reported by Adesunkanmi et al in Ile-Ife, Nigeria [13]. In Accra, Ghana,
one-third among breast cancer patients was lost to follow-up [19]. In
addition, reasons for absconding were found to be similar to that for late
presentation to the hospital [12].
Conclusion and recommendation
Breast cancer patients in Lagos present late with advanced stages of the
disease. Awareness campaigns and health education have so far failed to
change this trend in majority of patients. A new approach to breast cancer
information dissemination that will address already known causes of late
presentation and enhance early detection and presentation is desirable.
Quality of care for our breast cancer patients needs improvement. Provision
of adequate facilities for early diagnosis and treatment particularly,
radiotherapy machines are necessary. High default rate after diagnosis and
during treatment observed in this study is worrisome. This may be partly due
to misconceptions about breast cancer treatment. It should be addressed by
adopting new strategies that will encourage patients to take up and complete
their treatment accordingly. Default may lessen if cost of treatment is
reduced and made affordable.
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