Real-world challenges for patients with breast cancer in sub-Saharan Africa: a retrospective observational study of access to care in Ghana, Kenya and Nigeria

Abstract

Objective: To evaluate medical resource utilisation and timeliness of access to specific aspects of a standard care pathway for breast cancer at tertiary centres in sub-Saharan Africa.

Design: Data were retrospectively abstracted from records of patients with breast cancer treated within a prespecified 2-year period between 2014 and 2017. The study protocol was approved by local institutional review boards.

Setting: Six tertiary care institutions in Ghana, Kenya and Nigeria were included.

Participants: Health records of 862 patients with breast cancer were analysed: 299 in Ghana; 314 in Kenya; and 249 in Nigeria.

Interventions: As directed by the treating physician.

Outcome measures: Parameters selected for evaluation included healthcare resource and use, medical procedure turnaround times and out-of-pocket (OOP) payment patterns.

Results: Use of mammography or breast ultrasonography was <45% in all three countries. Across the three countries, 78%-88% of patients completed tests for hormone receptors and human epidermal growth factor receptor 2 (HER2). Most patients underwent mastectomy (64%-67%) or breast-conserving surgery (15%-26%). Turnaround times for key procedures, such as pathology, surgery and systemic therapy, ranged from 1 to 5 months. In Ghana and Nigeria, most patients (87%-93%) paid for diagnostic tests entirely OOP versus 30%-32% in Kenya. Similarly, proportions of patients paying OOP only for treatments were high: 45%-79% in Ghana, 8%-20% in Kenya and 72%-89% in Nigeria. Among patients receiving HER2-targeted therapy, the average number of cycles was five for those paying OOP only versus 14 for those with some insurance coverage.

Conclusions: Patients with breast cancer treated in tertiary facilities in sub-Saharan Africa lack access to timely diagnosis and modern systemic therapies. Most patients in Ghana and Nigeria bore the full cost of their healthcare and were more likely to be employed and have secondary or postsecondary education. Access to screening/diagnosis and appropriate care is likely to be substantively lower for the general population.

Keywords: breast tumours; health economics; health services administration & management; oncology; quality in health care.

Figure 1

Proportion of patients using key healthcare resources for management of breast cancer. ER, oestrogen receptor; HER2, human epidermal growth factor receptor 2; IHC, immunohistochemistry; LFT, liver function test; PR, progesterone receptor; UEC, urea/electrolytes/creatinine panel.

Figure 2

Mean number of cycles of trastuzumab received by patients paying out-of-pocket (OOP) only compared with those with third-party payer support.

Figure 3

Median turnaround time to receipt of key aspects of care by country and type of tertiary care centre (government vs private). IHC, immunohistochemistry.

Figure 4

Patients paying OOP for procedures. ER, oestrogen receptor; HER2, human epidermal growth factor receptor 2; IHC, immunohistochemistry; LFT, liver function test; OOP, out of pocket; PR, progesterone receptor; UEC, urea/electrolytes/creatinine panel.