Factors Contributing to Delayed Breast Cancer Presentation: A Prospective Study at Parirenyatwa Group of Hospitals, Harare, Zimbabwe 2010-2013

Background: Breast cancer is one of the most common female cancers in Zimbabwe. A considerable proportion of patients delay presentation, leading to high morbidity and mortality. Delay in presentation can either be provider or patient delay. Survival is related to the stage at presentation. Delayed presentation is associated with lower survival. Understanding the reasons for delay may help in reducing delays and morbidity and mortality. This study addresses these concerns.

Aim: To determine factors contributing to delayed breast cancer presentation at Parirenyatwa Group of Hospitals.

Methods: A prospective observational study of patients with the clinical and histological diagnosis of breast cancer attending Surgical Outpatient clinics awaiting surgery, or operated on from January 2010 to December 2013 were included. Patients were interviewed and specific questions relating to breast cancer risk and delay factors were recorded. Relevant investigations, including Human Immune Deficiency Virus (HIV) testing, were done and recorded. Final histology results were collected from Histopathology Department, analyzed and recorded. In addition to chi-square test for associated factors of delay and proportionate z test for percentage differences, the researchers validated the observed factors using discriminant analysis. Discriminant analysis was used to model the reasons and delay period with a cut-off point 3 months (< 3 months / ≥ 3 months).

Results: Seventy three patients were enrolled in the study. Forty nine (62.1%) were of rural domicile. Time to breast cancer presentation ranged from 1 to 52 months. The most common reason for delay (66%) was ignorance and secondly (18%) poverty. Fifty three (72.6%) patients were unemployed (p<0.05). Primary school was the highest level of education in 23 patients (31.5%), with 38 (52.1%) having attained secondary level education. Fifty-seven (78.1%) patients presented with a mass (p<0.05%) with pain occurring in 29 (39.7%) of patients. Fifty four patients (74%) had no knowledge of breast self-examination (BSE) and 37 (51%) of these patients were of rural domicile (p<0.05). Of the 37 rural patients with no knowledge of BSE 35 (94.5%), had primary level education (p<0.005). Fifty one (69.9%) patients consented to HIV testing, 7 (13.7%) were HIV positive. A low level of education, ignorance of breast cancer, poor socio-economic status, rural residence and lack of knowledge of BSE were important predictors of breast cancer delay to presentation. Old age, HIV status, level of education and family history were major reasons associated with breast cancer presentation delay.

Conclusion: The overwhelming majority of breast cancer patients attending Parirenyatwa Group of Hospitals presented with advanced disease. These patients were mostly of low socio-economic status. Current health education campaigns seem to be ineffective in improving breast cancer awareness. Strategies to reduce delays in presentation, through various interventions focused on education and poverty alleviation need to be formulated.