Factors Related to Incomplete Treatment of Breast Cancer and Validation of Mortality in Kumasi, Ghana

Background:
Breast cancer is the second most common cancer among African women and is the leading cause of cancer deaths among Ghanaian women (1-3).   Breast cancer data in Ghana is slowly becoming more available, though compared to developed nations the data are still limited.  Promising for researchers is the fact that breast cancer has become better documented through hospital admissions, revealing a high incidence of breast cancer that occurs among Ghanaian women (1).  Approximately 60% of breast cancer diagnoses tend to present at advanced disease, which is predicative of high mortality rates due to the unfavorable prognosis (1-2).  It is believed that  the prognostic factors leading to high mortality include a young age at presentation, advanced stage at diagnosis, large tumor size, high grade histologic subtypes and low rate of hormone receptor positivity (1).  Aside from the prognostic factors, studies have indicated genetic factors are unfavorable for indigenous African populations, suggesting a selectively aggressive biology.  This aggressive nature partly became apparent to researchers when analyzing histopathology specimens as well as analyzing surveillance data from the Caucasian American women, African American women, and Ghanaian women, with Ghanaian women having significantly higher estrogen receptor negative and triple negative disease, suggesting hereditary predisposition to developing breast cancer (4). Breast cancer control in Ghana is characterized by low awareness, late stage treatment, and poor survival, and with minimal resources to combat these issues, it is vital that the resources be allocated carefully (5).   Primary, secondary, and tertiary prevention as well as disease surveillance both on community and national scales are ideals, and Ghana is slowly moving towards these ideals by involving NGOs, international university students and professors, and through the practice of wise resource allocation and education.  No systematic national breast screening program exists for women in Ghana, though an influx of organizations are trying to curb the lack of screening by gaining funding for breast cancer screening centers and diagnostic technologies.6  Despite screening practices that are becoming more readily available and women’s education on breast self-examinations increasing, breast cancer incidence is increasing in Ghana, which would make it appear that the current interventions are either not targeting a high risk population, the women with early chronic disease burden, or the interventions are not implemented in a manner that addresses the patient or systems factors that need more attention.  According to recent research in Kumasi performed at Komfo Anokye University Hospital (KATH) by a student in the CEESP program, as well as a pilot study performed in Accra at the Korle Bu Teaching Hospital (KBTH), the percentage of women who abscond treatment is quite high, yet these women have only recently been followed-up at KBTH to gain an understanding of why once diagnosed, they do not continue cancer treatment at KBTH.  Results from the pilot study, which contained a sample of 66 newly diagnosed patients diagnosed over an 11 month period, suggested that 47% of the patients received treatment and 53% absconded treatment.  Of those patients that absconded treatment, 40% had received no treatment upon data collection (2).   

According to Wiredu and Armah, death certificate and autopsy records from cancer patients who sought treatment at KBTH were evaluated in 2006, yet prior to that time this data had not been collected since 1953 (7).   The aforementioned study does not delineate whether patients who did not receive treatment were included in this study, as results from this demographic were not described.  It is the women with diagnosed breast cancer who choose not to receive treatment that I wish to study, and I believe from this population, we can learn how to use behavioral health models to develop and implement interventions, policies, or education materials so breast cancer treatment can be wisely assessed by the patient upon the initial diagnosis.  The gap in knowledge exists not only to expand on the studies at KBTH and KATH regarding those who choose to not receive treatment, but also to understand the survival rates between those who did not seek treatment and those who did.  Furthermore, underreporting of deaths to the cancer registry is believed to affect the accuracy of the mortalities attributed to breast cancer, thereby making it more difficult to determine the style of intervention best suited for the diagnosed breast cancer patients who do not seek the suggested treatment and whose disease burden increases exponentially until succumbing to cancer.  

Specific Aims:
The first aim of the study is to collect information on patient factors and systems factors through cancer center medical records on all patients who were diagnosed with breast cancer over a period of 3 years, placing the cancer cases with the respective variables collected into two primary groups:  individuals who were adherent to physician treatment recommendations and individuals who did not follow up on treatment upon diagnosis at the cancer center.  The second aim is to develop a follow-up questionnaire and conduct interviews of those patients who did not continue treatment upon diagnosis to determine primary reasons for non-treatment seeking behavior.  The third aim is to cross reference all mortalities of individuals who had been diagnosed with breast cancer with the registry to determine the reporting accuracy and identify the factors affecting the accuracy of reporting.  Lastly, the fourth aim is to validate the mortality of patients with very advanced breast cancer cases to death certification records.

 References:
1. Yeboah-Ohene, M. and E. Adjei.  Breast cancer in Kumasi, Ghana.  Ghana Medical Journal  2012; 46(1):  8-13.
2. Clegg-Lamptey, J., Dakubo, J. and Y. N. Attobra.  Why do breast cancer patients report late or abscond during treatment in Ghana?  A pilot study.  Ghana Medical Journal 2009; 43(3):  127-131.
3. Bewtra, C.  Clinicopathologic features of female breast cancer in Kumasi, Ghana.  International Journal of Cancer Research 2010; 6(3):  154-160.
4. Stark, A., Kler, C.G., Martin, I., et al.  African Ancestry and higher prevalence of triple-negative breast cancer.  Cancer 2010; 116(21):  4926-4932.
5. Zelle, S.G., Nyarko, K.M., Bosu, W.K., et al.  Costs, effects, and cost effectiveness of breast cancer control in Ghana.  Tropical Medicine and International Health 2012; 17(8):  1031-1043.
6. Clegg-Lamptey, J.N.A. and Hodasi, W.M.  A study of breast cancer in Korle Bu Teaching Hospital:  Assessing the impact of health education.  Ghana Medical Journal 2007; 41(2):  72-77.
7. Wiredu, E.K. and Armah, H.B.  Cancer mortality patterns in Ghana:  a 10-year review of autopsies and hospital mortality.  BMC Public Health 2006; 6(159):  1-7.

Mark Obrist
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