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Factors Associated with Later-Stage Clinical Presentation Among Patients with Breast Cancer in Uganda

Aug 16, 2016

Uganda, similar to many countries in sub-Saharan Africa, faces a rapidly rising rate of breast cancer, with an increase of 5.2% per year for the past 15 years. Unlike in many other sub-Saharan African countries, Uganda offers patients no-cost surgery, radiation, and chemotherapy. However, treating these patients is often difficult because 77% of women with breast cancer in Uganda present to the clinic with advanced-stage disease, with 26% presenting with metastatic stage IV cancer. This late stage at presentation poses a challenge to improving survival rates in the country.

Seeking to address this challenge, a team of researchers from the United States collaborated with the Uganda Women’s Cancer Support Organization (UWOCASO) to create a survey that would give insight into several factors that might influence stage at presentation: women’s breast self-examination (BSE) practices, whether women had gone for a clinical breast examination (CBE) in the past year, and whom women prefer to turn to for information and education about presenting early for CBE if they detect a palpable lump; possible sources of information included health providers, family/friends, or societal sources, such as advertisement by the government, television, or radio. The researchers then looked at how these three factors intersected with demographic factors such as income, education, and geographic location.

The results of the survey are reported in the study “Breast Cancer Downstaging Practices and Breast Health Messaging Preferences Among a Community Sample of Urban and Rural Ugandan Women,” published in the Journal of Global Oncology (JGO), online, ahead of print, May 11.

The study’s first author, John R. Scheel, MD, PhD, explained that BSE was used as proxy for women’s awareness of changes in their breast and that CBE was used as a proxy for their level of engagement with the health care system for breast-related problems.

Study coauthor Benjamin O. Anderson, MD, said that Uganda was chosen as the site for this study because of its relatively strong cancer care infrastructure.

“It’s only appropriate to do a study about early detection in a place where patients can follow up with treatment, and treatment is available for free in Uganda,” Dr. Anderson said.

Location, education, and access to health care influence downstaging practices

The survey was given to 401 Ugandan women age 25 and older, who were mostly poor and had less than an elementary school education. Analysis of the survey data showed that 27% of respondents had engaged in BSE, and 15% had undergone a CBE. The study found that women who lived in urban locations, had higher education, had access to a health center as a regular source of care, and received breast cancer education were significantly more likely to engage in downstaging practices (BSE or CBE). Women who received prior education were twice as likely to have performed a BSE and more than five times more likely to have had a CBE compared to women who had not received breast cancer education.

In terms of the preferred source of information about clinical exams, Sixty-six percent of women indicated a preference to hear from their health provider. This preference was significantly associated with living in a rural location, having a health center as a regular source of care, and receiving breast cancer education.

Commenting on the findings, Dr. Scheel said the study can lay the groundwork for interventions aimed at lowering the stage of clinical presentation for breast cancer. “The findings make a strong case for the central role of the health providers in education about breast self-examination and clinical breast examination,” he said.

Implications for high-income countries

Dr. Anderson said it is important to remember that the same patterns of late-stage presentation can be found in many regions and communities across the United States.

“It’s important for us to look outside of the somewhat narrow perspective that we have in a high-income country and to recognize that not only are there issues in low- and middle-income countries, but there are issues in rural America and in underserved immigrant communities that are very similar to what is seen in Sub-Saharan Africa,” Dr. Anderson said. For example, Brooklyn and Manhattan “are only one bridge apart, and yet Brooklyn looks like a middle-income country in terms of how breast cancer presents. So we need to think about this issue more broadly and think about interventions closer to home as well.”


Dr. Scheel is a physician at the Seattle Cancer Care Alliance and an Assistant Professor of Radiology at University of Washington School of Medicine.

Dr. Anderson is Director at the Breast Health Clinic in Seattle Cancer Care Alliance, a Professor of Surgery and a Professor of Global Health at the University of Washington School of Medicine, and Chair and Director of The Breast Health Global Initiative at the Fred Hutchinson Cancer Research Center. An ASCO member since 2006, Dr. Anderson serves on the Journal of Global Oncology Editorial Board and has been a member of the International Affairs Committee and the Breast Cancer Symposium Steering Committee.

Abstract of the original JGO article.

PDF of the original JGO article.

Scheel JR, Molina Y, Patrick DL, et al. breast cancer downstaging practices and breast health messaging preferences among a community sample of urban and rural Ugandan women. J Glob Oncol. Epub 2016 May 11. 


The Exclusive Coverage series on ASCO.org highlights selected research from JCO, JOP, and JGO, with additional perspective provided by the lead or corresponding author.

@ 2016 American Society of Clinical Oncology

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