Welcome to part two of our five-part series about the state of pathology in resource-limited countries. We’ll continue with our coverage of sub-Saharan Africa (SSA) which experiences some of the direst of circumstances when it comes to cancer awareness, screening, diagnosis and treatment. This may be no truer than for breast cancer. As you will read, the lack of pathology has led to major gaps in healthcare and limited access to specialists, laboratory services and patient care facilities.
You may remember from our last post that the 5-year female breast cancer relative survival rates are 46% in Uganda and 12% in the Gambia, compared with 90% in the United States.1Up to 80% of women with breast cancer in SSA are diagnosed with late stage (stage III or IV) disease, compared with 15% of women in high-income countries.2 One method of detecting breast cancer at earlier stages is through mammography screening. In SSA, mammography screening is financially and technically challenging to implement and sustain, requiring high-quality machines, well-trained radiologists and technicians, and investments in pathology and treatment facilities, all of which are limited resources for this region.3 The struggles to diagnose breast cancer early in SSA has been attributed to patient- and provider-related factors. Patient-related factors include low awareness of breast cancer and the importance of early detection.4 Delay between symptom onset and healthcare seeking is common. Engagement with early detection practices such as mammography and breast examination is low and contributes to late stage at diagnosis.5 Provider-related factors include limited early detection programs, and an absence of facilities for diagnosis via mammography screenings6 which are not available in most countries of SSA.7 The gold standard for breast cancer diagnosis is still histology - but when regions do not have access to pathology, patients may not even receive a biopsy.
Treatment options for advanced stages of breast cancer are limited in SSA. Most women are treated with mastectomy, partly because of limited treatment options for late stage disease, but also because of poor availability of chemotherapy and radiotherapy facilities.8 Approximately two-thirds of SSA countries do not have radiotherapy facilities.9There is a lack of diagnostic, treatment, and outcomes data, which precludes governments’ ability to develop long-term teaching and training programs necessary to build a sustainable workforce to care for patients with cancer. As a result, many areas lack oncologists, oncologic surgeons, gynecologic oncologists, radiologists, experts in palliative care, and trained nurses. Without these services, it is difficult or impossible to recruit and retain specialists in cancer screening, diagnosis and treatment. So this vicious cycle continues, unbroken, unchanged, and in many areas, unnoticed.10
Is it possible for this vicious cycle to change? How can these gaps in patient care be filled? In our next blog post, we’ll tackle these questions and give our opinion as to the measured approaches that can be taken to help bring resources to regions with pathology scarcity.
Built on the vision of better patient outcomes, Instapath was founded in 2017 by engineers and scientists to enable patients to immediately know their cancer diagnosis. Our team made it our mission to develop fast and easy digital pathology technology so diagnosis can be made in minutes instead of days. To learn more about Instapath and our technology, visit https://instapathbio.com or contact us at firstname.lastname@example.org.
References 1 Sankaranarayanan R, Swaminathan R, Brenner H, Chen K, Chia KS, Chen JG, et al. Cancer survival in Africa, Asia, and Central America: a population-based study. Lancet Oncol. 2010;11(2):165–73.
2 Dalal S, Beunza J, Volmink J, Adebamowo C, Bajunirwe F, Nkelekela M, et al. Non-communicable diseases in sub-Saharan Africa: what we know now. Int J Epid. 2011;40(4):885–901.
3, 5 Breast Cancer: Black, E., Richmond, R. Improving early detection of breast cancer in sub-Saharan Africa: why mammography may not be the way forward. Global Health 15, 3 (2019).
4, 6 Jedy-Agba E, McCormack V, Adebamowo C, dos-Santos-Silvia I. Stage at diagnosis of breast cancer in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Glob Health. 2016;4(12):e923–35.
7 Brinton LA, Figueroa JD, Awuah B, Yarney J, Wiafe S, Wood SN, et al. Breast cancer in sub-Saharan Africa: opportunities for prevention. Breast Cancer Res Treat. 2014;144(3):467–78.
8 Tetteh D, Faulkner S. Sociocultural factors and breast Cancer in sub-Saharan Africa: implications for diagnosis and management. Women’s Health. 2016;12(1):147–56.
9 Dalal S, Beunza J, Volmink J, Adebamowo C, Bajunirwe F, Nkelekela M, et al. Non-communicable diseases in sub-Saharan Africa: what we know now. Int J Epid. 2011;40(4):885–901.
10 Roberts D, Wilson M. Improving Diagnostic Pathology Capacity for Global Cancer Care: Where to Start. Am J Clin Pathol. 2014; 141(2):150–1.