Assessing challenges and opportunities of treating breast cancer in Lesotho
Main Article Content
Abstract
Background: It has been estimated that, more than 60% of the new breast cancer cases and 70% of related deaths will be seen in Low-Middle Income Countries in the coming 20 years. In Lesotho, out of 228 women, 177 had heard about breast cancer while 72.9% had heard of breast cancer screening. Given limited treatment facilities and options in Lesotho, many patients die soon after diagnosis, before they are able to access treatment; to date this cannot be quantified. Another challenge that affects breast cancer management is treatment and travel-related costs, particularly for those not living close to the medical centre. Most patients are coming with advanced disease stage and are sent home for home-based care, some of which could have been prevented with early screening.
Aim: The aim of study is to determine challenges faced by breast cancer patients, the cost to the health system and the opportunities this may bring to the country.
Methods: A quantitative cross-sectional, prospective and retrospective study was conducted on 45 breast cancer patients who were initiated chemotherapy at the only cancer treatment centre in Lesotho; Senkatana oncology clinic located at the Botshabelo complex in Maseru.
Results: The majority of patients were facing challenges of arranging transport to the doctor (83.3%, n=15), of being far from the healthcare facilities even if transportation was available (77.8%, n=14), paying for healthcare (83.3%, n=15), paying for transport (77.8%, n=14) and paying for diagnostic test (88.9%, n=16) in all ages. Majority of patients who presented for care and treatment late faced challenges more than those who presented earlier. Diagnostic and monitoring laboratory test constituted 64.5% of total direct medical costs followed by 24.7 % from chemotherapy.
Conclusion: The challenges faced by breast cancer patients are of financial and practical nature and they get higher for patients who presented at advanced stage for care and treatment. In order to improve breast cancer care and treatment outcome at lower costs efforts for breast cancer awareness need to be intensified so that patients presented early at the health centers. In term of direct medical cost, the largest cost came from the diagnostic and monitoring laboratory tests.
Keywords:
Challenges, cancer services, Lesotho, breast cancer
Article Details
How to Cite
RAMATHEBANE, Maseabata et al.
Assessing challenges and opportunities of treating breast cancer in Lesotho.
Medical Research Archives, [S.l.], v. 11, n. 10, oct. 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/4583>. Date accessed: 15 may 2024.
doi: https://doi.org/10.18103/mra.v11i10.4583.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. https://doi.org/10.3322/caac.21660
2. Sharma R, Aashima, Nanda M, Fronterre C, Sewagudde P, Ssentongo AE, Yenney K, Arhin ND, Oh J, Amponsah-Manu F and Ssentongo P. Mapping Cancer in Africa: A Comprehensive and Comparable Characterization of 34 Cancer Types Using Estimates from GLOBOCAN 2020. Front. Public Health. 2022; 10:744.
https://doi.org/10.3389/fpubh.2022.839835
3. Bray F, Parkin DM; African Cancer Registry Network. Cancer in sub-Saharan Africa in 2020: a review of current estimates of the national burden, data gaps, and future needs. Lancet Oncol. 2022;23(6):719-728. https://doi.org/10.1016/S1470-2045(22)00270-4
4. Deo SV, Sharma J, Kumar S. GLOBOCAN 2020 report on global cancer burden: challenges and opportunities for surgical oncologists. Annals of surgical oncology. 2022;29(11):6497-500. https://doi.org/10.1245/s10434-022-12151-6
5. Omaka-Amari L, Ilo C, Nwimo I, Onwunaka C, Umoke C. Demographic differences in the knowledge of breast cancer among women in Ebonyi state Nigeria. IJNMH. 2015;1(3):18–27. Accessed: September 9, 2023. https://www.eajournals.org
6. Gakunga R, Parkin DM. Cancer registries in Africa 2014: a survey of operational. Int J Cancer. 2015;137:2045–52. https://doi.org/10.1002/ijc.29668
7. Ramathebane MM, Sooro MA, Kabuya RM, Sayed AR. Knowledge and attitudes relating to cervical and breast cancer among women in Maseru, Lesotho. African journal of primary health care & family medicine. 2022;14(1):1-8. http://dx.doi.org/10.4102/phcfm.v14i1.3459
8. Otieno ES, Micheni JN, Kimende SK et al. Delayed presentation of breast cancer patients. East Afr Med J 2010;87:147–150. DOI:10.4314/eamj.v87i4.62410.
9. Pace LE, Mpunga T, Hategekimana V et al. Delays in breast cancer presentation and diagnosis at two rural cancer referral centers in Rwanda. The Oncologist. 2015;20:780–788. https://doi.org/10.1634/theoncologist.2015-0429
10. Ukwenya AY, Yusufu LM, Nmadu PT et al. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr J Surg. 2008;46:106–110. Accessed: September 9, 2023.
http://www.scielo.org.za
11. Anderson BO, Yip CH, Smith RA, et al. Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer. 2008;113(8):2221–43. https://doi.org/10.1002/cncr.23844
12. Galukande M, Kiguli ME. Rethinking breast cancer screening strategies in resource-limited environments. Afr Health Sci J. 2010;10(1):89–92. DOI 10.1186/s12957-015-0632-4.
13. Brinton LA, Figueroa JD, Awuah B, Yarney J, Wiafe S, Wood SN, Ansong D, Nyarko K, Wiafe-Addai B, Clegg-Lamptey JN. Breast cancer in sub-Saharan Africa: opportunities for prevention. Breast Cancer Res Treat. 2014;144:467–78.
14. Dalal S, Beunza JJ, Volmink J, Adebamowo C, Bajunirwe F, Njelekela M, Mozaffarian D, Fawzi W, Willett W, Adami HO, Holmes MD. Noncommunicable diseases in sub-Saharan Africa: what we know now. Int J Epidemiol. 2011;40:885–901. https://doi.org/10.1093/ije/dyr050
15. Tetteh DA, Faulkner SL. Sociocultural factors and breast cancer in subSaharan Africa: implications for diagnosis and management. Womens Health (Lond). 2016;12:147–56. https://doi.org/10.2217/whe.15.76
16. Adesina A, Chumba D, Nelson AM et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol. 2013;14:e152–e157. https://doii.org/10.1016/S1470-2045(12)70598-3
17. African Strategies for Advancing Pathology Group Members. Quality pathology and laboratory diagnostic services are key to improving global health outcomes: Improving global health outcomes is not possible without accurate disease diagnosis. Am J Clin Pathol. 2015;143:325–328.
DOI: 10.1309/AJCP6K0DZCNVCSCI.
18. Mpunga T, Tapela N, Hedt-Gauthier BL et al. Diagnosis of cancer in rural Rwanda: Early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings. Am J Clin Pathol. 2014;142:541–545. https://doi.org/10.1309/AJCPYPDES6Z8ELEY
19. Gopal S, Krysiak R, Liomba NG et al. Early experience after developing a pathology laboratory in Malawi, with emphasis on cancer diagnoses. PLoS One. 2013;8:e70361. https://doi.org/10.1371/journal.pone.0070361
20. Gelband H, Sankaranarayanan R, Gauvreau CL et al. Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: Key messages from disease control priorities, 3rd edition. Lancet. 2015;387: 2133–44. 7. https://doi.org/10.1016/S0140-6736(15)00755-2
21. Sullivan R, Alatise OI, Anderson BO et al. Global cancer surgery: Delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015;16:1193–1224. https://doi.org/10.1016/S1470(15)00223-5
22. Meara JG, Hagander L, Leather AJ. Surgery and global health: A Lancet Commission. Lancet. 2014; 383:12–13. https://doi.org/10.1016/S0140-6736(13)62345-4
23. Stulac S, Binagwaho A, Tapela NM et al. Capacity building for oncology programmes in subSaharan Africa: The Rwanda experience. Lancet Oncol 2015;16:e405–e413. https://doi.org/10.1016/S1410-2045(15)00161-8
24. Shulman LN, Mpunga T, Tapela N et al. Bringing cancer care to the poor: Experiences from Rwanda. Nat Rev Cancer 2014;14:815–821. 36. https://www.nature.com. Access date: September 9, 2023.
25. Strother RM, Asirwa FC, Busakhala NB et al. AMPATH-Oncology: A model for comprehensive cancer care in Sub-Saharan Africa. J Cancer Policy 2003;1:e42–e48. https://doi.org/10.1016/j.jcpo.2013.06.002.
26. Afaya A, Laari TT, Seidu AA, Afaya RA, Daniels-Donkor SS, Yakong VN, Ahinkorah BO. Factors associated with the uptake of clinical breast examination among women of reproductive age in Lesotho: analysis of a national survey. BMC cancer. 2023;23(1):114. https://doi.org/10.1186/s12885-023-10566-2
27. Anyigba CA, Awandare GA, Paemka L. Breast cancer in sub-Saharan Africa: The current state and uncertain future. Experimental Biology and Medicine. 2021;246(12):1377-87.
DOI: 10.1177/15353702211006047.
28. Joko‐Fru WY, Miranda‐Filho A, Soerjomataram I, Egue M, Akele‐Akpo MT, N'da G, Assefa M, Buziba N, Korir A, Kamate B, Traore C. Breast cancer survival in sub‐Saharan Africa by age, stage at diagnosis and human development index: A population‐based registry study. International journal of cancer. 2020;146(5):1208-18. https://doi.org/10.1002/ijc.32406
29. Foerster M, McKenzie F, Zietsman A, Galukande M, Anele A, Adisa C, Parham G, Pinder L, Schüz J, McCormack V, dos‐Santos‐Silva I. Dissecting the journey to breast cancer diagnosis in sub‐Saharan Africa: Findings from the multicountry ABC‐DO cohort study. International journal of cancer. 2021 Jan 15;148(2):340-51.
30. Chasimpha S, McCormack V, Cubasch H, Joffe M, Zietsman A, Galukande M, Parham G, Pinder LF, Anele A, Adisa CA, Offiah AU. Disparities in breast cancer survival between women with and without HIV across sub-Saharan Africa (ABC-DO): a prospective, cohort study. The Lancet HIV. 2022 Mar 1;9(3):e160-71.
31. Phakathi B, Cubasch H, Nietz S, Dickens C, Dix-Peek T, Joffe M, Neugut AI, Jacobson J, Duarte R, Ruff P. Clinico-pathological characteristics among South African women with breast cancer receiving anti-retroviral therapy for HIV. The Breast. 2019 Feb 1;43:123-9.
32. Togawa K, Anderson BO, Foerster M, Galukande M, Zietsman A, Pontac J, Anele A, Adisa C, Parham G, Pinder LF, McKenzie F. Geospatial barriers to healthcare access for breast cancer diagnosis in sub‐Saharan African settings: The African Breast Cancer—Disparities in Outcomes Cohort Study. International journal of cancer. 2021 May 1;148(9):2212-26
33. Hapazari J. Challenges faced by unemployed people in Lesotho: A case of Manonyane rural community. South African Review of Sociology. 2019;50(1):65-82.
DOI: 10.1080/21528586.2019.1632041.
34. Grover S, Martei YM, Puri P, Prabhakar P, Mutebi M, Balogun OD, Price AJ, Freeman AH, Narasimhamurthy M, Rodin D, Rayne S. Breast cancer and HIV in Sub-Saharan Africa: a complex relationship. Journal of global oncology. 2017;4:1-1. DOI:10.1200/JGO.2016.006585.
35. Kohler RE, Gopal S, Miller AR, Lee CN, Reeve BB, Weiner BJ, Wheeler SB. A framework for improving early detection of breast cancer in sub-Saharan Africa: A qualitative study of help-seeking behaviors among Malawian women. Patient education and counseling. 2017 Jan 1;100(1):167-73.
36. Etminani-Ghasrodashti R, Kan C, Mozaffarian L. Investigating the role of transportation barriers in cancer patients’ decision making regarding the treatment process. Transportation Research Record. 2021 Jun;2675(6):175-87.
37. Addo IY, Acquah E, Ayebeng C, Dickson KS. Influence of distance to health facilities on clinical breast cancer screening behaviour among women in five sub-Saharan African countries. BMC Public Health. 2023 May 19;23(1):915.
38. Jedy-Agba E, McCormack V, Adebamowo C, dos-Santos-Silva I. Stage at diagnosis of breast cancer in sub-Saharan Africa: a systematic review and meta-analysis. The Lancet Global Health. 2016 Dec 1;4(12):e923-35.
39. Vanderpuye VD, Olopade OI, Huo D. Pilot survey of breast cancer management in sub-Saharan Africa. Journal of global oncology. 2017;3(3):194-200. DOI:10.1200/JGO.2016.004945.
40. Guzha NT, Thebe T, Butler N, Valodia PN. Development of a method to determine the cost of breast cancer treatment with chemotherapy at Groote Schuur Hospital, Cape Town, South Africa. South African Medical Journal. 2020 Apr 1;110(4):296-301.
41. Jalali FS, Keshavar K, Seif M, Akrami M, Jafari A, Ravangard R. Economic burden of breast cancer: a case of Southern Iran. Cost Effectiveness and Resource Allocation. 2023 Dec;21(1):1-8.
42. American Cancer Society Cancer Action Network. The cost of cancer. 2020 edition. Published 2023. Accessed September 8, 2023 https://www.fightcancer.org/costs-cancer
43. Ocran Mattila P, Ahmad R, Hasan SS, Babar ZU. Availability, affordability, access, and pricing of anti-cancer medicines in low-and middle-income countries: a systematic review of literature. Frontiers in Public Health. 2021;30(9):462. https://doi.org/10.3389/fpubh.2021.628744
44. Eze P, Lawani LO, Agu UJ, Acharya Y. Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis. Bulletin of the World Health Organization. 2022 May 5;100(5):337.
45. McGarvey N, Gitlin M, Fadli E, Chung KC. Increased healthcare costs by later stage cancer diagnosis. BMC Health Services Research. 2022 Sep 13;22(1):1155.
46. Blumen H, Fitch K, Polkus V. Comparison of treatment costs for breast cancer, by tumor stage and type of service. American health & drug benefits. 2016 Feb;9(1):23.
47. Sun L, Legood R, dos-Santos-Silva I, Gaiha SM, Sadique Z. Global treatment costs of breast cancer by stage: a systematic review. PloS one. 2018;13(11):e0207993. https://doi.org/10.1371/journal.pone.0207993
2. Sharma R, Aashima, Nanda M, Fronterre C, Sewagudde P, Ssentongo AE, Yenney K, Arhin ND, Oh J, Amponsah-Manu F and Ssentongo P. Mapping Cancer in Africa: A Comprehensive and Comparable Characterization of 34 Cancer Types Using Estimates from GLOBOCAN 2020. Front. Public Health. 2022; 10:744.
https://doi.org/10.3389/fpubh.2022.839835
3. Bray F, Parkin DM; African Cancer Registry Network. Cancer in sub-Saharan Africa in 2020: a review of current estimates of the national burden, data gaps, and future needs. Lancet Oncol. 2022;23(6):719-728. https://doi.org/10.1016/S1470-2045(22)00270-4
4. Deo SV, Sharma J, Kumar S. GLOBOCAN 2020 report on global cancer burden: challenges and opportunities for surgical oncologists. Annals of surgical oncology. 2022;29(11):6497-500. https://doi.org/10.1245/s10434-022-12151-6
5. Omaka-Amari L, Ilo C, Nwimo I, Onwunaka C, Umoke C. Demographic differences in the knowledge of breast cancer among women in Ebonyi state Nigeria. IJNMH. 2015;1(3):18–27. Accessed: September 9, 2023. https://www.eajournals.org
6. Gakunga R, Parkin DM. Cancer registries in Africa 2014: a survey of operational. Int J Cancer. 2015;137:2045–52. https://doi.org/10.1002/ijc.29668
7. Ramathebane MM, Sooro MA, Kabuya RM, Sayed AR. Knowledge and attitudes relating to cervical and breast cancer among women in Maseru, Lesotho. African journal of primary health care & family medicine. 2022;14(1):1-8. http://dx.doi.org/10.4102/phcfm.v14i1.3459
8. Otieno ES, Micheni JN, Kimende SK et al. Delayed presentation of breast cancer patients. East Afr Med J 2010;87:147–150. DOI:10.4314/eamj.v87i4.62410.
9. Pace LE, Mpunga T, Hategekimana V et al. Delays in breast cancer presentation and diagnosis at two rural cancer referral centers in Rwanda. The Oncologist. 2015;20:780–788. https://doi.org/10.1634/theoncologist.2015-0429
10. Ukwenya AY, Yusufu LM, Nmadu PT et al. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr J Surg. 2008;46:106–110. Accessed: September 9, 2023.
http://www.scielo.org.za
11. Anderson BO, Yip CH, Smith RA, et al. Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer. 2008;113(8):2221–43. https://doi.org/10.1002/cncr.23844
12. Galukande M, Kiguli ME. Rethinking breast cancer screening strategies in resource-limited environments. Afr Health Sci J. 2010;10(1):89–92. DOI 10.1186/s12957-015-0632-4.
13. Brinton LA, Figueroa JD, Awuah B, Yarney J, Wiafe S, Wood SN, Ansong D, Nyarko K, Wiafe-Addai B, Clegg-Lamptey JN. Breast cancer in sub-Saharan Africa: opportunities for prevention. Breast Cancer Res Treat. 2014;144:467–78.
14. Dalal S, Beunza JJ, Volmink J, Adebamowo C, Bajunirwe F, Njelekela M, Mozaffarian D, Fawzi W, Willett W, Adami HO, Holmes MD. Noncommunicable diseases in sub-Saharan Africa: what we know now. Int J Epidemiol. 2011;40:885–901. https://doi.org/10.1093/ije/dyr050
15. Tetteh DA, Faulkner SL. Sociocultural factors and breast cancer in subSaharan Africa: implications for diagnosis and management. Womens Health (Lond). 2016;12:147–56. https://doi.org/10.2217/whe.15.76
16. Adesina A, Chumba D, Nelson AM et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol. 2013;14:e152–e157. https://doii.org/10.1016/S1470-2045(12)70598-3
17. African Strategies for Advancing Pathology Group Members. Quality pathology and laboratory diagnostic services are key to improving global health outcomes: Improving global health outcomes is not possible without accurate disease diagnosis. Am J Clin Pathol. 2015;143:325–328.
DOI: 10.1309/AJCP6K0DZCNVCSCI.
18. Mpunga T, Tapela N, Hedt-Gauthier BL et al. Diagnosis of cancer in rural Rwanda: Early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings. Am J Clin Pathol. 2014;142:541–545. https://doi.org/10.1309/AJCPYPDES6Z8ELEY
19. Gopal S, Krysiak R, Liomba NG et al. Early experience after developing a pathology laboratory in Malawi, with emphasis on cancer diagnoses. PLoS One. 2013;8:e70361. https://doi.org/10.1371/journal.pone.0070361
20. Gelband H, Sankaranarayanan R, Gauvreau CL et al. Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: Key messages from disease control priorities, 3rd edition. Lancet. 2015;387: 2133–44. 7. https://doi.org/10.1016/S0140-6736(15)00755-2
21. Sullivan R, Alatise OI, Anderson BO et al. Global cancer surgery: Delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015;16:1193–1224. https://doi.org/10.1016/S1470(15)00223-5
22. Meara JG, Hagander L, Leather AJ. Surgery and global health: A Lancet Commission. Lancet. 2014; 383:12–13. https://doi.org/10.1016/S0140-6736(13)62345-4
23. Stulac S, Binagwaho A, Tapela NM et al. Capacity building for oncology programmes in subSaharan Africa: The Rwanda experience. Lancet Oncol 2015;16:e405–e413. https://doi.org/10.1016/S1410-2045(15)00161-8
24. Shulman LN, Mpunga T, Tapela N et al. Bringing cancer care to the poor: Experiences from Rwanda. Nat Rev Cancer 2014;14:815–821. 36. https://www.nature.com. Access date: September 9, 2023.
25. Strother RM, Asirwa FC, Busakhala NB et al. AMPATH-Oncology: A model for comprehensive cancer care in Sub-Saharan Africa. J Cancer Policy 2003;1:e42–e48. https://doi.org/10.1016/j.jcpo.2013.06.002.
26. Afaya A, Laari TT, Seidu AA, Afaya RA, Daniels-Donkor SS, Yakong VN, Ahinkorah BO. Factors associated with the uptake of clinical breast examination among women of reproductive age in Lesotho: analysis of a national survey. BMC cancer. 2023;23(1):114. https://doi.org/10.1186/s12885-023-10566-2
27. Anyigba CA, Awandare GA, Paemka L. Breast cancer in sub-Saharan Africa: The current state and uncertain future. Experimental Biology and Medicine. 2021;246(12):1377-87.
DOI: 10.1177/15353702211006047.
28. Joko‐Fru WY, Miranda‐Filho A, Soerjomataram I, Egue M, Akele‐Akpo MT, N'da G, Assefa M, Buziba N, Korir A, Kamate B, Traore C. Breast cancer survival in sub‐Saharan Africa by age, stage at diagnosis and human development index: A population‐based registry study. International journal of cancer. 2020;146(5):1208-18. https://doi.org/10.1002/ijc.32406
29. Foerster M, McKenzie F, Zietsman A, Galukande M, Anele A, Adisa C, Parham G, Pinder L, Schüz J, McCormack V, dos‐Santos‐Silva I. Dissecting the journey to breast cancer diagnosis in sub‐Saharan Africa: Findings from the multicountry ABC‐DO cohort study. International journal of cancer. 2021 Jan 15;148(2):340-51.
30. Chasimpha S, McCormack V, Cubasch H, Joffe M, Zietsman A, Galukande M, Parham G, Pinder LF, Anele A, Adisa CA, Offiah AU. Disparities in breast cancer survival between women with and without HIV across sub-Saharan Africa (ABC-DO): a prospective, cohort study. The Lancet HIV. 2022 Mar 1;9(3):e160-71.
31. Phakathi B, Cubasch H, Nietz S, Dickens C, Dix-Peek T, Joffe M, Neugut AI, Jacobson J, Duarte R, Ruff P. Clinico-pathological characteristics among South African women with breast cancer receiving anti-retroviral therapy for HIV. The Breast. 2019 Feb 1;43:123-9.
32. Togawa K, Anderson BO, Foerster M, Galukande M, Zietsman A, Pontac J, Anele A, Adisa C, Parham G, Pinder LF, McKenzie F. Geospatial barriers to healthcare access for breast cancer diagnosis in sub‐Saharan African settings: The African Breast Cancer—Disparities in Outcomes Cohort Study. International journal of cancer. 2021 May 1;148(9):2212-26
33. Hapazari J. Challenges faced by unemployed people in Lesotho: A case of Manonyane rural community. South African Review of Sociology. 2019;50(1):65-82.
DOI: 10.1080/21528586.2019.1632041.
34. Grover S, Martei YM, Puri P, Prabhakar P, Mutebi M, Balogun OD, Price AJ, Freeman AH, Narasimhamurthy M, Rodin D, Rayne S. Breast cancer and HIV in Sub-Saharan Africa: a complex relationship. Journal of global oncology. 2017;4:1-1. DOI:10.1200/JGO.2016.006585.
35. Kohler RE, Gopal S, Miller AR, Lee CN, Reeve BB, Weiner BJ, Wheeler SB. A framework for improving early detection of breast cancer in sub-Saharan Africa: A qualitative study of help-seeking behaviors among Malawian women. Patient education and counseling. 2017 Jan 1;100(1):167-73.
36. Etminani-Ghasrodashti R, Kan C, Mozaffarian L. Investigating the role of transportation barriers in cancer patients’ decision making regarding the treatment process. Transportation Research Record. 2021 Jun;2675(6):175-87.
37. Addo IY, Acquah E, Ayebeng C, Dickson KS. Influence of distance to health facilities on clinical breast cancer screening behaviour among women in five sub-Saharan African countries. BMC Public Health. 2023 May 19;23(1):915.
38. Jedy-Agba E, McCormack V, Adebamowo C, dos-Santos-Silva I. Stage at diagnosis of breast cancer in sub-Saharan Africa: a systematic review and meta-analysis. The Lancet Global Health. 2016 Dec 1;4(12):e923-35.
39. Vanderpuye VD, Olopade OI, Huo D. Pilot survey of breast cancer management in sub-Saharan Africa. Journal of global oncology. 2017;3(3):194-200. DOI:10.1200/JGO.2016.004945.
40. Guzha NT, Thebe T, Butler N, Valodia PN. Development of a method to determine the cost of breast cancer treatment with chemotherapy at Groote Schuur Hospital, Cape Town, South Africa. South African Medical Journal. 2020 Apr 1;110(4):296-301.
41. Jalali FS, Keshavar K, Seif M, Akrami M, Jafari A, Ravangard R. Economic burden of breast cancer: a case of Southern Iran. Cost Effectiveness and Resource Allocation. 2023 Dec;21(1):1-8.
42. American Cancer Society Cancer Action Network. The cost of cancer. 2020 edition. Published 2023. Accessed September 8, 2023 https://www.fightcancer.org/costs-cancer
43. Ocran Mattila P, Ahmad R, Hasan SS, Babar ZU. Availability, affordability, access, and pricing of anti-cancer medicines in low-and middle-income countries: a systematic review of literature. Frontiers in Public Health. 2021;30(9):462. https://doi.org/10.3389/fpubh.2021.628744
44. Eze P, Lawani LO, Agu UJ, Acharya Y. Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis. Bulletin of the World Health Organization. 2022 May 5;100(5):337.
45. McGarvey N, Gitlin M, Fadli E, Chung KC. Increased healthcare costs by later stage cancer diagnosis. BMC Health Services Research. 2022 Sep 13;22(1):1155.
46. Blumen H, Fitch K, Polkus V. Comparison of treatment costs for breast cancer, by tumor stage and type of service. American health & drug benefits. 2016 Feb;9(1):23.
47. Sun L, Legood R, dos-Santos-Silva I, Gaiha SM, Sadique Z. Global treatment costs of breast cancer by stage: a systematic review. PloS one. 2018;13(11):e0207993. https://doi.org/10.1371/journal.pone.0207993