Outcomes of a program to improve breast cancer early detection in Cote d’Ivoire.
Authors: Homian N'Da Marcelin , Kizub Darya Aleksandrovna , Miézan Niamké Adjouba Brigitte Aka , N'dah Kouame Justin , Allou Naureen , Ehounoud Nadège A. , Traore Asmaho Danielle épse , Duggan Catherine 
Published: June 2024

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Background: In Côte d'Ivoire >70% of women with breast cancer are diagnosed with Stage III/IV disease. Patients pay for all diagnosis and treatment costs. We evaluated the effect of provider education, patient navigation and financial support on time from presentation to diagnosis and treatment uptake. Methods: Setting. Five participating primary healthcare centers in Bouaké. Intervention: (1) Breast health training curricula for primary care providers (PCPs), community health workers (CHWs), and patient advocates/cancer survivors (PAs), based on findings from a qualitative assessment. Content included benign breast disease, cancer diagnosis and treatment (PCPs); raising awareness about breast cancer (CHWs); and patient navigation and treatment adherence support (PAs). 36 PCPs, 5 CHWs, and 2 cancer survivors were trained. (2) For indigent patients (almost all patients), the program paid for imaging and pathology diagnosis; for those diagnosed with cancer, costs of bloodwork, imaging, and chemotherapy. Participants: Women with breast symptoms presenting to health centers from December 2022-September 2023. Primary outcome: mean time from presentation to diagnostic resolution. Results: 223 women enrolled in the study. Mean age was 33.7 (st. dev 13.2). 195 (87.3%) were pre-menopausal. 16 (7.1%) had a family history of cancer. 96 (43%) had no formal education, 42 (18.8%) completed primary school or high school, while 85 (38.1%) completed college or university. Time from noticing symptoms to presenting to healthcare center was < 1 month for 96 (43%), 1-3 months for 33 (15%), 3-12 months for 28 (13%), and > 12 months for 62 (28%). The most common symptoms were breast pain in 150 (67.3%) and painless mass in 119 (53.3%). 175 (78.5%) were referred to the gynecology service at the University Teaching Hospital Bouaké for evaluation. 71 (31.8%) were treated with plan for follow-up as needed; 37 (16.6%) continued with surveillance; 90 (43.4%) were referred for breast ultrasound; 26 (11.7%) for mammography; 42 (18.8%) for breast biopsy; 2 receive antibiotics. Among 106 (91.4%) who had imaging, mean time from presentation to the healthcare center to imaging was 14.5 days (st. dev 15.6 days). Among 42 who had a breast biopsy, mean time from presentation to biopsy was 34.5 days (st. dev 27.4). Mean time from presentation to biopsy result was 64.7 days (st. dev 33.0 days). Seventeen (7.6%) patients were diagnosed with breast cancer. Five (29.4%) are undergoing treatment, one was lost to follow-up, and one died. Nine (52.9%) patients declined treatment despite many discussions with patient advocates, mainly citing fear of side-effects. Conclusions: Our program achieved the mean time of < 60 days from presenting to a healthcare center to diagnostic resolution either by imaging or biopsy recommended by the World Health Organization. Despite improving access to early diagnosis, program impact was limited due to suboptimal acceptance of treatment.