**5. Preventive behaviors and factors associated**

#### **5.1 Late and delayed presentation**

Most patients often present at a late stage during the course of the disease; with two-thirds (67%) of all African patients presenting at the advanced stage of breast cancer; albeit, 50% seen at stage 3 and 17% seen at stage 4. The highest level of

advanced or late presentation is in West Africa; which stands at 67% [16]. A close estimate of a multi-country study of 8 sub-Saharan countries reported an overall late-stage presentation of 64.8%; with the highest (91.7%) among the countries studied being reported in Harare-Zimbabwe and the lowest (42.6%) reported in Seychelles [12]. Similar report has been reported from cancer registries across Africa; and 18% of which are already metastatic at the time of diagnosis. (Joko-Fu WY et al, 2020) Other estimates have reported that 77% of all staged cases were stage III/IV at diagnosis [29]. In Southern Ethiopia, 66.5% of all diagnoses were made at advanced stages (3 and 4) of the disease [21]. Among patients with breast cancer in Rwanda, the diagnosis was made in about half (52.9%) at stage 3 [19]. In Kenya, almost twothirds (61.6%) of breast cancer patients have stages 3 and 4 when the diagnosis was made [18]. In Lagos-Nigeria and Addis Ababa-Ethiopia, about half (54% and 51.9%, respectively) of the diagnosis was made at stages 3 and 4 among similar patients [20, 22]. However, half (51.7%) of patients have their diagnosis made at stage 2 in Western Cape, South Africa [28]. In contrast, only 19.48% of breast cancer cases were diagnosed at stage 3 among patients in Cape Town, South Africa [27].

The delayed presentation was also reported in the reviewed literature. Only 25% presented within the first 3 months, and 30% within 1 year, of the onset of symptoms among breast cancer patients in Khartoum-Sudan [30]. In the Central African Republic, only 30% presented within the first year of the onset of symptoms among breast cancer patients in Khartoum-Sudan [9]. Also, in Sierra Leone and Rwanda, 66.7% and 88.6% respectively, presented after 12 months among participants in population-based surveys [10].

Many factors have been said to be responsible for delayed or late presentation for screening and treatment for breast cancer among sub-Saharan African populations. A prior diagnosis of breast cancer has been shown to increase the odds of delayed presentation; with those diagnosed within at least 3 months with higher odds of late presentation compared to those diagnosed more recently (3–12 months – OR: 9.6 [95%CI: 9.55, 9.75]; p < 0.00 and >12 months –OR: 9.3 [95%CI: 9.33, 9.33]; p < 0.00) among breast cancer patients in Khartoum, Sudan. The fear of mastectomy/chemotherapy is the commonest reason for delays among Sudanese breast cancer patients [30].

## **5.2 Non-presentation and use of traditional healers**

About 43% and 26.7% of Burkinabe women either do nothing or visit traditional healers, respectively, about their breast-related conditions. Medical advice is only sought in 30% of the cases [24].
