**5.3 Low utilization of screening services**

Early diagnosis has been said to improve survival; with a 3-year relative survival of 78% (95%CI: 71.6–83.3) among those diagnosed at the early stages of cancer compared with 40.3% (95%CI: 34.9–45.7) relative survival when the diagnosis is made at advanced (III and IV) stages of the disease [12]. However, the use of mammography and other screening modalities is very low in sub-Saharan Africa for screening and aiding the diagnosis of breast cancer. This hovers between 3.61% of community-based Ghanaian women and a quarter (23.7%) screening level among community-based women of reproductive age in Namibia.3132 Other levels of utilization between these

two ends include 5.2% breast cancer screening in the Ivory coast [31]; with 13.4% mammography screening among the south African general women population [32]; mammography screening of 15.5% among older women in South Africa [33]; and 18.6% mammography screening rate among patients in Southern Ethiopia [21].

Several factors have been found to explain the limited use of mammography services. This includes ethnicity, age, level of education, marital status, residence, type of employer, country of residence, wealth index, number of living children, possession of household items of worth, health insurance coverage, level of physical activity and presence of chronic diseases and regular visitation of health facility [31].

Older age is a strong predictor of mammography screening among African women. Phaswana-Mafuya N and Peltzer K reported that older middle-aged (40–49 years) and elderly (60–69 years) significantly increases the likelihood of mammography screening compared to the early middle ages (30–39 years) among South African women; and likelihood increases with age among this population (40–49 years – OR: 2.39 [95%CI: 1.54, 3.69] and 60–69 years – OR: 2.70 [95%CI: 2.70, 8.10]; p < 0.001) [32]. Also, Older women of the reproductive age group (25–49 years) are significantly more likely to access breast cancer screening compared to younger women of the reproductive age group (35–49 years – OR: 1.73 [95%CI: 1.56, 1.91]; p < 0.001; 25–34 years – OR: 1.41 [95%CI: 1.29, 1.54]; p < 0.001) [31]. However, Calys-Tagoe BNL et al. reported that older age is a negative predictor of mammography use. Those that are at least 70 years are significantly less likely to have used mammography screening services compared to younger women in Ghana (≥ 70 years – OR: 0.42 [95%CI: 0.19, 0.93]; p < 0.05) [34].

Also, Ethic group has been said to be an important index of access to mammography services. Calys-Tagoe BNL et al. reported that those of the majority ethnic group are significantly more likely to use mammography services compared to other ethnic groups among Ghanaian women (Akan – OR: 3.41 [95%CI: 1.88, 6.16]; p < 0.001) [34]. This was corroborated by Phaswana-Mafuya N and Peltzer K reported that whites, colored and Asian south Africans were significantly more likely to have mammography services compared to black South African women; with whites having the highest odds of mammography access (whites – OR: 5.06 [95%CI: 3.36, 7.60]; colored – OR: 2.87 [95%CI: 1.87, 4.41] and Indian/Asian 2.52 [95%CI: 1.47, 4.32]) [32]. Further insight was provided by Pelztzer K and Phaswana-Mafuya N as they reported that older adult white ad Indian/Asian adult women are significantly more likely to have used mammography compared to older adult Black South African women. (Asian/ Indian – OR: 4.08 [95%CI: 1.71, 9.71]; p < 0.01; whites - OR: 3.33 [95%CI: 1.54,7.19]; p < 0.01) [33]. In this wise, Asian/Indians have higher odds compared to whites which might have been due to the variation in the availability of social support as this demography of south Africans with the highest access to mammography services aged.

An increasing level of education has been said to increase the odds of mammography screening among Sub-Saharan African populations. Phaswana-Mafuya N and Peltzer K reported that south African women with at least grade 8 were reported to be significantly more likely to access mammography services compared to grades 0–7 (grade 8 – OR: 2.25 [95%CI: 1.34, 3.78; p < 0.01; grade ≥ 12 – OR: 2.72 [95%CI: 1.55, 4.77]; p < 0.001) [32]. In fact, Pelztzer K and Phaswana-Mafuya N reported that any level of access to education is a strong predictor of mammography use among older adult south African women compared to those with no formal education. (primary

education – OR: 2.76 [95%CI: 2.31, 5.85]; p < 0.01; at least secondary education – OR: 3.81 [95%CI: 1.88, 7.74]; p < 0.001) [33]. Sub-Saharan Africans with at least a formal education are significantly more likely to do breast cancer screening compared to those with no formal education, and the odds of breast cancer screening increase with the level of education. (Primary – OR: 1.77 [ 95%CI: 1.56, 2.01]; p < 0.01; at least secondary – OR: 2.33 [95%CI: 2.05,2.66]; p < 0.001) [31].

Ever being in a partnered relationship is a significant predictor of breast cancer screening among African populations compared to single African populations (married/living with partner – OR: 1.13 [95%CI: 1.04, 1.22]; p = 0.003; widow/divorce/ separated – OR: 1.15 [95%CI: 1.03, 1.28]; p = 0.01) [31].

Country of residence is a significant determinant of mammography services use among African populations. Namibians, Burkinabe and Kenyans are significantly more likely to use mammography services compared to Ivoirians; with Namibians having the highest odds of breast cancer screening among the studied African countries (Namibia – OR: 3.3 [95%CI: 2.90, 3.83]; p < 0.001; Burkina Faso – OR: 1.58 [95%CI: 1.32, 1.89]; p < 0.001; Kenya – OR: 1.92 [95%CI: 1.67, 2.21]; p < 0.001) [31].

Place of residence has been shown to determine the use of mammography services among African populations. Phaswana-Mafuya N and Peltzer K reported that rural informal residents are significantly less likely to have used mammography services compared to urban formal dwelling South African women. (Rural informal – OR: 0.40 [95%CI: 0.24, 0.72]; p < 0.01) [32].

Employment status is also a significant predictor of mammography utilization. Ghanaian women who are self-employed and those in the informal sectors are less likely to use mammography services compared to others in the civil service (selfemployed – OR: 0.21 [95%CI: 0.11, 0.42]; p < 0.000; informal - OR: 0.26 [95%CI: 0.12, 0.57]; p < 0.001) [34].

Possession of household items of worth has also been said to determine breast cancer screening. Possession of television was reported to increase the likelihood of breast cancer screening among African populations compared to those who do not (possession of TV – OR: 1.17 [95%CI: 1.08, 1.27]; p < 0.001) [31].

Socioeconomic status has been said to be a significant predictor of mammography services utilization. Pelztzer K and Phaswana-Mafuya N reported that south African older adult women with a high wealth index are twice more likely to use mammography services compared to those with a low wealth index (high wealth index – OR: 2.18 [ 95%CI: 1.00, 4.76]; p < 0.05) [33].

Lifestyle behaviors have also been an important determinant of the use of mammography services. Phaswana-Mafuya N and Peltzer K reported that south African women who reported moderate-vigorous physical activity significantly have higher odds of mammography services utilization compared to the physically inactive south African women (moderate-vigorous physical activity – OR: 1.55 [95%CI: 1.12; 2.13]; p < 0.01) [32].

The presence of chronic diseases has also been said to be a strong predictor of mammography service use. South African women with chronic diseases are significantly more likely to use mammography services compared to those with none (at least one chronic disease – OR: 1.49 [95%CI: 1.08, 2.05]; p < 0.05) [32]. Similar outcomes were reported among older South African women by the same authors (at least 2 chronic conditions – OR: 1.92 [95%CI: 1.01, 3.63]) [33].

Access to medical aid has also been said to be a strong predictor of mammography services use. South African women with medical aid were twice significantly more

*Epidemiology of Breast Cancer in Sub-Saharan Africa DOI: http://dx.doi.org/10.5772/intechopen.109361*

likely to use mammography services compared to south African women who have no medical aid [32]. This was further corroborated by the same authors among Older south African women; where older south African women with health insurance are twice significantly more likely to use mammography services compared to those who are not covered by health insurance (health insurance – OR: 2.71 [95%CI: 1.57, 4.66]; p < 0.001) [33].

Health facility visitation has also been said to be associated with breast cancer screening among women of reproductive age group; with those who frequently visited health facilities reporting higher odds of mammography services use compared with those who do not (OR: 1.37 [95%CI: 1.28, 1.45]; p < 0.001) [31].

#### **6. Common modalities of treatment**

Traditionally, breast cancer is commonly treated through chemotherapy, immunotherapy, hormonal therapy, biological therapy, radiotherapy and surgery [7]. Reported modalities of treatment in the last decade reported that chemotherapy, hormonal therapy and surgery remain the mainstay of management in many settings in sub-Saharan Africa in the last decade. Overall, breast cancer patients had surgery; with an overall mastectomy prevalence of 71% [95%CI: 51, 88]; with beast conserving surgery at 1% [95%CI: 0–2]. Chemotherapy was used in the treatment of 83% [95%CI: 64, 96]; and 77% received hormonal therapy for their treatments in the region [16]. However, country-specific treatment modalities have been reported at varying rates and types across sub-Saharan Africa.

Gabretsadik reported the use of chemotherapy, surgery and hormonal therapy in southern Ethiopia; where Doxorubicin, cyclophosphamide and paclitaxel every 3 weeks for 8 cycles are used for the treatment of stage 1–3) was reported in 59% of cases; doxorubicin and cyclophosphamide every 3 weeks for 6 cycles was reported in 41% of cases and modified radical mastectomy was reported in 35.1% of cases [21]. Also, hormonal therapy has been reported for premenopausal men and women; in which Tamoxifen use was reported in 76.7% of cases. For hormonal therapy for post-menopausal women in which anastrozole after surgery has been reported in 23.3% of cases. Chemotherapy alone, chemotherapy plus surgery and chemotherapy, surgery and hormonal therapy are reported in 65%, 20% and 35%, respectively [21].

Degu A and Kebede K reported different regimens used in the management of breast cancer patients in Gondar, Ethiopia. The commonest regimen was an Adriamycin-Cyclophosphamide combination (Adjuvant and Neoadjuvant, 43% and 22% respectively) and Tamoxifen (Adjuvant and Neoadjuvant, 30% and 8%, respectively) [17].

Kramer and colleagues reported the use of modified radical mastectomy surgery among 73.35% of patients; Axillary lymph node dissection in 78.23%; chemotherapy in 72.78%; hormonal therapy in 70.49% of cases and radiotherapy in 63.32% of cases. Similarly, different combinations of these modalities of treatment were also reported: wide local excision and radiotherapy in 95.24%; modified radical mastectomy and chemotherapy in 88.44% of cases; wide local excision and chemotherapy in 78.85% of cases and modified radical mastectomy and radiotherapy in 57.65% of cases among south African patients [27]. Similarly higher utilization rates of different modalities have been reported from the Central African Republic; where it was

reported that 95.4% had surgery; and 91.4% having had chemotherapy and a lower 30.4% having had radiotherapy in the course of breast cancer treatments among patients [9].

Almost similar modalities of treatment were reported among Patients in Burkina Faso where 72.9% and 74.4% had chemotherapy and surgery, respectively. However, a lower proportion (28.6%) of these patients had radiotherapy [23]. Similar reports were observed in Addis Ababa-Ethiopia, where 83.9% had chemotherapy, and 88.1% had had surgery; with 7.9% and 11.4%, having had radiotherapy and hormonal therapy, respectively [22]. Lower utilization has however been reported in Lagos-Nigeria where 50% had chemotherapy; 28.5% have had a combination of chemotherapy and surgery; with 12.5% have had chemotherapy and radiotherapy, and 9.0% had radiotherapy only [20].
