Barriers to Breast Cancer Care for Women Presenting at District and Regional-Level Hospitals in Ghana: Findings From the African Breast Cancer-Disparities in Outcomes Ghana Study

PURPOSE: The WHO Global Breast Cancer Initiative (GBCI) aims to improve breast cancer (BC) survival through early stage at diagnosis, prompt diagnostic evaluation, and appropriate multimodality treatment. Care pathway analysis helps to evaluate delay and dropouts through this process. Little is known about the BC care pathway of women first presenting at lower level of health systems in Africa. METHODS: Between March 2023 and February 2024, we prospectively recruited 243 women age ≥18 years in eight (six district, one regional and teaching) hospitals who, owing to breast symptoms, were referred for breast biopsy in the Oti and Volta regions of Ghana. We determined the percentages of biopsy uptake (study paid if needed), histology results receipt, survival, and treatment initiation and explored how patient-, family-, and health system-related factors influenced care pathways. RESULTS: Of the 243 women referred, 53 (21.1%) did not have biopsy taken for health system-related (n = 22, 41%) and participant-related (n = 26, 59%) reasons. Among 190 women who had a biopsy, 102 (54%) were malignant. The median time from first visit (recruitment) to obtaining biopsy results was 14 days (IQR, 9-27). Among malignant cases, 61% (62/102) were stage III/IV (GBCI pillar 1) and 65 (64%) of 102 initiated treatment (GBCI pillar 3) with a median time from first visit to treatment initiation of 76 days (IQR, 36-131). Thirty-seven (36%) women whose biopsies were malignant did not initiate treatment because of participant-related (19 [51%]) and health system-related (12 [32%]) factors. The 1-year survival was 76% (95% CI, 66 to 84). CONCLUSION: In a unique study of women from lower levels of the health system in Ghana, we observed large gaps in biopsy uptake and treatment access, but excellent pathology turnaround times.