Screening for breast cancer has resulted in early diagnosis and a reduction in mortality.⁷ Breast self examination (BSE), clinical breast examination (CBE), screen-film mammography, digital mammography, magnetic resonance imaging and ultrasound have all been used to detect cancers prior to confirmation by pathology. Although there are controversies about the value of each of these screening methods, the weight of evidence favours screening by mammography in women aged 40 years and above. There is an additional incremental benefit from clinical breast examination (CBE), since it detects some cancers missed by mammography; but the additional benefit of CBE with mammography is not known.^7,8 The practice of BSE, however, has not been shown to reduce mortality from breast cancer. It has rather been shown to lead to an increase in the number of biopsies for benign disease.^7–11

There is no systematic national screening programme that involves mammography to women at risk from breast cancer in Ghana. There are some nongovernmental organisations (NGOs) and other well-meaning groups who organise breast cancer awareness talks, teach women BSE and offer CBE as a means of offering ‘breast screening’.²

Programmes to encourage early detection like mammographic screening, CBE and perhaps BSE, may not achieve the desired aim of achieving early diagnosis in Ghana since our patients do not report to hospital for months after they themselves detect an obvious abnormality in their breasts. Even in the developed countries many breast cancers are identified by the patients themselves incidentally.¹² The difference with them is that they report early to hospital.

In Ghana the interval between detection of a breast lump and presentation to hospital for investigation and treatment (8 to 10 months)¹ is so long that addressing the causes of delayed presentation is perhaps much more important than promoting early detection.

After presenting late to hospital, many patients in Ghana further abscond during breast cancer treatment. In the Korle Bu Teaching hospital 12.8% abscond after the diagnosis is made, and a further 10% do not complete their treatment.¹ The latter group include patients who start neoadjuvant therapy but stop treatment and do not proceed to have surgery. Some of these absconders later return with more advanced and often inoperable, incurable disease.

The second questionnaire was administered to patients who absconded but had returned after variable periods to continue their treatment. Questions and information recorded included the following: the duration of absence, the reason for absconding, the stage of the disease at the time they absconded and the current stage of the disease.

Their standard of education and marital status are shown in Tables 1 and ​and22.

The main reasons given for delayed reporting were previous hospital consultation and ignorance. It is significant that of the 48 women who sought previous consultation, the diagnosis was made in only 23 (52%) of them. This is an issue that requires further investigation. Ignorance has been previously recognised as a cause of delayed presentation of breast cancer in Ghana.¹³

The four main causes of patients absconding are the same as the next common causes of delayed presentation: fear of mastectomy, the use of herbal treatment, resort to prayers and prayer camps, and financial incapability. This shows that after many women finally report at the Korle Bu Teaching hospital with breast cancer, the reasons for delayed reporting are not addressed. They therefore later abscond for the same reasons, mainly to avoid mastectomy.

The fear of mastectomy can possibly be addressed by a number of measures. These include trying to dispel the misconceptions that link mastectomy to death, giving opportunity to patients to express their fears, offering counselling, and exposing newly-diagnosed patients to healthy breast cancer survivors. As the study shows, the main fear of newly-diagnosed patients was the fear of mastectomy; many did not receive counselling or have the opportunity to express their fears. The patients were therefore at risk of absconding when mastectomy was due. The wish of many newly diagnosed patients to meet with a survivor shows that they wanted to know more about breast cancer and have their questions answered. The resorts to herbal treatment and prayer/prayer camps are other significant causes of delayed reporting and absconding that need to be addressed.

Not many of the women knew or practised BSE. The usefulness of BSE has been questioned and is currently considered optional by the American Cancer Society.¹⁴ It has not been shown to cause any decrease in mortality from breast cancer.^9,10,11 However, these studies have been done in countries where there are screening programmes and women are breast cancer aware. In Ghana, as in many developing countries, the usefulness of BSE has not been shown to be ineffective. In the absence of screening mammography it is perhaps useful to continue to teach BSE.

This study brings up interesting results about the limited usefulness of present efforts by NGOs and other groups performing community-based clinical breast examination. That 14 (21.2%) of the breast cancers were discovered through these ‘screening’ programmes shows that these programmes are probably reaching a large number of people. However, the duration of symptoms in these ‘screendetected’ cancers is worrying: it is as long as for other patients who detected their lumps by other means. These ‘screened’ patients were examined in the community and informed they had a problem with their breasts; yet they waited for periods between six weeks to two years (mean 47, median 39 weeks) before reporting to the Korle Bu Teaching Hospital. The limited usefulness of these extension programmes is also demonstrated by a previous study in Ghana where a surgical team toured the country and detected suspected breast cancer in some communities: most of the women were already aware of the lump, some refused biopsies and others refused treatment.¹³

A previous study in this hospital showed that 12.8% of breast cancer patients abscond after diagnosis and do not even start treatment.² Those that returned usually had more advanced disease. This study shows the same trend. The fear of mastectomy, resort to herbal treatment and prayer camps, and the lack of funds are the main reasons for absconding given by the returnees. Clearly these need to be addressed at the time of diagnosis. Among the women who started neoadjuvant chemotherapy before absconding, many reported a downsizing of their tumours, and absconded only when they were advised to have surgery. A few stopped treatment because they were out of funds.

The resort to herbs and prayer camps indicate that patients, irrespective of their level of education, have deeply held beliefs and they resort to these other measures in their time of vulnerability.¹⁵