The two sets of patients had similar levels of education. Although fewer of the absconding patients had tertiary education compared with newly-diagnosed patients, this was not significant (p=0.06). With regard to marital status, there was a significantly greater chance of married women absconding compared to those reporting for the first time (p=0.001).
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
It appears from this study that dealing with the issues that make patients present late to hospital is much more important than offering community-based CBE or screening; the patients still present late. Educative measures include making patients aware of the dangers of breast cancer, the importance of early diagnosis, and dispelling the fears and misconceptions that keep women with suspected breast cancer from reporting to hospital. Also, dealing with the main fears and misconceptions of patients at the time of diagnosis is likely to reduce the number of patients who subsequently abscond.