Geospatial disparities in breast cancer care in sub-Saharan Africa: time to act

In low-income and middle-income countries, specialised care for cancers is often only available in a few national or regional centres located in large urban cities, hence accessing timely diagnosis and treatment can be challenging. For breast cancer, one of the many identified challenges is the location of patients relative to the site of care. Although many previous studies in Africa have focused on the influence of geospatial locations on the pattern of access to cancer care, in The Lancet Global Health, Joanne Kim and colleagues1Kim J Macharia PM McCormack V et al.Geospatial disparities in survival of patients with breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes cohort (ABC-DO): a prospective cohort study.Lancet Glob Health. 2024; (published online May 21.)https://doi.org/10.1016/S2214-109X(24)00138-4Google Scholar explored the relationship of the distance from a treatment centre with the outcome of breast cancer treatment in patients from the African Breast Cancer-Disparities in Outcome cohort across five sub-Saharan African countries. They examined the 4-year survival of 2101 women and observed poorer survival in rural dwellers among whom mortality was found to increase with distance from the hospital (>50 km) and travel time (>1 h). More urban dwellers presented with early-stage disease, but rural-dwelling women with early-stage disease had poorer survival compared with urban dwellers. Women living in rural areas had crude 4-year survival of 37% (95% CI 32–42) versus 54% (46–62) in women in urban areas (adjusted hazard ratio 1·35 [95% CI 1·07–1·71]). This finding opens up more discussion about the interaction between a patient's geolocation, early presentation, and disease outcome. Although previous studies showed a linear relationship between travel time, late presentations with stages III and IV cancers, and increased risk of death,2Knapp GC Tansley G Olasehinde O et al.Geospatial access predicts cancer stage at presentation and outcomes for patients with breast cancer in southwest Nigeria: a population-based study.Cancer. 2021; 127: 1432-1438Crossref PubMed Scopus (8) Google Scholar, 3Shita A Yalew AW Seife E et al.Survival and predictors of breast cancer mortality in South Ethiopia: a retrospective cohort study.PLoS One. 2023; 18e0282746Crossref PubMed Scopus (3) Google Scholar Kim and colleagues' study1Kim J Macharia PM McCormack V et al.Geospatial disparities in survival of patients with breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes cohort (ABC-DO): a prospective cohort study.Lancet Glob Health. 2024; (published online May 21.)https://doi.org/10.1016/S2214-109X(24)00138-4Google Scholar shows poor survival even in early stages of disease among rural dwellers. Geospatial location and the methods adopted for calculation can be fraught with errors, particularly in semi-urban and rural Africa. Street mapping and point location with a home address can be difficult in many places where streets and houses are not numbered. The geospatial data infrastructure is not well developed in many parts of sub-Saharan Africa, creating challenges for spatial estimation.3Shita A Yalew AW Seife E et al.Survival and predictors of breast cancer mortality in South Ethiopia: a retrospective cohort study.PLoS One. 2023; 18e0282746Crossref PubMed Scopus (3) Google Scholar The use of straight-line distance from home is convenient for calculating distance, but cannot suffice for a rural patient whose road transportation might include travelling from one town to another to receive care from major health-care facilities. Assigning speed to a road on the basis of its class presumes that the road is in good condition and the mode of transportation is adequate to attain the speed, besides other factors. The inclusion of distance-based travel time and travel costs is commendable, but patient-reported travel time and costs could give insight into local factors that influence both. In both urban and rural Africa, several social and financial factors influence early disease manifestation, access to care, and treatment uptake, all of which might skew apparent treatment outcomes. These factors go beyond geographical location, travel time, and cost. For example, children or family members who would pay for the medical care frequently live in cities, requiring the patient to relocate to receive care. The choice of care facility can also be influenced by the strong family ties found in traditional African settings, often leading to a preference for a distant location just to facilitate family support. Once more, accurately categorising such groups as urban or rural can be difficult, and a patient's choice of domicile might not reflect their other goals, how they seek treatment, or their financial situation. Another study highlighted biological and genetic disadvantages occurring in geographical clusters,5Goel N Hernandez AE Antoni MH et al.ZIP code to genomic code: neighborhood disadvantage, aggressive breast cancer biology, and breast cancer outcomes.Ann Surg. 2024; (published online March 28.)https://doi.org/10.1097/SLA.0000000000006283Crossref Google Scholar showing that many factors can contribute to the outcomes of breast cancer treatment. There is a need to keep these nuanced, context-specific factors in mind when designing studies on geospatial location, cancer diagnosis, and treatment outcomes. Evidence from this study and previous studies reinforces the need to do a lot more to enhance the diagnosis and treatment of cancers in sub-Saharan Africa—particularly breast cancer, which is expected to increase in incidence.6Azubuike SO Muirhead C Hayes L McNally R Rising global burden of breast cancer: the case of sub-Saharan Africa (with emphasis on Nigeria) and implications for regional development: a review.World J Surg Oncol. 2018; 16: 63Crossref PubMed Scopus (139) Google Scholar The concerted effort of governments and non-governmental organisations to establish national, regional, and local cancer diagnosis and treatment centres must be encouraged. The Lancet Oncology Commission on cancer in sub-Saharan Africa7Ngwa W Addai BW Adewole I et al.Cancer in sub-Saharan Africa: a Lancet Oncology Commission.Lancet Oncol. 2022; 23: e251-e312Summary Full Text Full Text PDF PubMed Google Scholar advocates the adoption of regional solutions to overcome some of these challenges. In particular, access to radiation therapy—a key component of breast cancer treatments—constitutes a huge travel burden, and many experts have advocated hypofractionation as a possible solution.7Ngwa W Addai BW Adewole I et al.Cancer in sub-Saharan Africa: a Lancet Oncology Commission.Lancet Oncol. 2022; 23: e251-e312Summary Full Text Full Text PDF PubMed Google Scholar, 8Patel S Olatunji E Mallum A et al.Expanding radiotherapy access in sub-Saharan Africa: an analysis of travel burdens and patient-related benefits of hypofractionation.Front Oncol. 2023; 131136357Crossref Scopus (0) Google Scholar With the financial toxicity from out-of-pocket payment for breast cancer care contributing to late presentation and poor treatment uptake,9Knapp GC Wuraola FO Olasehinde O Romanoff A Kingham PT Alatise OI The out-of-pocket cost of breast cancer care at a public tertiary care hospital in Nigeria: an exploratory analysis.Pan Afr Med J. 2022; 41: 272Crossref PubMed Scopus (9) Google Scholar the adoption and expansion of universal health coverage for cancer care in the subregion is equally crucial. I declare no competing interests. Geospatial disparities in survival of patients with breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes cohort (ABC-DO): a prospective cohort studyGeospatial barriers reduce survival of patients with breast cancer in sub-Saharan Africa. Specific attention is needed to support patients with early-stage breast cancer living in rural areas far from cancer treatment facilities.