1.

0 Background
“Cancer is such a prevalent set of conditions and so costly, it magnifies what we know to be true
about the totality of the health care system. It exposes all of its strengths and weaknesses.”
(Institute of Medicine, 2013)[1].

Low- and middle-income countries (LMICs) have to deal with the dual epidemiological burdens
of communicable diseases, as well as chronic and non-communicable diseases (NCDs)[2]. The
complexities and inequities faced by LMICs in dealing with these epidemiological challenges are
best epitomised by their struggle with cancer[3].

Data from 2005 to 2015 show that the proportion of deaths from NCDs rose globally from 65%
to 71%[3]. During the same period, deaths due to cancer increased from 14% in 2005 to 16% in
2015[3]. On the other hand, deaths due to communicable, maternal, neonatal, and nutritional
diseases decreased from 26% to 20%[3]. The main reasons behind this altered disease burden are
the prolonged longevity of populations, the “modernisation” of lifestyles causing increased
exposure to many chronic disease risk factors, and improved medical interventions[4]. The
international health community has responded to the emerging threat of NCDs in several ways -
such as the 2011 United Nations Political Declaration on NCDs Prevention and Control,25 the
World Health Organisation Global Action Plan for the Prevention and Control of NCDs
20132020,26 and the integration of NCDs in the Sustainable Development Goals.27

Cancer is a major public health problem in both high-income countries (HIC) and LMICs.
Cancer incidence is expected to rise rapidly in LMICs due to the epidemiological transition,
which will further strain their limited health care resources [8]. Appropriate allocations of
resources for cancer prevention, early diagnosis, and curative and palliative care requires detailed
knowledge about the local burden of cancer. Results from the Global Burden of Disease (GBD)
2015 study28 show that although age-standardised incidence rates for all cancers (combined)
increased in 174 of 195 countries or territories (Figure 1) between 2005-15, age-standardised
death rates (ASDRs) for all cancers combined were decreased in 140 of 195 countries.
Figure 1: Relative changes in age-standardised cancer incidence rates in both sexes for all
cancers in 195 countries and territories from 2005 to 2015.

1.2 Introduction
This research was carried out at Kitwe Central Hospital, in Kitwe of the Copperbelt Province of
Zambia. Kitwe Teaching Hospital is the only tertiary hospital in the city of Kitwe and one of the
three teaching hospitals in Zambia. It has 630 bed spaces. Kitwe city is the third largest city in
development and infrastructure located on the Copperbelt province of Zambia , it has the
population of 517,343, with more than 50 health infrastructure and Kitwe Teaching Hospital as
the only referral hospital.

Picture of Kitwe Central Hospital Required Here

There is no national registry for cancer in Zambia and therefore there are no comprehensive data
available on cancer incidence and mortality. The Globocan project of the International Agency
for Research on Cancer (IARC) utilises data from the 28 population-based cancer registries
belonging to the network of the National Cancer Registry programmes (NCRP)[6] to predict
cancer incidence for the whole country. This has its own limitations because more than half of
these registries are based in urban areas. Similarly, mortality data available from most rural areas
is not reliable due to underreporting. However, at present, the Globocan estimates [9] are the
only available information on which the planning of Zambia cancer control policies can be
carried out.

Breast cancer is the malignant tumour of the breast. Every woman is at risk of developing breast
cancer. Breast cancer has become the most frequently diagnosed form of neoplastic disease in
women in Zambia and is now the most common cause of cancer death in the country, accounting
for more than a fifth of all female cancer mortality [8].

Figure 2 and 3 shows the Cancer Country Profile, 2014 by the World Health Organisation[10].

Figure 2: Cancer mortality profile in Zambia.

Figure 3: Age standardized mortality trends in Zambia.

In 2012, A strong family history means that a mother, sibling, child, had breast cancer. Another
risk factor is the age at which a woman begins her menstrual cycle. Women who start their
menstrual cycle below the age of 14 years old have the higher risk of breast cancer. Race is also
a contributor to the risk factor for breast cancer. White women in North America as slightly
higher risk than black, Hispanic or Asian women and considerably higher risk than women who
have recently immigrated from asia. The age at which the woman gives birth to her first child
can also determine the risk for breast cancer. Women who gives birth to their first child at the
age of 19 have the higher risk for breast cancer. risk also increases with amount of alcohol
consumed, hence women who drink alcohol are at a higher risk for breast cancer.the use of oral
contraceptives birth control pills can slightly increase the risk, and the sight risk gradually
disappears when birth control pills are no longer used (halls, 2008) Other risk factors include a
personal history of breast cancer or ovarian cancer, therapeutic radiation treatment, having breast
cancer type 1 or type 2.

According to the latest world health Organisation (WHO) data published in 2017, breast cancer
is 22nd on the list of the leading causes of death in Zambia and in the same year breast cancer
deaths in Zambia reached 446 or 0.39% of total deaths. The age adjusted death rate is 11.69 per
100,000 of population ranks in Zambia number 139 in the world.
Cancer is one of the world leading causes of morbidity and mortality.it is estimated that by 2030
cancer will kill 1million Africans each year. Breast and cervical cancer are the most common
malignancies and cause of cancer related death among women, 1 in 8 women will be diagnoised
with breast cancer in their life time. the cancer disease hospital (CDH) in Lusaka is the first and
only cancer treatment center offering radiation therapy in this country of over 14million people

The cancer disease hospital is mandated to ensure that all Zambians have equity of access to not
only radiotherapy treatment for cancer, but mordalities of cancer treatment including
chemotherapy and surgery.
Data from the cancer centre has shown that most women in kitwe who suffer from breast cancer
first visit health care centres when they have already reached the late stages. The common
reasons for delay in seeking medical advice early are illiteracy, ignorance, myths and
superstitions, as well as financial constraints. Scientific studies have demonstrated that women
who seek treatment in the early stages of breast cancer have a better chance of survival. In order
to develop effective strategies for the early detection of breast cancer, it is imperative to have a
deeper understanding of women’s awareness of disease symptoms and their attitudes towards the
disease. This is important since simple preventive strategies such as breast selfexamination can
be implemented successfully only with women’s active involvement. Focused studies from
defined geographical regions are needed since there are huge variations in the political, cultural
and socio-economic conditions as well as access to health services across the country.

Mortality due to breast cancer can be reduced by the early diagnosis of disease, as well as by
early treatment initiation. Many symptomatic breast cancer patients experience long delays in
obtaining diagnosis and treatment which can negatively affect their prognosis. Therefore, it is
crucial to minimise the time between the initial detection of the disease to the diagnosis by a
clinician and to the initiation of treatment. ‘Patient delay’ refers to the interval between a
patient’s self-discovery of breast cancer symptoms and medical evaluation.

1.2 Statement of Problem

The reasons why women of child bearing age access breast cancer screening in the late stage
include: lack of diagnostic and treatment facilities close to their homes, centralised treatment
facilities are only available in towns .Poor health seeking behaviours due to lack of information
about cancer, fear of the unknown is another reason why people present late ,some married
women fear that their husbands might leave them after the diagnosis of breast cancer and others
believe that cancer is caused by witchcraft hence they seek attention of the traditional healer.
These myths and misconceptions deter people from identifying the disease for what it is and
seeking medical attention for it. According to the Data collected at Kitwe teaching hospitals out
patients departments 2, in 2019 305 females of child bearing age where screened, 65 where
 suspected to have cancer and out of 65, 10 where confirmed to have breast cancer in their late
stage.

1.3 Theoretical Framework

The figure below presents the theoretical framework for the study.

Myths about breast cancer

Lack of mammogram at Kitwe teaching hospital Lack of knowledge about breast cancer among women of child bearing age

To determine the factors that lead to late

breast cancer screening of women of child
bearing age at Kitwe teaching Hospital

f awareness of breast cancer screening

Religious beliefs

Lack of trained personnel to conduct breast cancer screening at Kitwe Teaching Hospital
1.4 Justification

1.5 Variables

1.4 General Objectives

The main objective of this research was to measure knowledge, attitudes, and practices regarding
breast cancer at Kitwe Teaching Hospital with identifying the determinants for delays in the care
and quality of life (QoL) in breast cancer patients. We hope that the findings of this research will
serve to improve the delivery of care at Kitwe Teaching Hospital and thus strengthen the health
care system for breast cancer control and management.

1.4.1 Specific Objectives

 To define breast cancer
 To outline the predisposing factors of breast cancer
 To explain the global and local background of breast cancer.
 To assess the knowledge of breast cancer risks factors among women of child bearing age
at Kitwe Teaching Hospital
 Teach women of child bearing age at Kitwe Teaching Hospital early signs and symptoms
of breast cancer.
 To demonstrate to women of child bearing age how to conduct self- breast examine.
 To reduce the incidence of late breast cancer screening at Kitwe Teaching Hospital.
 To determine the factors that lead to breast cancer screening by women of child bearing
age at Kitwe Teaching Hospital.

1.7 Significance of Study

Late diagnosis is a major factor for the high mortality in breast cancer patients as most patients
present in the advanced stage of disease. This is attributed to a lack of awareness and the non-
existence of breast cancer screening programs in Zambia. In setups where healthcare resources
are limited, early detection may have a positive impact on the delivery of breast cancer
treatment, that is, treatment at earlier stage is likely to be more feasible and less complex.

As breast cancer is a topic that is not freely discussed in Zambia because of cultural taboo, there
is an urgent need for information and education on awareness of breast cancer and its early
detection measures. This information can help the health authorities to plan strategies for the
early reporting of breast cancer patients to health service providers.

Identifying barriers leading to a delay in diagnosis and the management of breast cancer patients
can help to ensure that the limited resources are invested in appropriate and well-designed
interventions for the maximum impact. In a study in at Kitwe Teaching Hospital, it reported a
patient delay of 11 months among women with breast cancer, with old age being identified as the
main factor associated with the delay. Delay may be defined as the period between the first
consultation and diagnosis. Delays are very much dependent on the socioeconomic context of the
region, the health care infrastructure availability and accessibility by the population; therefore
local studies are required to capture the dimension of these problems

The result of the study will be of great benefit to the following:

Women Of Child Bearing Age: the study will give information to women of child bearing age
about the importance of breast cancer screening, importance of self- breast examination,
predisposing factors to breast cancer and reduce on mortality rate caused by breast cancer.

Health Workers: the results of the study will help health workers evaluate the type of care
rendered to the women of the child bearing age, if it is holistic or not, to also determine the scope
of knowledge the women of child bearing age have about breast cancer.

Kitwe Teaching Hospital Management: This study will help the management to foster new
ways of enhancing knowledge to women of child bearing age those that accesses their health
needs at kitwe teaching hospital and also will help in the reduction of refferals of breast cancer to
cancer disease hospital and deaths.
1.7 Operational Definitions
Research: This is a systematic investigation into and study of materials and sources in order to
establish facts and reach new conclusion. (Google, 2019).
Breast Cancer: This is the cancer that forms in the cells of the breast (www.cdc.org.za , on 1st
December, 2019, at 15:00)
Mammograph: This is the process of using low- energy x-rays to exam the human breast for
diagnosis and screening (Wikipedia.org).
Screening: This is the evaluation or investigation of something as part of a methodical survey, to
assess suitability for a particular role or purpose (Webster dictionary, 2003)
Factor: This the circumstance, facts or influence that contributes to the results (www.oxyford
,za)
Child Bearing Age: This is the process of conceiving, being pregnant with and giving birth to
children which is from puberty to menopause(https://www.healthline.com)

1.9 Research Question

What are the factors that lead to late breast cancer screening among women of child bearing age
at Kitwe Teaching hospital.