The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation

Background. In Haiti, breast cancer patients present at such advanced stages that even modern therapies offer modest survival benefit. Identifying the personal, sociocultural, and economic barriers-to-care delaying patient presentation is crucial to controlling disease. Methods. Patients presenting to the H？pital Bon Sauveur in Cange were prospectively accrued. Delay was defined as 12 weeks or longer from initial sign/symptom discovery to presentation, as durations greater than this cutoff correlate with reduced survival. A matched case-control analysis with multivariate logistic regression was used to identify factors predicting delay. Results. Of patients accrued, 90 (73%) reported symptom-presentation duration and formed the basis of this study: 52 patients presented within 12 weeks of symptoms, while 38 patients waited longer than 12 weeks. On logistic regression, lower education status (OR = 5.6, ), failure to initially recognize mass as important (OR = 13.0, ), and fear of treatment cost (OR = 8.3, ) were shown to independently predict delayed patient presentation. Conclusion. To reduce stage at presentation, future interventions must educate patients on the recognition of initial breast cancer signs and symptoms and address cost concerns by providing care free of charge and/or advertising that existing care is already free. 1. Introduction Breast cancer remains the most common cancer and most common cause of cancer-related death amongt women worldwide [1]. While incidence rates have historically been higher in the developed world, recent evidence suggests an alarming increase in both incidence and mortality in low-income developing countries (LIDCs) [2]. Coupled with stable-to-declining age-standardized mortality rates in developed countries [3], an increasing number of preventable breast cancer deaths will continue to shift to LIDCs worldwide. Within LIDCs, the problem is further exacerbated as relative survival rates (approximated as the complement of the mortality-to-incidence ratio [4]) are lower due to both advanced stage at presentation and inaccessibility of potentially curative therapy [2, 5]. For example, in one study of sub-Saharan Africa, 90% of breast cancer patients presented with stage III or IV disease, a median tumor size of 10？cm, and palpable nodal metastasis [6]. These patterns of disease can be so advanced that even optimal western therapy may offer minimal survival benefit. This is distinctly different than in the developed world, where the majority of women present with early-stage disease, and more than 80% survive at least