Breast cancer is a major public health problem globally,¹ with an estimated 2.3 million new cases reported in 2022.² Furthermore, breast cancer was reported as the fifth leading cause of mortality among cancers, accounting for 685 000 women.³ The occurrence of breast cancer among women has been attributed to complex interactions among genetic, hormonal, population structure, lifestyle and environmental factors.⁴ Emerging evidence suggests that mortality because of breast cancer in most parts of sub-Saharan Africa is partly because of late diagnosis,⁵ as 80% of African women are reported to have been diagnosed with advanced cancer stages (III or IV) at first diagnosis.⁶

Breast cancer stages are classified using the American Joint Committee on Cancer (AJCC) TNM system.⁷ The TNM system determines the size and location of the primary tumour (T), the involvement of the lymph nodes (N) and the extent of metastasis (M). The non-invasive ductal carcinoma in situ (DCIS) phase is classified as stage 0, and stages I through IV are used for invasive breast cancer. The greater the number is, the more the cancer has spread. Early diagnosis is associated with stages 0, I and II, and advanced stages (III and IV) are associated with late diagnosis.⁷ Late diagnosis of breast cancer leads to a reduced survival rate.⁸

Breast cancer is increasingly becoming a public health burden in Botswana.⁹ According to the World Health Organization (WHO), of all reported cancers (2317) reported in 2022, female breast cancer accounted for 11.1% (n = 257) new cases, making it the second most common cancer after cervical cancer.² Furthermore, the country’s age-adjusted breast cancer incidence rate increased from 17.5 per 100 000 women in 2018 to 20.0 per 100 000 women in 2020,¹⁰ whereas the age-adjusted mortality rate of breast cancer increased from 8.64 per 100 000 women to 20.0 per 100 000 women in 2020,¹¹ suggesting the need for improved optimal disease-management strategies.

Several studies have shown that early diagnosis is critical for improving the survival rates and quality of life of women with breast cancer.^12,13 However, some studies have indicated that between 72% and 90% of women present with advanced stages of breast cancer at first diagnosis in Botswana.^14,15 The high prevalence of late diagnosis is a cause for concern for a country with health expenditures equivalent to 6.1% of the gross domestic product¹⁶ and free delivery of health services to all citizens through a hierarchical network of public health facilities. There is a need for comprehensive approaches to gain a thorough understanding of the factors associated with the late diagnosis of breast cancer in Botswana to develop evidence-based policies and strategies for improved screening and early detection programmes. We therefore sought to determine the patient-level factors associated with late breast cancer diagnosis among women at four designated oncology centres in Botswana.

The stage at first diagnosis is a critical measure for improved cancer care and increases the likelihood of survival of female breast cancer patients. Our study revealed that almost half (45.91%) of women presented with advanced stages (III/IV) of breast cancer at the time of first diagnosis, which is consistent with findings from Egypt, with a 47.5% late diagnosis rate²¹; Togo, with 55.1%^22,23 and Sudan, with 50.1%.²⁴ Although the prevalence of late diagnosis in Botswana may be lower than that reported within regions such as Zimbabwe (> 80%) as reported in 2023²⁵; Tanzania at 80% in 2022²⁶; Kenya at 80% in 2022²⁷; Zambia at 66% in 2020²⁸ and South Africa at 63.3% in 2022,⁹ late diagnosis still remains a challenge necessitating increased health education and cancer screening campaigns across the country. Overall, our study suggests that routine screening efforts, awareness campaigns and health education need to be encouraged at all levels of healthcare.

The findings from our study also suggest that progress has been made over the years in enhancing cancer care among women in Botswana. Earlier studies have suggested that the prevalence of late diagnosis is variable but greater than that reported in this study. For example, a study conducted in 2013 suggested that 90% of women presented with late-stage breast cancer.¹⁵ This percentage decreased to 56.6% in 2018²⁹ but increased to 64.7% in 2022.⁹

Although this finding reflects some significant strides in early diagnosis efforts, Botswana’s rates are still considered high compared with rates of late-stage diagnosis of breast cancer in high-income countries. Our study revealed that late breast cancer diagnosis was associated with being single and formally employed. Furthermore, this study shows that second-degree breast cancer family history is protective against late cancer diagnosis. Knowledge of family cancer history is critical for early diagnosis, as demonstrated in other studies.^30,31,32

Studies have shown that women with a family history of breast cancer are more likely to develop bilateral cancer at a younger age and these cases also tend to have a less favorable prognosis.^33,34 Thus, service providers can utilise ‘documented family cancer history tools’ to identify women at increased risk of cancer and help develop personalised plans for cancer prevention and early detection, as demonstrated elsewhere.³⁵ This documented family cancer history tool can be used to identify people at increased risk of cancer and help personalise plans for cancer prevention and early detection. The utilisation of family cancer histories calls for strengthened communication among individuals, families and healthcare providers, as demonstrated in other studies.^36,37

Although this study indicated that second-degree breast cancer family history is associated with late breast cancer diagnosis, earlier studies reported that other sociodemographic, personal behaviours or choices and inherited or genetic predisposition factors are associated with stage at the first time of breast cancer diagnosis and survival.³⁸ It is important to prioritise early identification of all patient-level risk factors to enable proactive clinical management. Awareness of these patient-level factors can facilitate early diagnosis of breast cancer and ultimately prevent exposure to these modifiable factors. Public health education helps women understand the importance of early detection and treatment.

Reducing the incidence of late-stage cancer has become critical in enhancing the incidence of breast cancer among several African governments. For example, the Africa Centers for Disease Control and Prevention (Africa CDC) is supporting African Union member states in comprehensively strengthening systems with a strong focus on multisectoral prevention of breast cancer and other non-communicable diseases (NCDs). The African governments are guided by a framework with six African CDC strategic priorities.³⁹ Furthermore, governments are following the recommended pathway with a focus on: (1) patients’ awareness and access to care; (2) clinical evaluation, diagnosis and staging and (3) access to subsequent treatment.⁴⁰

In Botswana, the government has taken deliberate and strategic action to move the health promotion and disease prevention aspects of NCDs to the National AIDS Council (NACA), now called the National AIDS and Health Promotion Agency (NAHPA). This move elevated the importance of NCDs by allowing them to cross-cut high-level priority status in the Office of the President. This also provides an opportunity for NAPHA to leverage lessons learned during the HIV and AIDS epidemic response. These include governance issues, financing, human resources, products and technologies, information systems and community engagement, which will be translated into the fight against NCDs.

Recently, Botswana has taken several initiatives in addressing gaps in prevention and support services. These gaps include shortages of specific trained staff, long delays in cancer detection and diagnosis and shortages of cancer medications and weak monitoring and evaluation systems.⁴¹ The initiatives implemented to address the gaps include the establishment of a national, comprehensive cancer care and prevention programme through the following:

This study underscores the importance of continued advocacy and education in improving the health-seeking behaviour of women in the context of breast cancer. This study suggests the creation of awareness and enhanced screening strategies as critical strategies for early breast cancer diagnosis. Addressing the challenge of late breast cancer diagnosis in Botswana requires a multifaceted approach through awareness creation and enhanced screening. Health initiatives and policies should focus on emphasising the importance of early detection and screening for breast cancer among women. In addition, breast cancer screening programmes should be implemented across all geographic regions of Botswana, with a particular focus on areas that target underserved populations. These initiatives could lead to earlier identification of breast cancer cases and better patient outcomes.

Our findings indicate that almost half (45.91%) of the study participants presented with advanced stages of breast cancer at the time of initial diagnosis, indicating a need to improve awareness, knowledge and benefits of breast cancer screening and diagnosis. While we did not study all women in Botswana the geographical spread of our sample reflects a countrywide problem. Hence, we recommend that Botswana upscales cancer awareness campaigns.