Cancer Screening in The Middle of An Armed-Violence in The North West Region of Cameroon

Purpose and Objectives: This study aimed to assess cancer-related behavioral intentions, service utilization, awareness, and the incidence of the most common cancers in a rural region of Cameroon, which has been affected by armed conflict since 2017.

Materials and Methods: One month prior to the screening, announcements were disseminated through local churches, community radio, and relevant WhatsApp groups. A general health education session was conducted by the head of the screening unit, during which attendees were informed about the procedures, potential benefits, and possible discomforts. An informed consent was obtained from each of the participants. Screening included breast palpation, visual inspection of the cervix before and after application of acetic acid or Lugol's iodine, digital rectal examination (DRE) of the prostate, and a quantitative test for prostate-specific antigen (PSA).

Results: Breast Examination: Among 230 female participants, 2.6% were found to have breast lesions on physical examination.

Cervical Screening: Visual inspection of the cervix post-application of acetic acid and Lugol's iodine revealed that 23.1% of the 230 women screened had findings suspicious for cervical cancer.

Prostate Screening: Of the 74 male participants, 56 (75.7%) had PSA levels above 4 ng/ml, indicating the need for further evaluation via prostate biopsy.

Conclusion: The screening successfully identified previously undetected lesions, underscoring the value of community-based cancer screening as a tool for early diagnosis, especially in conflict-affected rural settings.

Investing in cancer screening is a proven strategy to reduce the cancer burden in many resource- limited countries. Screening women aged 21-65 years-or from age 30, lowered to 25 for those living with Human Immunodeficiency Virus (HIV)-can detect cervical cancer at a stage when it is still treatable [1-3]. Pre-cancerous lesions, which often present without symptoms, can be identified through screening, making cervical cancer one of the most preventable forms of cancer [4]. It is estimated that one-third of cervical cancer cases could benefit from early detection and prompt treatment [5]. In Sub-Saharan Africa (SSA), healthcare systems are often constrained by limited human, material, and financial resources. This region is projected to face a growing cancer crisis, particularly with cervical cancer, as the number of cases is expected to exceed one million by 2030 [6-8]. To mitigate this trend, countries must prioritize investments in cancer screening, early diagnosis of Human Papillomavirus (HPV) infections, and increased HPV vaccination coverage. In response to this need, the Cameroon Oncology Center (COC)-a privately owned oncology hospital based in Douala-organized free cancer screenings during October, in observance of Breast Cancer Awareness Month, locally known as October Rose. The screenings were conducted in Mbengwi Central Sub-Division, a rural area in the North West Region of Cameroon in October 2023. Mbengwi has a core population of fewer than 53,000 residents, with the broader sub-division comprising approximately 45,000 individuals across 29 villages, each led by a second-class chief known as a "fon." Since 2017, the North West and South West Regions of Cameroon have been affected by the Anglophone Crisis-an ongoing armed conflict between the Cameroonian Government and separatist groups, notably the Ambazonia movement. This conflict has led to widespread displacement, with many residents fleeing to regional capitals such as Bamenda and Buea, or seeking refuge in forests and remote areas. As a result, healthcare services at the District Hospital of Mbengwi have been significantly disrupted or discontinued. Against this backdrop, the Cameroon Oncology Center partnered with Micro Global Health and Diagnostic Medical Center–Mbengwi, a local healthcare provider, to deliver free cancer screening services to the residents of this underserved health district

As in previous years, Cameroon Oncology Center (COC) celebrated the Breast Cancer Awareness Month by performing free cancer screenings not only for breast cancer but also for cervical and prostate cancers. The medical and paramedical personnel, in collaboration with Micro Global Health and Diagnostic Medical Center (MGDMC), conducted health screenings on Saturday, October 21, 2023, which extended to Sunday, October 22, 2023, due to the high turnout. Initial approval for the screening was issued by the District Medical Officer (DMO), facilitating subsequent approval and authorization from the Divisional Officer (DO) for Mbengwi Central Sub Division. The DO informed the military and parliamentarians about the screening. A month before the screening, flyers and banners were prepared and posted throughout the health district, advertising the free cancer screening. Information was also disseminated via the local community radio station, local churches, and other places of worship, ensuring comprehensive sensitization of the population. The screening was conducted by a team led by a generalist who had undergone intensive training and assessment on the procedure. He was assisted by three specially trained nurses and the head of the laboratory service for Cameroon Oncology Center. The protocols used were consistent with those employed in previous screening programs over the past six years in other localities in Cameroon. Participants also had their blood pressure, blood sugar, and basic non-fasting cholesterol levels measured before being screened. On Saturday, by 8:00 am, the premises of MGDMC were filled with participants, accompanied by singing and chanting. A health talk on cancer was delivered in both English and the local language (Meta) by the head of the screening team. Topics included warning signs of breast, rectal, prostate, and cervical cancers, information on who to contact or what to do if cancer is suspected, and the importance of maintaining a healthy lifestyle. Gender-specific education was provided on breast and cervical cancers for women, and breast and prostate cancers for men, with a focus on self- examination. Each participant was first received by trained nursing staff who conducted a vital sign assessment and assisted them in completing a questionnaire, which collected data on general health, health knowledge, and relevant social and family history. The nurse also assigned a screening reference number. Participants were then received by the screening personnel, who obtained individual informed consents after educating them on the procedure, benefits, and possible discomforts. The examination focused on the breasts and cervix for females, and the prostate for males, ensuring a comprehensive screening process. Evaluation included palpation of the breasts, visual inspection of the cervix before and after applying acetic acid and/or Lugol's iodine, digital rectal examination of the prostate, and quantitative testing for prostate-specific antigen (PSA) for male participants. Further investigations, such as breast ultrasound, pelvic ultrasound, Pap smear, and thorax-abdomen-pelvic CT scan with contrast, were requested for individuals with suspicious lesions.

Socio-demographic and educational characteristics of the participants

Age distribution of participants

A total of 304 individuals participated in the cancer screening program, which included screenings for breast, cervical, and prostate cancer. Of these participants, 230 (75.6%) were female, while 74 (24.3%) were male. The age of participants ranged from 20 years to over 60 years, with no individuals under the age of 20. As shown in Table 1, most of the participants—both male and female—belonged to the 60 years and older age group. This trend may be attributed to the migration of younger individuals to economic hubs, potentially leading to a higher concentration of older adults in the area.

Table 1: Distribution of participants in age groups.

Matrimonial status of participants

Matrimonial status was recorded for all 304 participants in the screening program. As shown in Table 2, there is a notable gender disparity in marital status. Over 90% of male participants were currently married, compared to approximately 60% of female participants. This indicates a high overall propensity for marriage within the community. Only 6.9% of female participants and 2.7% of male participants were unmarried. This pattern is significant, as marriage often marks the beginning of sustained childbearing, which may result in multiple full-term pregnancies—a known risk factor for cervical cancer. Given this context, achieving broad participation in cervical cancer screening is crucial. Ensuring that all eligible women are included in screening efforts could significantly enhance early detection and prevention in this community.

Table 2: Matrimonial status of participants.

Highest attained level of education of participants

Educational attainment was recorded for all 304 participants in the screening program. The table below presents the distribution of participants by their highest level of education completed, along with gender-specific differences.

As indicated in the data, the majority of both male and female participants had completed only primary-level education. This has important implications for public health initiatives, particularly in the areas of sensitization, health education, and community mobilization for cancer screening. To ensure effective outreach and engagement, health communication strategies should be tailored to a primary school literacy level. This approach would enhance understanding and participation, especially in communities with limited formal education.

Table 3: Level of education of participants.

Service use intentions

Action to take if diagnosed with cancer

Data on participants’ intended actions if diagnosed with cancer was collected from all 304 individuals. The overwhelming majority indicated that they would seek modern medical treatment in the event of a cancer diagnosis. This preference remained consistent across both male and female participants. Only a very small proportion of respondents stated that they would either resign themselves to death or seek spiritual deliverance instead of medical care. This finding presents a valuable opportunity for expanding cancer treatment services in the community, as there is clear evidence of willingness to utilize modern healthcare options if they are made accessible.

Table 4: Distribution of participants according to action that would be implemented if diagnosed of cancer.

Attitudes Toward HPV Vaccination for Minors

Majority of female participants (61.3%) expressed willingness to allow girls aged 11–12 years to receive the HPV vaccine. In contrast, a significant proportion of male participants (83.78%) indicated that they would not permit vaccination for girls in this age group. This stark gender disparity in attitudes has serious policy and strategic implications, particularly because men often occupy key decision-making roles within families and the broader community. The resistance among male participants highlights an urgent need for targeted sensitization efforts, especially aimed at educating men on the safety and benefits of HPV vaccination in preventing cervical cancer.

Table 5: Distribution of participants according to willingness to allow girls 11-12 years to receive HPV vaccine.

Service Use Behavior

History of Genital Warts

Information on past or present diagnosis of genital warts was collected from 230 female and 74 male participants. As shown in Table 6, approximately 1 in 5 females reported having been diagnosed with genital warts at some point, compared to 1 in 20 males. Notably, 82.4% of male participants reported being unsure whether they had ever been diagnosed with genital warts. This lack of awareness among males may reflect limited access to or utilization of sexual health services, or a general lack of knowledge about HPV-related conditions. A 2017 study in Taiwan involving 213,541 cancer cases found that individuals with a history of genital warts had a significantly increased risk of HPV-related cancers, particularly anogenital malignancies [9]. These findings underscore the importance of early detection, education, and prevention strategies, including HPV vaccination and regular screening.

Table 6: Distribution of participants according to past history of genital warts.

Participation in Past Cancer Screening

Data on prior use of cancer screening services was collected from all 304 participants. As shown in Table 7, only 25.7% of male participants reported having ever attended a cancer screening session. Among female participants, this proportion was slightly higher at 34.3%. While the relatively low participation among men may be influenced by the small sample size, the overall findings suggest a low uptake of cancer screening services-a trend consistent with patterns observed across sub-Saharan Africa (SSA) [10–11].

Supporting this observation, studies conducted in Cameroon by other researchers have similarly reported low screening rates:

17.5% in Yaoundé [12]

28.4% in Buea [13]

43.48% in Kumbo West [14]

These findings highlight the need for targeted awareness campaigns and improved access to screening services, particularly for men and underserved populations.

Table 7: Distribution of participants according to ever use of a cancer screening services.

Former Participation in HIV Screening

Data on prior HIV testing was collected from all 304 participants. As shown in Table 8, a large majority of both male (95.9%) and female (98.6%) participants reported having undergone at least one HIV test. Only a small fraction of participants in each gender group had never been tested. This high level of participation reflects the success of widespread public health campaigns, particularly those promoting the message to “know your HIV status.” It also demonstrates a strong level of engagement with preventive health services in the community. Given that a weakened immune system is a recognized risk factor for cancer [5], the high uptake of HIV testing presents an opportunity to integrate cancer screening education and services into existing HIV outreach programs.

Table 8: Distribution of participants according to ever uptake of HIV screening.

Use of a Method of Contraception by Female Participants

Data on contraceptive use was collected from 230 female participants. As shown in Table 9, 57.13% reported never having used any method of contraception. Among those who had used contraception, oral tablets were the most reported method. This finding has important implications for reproductive health and cancer prevention. Prolonged use of combined oral contraceptive pills has been associated with an increased risk of cervical cancer, whereas the use of intrauterine contraceptive devices (IUCDs) is considered protective [5]. However, the current screening did not capture information on the duration of contraceptive use or whether the tablets used were combined or progesterone-only, limiting the ability to assess individual risk more precisely.

Table 9: Distribution of the female participants according to ever use of a method of contraception.

Awareness

Preventability of Cancer

Data on participants’ knowledge regarding the preventability of cancer was collected from all 304 individuals. As shown in Table 10, 67% of female participants and 58.1% of male participants responded affirmatively, indicating that they believe cancer is preventable. This level of awareness, while encouraging, is lower than findings from a 2012 study in Nigeria by Oyedunni et al. [11], where 82% of respondents-primarily female nurses-believed cancer could be prevented. The higher awareness in that study may be attributed to the participants’ medical background and professional exposure. Despite the relatively widespread awareness observed in the current study, this knowledge has not yet translated into increased participation in cancer screening programs. As noted in previous sections, screening uptake remains low in Cameroon [12–13, 15], underscoring the need to bridge the gap between awareness and action through targeted education and accessible screening services.

Table 10: Distribution of the participants according to responses on preventability of cervical cancer.

Family History of Cancer

Data on family history of cancer was collected from all 304 participants, as shown in Table 11. More than 1 in 5 female participants and 1 in 20 male participants reported having at least one family member who had been diagnosed with or was currently living with cancer. Notably, 82.4% of male participants—who traditionally serve as family heads in this cultural context—were unaware of whether cancer had occurred in their families. This significant gap in awareness may reflect limited communication about health issues within families or a lack of emphasis on family medical history. Having a biological relative with cancer is a known genetic risk factor for developing the disease [5]. Although the overall proportion of participants with a known family history is relatively low, those who are aware of such histories could serve as valuable advocates for cancer education and screening within their communities, given their firsthand experience with the burden of the disease.

Table 11: Distribution of participants according family history of cancer.

Awareness on the Human Papilloma Virus (HPV) and Link to Cervical Cancer

Awareness of the Human Papillomavirus (HPV) was assessed among all 304 participants, as presented in Table 12. Overall, awareness was limited. Notably, none of the male participants had ever heard of HPV. Among female participants, 30% reported awareness of the virus. A similar trend was observed regarding knowledge of the link between HPV and cancer. While some women who were aware of HPV also recognized its association with cancer, the proportion was even lower than those who had simply heard of the virus. This limited awareness may be attributed to the absence of co-testing-the simultaneous screening for cervical cancer and HPV-which is not yet implemented in Cameroon, despite recommendations by the American College of Obstetricians and Gynecologists (ACOG). This gap underscores the need for enhanced public education and integration of HPV testing into national screening programs.

Table 12: Distribution of participants according to awareness on HPV.

Cancer Screening Output for Female Participants

Breast Physical Examination of the Female Participants

Physical examination results were available for all 230 female participants. As shown in Table 13, only 3.5% of the women were found to have a breast lesion during the screening. It is important to note that clinical breast examination (CBE) has a relatively low sensitivity, estimated between 17% and 24%, for detecting early-stage breast cancer lesions [16–17]. This underscores the need to complement physical examinations with more sensitive diagnostic tools, such as mammography or ultrasound, particularly in high-risk populations.

Table 13: Distribution of the female participants according to findings on breast physical examination.

Visual Inspection Findings of the Cervix Before and After Application of Acetic Acid or Lugol

Results from the visual inspection of the cervix were available for all 230 female participants. As shown in Table 14, Section 1, 14.8% of participants presented with structural cervical lesions during the initial examination, while 4.3% (10 women) were found to be menstruating and therefore did not undergo the initial inspection. These women were later screened using visual inspection after application of acetic acid or Lugol iodine. Among the 220 women who completed this procedure, 23.1% (53 women) were found to have suspicious lesions requiring further investigation, as indicated in Table 14, Section 2. These findings underscore the critical importance of routine cervical cancer screening, particularly given that none of the women reported any related symptoms. As supported by existing evidence, precancerous cervical lesions are typically asymptomatic, yet they can be effectively identified through screening-making cervical cancer one of the most preventable malignancies when detected early [5, 12, 18].

Table 14: Distribution of the participants according to findings on visual inspection of cervix before and after application of acetic acid and/or Lugol.

Cancer Screening Output for Male Participants: Prostate Digital Examination Findings and PSA Titers

Prostate screening results, including digital rectal examination (DRE) and prostate-specific antigen (PSA) titers, were available for all 74 male participants, as detailed in Table 15. 28.4% of participants were found to have an enlarged prostate on digital examination. PSA testing revealed that 41.9% had titers between 4–20 ng/ml, while 33.8% had levels above 20 ng/ml. According to the National Cancer Institute, a PSA level above 4 ng/ml is considered abnormal and may warrant a prostate biopsy [19]. Based on this criterion, 75.7% of the male participants in this study may require further diagnostic evaluation. These findings underscore the importance of routine prostate cancer screening, particularly in asymptomatic individuals. In resource-limited settings, where access to PSA testing may be constrained, digital rectal examination remains a valuable and cost-effective tool for identifying men who may need further assessment.

 Table 15: Distribution of the male participants according to results of digital examination of the prostate and PSA titers.

Evacuation

After the screening program was completed, Cameroon Oncology Center and Micro Global Health and Diagnostic Medical Center decided to foot the bill of further investigation of any of the participants including any transport cost. Subsequently eight (8) breast cancer screening participants were evacuated to Bamenda, the regional capital of the North West Region for a mammogram but unfortunately none of the mammography machines were functional. These participants were subsequently evacuated to Douala for the mammogram which were performed with good outcome for all patients (all negative). A recommendation was made to evacuate 25 prostate participants (with PSA titers readings above 20ng/ml) to the Cameroon Oncology Center in Douala for further testing and evaluation but in the end only 15 patients were able to travel to Doula. The rest of the prostate cancer participants could not be contacted for many reasons. When the prostate cancer participants arrived Douala, the PSA was repeated again. They also underwent digital rectal exams by the urologist. Based on the PSA results and digital rectal exams, only 5 participants out of 15 proceeded to have a prostate biopsy. Interesting most of prostate PSA reading that recorded high were normal after repeated PSA testing in Douala. So, it is important to collect blood sample for PSA testing before any digital rectal exams. Collecting blood sample after prostate disturbance through the rectal examination has been shown to temporally raise PSA level. 53 cervical cancer screening participants were asked to return to Micro Global Health and Diagnostic Medical Center on a specific day for palp smear but not all the participants showed up. Those that did not show were asked to travel to Bamenda on a later day to complete their palp smear. Some of the cervical cancer screening participants with advanced probable disease were evacuated to Douala together with the prostate screening participants for biopsy and thorax, abdomen and pelvis (TAP) scan with contrast.

This turn out to be an expensive endeavor for both Cameroon Oncology Center and Micro Global Health and Diagnostic Medical Center after spending in excess of $10,000 for the screening, transport and all the scans, mammogram fees, transport and feeding to participants that travel to Bamenda and Douala. Financial appeal to indigens and elites of the Meta tribe where Mbengwi Central Sub Division is located yielded zero dollars and so the continuous follow up of the participants was terminated.

The high turnout for the screening exercise can be attributed to two key factors

An effective sensitization campaign, which was launched a month prior to the event. This campaign successfully engaged household heads and leaders of local associations, ensuring widespread awareness and community mobilization.

Timely authorization from government authorities, which facilitated early planning and smooth execution of the screening activities.

The screening exercise proved to be highly valuable, as it successfully identified lesions that participants themselves had not reported. This outcome reinforces the critical role of routine cancer screening in the early detection and diagnosis of potentially life-threatening conditions, even in the absence of symptoms. It is also important for screening to have a plan for referring the patients for follow-up care for further testing and treatment if required than just screening to say the participants may have cancer but no option for them to access care especially in a resource limited region like the North West Region of Cameroon.

Conflicts of Interest

There were no conflicts of interest in this study.

Ethical Approval

Not applicable.

Acknowledgements

The authors would like to acknowledge with thanks the staff of Cameroon Oncology Center and the staff of Micro Global Health and Diagnostic Medical Center.