Breast Cancer Pathology Services in a Low-Resource Setting: The Experience of Cameroon Oncology Center

Purpose: The objective of this study was to find out the quality of pathology reports that were brought by breast cancer patients who consulted at Cameroon Oncology Center (COC), an independent private cancer center in Sub-Saharan Africa (SSA) in the Republic of Cameroon.
Methods: We reviewed the medical records of all the cancer patients who consulted at Cameroon Oncology Center between April 2019 and April 2022. The medical files of all the breast cancer patients were then selected for further review. The availability of the pathology report was noted. For each patient file that had a pathology report, we then determined the quality of the pathology report by noting if the pathology report included immunochemistry, tumour margins, and lymph node status.
Results: Of a total 1632 patients who consulted at Cameroon Oncology Center between April 1st, 2019 and April 1st, 2022, 592 were breast cancer patients. This represents 36.3% of the total cancer population who consulted. Of the 592 breast cancer cases, only 170 (28.7%) had pathology reports. We found that less than 50% (81) of the group with pathology reports could be described as detailed (positive/negative margin or lymph nodes status). Additionally, of the 170 pathology reports, only 24 (14.1%) had immunochemistry performed, and only 15 (2.5%) had reports that included histochemistry, tumour margins and lymph node status.
Conclusion: In the entire cohort of 592 breast cancer patients seen at COC over a three-year period, only 2.5% (15) of the patients had complete pathology reports. This really low number of complete pathology report represents a significant impediment to the provision of quality care for most of the cancer patients who consulted at COC. Pathology reports came from 34 pathologists which indicated that the number of pathologists per million of the population to be approximately 1 which is much higher than values in the literature of 1 pathologist per 6 million of the population  reported  in the literature for some countries in Sub Saharan Africa.

The burden of cancer in Sub-Saharan Africa (SSA) is increasing rapidly with an estimated number of new cancer patients exceeding 800,000 in 2020 [1]. This number is expected to grow to 1.2 million  new cancers by 2030 [1]. Health care systems in Sub-Saharan African countries are not prepared to cope with the growing cancer incidence [2] as they are facing many challenges including limited financial funds allocated to healthcare. Most countries in SSA allocate only 3-5% of their budget for healthcare expenditure despite the Abuja declaration of 2001 urging African Union member states to allocate at least 15% of national budgets to the health sector [3,4].

Modern cancer services are capital intensive and the lack of funding is one of the main reasons limiting the establishment of radiotherapy services in SSA which usually require upfront capital which run into millions of dollars (US). Additionally, lack of trained personnel specialized in different aspects of the cancer care continuum is another major problem. The pathology service, is a critical component of modern oncology care but unfortunately it is rudimentary in many countries across SSA including Chad and South Sudan, where the number of trained pathologists is about one per six million of the population [5]. However, pathology is vital for the diagnosis and management of cancer [6-10]. Insufficient pathology services can lead to a cycle of ineffective healthcare knowledge and practice [10,11]. Even when such reports are available, they are often incomplete, lacking critical pieces of information necessary for appropriate treatment decisions especially for curative intent. Most pathologists operating in SSA face many challenges including lack of modern equipment, training and sometimes even recognition by other specialists about their importance [7, 12-14] The scarcity of pathologists, pathology technicians, and equipment affects the quality of their work and the results provided [9,15]. Sometimes the quality of the tissue sample received and its description by the surgeons even before it reaches the pathologists also affect the quality of the pathology report that would eventually be generated.

Cameroon Oncology Center (COC) opened her doors for clinical operations on April 1st, 2019. This centre was initiated to fill a big void in the provision of radiotherapy services for cancer patients in Cameroon and the sub-region in general. COC is an independent private oncology center that treats cancer patients from Cameroon and all the surrounding countries that include Chad, Gabon, Democratic Republic of Congo, Congo Brazzaville, Equatorial Guinea and Central Africa Republic. It is the only cancer center in Cameroon and the central African sub-region with a modern medical linear accelerator (linac). COC has eight chemotherapy infusion chairs and patients can get their chemotherapy in their private rooms. The first radiotherapy patient received radiation treatment on April 1st, 2019 on a computer-controlled Varian Clinac 21EX medical linear accelerator (Varian Medical Systems, Palo Alto, CA) which has photon and electron beams for radiotherapy administration. COC is the first and currently the only cancer centre in Cameroon to operate a medical linear accelerator for the delivery of radiation treatment to cancer patients in the CEMAC (Economic and Monetary Community of Central Africa)zone of central Africa.

Cameroon Oncology Center presently does not offer any major surgical or pathology services so prospective cancer patients have to bring all the relevant surgical history and pathology report with them for use in treatment decision making. Patients who do not have biopsy results at the time of presentation/consultation are referred to an outside health facility for biopsy and histopathology diagnosis. The purpose of this work is to study in details the pathology reports of breast cancer patients consulted at COC between April 1st, 2019 and April 1st 2022.

The medical records of all the patients who consulted at Cameroon Oncology Center between April1st, 2019 and April 30th, 2022 were reviewed. The pathology reports were extracted and those for breast cancer cases were then selected and scrutinized for details. The following information was extracted from the pathology report if available: patient’s name and date of birth; disease site; stage of cancer; place of origin; referring hospital; name of the pathologist and their institution of practice; status of margin if reported; immunochemistry analysis if reported; and results of cancer biomarker if reported. An excel spreadsheet was created and data was recorded on this excel spreadsheet for analysis.

Between April1st, 2019 and April 30th, 2022, a total of 1632 patients were consulted at Cameroon Oncology Center. Out of the 1632 cancer patients, 592 of them were breast cancer cases representing 36.3% of the total cohort. We found that out of the 592 breast cancer patients, 170 had pathology reports. Table 1 shows the age distribution of the 170 breast patients with pathology reports we received at Cameroon Oncology Center.

In all 34 pathologists from 30 institutions (both elite private and public institutions mostly in Cameroon) authored the pathology reports of the breast cancer patients included in this study. The institutions in Cameroon with the highest number of pathology reports were Centre Pasteur Yaoundé (42 out of the 170 patients representing 24.7%), followed by Mbingo Baptist Health System with 22 cases (12.9%), Douala General Hospital (14 cases representing 8%), and Buea Regional Hospital with 12 cases (7%). Two cases were referred out of Cameroon (Gabon, and Kokilaben Hospital in India).

Table 1: The distribution of breast cancer patients with pathology reports according to age group

In order to characterize or rate the quality of the pathology reports, we further sub-grouped the reports into 4 categories as follows:

Category 1 pathology report. It has the diagnosis, size of tissue specimen received, site from where it was obtained, colour, parenchyma details, margin status, lymph nodes status and stains used if done.

Category 2 pathology report which, has the diagnosis, tissue size, colour but no other details.

Category 3 pathology report. This category has the diagnosis and the size of the tissue sample but no other information.

Category 4 pathology report. It has only the diagnosis and no other information.

Table 2 shows the distribution of the 170pathology reports according to the details in the reports.

Table 2: Distribution of pathology reports based on the details in the reports

The next important characteristic to establish from the pathology report was whether  is to chemistry was performed on the tissue sample. Of the 170 pathology reports, only 24 (14.1%)had histochemistry performed, and only 15 (8.8%) had reports that included histochemistry, tumour margins and lymph node status. So, 15 patients represent only 2.5% of the 592 breast cancer patients who consulted at Cameroon Oncology Center.

Over a three-year period (2019-2022), 592 (36.3%) out of the 1632 cancer patients evaluated at Cameroon Oncology Center were breast cancer patients, of whom 170 (28.7%) had pathology reports at the time of presentation. Of those with pathology reports, only 81 (47.6%) had very detailed reports that included margin and lymph nodes status. Thus, margin status and lymph node status were unknown in over 52% of the pathology reports seen at COC.

Furthermore, immunohistochemistry was performed on only 24 (14.1%) of the 170 pathology specimens reported. Taken together, of the entire cohort of 592 breast cancer patients seen at COC between April 2019 and April2022, only 2.5% (15) of the patients had expected complete pathology reports sufficient for treating clinicians to make appropriate treatment decisions for breast cancer patients, which is quite an abysmally low rate. Of note the few reports with immunohistochemistry were from Centre Pasteur Yaoundé and Cabinetd’ Anatomie et de Cytologie Pathologiques even though there were at least 30 practicing pathologists from a wide variety of centres both in the public and private sectors where many of these pathology reports were generated. Sometimes, the finalized reports do not match with the clinical presentations of cancer and when a repeat biopsy is required, it may take weeks and sometimes months, while the cancer is progressing hence oncologists are forced to treat without an adequate report especially for palliative intent. Some cancer patients after waiting for their pathology report usually sort alternative treatment to herbalists. They only come back when the cancer is metastatic and they are having serious symptoms.

A discussion with some of the pathologists indicate that most of the surgeries that are done for breast cancers in Cameroon is performed by general physicians and they often do not send the any sample for any pathological studies. Samples are sometimes given by the surgeons or the operating physician to patient to take to a pathology lab for studies. These patients do not take them to the lab as this usually involve additional payment to the pathology laboratory. Some patients do not take these samples to the lab for lack of funds or simple ignorance.

The pathology reports analysed came from 30 pathologists that work in Cameroon. Thus, one may extrapolate that the 30 pathologists who authored the patients reports included in this analysis represent a significant proportion of the total number of pathologists in Cameroon. So, we can assume that there are at least 30 pathologists for a Cameroonian population of about 27 million inhabitants.1 This implies that there is roughly one pathologist per one million of the population. That is, in Cameroon, the number of pathologists per head of population is about 1/1,000,000. It is likely that the actual number of trained pathologists maybe more thus giving a ratio of more than one pathologist per million of the population which will still be better than previous estimates, based on surveys, which put the ratio at one pathologist for 4 million of the population [5,17,18].

For instance, in 2016, the number of pathologist in Cameroon was estimated to be 0.28 pathologists per million in habitants [16]. Therefore, the results from our study (that is, the number of pathologists per head of population) which are based on real data are much better than the published data based on surveys which suggested lower numbers. A study by Nelson et al [5]. on the number of pathologists in Africa showed that the average number of pathologists per head of population is 1/1,000,000. This is in contrast with the ratio of one pathologist to 15,000–20,000 people in the US or UK, a difference of between 50 and 70 fold [7,10]. Moreover, the study showed that the distribution of pathologists in Africa is uneven, and only seven countries (South Africa, Nigeria, Ghana, Kenya, Ethiopia, Uganda and Tanzania) have less than one million persons per pathologist. Cameroon can therefore certainly be added to this list.

This work highlights a huge unmet need in Cameroon and by extension the central Africa sub- region as concerns cancer treatment. Without a good pathology report, it is very challenging to use even available tools albeit insufficient to treat cancer. For breast cancer patients the tumour margins and lymph node status are critical in determining the extent of radiation, whether re- resection is necessary and use of chemotherapy (lymph node status) and hormone status are critical in determining the benefit of hormone therapy post radiation therapy. For breast cancers, some head and neck cancers, immunohistochemistry (IHC) analysis is often required but reagents are not available which also affect the quality of the report [12]. IHC is essential in modern pathology and is often required to identify the precise type of tumour, and therefore the correct choice of treatment [16].

Clinically, our greatest problem at Cameroon Oncology Center has been the lack of reliable histo- pathology services in Cameroon. Obtaining a repeat biopsy or a second opinion for a biopsy may take another 6-8 weeks. The slides are not always available to get a second opinion. Often the hormonal status for breast cancer is unknown and only a few labs report even do this. So, one should note that reports such as the present study may be used by authorities and professional organizations to develop certain minimum acceptable guidelines of what should constitute an ap- propriate pathology report and also develop quality control measures. Digital pathology may also help fill the void and one hope that resources can be procured to establish a digital pathology service at Cameroon Oncology Center. Cameroon Oncology Center presently has the only modern radiation equipment in the country and is at the forefront of research. COC’s most recent publications described: (i) our approach to commissioning Cameroon’s first linear acceleration for cancer radiation therapy; (ii) dosimetric audit quality assurance tests employed at COC to ensure that cancer patients receive safe, effective and high-quality radiation treatments; and (iii) a hybrid telemedicine program for our oncology services [19-21].

This study performed an analysis of the pathology reports of all breast cancer patients who sort consultation at Cameroon Oncology Center, a privately owned cancer oncology center in the Republic of Cameroon. The analysis showed that about 29% (170) of the 592-breast cancer population who consulted at the Center between April 2019 and April 2022 had pathology reports at the time of presentation. However, in the entire cohort of the 592 breast cancer patients, only 2.5% (15) had complete histopathology reports that included histochemistry, tumour margins, and lymph node status necessary for oncologists to make appropriate treatment decisions for breast cancer patients. The study highlights further that, in Cameroon, the number of persons per  pathologist could be less than one million.

The authorsacknowledge with thanks the staff of CameroonOncology Center for their contributions.