Case of the Week: Breast Cancer



SF and her lateral chest wall mass

SF is a 34 year old Fulani woman who travelled from Burkina Faso (the country to the north of Ghana) to be evaluated for a mass on her right chest wall.  She stated that it started as a small sore just before the birth of her last child approximately nine months prior.  On exam, she had a large fungating mass on the lateral aspect of her right chest.  The lateral aspect of her right breast involved on exam and she had no palpable axillary lymph nodes.  The mass did not seem to be attached to the underlying chest wall so I was able to resect the mass and place a skin graft in the defect which was left.  Pathology returned as an adenocarcinoma with a lymph node that was taken during surgery positive for disease.  She recovered well after her surgery and the skin graft healed nicely.


Breast cancer is one of the leading malignancies here in Ghana.  In 2007 it was estimated that breast cancer accounted for 15.4% of malignancies and about 70% of the women diagnosed with breast cancer present in the advanced stages of the disease.  Studies have also shown that women in Ghana are more likely to have high-grade tumors that are triple negative for hormone receptors.  This results in more aggressive disease and higher mortality rates.  Breast cancer is also seen here in Ghana in much younger women.

Peau d'orange skin changes seen with inflammatory
breast cancer 

It has been my experience to see women in the late stages of the disease.  I have seen many patients with large ulcerative lesions of the chest that have totally replaced the breast and who no treatment can be offered.  Those that I have been able to do mastectomies on have all had positive lymph nodes and advanced disease.  Women delay in coming to see a physician for many reasons.  For many in the North it is a lack of education and awareness that what they are experiencing in their breast is abnormal.  There is a cost associated with traveling to a health facility that many cannot afford.  There is also an underlying belief in fatalism here in Ghana, which leads women with breast cancer to have a feeling of hopelessness and helplessness and therefore leads to denial as the primary means of coping with what is happening.

Large medial breast cancer

Women finally present to clinics when their pain has become unbearable or when the fungating lesions are so large, infected, and necrotic that they have been ostracized by their community and family because of the smell of the wound.  Once they have made their way to a clinic, the main challenge is to convince the patient of the treatment they need.  It has been very difficult to get patients who are candidates to agree to mastectomies because they see it as an amputation, which is frowned upon here in Ghana.  I have been lucky because I have an ally on my side here at the BMC.  One of our medical assistance is a breast cancer survivor and I have begun to send all of my patients to see and discuss surgery with her.  I figure she can explain to the women better why they need a mastectomy with more cultural sensitivity than I.  Since I have begun that practice, more of the patients are showing up for their scheduled mastectomies than earlier in the year. 

The Breast Health Global Initiative and the Susan G. Komen for the Cure have established a Ghana Breast Cancer Alliance to help try to decrease breast cancer mortality by increasing earlier detection.  It was announced in September that the Alliance acquired a mobile detection and education van for outreach programs to rural Ghana.  I am hoping to get the Baptist Medical Center on their schedule of stops so that better breast care can be given to the women of Northern Ghana.