Breast cancer surgical services in South Africa: Availability and barriers to guideline-concordant care

Background. Female breast cancer has become the most frequently diagnosed cancer globally. The incidence of cancer in South Africa (SA) is projected to double by 2030, and services to address the growing burden of disease are urgently needed. The distribution and capacity of existing breast cancer surgical services in SA haVE not been reported. Objective. To provide a quantitative descriptive analysis of the status of breast cancer surgical services in the public healthcare sector in SA. Methods. A descriptive cross-sectional analysis of breast cancer surgical services was performed, including the burden of disease, stage of diagnosis, available diagnostic and therapeutic modalities, waiting time to surgery and barriers to care. Clinicians at every public sector healthcare facility providing surgical care to breast cancer patients were approached to complete a quantitative survey for the year 2019. Results. Data from 43 hospitals across all nine SA provinces were included. Clinicians reported a greater proportion of late-stage breast cancer (67%) than early breast cancer (33%) at diagnosis. The less urban provinces had poorer access to diagnostic and staging modalities. Most facilities were able to provide breast-conserving surgery (79%), while fewer facilities could offer sentinel lymph node biopsy (SLNB) (53%) and still fewer could offer breast reconstruction (35%). Clinicians cited the foremost barriers to standard of care as advanced disease at diagnosis, inadequate access to surgical expertise and lack of access to essential equipment. The national average waiting time for surgery (28 days) is within the recommended timeframe from decision to treat. The representation of the multidisciplinary team across facilities does not comply with national staffing recommendations for a breast unit. Conclusion. Broad disparities exist in access to essential staging and diagnostic modalities between facilities in different provinces. In many settings, there is limited capacity to provide key surgical interventions, particularly SLNB and breast reconstruction. These findings suggest that breast cancer care in most settings within the public healthcare sector is not concordant with proposed national guidelines. There is an urgent need to address the deficits in the distribution and capacity of breast cancer surgical services in SA.