Clinical features, diagnosis, and referral of patients with breast abnormalities in primary health care settings in rural Ethiopia: a retrospective record analysis

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At the primary health care level, understanding the magnitude of different breast abnormalities and current referral practices can improve patient-centred health care services, enhance patient education and awareness, and encourage interdisciplinary collaboration to enhance breast cancer outcomes, in line with the World Health Organization Breast Cancer Global Initiative (GBCI) Pillar One Goal. Thus, this study aims to explore the burden of breast-related abnormalities and their clinical features during presentation, diagnosis, treatment, and referral practices at the primary health care level in Ethiopia. Methods A facility-based retrospective record analysis was conducted in 2022. All documented cases of breast abnormalities among women at outpatient departments of 17 primary health care facilities were included. Results Of all women who presented at outpatient departments, breast abnormalities were estimated at 5 per 1,000 women patients. The proportion of suspected diagnoses of breast cancer among women with breast-related complaints was 7.5% (n = 25/335). Among women with breast-related complaints, half (50.7%, n = 170) presented with a complaint of breast pain, and approximately half (47.2%, n = 158) presented to the health facility within < 1 month from the onset of symptoms. More than half of the women (63.0%, n = 211) were diagnosed with breast infection/mastitis. A total of 57.1% (n = 194) of women with breast complaints were treated with antibiotics and pain medication. The proportion of women who received surgical treatment at primary hospitals was 2.6% (n = 14). Overall, the study found a 6.0% (n = 20) referral rate and 23.0% (n = 101/436) incomplete patient record. Conclusion Women in Ethiopia often present to primary health care facilities with breast pain and suspected mastitis. In this study, a suspected diagnosis of breast cancer was found in 1 in 13 cases. This highlights the need for diagnostic services, and coordination to distinguish between benign conditions and serious malignant diseases. Strengthening primary health care services in terms of symptom recognition, referral communication, and documentation is essential to achieve the GBCI goal to contribute to the reduction of breast cancer mortality. primary health care referral pattern breast abnormalities Global Breast Cancer Initiative Ethiopia Figures Figure 1 Figure 2 Background Breast cancer is the most commonly diagnosed cancer, with an estimated 2.3 million new cases, accounting for 11.7% of all cancer cases ( 1 ). In low- and middle-income countries (LMICs), a significant proportion of women with breast cancer present with or are ultimately diagnosed at a later stage of the disease ( 2 ). Some of the most rapid increases are occurring in sub-Saharan Africa (SSA). Studies project that between 2020 and 2029, 416,000 women will die of breast cancer in SSA; however, with earlier diagnosis and improved treatment, at least one-third of these deaths may be prevented ( 3 ). In Ethiopia, breast cancer is the most common cancer, accounting for 9,061 (22.6%) deaths annually ( 4 ). A study from South and Southwest Ethiopia showed that 72.5% of patients with breast cancer were diagnosed at advanced stages (stages III and IV) ( 5 ). Similarly, a systematic review and meta-analysis covering 17 SSA countries revealed that 74.7% of women were diagnosed at a late stage. Moreover, patients who reported a painless breast lump as their chief complaint were twice as likely to experience a delay in their breast cancer diagnosis ( 6 ). The Global Breast Cancer Initiative (GBCI) emphasises the importance of primary health care (PHC) involvement in the continuum of breast cancer care, recommending early identification of breast symptoms and timely referral to diagnostic facilities ( 7 ). Ethiopia has recently implemented a breast cancer guideline that aligns with these recommendations, highlighting the role of PHC facilities in health promotion, early symptom detection, clinical breast examination, and prompt referral linkage to diagnostic services ( 8 ). The overall burden of breast-related complaints among women seen at outpatient departments (OPDs) has not been well studied, particularly in LMICs. In a study from the United States, breast-related complaints accounted for 3% of overall complaints at PHC facilities ( 9 ). In the United Kingdom, general practitioners at PHC clinics see at least one patient with a breast abnormality per week ( 10 ). However, studies from LMICs have shown that 74.0–88.4% of patients with breast cancer initially present at health facilities with a breast lump, with pain being the most common symptom prompting them to seek medical care. Additional symptoms include breast discharge, swelling, lumps under the arms, and itching ( 11 – 13 ). These abnormal breast findings must be thoroughly investigated, triaged, and treated. Studies have indicated that the incidence of breast cancer is slightly higher in patients with histologically confirmed benign breast diseases than in the general population ( 14 , 15 ). This underscores the importance of monitoring patients with breast abnormalities, particularly those in low-resource settings where health care-seeking behaviour is often low due to various factors, including the affordability of health services ( 16 ). Provider delay often stems from primary care physicians failing to consider cancer during the initial consultation ( 17 ). A study from the United Kingdom suggested that primary care physician visits were associated with improved breast cancer outcomes and that adequate primary care can be a key factor in achieving optimal outcomes ( 18 ). However, a study in Ethiopia found that the first visit to a health centre can contribute to diagnostic delay ( 19 ). In many LMICs, PHC diagnostic capacities are inadequate, leading to poor health outcomes ( 20 ). Research on the quality of routine PHC in LMICs indicates that care is often insufficient, with significant variation between and within regions ( 20 ). Studies from Indian and Chinese PHC clinics revealed that providers completed only one-third of the recommended medical history and physical examinations; moreover, they provided diagnoses in just 36% of cases, and only 12% of these diagnoses were correct ( 21 ). Despite structural differences, PHC-oriented health systems consistently produce better outcomes, greater equity, and improved efficiency ( 22 ). PHC providers play a crucial role across the cancer care continuum, from promoting accurate screening and diagnosis to delivering care during and after cancer treatment, including managing comorbidities [18]. A well-structured PHC system, including capacity building for providers, an efficient referral system, and patient-centred guidance for diagnostic and treatment services, could improve quality and reduce delays within the health care system [19]. To support this, high-quality evidence is needed on the prevalence and nature of breast complaints at the PHC level. Therefore, this study aims to provide baseline data on the clinical features, diagnosis, treatment, and referral experiences of patients with breast-related complaints at the PHC level in Ethiopia. This information can serve as a foundation for health care planners and help identify research gaps. Methods Study design and area A retrospective facility-based medical record review was conducted in selected PHC facilities. The included facilities were part of an oncology research network supported by the Else Kröner Center for Cancer Care and the project Developing InterNational CollaboratioN in Ethiopia to Support oncology at primary Health care levels (DINKNESH). This research network comprises 94 health facilities, including 15 hospitals and 15 health centres with 64 satellite health posts. The 15 health centres, 3 primary hospitals, and 64 satellite health posts are classified as PHC-level facilities. Additional hospitals in the area include general hospitals and comprehensive hospitals, which serve as referral points for PHC facilities within Ethiopia’s three-tier health system. This study included 17 PHC facilities from project sites distributed across 3 regions, each with distinct demographic and geographic characteristics: the Oromia region (5 health centres), the Central Ethiopia region (2 hospitals, 7 health centres), and the Southern Ethiopia region (1 hospital, 2 health centres). The 64 health posts were not included because they focus on health promotion activities within the community and do not provide clinical services. Study population and period The study population comprised women aged ≥18 years who presented with breast-related complaints at the OPDs of the 17 health facilities between 1 January 2022 and 31 December 2022. Men with breast-related complaints were excluded. Medical records (n = 101) that did not clearly state the patient’s complaint or diagnosis, or only recorded unrelated diagnoses, were omitted from the analysis. Sampling and data collection Initially, potential cases were identified from patient registration books related to breast complaints at OPDs. Medical record numbers were extracted from the registry books using the Ethiopian Simplified Version of the International Classification of Diseases (ESF-ICD-11) Health Center Edition (23). Medical records were selected based on the registered diagnoses associated with breast-related disorders according to the ESF-ICD-11 classification. Two trained research assistants, both nurses by profession, extracted medical records from the registries. Once identified, the corresponding patient medical records were retrieved. Data were then collected using extraction sheets developed based on a review of the literature (24, 25), capturing information on clinical features, diagnostics, treatment, referrals, follow-ups, and appointments. Data extraction was performed by two individuals (E.G., A.S.). Data analysis Descriptive analysis was conducted using means, standard deviations, frequencies, and percentages. Age was categorized in groups and cross tabulation were conducted to explain the outcome variable. Data were entered into EpiData version 4.1 and exported to SPSS version 25 for analysis. Operational definitions Breast-related complaints: The chief complaint a woman presents with when visiting the OPD at a PHC facility. Current breast-related complaint: A breast-related complaint that occurred in 2022 and is recorded in the registry. If multiple visits occurred, the most recent visit was taken as the reference point, while earlier visits were considered previous breast-related complaints. Previous breast-related complaint: A breast-related complaint documented before the current complaint, traced through the patient’s medical records. Suspected diagnosis: A diagnosis documented by the OPD professional based on the woman’s presenting complaints at the PHC unit. It includes cases referred for further evaluation or treated at the PHC facility with first-line treatment. Pathologically confirmed diagnosis: A diagnosis made by a health professional following pathological findings, in addition to clinical examination with or without imaging, typically performed at primary hospitals. Ethical approval Ethical clearance was obtained from the College of Health Sciences Institutional Review Board of Addis Ababa University (007/24/SPH) and Martin Luther University Halle-Wittenberg (2024-113). The requirement for individual informed consent was waived by Institutional Review Board of Addis Ababa University (ethical approval number: 007/24/SPH). Permission was obtained from the facility administrations and regional health offices. Results In total, 436 cases were retrieved from the registry of adult OPDs. Among these, 335 patient medical records were included in the analysis (Figure 1). Sociodemographic characteristics The patients’ age (mean ± standard deviation) was 29 ± 8.7 years (range, 18–70 years). The majority of women (48%; n = 162) were in the 20- to 29-year age group, followed by 32% (n = 107) in the 30- to 39-year age group (Table 1). In total, 55% (n = 185) of the patients were from central Ethiopia. The minimum number of women who visited the OPD in 2022 was 2,291, with a maximum of 24,398 per facility. Among these, a minimum of 4 and a maximum of 151 breast-related abnormalities were registered per health facility for the year 2022 (Additional File 1). The average proportion of breast-related complaints among women presenting at the OPD in PHC settings was 5 per 1,000 women per year. Clinical presentation Overall, 50.7% (n = 170) of the patients presented with complaints of breast pain, followed by 14.6% (n = 49) who reported breast swelling. Nearly one-quarter (24.7%, n = 83) of the patient records failed to document the complaints of women during their presentation, with only the diagnosis and treatment information recorded (Table 1). Table 1. Sociodemographic and clinical characteristics of women presenting with breast complaints at 17 PHC facilities in 2022 Characteristics ( total : n = 335) n % Age groups, years <20 20 6 20–29 162 48 30–39 107 32 40–49 31 9 50–59 8 2 ≥60 7 2 Mean ± standard deviation 29 ± 8.7 years Region Oromia 114 34 Central Ethiopia 185 55.2 Southern Ethiopia 36 10.7 Type of health facility Health centre 194 57.9 Primary hospital 141 42.1 Main complaint Pain 170 50.7 Swelling 49 14.6 Mass 20 6 Other a 11 3.3 Not documented 83 24.7 a Wound care, itching, follow-up Twenty-eight patients (8.4%) visited the health facility at least once with complaints of breast symptoms prior to the current presentation. Of these, nine (2.6%) patients came twice, two patients came three times, and one patient came four or five times with the same complaint. The interval between the current presentation and the first previous visit ranged from 1 day to 7 years (median: 1.5 months, interquartile range: 10–22 days). According to the duration of the chief complaint listed in the medical records, nearly half of the patients (47.2%; n = 158) presented to the facility within <1 month from the onset of symptoms. Among these patients, 63.0% (n = 101) were in the 21- to 30-year age group (Table 2). Suspected diagnosis and treatment Overall, 7.4% (n = 25) of the women had a suspected diagnosis of breast cancer. Among these, 64.0% (n = 16) were from primary hospitals. Nearly two-thirds of the women (63.0%; n = 211) were diagnosed with breast infection/mastitis, followed by fibroadenoma (11.3%; n = 38). Of the total suspected cases of mastitis, 65.4% (n = 138) were diagnosed at health centres (Figure 2). Among patients who attended PHC facilities, 54.5% (n = 115) had mastitis and were aged 20–29 years, whereas 52.0% (n = 13) of those suspected of having breast cancer were aged 40–49 years (Table 2). Table 2. Age distribution and symptom duration of patients in relation to suspected diagnosis, 2022, Ethiopia Breast infection Fibroadenoma Breast pain/ mastalgia Breast cancer Abscess Others Not documented Total Age group , years >20 10 (4.7) 5 (13.2) 4 (12.9) 0 (0.0) 0 (0.0) 1 (11.1) 0 (0.0) 20 (6.0) 20–29 115 (54.5) 16 (42.1) 17 (54.8) 1 (4.0) 7 (50.0) 3 (33.3) 3 (42.9) 162 (48.0) 30–39 71 (33.6) 11 (28.9) 8 (25.8) 6 (24.0) 4 (28.6) 4 (44.4) 3 (42.9) 107 (31.9) 40–49 10 (4.7) 4 (10.5) 2 (6.5) 13 (52.0) 1 (7.1) 0 (0.0) 1 (14.3) 31 (9.3) 50–59 2 (0.9) 2 (5.3) 0 (0.0) 3 (12.0) 1 (7.1) 0 (0.0) 0 (0.0) 8 (2.4) ≥60 3 (1.4) 0 (0.0) 0 (0.0) 2 (8.0) 1 (7.1) 1 (11.1) 0 (0.0) 7 (2.1) Total 211 (100) 38 (100) 31 (100) 25 (100) 14 (100) 9 (100) 7 (100) 335 (100) Duration of chief compliant , months ≤1 126 (59.7) 5 (13.2) 16 (51.6) 3 (12.0) 3 (21.4) 2 (22.2) 3 (42.9) 158 (47.2) >1 to <6 4 (1.9) 0 (0.0) 0 (0.0) 8 (32.0) 1 (7.1) 0 (0.0) 0 (0.0) 13 (3.9) ≥6 months 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0) 1 (7.1) 1 (11.1) 0 (0.0) 6 (1.8) Not documented 81 (38.4) 33 (86.8) 15 (48.4) 10 (40.0) 9 (64.3) 6 (66.7) 4 (57.1) 158 (47.2) Total 211 (100) 38 (100) 31 (100) 25 (100) 14 (100) 9 (100) 7 (100) 335 (100) Data are presented as n (%). Among all patients, 97.9% (n = 328) had a documented suspected diagnosis. Among women who presented with breast complaints, 59.1% (n = 194) were treated with antibiotics and pain relief medication, whereas 4.2% (n = 14) of the patients received surgical treatment. All surgical treatments were administered at primary hospitals; four involved total mastectomy, five involved surgical excision of a fibroma, and five involved abscess drainage (Table 3). Table 3. Measures taken at the facilities in relation to suspected diagnoses among women with breast-related symptoms, 2022, Ethiopia Breast infection Fibroadenoma Breast pain/mastalgia Breast cancer Abscess Other a Total Combined antibiotics and analgesics 172 (81.5) 5 (13.2) 11 (35.5) 0 (0.0) 6 (42.9) 0 (0.0) 194 (59.1) Analgesics alone 17 (8.1) 24 (63.2) 16 (51.6) 0 (0.0) 0 (0.0) 4 (44.4) 61 (18.6) Antibiotics alone 19 (9.0) 2 (5.3) 2 (6.5) 0 (0.0) 0 (0.0) 0 (0.0) 23 (7.0) Referred 0 (0.0) 2 (5.3) 0 (0.0) 13 (52) 3 (21.4) 2 (22.2) 20 (6.1) Surgery 0 (0.0) 5 (13.2) 0 (0.0) 4 (16.0) 5 (35.7) 0 (0.0) 14 (4.2) Other b 3 (1.4) 0 (0.0) 2 (6.5) 3 (12.0) 0 (0.0) 1 (11.1) 9 (2.7) Not documented 0 (0.0) 0 (0.0) 0 (0.0) 5 (20.0) 0 (0.0) 2 (22.2) 7 (2.1) Total 211 (100) 38 (100) 31 (100) 25 (100) 14 (100) 9 (100) 328 (100) Data are presented as n (%). a Wound, follow-up for known breast cancer b Wound care, appointment Among patients with a suspected diagnosis of breast cancer, 32% (n = 8) were pathologically confirmed as having breast cancer, while 68% (n = 17) were diagnosed clinically and through ultrasound guidance. Overall, of the 17 patients with suspected breast cancer identified through clinical examination and imaging, 10 had been referred, 3 had been appointed, and 5 had no documentation (Table 3). Among women with a suspected diagnosis of breast cancer, 64% (n = 18) presented with a mass and swelling. Among the eight patients with pathologically diagnosed breast cancer, four had undergone surgical treatments locally, and three had been referred. Among patients with pathologically confirmed breast cancer, four were diagnosed at stage IIIB, one was diagnosed at stage IV, and three had no documentation of the stage at diagnosis. Four patients with confirmed diagnoses had ductal cell carcinoma. Referrals of patients with breast abnormalities Among the 335 patients with breast-related complaints, 6% (n = 20) were referred to another facility. Fifty-two percent (n = 13) of the referred patients were suspected of having breast cancer. Of the overall referred patients with breast complaints, 85% (n = 17) were from health centres. The reasons for referral were not sufficiently documented for 45% (n = 9) of the patients, whereas 30% (n = 6) were referred for further diagnosis and 25% (n = 5) were referred for better treatment. Discussion The proportion of patients with breast-related complaints presenting to PHC facilities in our study was < 1%. However, the absolute number was still considerable. A community-based study among adult women in Ethiopia in 2018 revealed that current breast complaints were prevalent in 3.4% of participants; only approximately 1.4% of women in the community had previously sought treatment for their breast complaints, and half of the women reported pain as the main symptom. This finding is similar to our study, in which 50.7% of the women presented with complaints of breast pain (26). Our findings are slightly higher than those of a study conducted in South Africa, in which 27.7% of women visiting a health facility with breast abnormalities complained of breast pain. However, it is lower than the 72.0% reported in a study conducted in Ghana. These differences can be explained by variations in study settings: the South African and Ghanaian studies were conducted at designated breast care departments, whereas our study was conducted in general OPDs (27, 28). Other studies performed in Ethiopia revealed that the initial complaint of women with breast cancer was a painless lump (82.6% and 88.4%), and the proportion of those with complaints of breast pain was low (11, 13). In general, pain is more often associated with benign conditions than with malignant breast cancer. Nevertheless, all abnormalities require diagnostic services. In our study, 8.4% of patients who visited the PHC facility had a history of presenting with the same complaint during a previous visit. Thirty-two women who had their first visit returned for a second visit. A study in Sri Lanka revealed that more than two visits to health facilities before a diagnosis were associated with diagnostic delay; additionally, a greater number of visits was associated with a higher degree of system delay (29). Because primary care centres are the first point of contact and are close to the community, proper identification, treatment, and referral of patients with breast abnormalities are essential to build trust and reduce the number of repeated visits for the same complaint. The GBCI framework also recommends and emphasises timely referral of breast abnormalities for the early detection of breast cancer (7). An Ethiopian study reported that the first initial visit to a health centre is associated with diagnostic delay compared with direct presentation at a higher-level hospital (19). This highlights the dilemma of how to best ensure patient navigation: on one hand, a standardized patient flow recommends first presentation at the health centre level for any complaint; on the other hand, diagnostic services are provided at higher health service levels after referral, leading to a time gap. Clear guidelines should be given to health professionals regarding the appropriate time frames to follow for an initial suspicion of breast cancer, as well as for non-revolving breast complaints that could turn out to be breast cancer. These results imply the need to increase awareness among PHC professionals regarding breast cancer symptoms to reduce delays and enhance early referral and detection. This combined evidence underscores the importance of clinical breast examination at PHC facilities to facilitate the proper identification of breast cancer symptoms and improve referrals. In our study, the majority of women (40.2%) presented with breast-related complaints within the 21- to 40-year age group. This is consistent with studies in other low-resource settings, such as India, where most symptomatic breast abnormalities occur at a younger age (14). This trend reflects the young population structure that is also present in Ethiopia. In our study, more than half (63%) of the patients had a suspected diagnosis of breast infection/mastitis. The majority of women who presented with a breast complaint were treated with antibiotics and pain-relief medications. In total, 2.6% of the patients received surgical treatment. In a community-based study in Ethiopia, 107 symptomatic women had visited a health facility before; of these, 61% had been treated with antibiotics and analgesics, similar to our study, and 14 (13%) had received surgical treatment. The difference in surgical treatment was likely due to treatment at higher-level hospitals also being mentioned (26). This confirms that approximately two-thirds of women with breast complaints are likely to have a diagnosis of mastitis, reflecting the high proportion of women breastfeeding within the young population. Among the women who visited PHC facilities for breast complaints in our study, 7.5% had a suspected diagnosis of breast cancer. This finding is consistent with a study in Zambia, in which 10% of women who visited clinics with breast symptoms had clinical and/or ultrasound indications for further histologic evaluation. It is also within the range of a study in Ghana, where the proportion of breast cancer among women presenting with a breast lump was 17.9% (28, 30). The proportion of patients referred for breast abnormalities was lower than that reported in other studies (31). This can be explained by the incomplete documentation systems in place, the lack of tracking systems and referral guidelines, and the insufficient number of trained health professionals involved in clinical breast examinations. Strengths and limitations This study is one of the few to have described the clinical features, referrals, documentation, and treatment of women who present with breast complaints at the PHC level in a low-resource setting. To our knowledge, it is the first such study in Ethiopia. However, the study has limitations because it is a retrospective record review. Due to incomplete documentation, the overall situation of clinical presentation, especially the further outcomes of patient pathways (e.g., timeliness of treatment for referred patients), was not assessed. Implications for practice and research This study highlights the need for improved documentation of clinical breast care at the PHC level. It suggests that much needs to be done to equip PHC facilities and professionals with the necessary documentation standards, support, as well as increased awareness and skills regarding breast cancer symptoms and referral guidelines to effectively implement the recently launched guidelines. Further research should be conducted to understand the reasons behind incomplete documentation. Additionally, future studies should explore the implementation of electronic-based documentation and referral systems to enhance clinical care. Conclusion Women fairly commonly present to PHC facilities for breast abnormalities in Ethiopia, with breast pain being the most frequent complaint and mastitis being the most common clinical diagnosis. In this study, the proportion of suspected diagnoses of breast cancer among women with a breast-related complaint was 1 in 13. The low proportion of referrals and the incomplete documentation of patient profiles, duration of symptoms, clinical features, and diagnoses highlight the need for improvements in communication and referral protocols at the PHC level. Clear pathways to diagnostic triage centres are essential. Because PHC facilities are the first point of contact where the initial presentation of breast symptoms is addressed, achieving the GBCI goal of detecting 60% of cancer cases early and improving patient navigation systems requires strengthening PHC facilities in terms of symptom recognition, referral communication, and documentation. Abbreviations DINKNESH Developing InterNational research collaboration in Ethiopia is under implementation to support oncology at primary Health care levels ESF-ICD-11 Ethiopian Simplified Version of the International Classification of Diseases GBCI Global Breast Cancer Initiative LIMICs low- and middle-income countries OPD outpatient department PHC primary health care SSA sub-Saharan Africa Declarations Ethics approval and consent to participate Ethical clearance was obtained from the College of Health Sciences Institutional Review Board of Addis Ababa University (ethical approval number: 007/24/SPH) and Martin Luther University Halle, Wittenberg (ethical approval number: 2024-113). The requirement for individual informed consent was waived by Institutional Review Board of Addis Ababa University (ethical approval number: 007/24/SPH). Permission was obtained from the facility administration and from the regional offices. All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration. Patient information was kept confidential. Consent for publication Not Applicable Accessibility of data and materials The datasets generated and/or analysed during the current study are not publicly available because of the confidentiality and privacy of patient information but are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Else Kröner-Fresenius Foundation Grant No. 2018_HA31SP. The project on which this publication is based was funded in part by the German Federal Ministry of Education and Research (01KA2220B). This work was supported by a grant from the Hospital Partnership through Deutsche Gesellschaft für Internationale Zusammenarbeit, funded by the Ministry for Economic Cooperation and Development (ID 81281915). This research was funded in whole or in part by the Science for Africa Foundation through the Developing Excellence in Leadership, Training, and Science in Africa (DELTAS Africa) programme [Del-22-008], with support from Wellcome Trust and the United Kingdom Foreign, Commonwealth & Development Office, and is part of the EDCPT2 programme, supported by the European Union. Authors’ contributions EG, the principal investigator, led the study’s conception and execution as well as the development of the manuscript. SG, the primary supervisor, provided extensive revisions to the manuscript, contributing significantly to conceptualization and design. EA and MG offered valuable input during the final manuscript review, contributing to both design and execution. AS contributed to the data extraction and manuscript review and input. AD, AT, and SR contributed to the study methodology and provided comments on the manuscript. ESK actively participated in the study conduct and design, offering valuable feedback. AA contributed insights to refining the methodology and execution during the final manuscript review. EJK, the main supervisor, was involved in the study conceptualization and execution and meticulously reviewed the manuscript. All authors have read and approved the final version of the manuscript. Acknowledgments Our special thanks go to all the health facility administrators, regional focal persons, and two research assistants who facilitated this study. We are deeply grateful for your support and for your crucial role in the processes of obtaining and reviewing the medical records for this study. We sincerely appreciate the time and effort you devoted to this work, as your contributions have been instrumental in bringing this project to fruition. We would also like to express our gratitude to the Addis Ababa University School of Public Health and Martin Luther University Halle-Wittenberg for their continuous support throughout the conduct of this study. References Sung H, Ferlay J, Siegel RL, Global Cancer S. 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 2021;71(3):209 – 49. Martei YM, Pace LE, Brock JE, Shulman LN. Breast Cancer in Low- and Middle-Income Countries: Why We Need Pathology Capability to Solve This Challenge. Clin Lab Med. 2018;38(1):161–73. McCormack V, McKenzie F, Foerster M, Zietsman A, Galukande M, Adisa C, et al. Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study. Lancet Global health. 2020;8(9):e1203–12. Ferlay JEM, Lam F, Laversanne M, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F, Global Cancer Observatory. : Cancer Today. Lyon, France: International Agency for Research on Cancer. 2024 [Available from: Available from: https://gco.iarc.who.int/today , accessed [14 Feb. 2025]. Tesfaw A, Getachew S, Addissie A, Jemal A, Wienke A, Taylor L, et al. Late-Stage Diagnosis and Associated Factors Among Breast Cancer Patients in South and Southwest Ethiopia: A Multicenter Study. Clin Breast Cancer. 2021;21(1):e112–9. Jedy-Agba E, McCormack V, Adebamowo C, dos-Santos-Silva I. Stage at diagnosis of breast cancer in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Global Health. 2016;4(12):e923–35. WHO. Global Breast Cancer Initiative Implementation Framework Assessing, strengthening and scaling up services for the early detection and management of breast cancer. 2023. Federal Ministry of Health E. National Guideline for Breast Health, early diagnosis and timely Breast cancer managment in Ethiopia(2024–2028). 2023. Margaret ME, Robert L, Phillips L Jr., Inge O, Martin CM. Characterizing Breast Symptoms in Family Practice. Annals Family Med. 2008;6(6):528. Walker S, Hyde C, Hamilton W. Risk of breast cancer in symptomatic women in primary care: a case-control study using electronic records. Br J Gen practice: J Royal Coll Gen Practitioners. 2014;64(629):e788–93. Tesfaw A, Demis S, Munye T, Ashuro Z. Patient Delay and Contributing Factors Among Breast Cancer Patients at Two Cancer Referral Centres in Ethiopia: A Cross-Sectional Study. J Multidisciplinary Healthc. 2020;13(null):1391–401. Moodley J, Cairncross L, Naiker T, Constant D. From symptom discovery to treatment - women's pathways to breast cancer care: a cross-sectional study. BMC Cancer. 2018;18(1):312. Dye TD, Bogale S, Hobden C, Tilahun Y, Deressa T, Reeler A. Experience of Initial Symptoms of Breast Cancer and Triggers for Action in Ethiopia. Int J Breast Cancer. 2012;2012(1):908547. Narasimhaiah K, Reddy TVN, Archana B. A clinical study of benign breast diseases at a tertiary care hospital. Int J Surg. 2021;5(4):130–3. Johansson A, Christakou AE, Iftimi A, Eriksson M, Tapia J, Skoog L, et al. Characterization of Benign Breast Diseases and Association With Age, Hormonal Factors, and Family History of Breast Cancer Among Women in Sweden. JAMA Netw Open. 2021;4(6):e2114716–e. Alem B, Abebu T, Zerihun T, Tadios L, Amare A, Getenet D. Delay in health-seeking behaviour and associated factors among adult patients with cancer in Ethiopia: a multicentre cross-sectional study. BMJ Open. 2023;13(8):e071406. Unger-Saldaña K. Challenges to the early diagnosis and treatment of breast cancer in developing countries. World J Clin Oncol. 2014;5(3):465–77. Roetzheim RG, Ferrante JM, Lee JH, Chen R, Love-Jackson KM, Gonzalez EC, et al. Influence of primary care on breast cancer outcomes among Medicare beneficiaries. Ann Fam Med. 2012;10(5):401–11. Gebremariam A, Addissie A, Worku A, Assefa M, Pace LE, Kantelhardt EJ, et al. Time intervals experienced between first symptom recognition and pathologic diagnosis of breast cancer in Addis Ababa, Ethiopia: a cross-sectional study. BMJ Open. 2019;9(11):e032228. Asaf B, Jocelyn F, Hannah R, Ami K, Hong W, Jeremy HV, et al. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Global Health. 2019;4(Suppl 8):e001551. Das J, Hammer J. Quality of Primary Care in Low-Income Countries: Facts and Economics. Annual Review of Economics. 2014;6(Volume 6, 2014):525 – 53. Sanders D, Schaay N, Mohamed S. Primary Health Care. In: Quah SR, editor. International Encyclopedia of Public Health (Second Edition). Oxford: Academic Press; 2017. pp. 5–14. Ethiopia simplified version in international classification of disease (ESF-ICD11). In: Ethiopia MoH, editor Health Center edition ed2022. Tesfaw A, Getachew S, Addissie A, Jemal A, Wienke A, Taylor L, et al. Late-Stage Diagnosis and Associated Factors Among Breast Cancer Patients in South and Southwest Ethiopia: A Multicenter Study. Clin Breast Cancer. 2021;21(1):e112–9. Aragaw T, Eyerusalem G, Adamu A, Lesley T, Eva JK, Sefonias G. Clinical Profiles, Diagnosis and Treatment for Breast Cancer Patients in Hawassa Comprehensive Specialized and Teaching Hospital in Southern Ethiopia: Descriptive Analysis. Ethiop J Health Dev. 2023;37(3). Ayele W, Addissie A, Wienke A, Unverzagt S, Jemal A, Taylor L, et al. Breast Awareness, Self-Reported Abnormalities, and Breast Cancer in Rural Ethiopia: A Survey of 7,573 Women and Predictions of the National Burden. Oncologist. 2021;26(6):e1009–17. Rayne S, Lince-Deroche N, Hendrickson C, Shearer K, Moyo F, Michelow P, et al. Characterizing breast conditions at an open-access breast clinic in South Africa: a model that is more than cancer care for a resource-limited setting. BMC Health Serv Res. 2017;17(1):63. Ohene-Yeboah M, Amaning E. Spectrum of complaints presented at a specialist breast clinic in kumasi, ghana. Ghana Med J. 2008;42(3):110–3. Hewage SA, Samaraweera S, Joseph N, Kularatna S, Gunawardena N, Presentation. Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country. Clin Oncol. 2022;34(9):598–607. Songiso M, Pinder LF, Munalula J, Cabanes A, Rayne S, Kapambwe S et al. Minimizing Delays in the Breast Cancer Pathway by Integrating Breast Specialty Care Services at the Primary Health Care Level in Zambia. JCO Global Oncol. 2020(6):859–65. Cherlin DS, Mwaiselage J, Msami K, Heisler Z, Young H, Cui Q et al. Breast Cancer Screening in Low-Income Countries: A New Program for Downstaging Breast Cancer in Tanzania. 2022;2022:9795534. Additional Declarations No competing interests reported. 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10:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6202235/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6202235/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-026-03255-z","type":"published","date":"2026-03-11T15:58:22+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82053298,"identity":"c40df169-c4c5-46bb-b0df-5cb3964decba","added_by":"auto","created_at":"2025-05-06 10:10:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45046,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of medical record selection, 2025\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6202235/v1/cd0eb55819dd5221bbe7d8ed.png"},{"id":82053297,"identity":"42a3c6e6-7428-479b-b289-84d2372a3b25","added_by":"auto","created_at":"2025-05-06 10:10:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22878,"visible":true,"origin":"","legend":"\u003cp\u003eSuspected diagnoses recorded in the medical records by facility type, 2022, Ethiopia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eItching, galactoceles, and wound care\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6202235/v1/04088eb7ca715d4e8486aca3.png"},{"id":104739373,"identity":"cd770b0a-373b-4902-b912-e1d88aa3299f","added_by":"auto","created_at":"2026-03-16 16:04:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1132053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6202235/v1/8f6f1b0c-6741-473f-b97f-e06653a2c234.pdf"},{"id":82053300,"identity":"b4dc4a31-79e4-4aca-a4df-785410327741","added_by":"auto","created_at":"2025-05-06 10:10:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16689,"visible":true,"origin":"","legend":"","description":"","filename":"Eyerusalemsupplmentaryfile1submission.docx","url":"https://assets-eu.researchsquare.com/files/rs-6202235/v1/f1442f53d591fa41cf2a8e41.docx"},{"id":82051630,"identity":"7d95b6cc-c2a9-4fae-a6ff-79c8aea4d642","added_by":"auto","created_at":"2025-05-06 10:02:49","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":87552,"visible":true,"origin":"","legend":"","description":"","filename":"EyerusalemSupplementaryfile2submission.doc","url":"https://assets-eu.researchsquare.com/files/rs-6202235/v1/7d529c795874d08505486be0.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical features, diagnosis, and referral of patients with breast abnormalities in primary health care settings in rural Ethiopia: a retrospective record analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eBreast cancer is the most commonly diagnosed cancer, with an estimated 2.3\u0026nbsp;million new cases, accounting for 11.7% of all cancer cases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In low- and middle-income countries (LMICs), a significant proportion of women with breast cancer present with or are ultimately diagnosed at a later stage of the disease (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Some of the most rapid increases are occurring in sub-Saharan Africa (SSA). Studies project that between 2020 and 2029, 416,000 women will die of breast cancer in SSA; however, with earlier diagnosis and improved treatment, at least one-third of these deaths may be prevented (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Ethiopia, breast cancer is the most common cancer, accounting for 9,061 (22.6%) deaths annually (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A study from South and Southwest Ethiopia showed that 72.5% of patients with breast cancer were diagnosed at advanced stages (stages III and IV) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Similarly, a systematic review and meta-analysis covering 17 SSA countries revealed that 74.7% of women were diagnosed at a late stage. Moreover, patients who reported a painless breast lump as their chief complaint were twice as likely to experience a delay in their breast cancer diagnosis (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Global Breast Cancer Initiative (GBCI) emphasises the importance of primary health care (PHC) involvement in the continuum of breast cancer care, recommending early identification of breast symptoms and timely referral to diagnostic facilities (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Ethiopia has recently implemented a breast cancer guideline that aligns with these recommendations, highlighting the role of PHC facilities in health promotion, early symptom detection, clinical breast examination, and prompt referral linkage to diagnostic services (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe overall burden of breast-related complaints among women seen at outpatient departments (OPDs) has not been well studied, particularly in LMICs. In a study from the United States, breast-related complaints accounted for 3% of overall complaints at PHC facilities (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In the United Kingdom, general practitioners at PHC clinics see at least one patient with a breast abnormality per week (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, studies from LMICs have shown that 74.0\u0026ndash;88.4% of patients with breast cancer initially present at health facilities with a breast lump, with pain being the most common symptom prompting them to seek medical care. Additional symptoms include breast discharge, swelling, lumps under the arms, and itching (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese abnormal breast findings must be thoroughly investigated, triaged, and treated. Studies have indicated that the incidence of breast cancer is slightly higher in patients with histologically confirmed benign breast diseases than in the general population (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This underscores the importance of monitoring patients with breast abnormalities, particularly those in low-resource settings where health care-seeking behaviour is often low due to various factors, including the affordability of health services (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eProvider delay often stems from primary care physicians failing to consider cancer during the initial consultation (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A study from the United Kingdom suggested that primary care physician visits were associated with improved breast cancer outcomes and that adequate primary care can be a key factor in achieving optimal outcomes (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, a study in Ethiopia found that the first visit to a health centre can contribute to diagnostic delay (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In many LMICs, PHC diagnostic capacities are inadequate, leading to poor health outcomes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Research on the quality of routine PHC in LMICs indicates that care is often insufficient, with significant variation between and within regions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Studies from Indian and Chinese PHC clinics revealed that providers completed only one-third of the recommended medical history and physical examinations; moreover, they provided diagnoses in just 36% of cases, and only 12% of these diagnoses were correct (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Despite structural differences, PHC-oriented health systems consistently produce better outcomes, greater equity, and improved efficiency (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). PHC providers play a crucial role across the cancer care continuum, from promoting accurate screening and diagnosis to delivering care during and after cancer treatment, including managing comorbidities [18].\u003c/p\u003e \u003cp\u003eA well-structured PHC system, including capacity building for providers, an efficient referral system, and patient-centred guidance for diagnostic and treatment services, could improve quality and reduce delays within the health care system [19]. To support this, high-quality evidence is needed on the prevalence and nature of breast complaints at the PHC level. Therefore, this study aims to provide baseline data on the clinical features, diagnosis, treatment, and referral experiences of patients with breast-related complaints at the PHC level in Ethiopia. This information can serve as a foundation for health care planners and help identify research gaps.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and area\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective facility-based medical record review was conducted in selected PHC facilities. The included facilities were part of an oncology research network supported by the Else Kröner Center for Cancer Care and the project Developing InterNational \u0026nbsp;CollaboratioN in Ethiopia to Support oncology at primary Health care levels (DINKNESH). This research network comprises 94 health facilities, including 15 hospitals and 15 health centres with 64 satellite health posts. The 15 health centres, 3 primary hospitals, and 64 satellite health posts are classified as PHC-level facilities. Additional hospitals in the area include general hospitals and comprehensive hospitals, which serve as referral points for PHC facilities within Ethiopia’s three-tier health system.\u003c/p\u003e\n\u003cp\u003eThis study included 17 PHC facilities from project sites distributed across 3 regions, each with distinct demographic and geographic characteristics: the Oromia region (5 health centres), the Central Ethiopia region (2 hospitals, 7 health centres), and the Southern Ethiopia region (1 hospital, 2 health centres). The 64 health posts were not included because they focus on health promotion activities within the community and do not provide clinical services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population and period\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population comprised women aged ≥18 years who presented with breast-related complaints at the OPDs of the 17 health facilities between 1 January 2022 and 31 December 2022. Men with breast-related complaints were excluded. Medical records (n = 101) that did not clearly state the patient’s complaint or diagnosis, or only recorded unrelated diagnoses, were omitted from the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edata\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitially, potential cases were identified from patient registration books related to breast complaints at OPDs. Medical record numbers were extracted from the registry books using the Ethiopian Simplified Version of the International Classification of Diseases (ESF-ICD-11) Health Center Edition (23). Medical records were selected based on the registered diagnoses associated with breast-related disorders according to the ESF-ICD-11 classification. Two trained research assistants, both nurses by profession, extracted medical records from the registries. Once identified, the corresponding patient medical records were retrieved. Data were then collected using extraction sheets developed based on a review of the literature (24, 25), capturing information on clinical features, diagnostics, treatment, referrals, follow-ups, and appointments. Data extraction was performed by two individuals (E.G., A.S.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive analysis was conducted using means, standard deviations, frequencies, and percentages. Age was categorized in groups and cross tabulation were conducted to explain the outcome variable. Data were entered into EpiData version 4.1 and exported to SPSS version 25 for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edefinitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBreast-related complaints: The chief complaint a woman presents with when visiting the OPD at a PHC facility.\u003c/p\u003e\n\u003cp\u003eCurrent breast-related complaint: A breast-related complaint that occurred in 2022 and is recorded in the registry. If multiple visits occurred, the most recent visit was taken as the reference point, while earlier visits were considered previous breast-related complaints.\u003c/p\u003e\n\u003cp\u003ePrevious breast-related complaint: A breast-related complaint documented before the current complaint, traced through the patient’s medical records.\u003c/p\u003e\n\u003cp\u003eSuspected diagnosis: A diagnosis documented by the OPD professional based on the woman’s presenting complaints at the PHC unit. It includes cases referred for further evaluation or treated at the PHC facility with first-line treatment.\u003c/p\u003e\n\u003cp\u003ePathologically confirmed diagnosis: A diagnosis made by a health professional following pathological findings, in addition to clinical examination with or without imaging, typically performed at primary hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eapproval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the College of Health Sciences Institutional Review Board of Addis Ababa University (007/24/SPH) and Martin Luther University Halle-Wittenberg (2024-113). The requirement for individual informed consent was waived by Institutional Review Board of Addis Ababa University (ethical approval number: 007/24/SPH). Permission was obtained from the facility administrations and regional health offices.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 436 cases were retrieved from the registry of adult OPDs. Among these, 335 patient medical records were included in the analysis (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patients\u0026rsquo; age (mean \u0026plusmn; standard deviation) was 29 \u0026plusmn; 8.7 years (range, 18\u0026ndash;70 years). The majority of women (48%; n = 162) were in the 20- to 29-year age group, followed by 32% (n = 107) in the 30- to 39-year age group (Table 1). In total, 55% (n = 185) of the patients were from central Ethiopia.\u003c/p\u003e\n\u003cp\u003eThe minimum number of women who visited the OPD in 2022 was 2,291, with a maximum of 24,398 per facility. Among these, a minimum of 4 and a maximum of 151 breast-related abnormalities were registered per health facility for the year 2022 (Additional File 1). The average proportion of breast-related complaints among women presenting at the OPD in PHC settings was 5 per 1,000 women per year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 50.7% (n = 170) of the patients presented with complaints of breast pain, followed by 14.6% (n = 49) who reported breast swelling. Nearly one-quarter (24.7%, n = 83) of the patient records failed to document the complaints of women during their presentation, with only the diagnosis and treatment information recorded (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1. Sociodemographic and clinical characteristics of women presenting with breast complaints at 17 PHC facilities in 2022\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics (\u003c/strong\u003e\u003cstrong\u003etotal\u003c/strong\u003e\u003cstrong\u003e: n\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;=\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e335)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003egroups,\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u0026lt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e20\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u0026ge;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eMean\u0026nbsp;\u0026plusmn; standard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 313px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;29 \u0026plusmn; 8.7 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eOromia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eCentral Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e55.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eSouthern Ethiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of health facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eHealth centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e57.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003ePrimary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecomplaint\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e50.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eSwelling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eMass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eOther\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 282px;\"\u003e\n \u003cp\u003eNot documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eWound care, itching, follow-up\u003c/p\u003e\n\u003cp\u003eTwenty-eight patients (8.4%) visited the health facility at least once with complaints of breast symptoms prior to the current presentation. Of these, nine (2.6%) patients came twice, two patients came three times, and one patient came four or five times with the same complaint.\u003c/p\u003e\n\u003cp\u003eThe interval between the current presentation and the first previous visit ranged from 1 day to 7 years (median: 1.5 months, interquartile range: 10\u0026ndash;22 days).\u003c/p\u003e\n\u003cp\u003eAccording to the duration of the chief complaint listed in the medical records, nearly half of the patients (47.2%; n = 158) presented to the facility within \u0026lt;1 month from the onset of symptoms. Among these patients, 63.0% (n = 101) were in the 21- to 30-year age group (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuspected diagnosis and treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 7.4% (n = 25) of the women had a suspected diagnosis of breast cancer. Among these, 64.0% (n = 16) were from primary hospitals. Nearly two-thirds of the women (63.0%; n = 211) were diagnosed with breast infection/mastitis, followed by fibroadenoma (11.3%; n = 38). Of the total suspected cases of mastitis, 65.4% (n = 138) were diagnosed at health centres (Figure 2).\u003c/p\u003e\n\u003cp\u003eAmong patients who attended PHC facilities, 54.5% (n = 115) had mastitis and were aged 20\u0026ndash;29 years, whereas 52.0% (n = 13) of those suspected of having breast cancer were aged 40\u0026ndash;49 years (Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2. Age distribution and symptom duration of patients in relation to suspected diagnosis, 2022, Ethiopia\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"113%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreast infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFibroadenoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreast pain/\u003c/strong\u003e\u003cstrong\u003emastalgia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreast cancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbscess\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOthers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edocumented\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003cstrong\u003e, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026gt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10\u0026nbsp;(4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e20\u0026nbsp;(6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e20\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e115\u0026nbsp;(54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e16\u0026nbsp;(42.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e17\u0026nbsp;(54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e7\u0026nbsp;(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e162\u0026nbsp;(48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e71\u0026nbsp;(33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e11\u0026nbsp;(28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e8\u0026nbsp;(25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e6\u0026nbsp;(24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e107\u0026nbsp;(31.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10\u0026nbsp;(4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e13\u0026nbsp;(52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e31\u0026nbsp;(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e8\u0026nbsp;(2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ge;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e7\u0026nbsp;(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e211\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e38\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e31\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e25\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e14\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e9\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e7\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e335\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of chief compliant\u003c/strong\u003e\u003cstrong\u003e, months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026le;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e126\u0026nbsp;(59.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e16\u0026nbsp;(51.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e158\u0026nbsp;(47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026gt;1 to \u0026lt;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e8\u0026nbsp;(32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e13\u0026nbsp;(3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ge;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e6\u0026nbsp;(1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eNot documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e81\u0026nbsp;(38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e33\u0026nbsp;(86.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e15\u0026nbsp;(48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e10\u0026nbsp;(40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e9\u0026nbsp;(64.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e6\u0026nbsp;(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e158\u0026nbsp;(47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e211\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e38\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e335\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as n (%).\u003c/p\u003e\n\u003cp\u003eAmong all patients, 97.9% (n = 328) had a documented suspected diagnosis. Among women who presented with breast complaints, 59.1% (n = 194) were treated with antibiotics and pain relief medication, whereas 4.2% (n = 14) of the patients received surgical treatment. All surgical treatments were administered at primary hospitals; four involved total mastectomy, five involved surgical excision of a fibroma, and five involved abscess drainage (Table 3).\u003c/p\u003e\n\u003cp\u003eTable 3. Measures taken at the facilities in relation to suspected diagnoses among women with breast-related symptoms, 2022, Ethiopia\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"101%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003eBreast infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eFibroadenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eBreast pain/mastalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eBreast cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eAbscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eOther\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eCombined antibiotics\u0026nbsp;and\u0026nbsp;analgesics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e172 (81.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e11\u0026nbsp;(35.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e6\u0026nbsp;(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e194\u0026nbsp;(59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eAnalgesics alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e17\u0026nbsp;(8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e24\u0026nbsp;(63.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e16\u0026nbsp;(51.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e61\u0026nbsp;(18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eAntibiotics\u0026nbsp;alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e19 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e23\u0026nbsp;(7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eReferred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e13\u0026nbsp;(52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e20\u0026nbsp;(6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e14\u0026nbsp;(4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eOther\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e3\u0026nbsp;(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e1\u0026nbsp;(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e9\u0026nbsp;(2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eNot documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e2\u0026nbsp;(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e7\u0026nbsp;(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e211\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e38\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e328\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as n (%).\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eWound, follow-up for known breast cancer\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eWound care, appointment\u003c/p\u003e\n\u003cp\u003eAmong patients with a suspected diagnosis of breast cancer, 32% (n = 8) were pathologically confirmed as having breast cancer, while 68% (n = 17) were diagnosed clinically and through ultrasound guidance. Overall, of the 17 patients with suspected breast cancer identified through clinical examination and imaging, 10 had been referred, 3 had been appointed, and 5 had no documentation (Table 3). Among women with a suspected diagnosis of breast cancer, 64% (n = 18) presented with a mass and swelling. Among the eight patients with pathologically diagnosed breast cancer, four had undergone surgical treatments locally, and three had been referred. Among patients with pathologically confirmed breast cancer, four were diagnosed at stage IIIB, one was diagnosed at stage IV, and three had no documentation of the stage at diagnosis. Four patients with confirmed diagnoses had ductal cell carcinoma.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferrals of patients with breast abnormalities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 335 patients with breast-related complaints, 6% (n = 20) were referred to another facility. Fifty-two percent (n = 13) of the referred patients were suspected of having breast cancer. Of the overall referred patients with breast complaints, 85% (n = 17) were from health centres. The reasons for referral were not sufficiently documented for 45% (n = 9) of the patients, whereas 30% (n = 6) were referred for further diagnosis and 25% (n = 5) were referred for better treatment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe proportion of patients with breast-related complaints presenting to PHC facilities in our study was \u0026lt; 1%. However, the absolute number was still considerable. A community-based study among adult women in Ethiopia in 2018 revealed that current breast complaints were prevalent in 3.4% of participants; only approximately 1.4% of women in the community had previously sought treatment for their breast complaints, and half of the women reported pain as the main symptom. This finding is similar to our study, in which 50.7% of the women presented with complaints of breast pain (26). Our findings are slightly higher than those of a study conducted in South Africa, in which 27.7% of women visiting a health facility with breast abnormalities complained of breast pain. However, it is lower than the 72.0% reported in a study conducted in Ghana. These differences can be explained by variations in study settings: the South African and Ghanaian studies were conducted at designated breast care departments, whereas our study was conducted in general OPDs (27, 28). Other studies performed in Ethiopia revealed that the initial complaint of women with breast cancer was a painless lump (82.6% and 88.4%), and the proportion of those with complaints of breast pain was low (11, 13). In general, pain is more often associated with benign conditions than with malignant breast cancer. Nevertheless, all abnormalities require diagnostic services.\u003c/p\u003e\n\u003cp\u003eIn our study, 8.4% of patients who visited the PHC facility had a history of presenting with the same complaint during a previous visit. Thirty-two women who had their first visit returned for a second visit. A study in Sri Lanka revealed that more than two visits to health facilities before a diagnosis were associated with diagnostic delay; additionally, a greater number of visits was associated with a higher degree of system delay (29). Because primary care centres are the first point of contact and are close to the community, proper identification, treatment, and referral of patients with breast abnormalities are essential to build trust and reduce the number of repeated visits for the same complaint. The GBCI framework also recommends and emphasises timely referral of breast abnormalities for the early detection of breast cancer (7). An Ethiopian study reported that the first initial visit to a health centre is associated with diagnostic delay compared with direct presentation at a higher-level hospital (19). This highlights the dilemma of how to best ensure patient navigation: on one hand, a standardized patient flow recommends first presentation at the health centre level for any complaint; on the other hand, diagnostic services are provided at higher health service levels after referral, leading to a time gap. Clear guidelines should be given to health professionals regarding the appropriate time frames to follow for an initial suspicion of breast cancer, as well as for non-revolving breast complaints that could turn out to be breast cancer.\u003c/p\u003e\n\u003cp\u003eThese results imply the need to increase awareness among PHC professionals regarding breast cancer symptoms to reduce delays and enhance early referral and detection. This combined evidence underscores the importance of clinical breast examination at PHC facilities to facilitate the proper identification of breast cancer symptoms and improve referrals.\u003c/p\u003e\n\u003cp\u003eIn our study, the majority of women (40.2%) presented with breast-related complaints within the 21- to 40-year age group. This is consistent with studies in other low-resource settings, such as India, where most symptomatic breast abnormalities occur at a younger age (14). This trend reflects the young population structure that is also present in Ethiopia.\u003c/p\u003e\n\u003cp\u003eIn our study, more than half (63%) of the patients had a suspected diagnosis of breast infection/mastitis. The majority of women who presented with a breast complaint were treated with antibiotics and pain-relief medications. In total, 2.6% of the patients received surgical treatment. In a community-based study in Ethiopia, 107 symptomatic women had visited a health facility before; of these, 61% had been treated with antibiotics and analgesics, similar to our study, and 14 (13%) had received surgical treatment. The difference in surgical treatment was likely due to treatment at higher-level hospitals also being mentioned (26). This confirms that approximately two-thirds of women with breast complaints are likely to have a diagnosis of mastitis, reflecting the high proportion of women breastfeeding within the young population.\u003c/p\u003e\n\u003cp\u003eAmong the women who visited PHC facilities for breast complaints in our study, 7.5% had a suspected diagnosis of breast cancer. This finding is consistent with a study in Zambia, in which 10% of women who visited clinics with breast symptoms had clinical and/or ultrasound indications for further histologic evaluation. It is also within the range of a study in Ghana, where the proportion of breast cancer among women presenting with a breast lump was 17.9% (28, 30).\u003c/p\u003e\n\u003cp\u003eThe proportion of patients referred for breast abnormalities was lower than that reported in other studies (31). This can be explained by the incomplete documentation systems in place, the lack of tracking systems and referral guidelines, and the insufficient number of trained health professionals involved in clinical breast examinations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003elimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is one of the few to have described the clinical features, referrals, documentation, and treatment of women who present with breast complaints at the PHC level in a low-resource setting. To our knowledge, it is the first such study in Ethiopia. However, the study has limitations because it is a retrospective record review. Due to incomplete documentation, the overall situation of clinical presentation, especially the further outcomes of patient pathways (e.g., timeliness of treatment for referred patients), was not assessed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications\u0026nbsp;for practice and research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study highlights the need for improved documentation of clinical breast care at the PHC level. It suggests that much needs to be done to equip PHC facilities and professionals with the necessary documentation standards, support, as well as increased awareness and skills regarding breast cancer symptoms and referral guidelines to effectively implement the recently launched guidelines. Further research should be conducted to understand the reasons behind incomplete documentation. Additionally, future studies should explore the implementation of electronic-based documentation and referral systems to enhance clinical care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWomen fairly commonly present to PHC facilities for breast abnormalities in Ethiopia, with breast pain being the most frequent complaint and mastitis being the most common clinical diagnosis. In this study, the proportion of suspected diagnoses of breast cancer among women with a breast-related complaint was 1 in 13. The low proportion of referrals and the incomplete documentation of patient profiles, duration of symptoms, clinical features, and diagnoses highlight the need for improvements in communication and referral protocols at the PHC level. Clear pathways to diagnostic triage centres are essential. Because PHC facilities are the first point of contact where the initial presentation of breast symptoms is addressed, achieving the GBCI goal of detecting 60% of cancer cases early and improving patient navigation systems requires strengthening PHC facilities in terms of symptom recognition, referral communication, and documentation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDINKNESH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e Developing InterNational research collaboration in Ethiopia is under implementation to support oncology at primary Health care levels\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eESF-ICD-11\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEthiopian Simplified Version of the International Classification of Diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGBCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGlobal Breast Cancer Initiative\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eLIMICs\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOPD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eoutpatient department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePHC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprimary health care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSSA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esub-Saharan Africa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the College of Health Sciences Institutional Review Board of Addis Ababa University (ethical approval number: 007/24/SPH) and Martin Luther University Halle, Wittenberg (ethical approval number: 2024-113). The requirement for individual informed consent was waived by Institutional Review Board of Addis Ababa University (ethical approval number: 007/24/SPH). Permission was obtained from the facility administration and from the regional offices. All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration. Patient information was kept confidential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAccessibility of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available because of the confidentiality and privacy of patient information but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Else Kröner-Fresenius Foundation Grant No. 2018_HA31SP. The project on which this publication is based was funded in part by the German Federal Ministry of Education and Research (01KA2220B). This work was supported by a grant from the Hospital Partnership through Deutsche Gesellschaft für Internationale Zusammenarbeit, funded by the Ministry for Economic Cooperation and Development (ID 81281915). This research was funded in whole or in part by the Science for Africa Foundation through the Developing Excellence in Leadership, Training, and Science in Africa (DELTAS Africa) programme [Del-22-008], with support from Wellcome Trust and the United Kingdom Foreign, Commonwealth \u0026amp; Development Office, and is part of the EDCPT2 programme, supported by the European Union.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEG, the principal investigator, led the study’s conception and execution as well as the development of the manuscript. SG, the primary supervisor, provided extensive revisions to the manuscript, contributing significantly to conceptualization and design. EA and MG offered valuable input during the final manuscript review, contributing to both design and execution. AS contributed to the data extraction and manuscript review and input. AD, AT, and SR contributed to the study methodology and provided comments on the manuscript. ESK actively participated in the study conduct and design,\u0026nbsp;offering valuable feedback. AA contributed insights to refining the methodology and execution during the final manuscript review. EJK, the main supervisor, was involved in the study conceptualization and execution and meticulously\u0026nbsp;reviewed the manuscript. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur special thanks go to all the health facility administrators, regional focal persons, and two research assistants who facilitated this study. We are deeply grateful for your support and for your crucial role in the processes of obtaining and reviewing the medical records for this study. We sincerely appreciate the time and effort you devoted to this work, as your contributions have been instrumental in bringing this project to fruition. We would also like to express our gratitude to the Addis Ababa University School of Public Health and Martin Luther University Halle-Wittenberg for their continuous support throughout the conduct of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Global Cancer S. 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 2021;71(3):209\u0026thinsp;\u0026ndash;\u0026thinsp;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartei YM, Pace LE, Brock JE, Shulman LN. Breast Cancer in Low- and Middle-Income Countries: Why We Need Pathology Capability to Solve This Challenge. Clin Lab Med. 2018;38(1):161\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCormack V, McKenzie F, Foerster M, Zietsman A, Galukande M, Adisa C, et al. Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study. Lancet Global health. 2020;8(9):e1203\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerlay JEM, Lam F, Laversanne M, Colombet M, Mery L, Pi\u0026ntilde;eros M, Znaor A, Soerjomataram I, Bray F, Global Cancer Observatory. : Cancer Today. Lyon, France: International Agency for Research on Cancer. 2024 [Available from: Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://gco.iarc.who.int/today\u003c/span\u003e\u003cspan address=\"https://gco.iarc.who.int/today\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, accessed [14 Feb. 2025].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTesfaw A, Getachew S, Addissie A, Jemal A, Wienke A, Taylor L, et al. Late-Stage Diagnosis and Associated Factors Among Breast Cancer Patients in South and Southwest Ethiopia: A Multicenter Study. Clin Breast Cancer. 2021;21(1):e112\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJedy-Agba E, McCormack V, Adebamowo C, dos-Santos-Silva I. Stage at diagnosis of breast cancer in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Global Health. 2016;4(12):e923\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Global Breast Cancer Initiative Implementation Framework Assessing, strengthening and scaling up services for the early detection and management of breast cancer. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Ministry of Health E. National Guideline for Breast Health, early diagnosis and timely Breast cancer managment in Ethiopia(2024\u0026ndash;2028). 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMargaret ME, Robert L, Phillips L Jr., Inge O, Martin CM. Characterizing Breast Symptoms in Family Practice. Annals Family Med. 2008;6(6):528.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker S, Hyde C, Hamilton W. Risk of breast cancer in symptomatic women in primary care: a case-control study using electronic records. Br J Gen practice: J Royal Coll Gen Practitioners. 2014;64(629):e788\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTesfaw A, Demis S, Munye T, Ashuro Z. Patient Delay and Contributing Factors Among Breast Cancer Patients at Two Cancer Referral Centres in Ethiopia: A Cross-Sectional Study. J Multidisciplinary Healthc. 2020;13(null):1391\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoodley J, Cairncross L, Naiker T, Constant D. From symptom discovery to treatment - women's pathways to breast cancer care: a cross-sectional study. BMC Cancer. 2018;18(1):312.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDye TD, Bogale S, Hobden C, Tilahun Y, Deressa T, Reeler A. Experience of Initial Symptoms of Breast Cancer and Triggers for Action in Ethiopia. Int J Breast Cancer. 2012;2012(1):908547.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarasimhaiah K, Reddy TVN, Archana B. A clinical study of benign breast diseases at a tertiary care hospital. Int J Surg. 2021;5(4):130\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohansson A, Christakou AE, Iftimi A, Eriksson M, Tapia J, Skoog L, et al. Characterization of Benign Breast Diseases and Association With Age, Hormonal Factors, and Family History of Breast Cancer Among Women in Sweden. JAMA Netw Open. 2021;4(6):e2114716\u0026ndash;e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlem B, Abebu T, Zerihun T, Tadios L, Amare A, Getenet D. Delay in health-seeking behaviour and associated factors among adult patients with cancer in Ethiopia: a multicentre cross-sectional study. BMJ Open. 2023;13(8):e071406.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnger-Salda\u0026ntilde;a K. Challenges to the early diagnosis and treatment of breast cancer in developing countries. World J Clin Oncol. 2014;5(3):465\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoetzheim RG, Ferrante JM, Lee JH, Chen R, Love-Jackson KM, Gonzalez EC, et al. Influence of primary care on breast cancer outcomes among Medicare beneficiaries. Ann Fam Med. 2012;10(5):401\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGebremariam A, Addissie A, Worku A, Assefa M, Pace LE, Kantelhardt EJ, et al. Time intervals experienced between first symptom recognition and pathologic diagnosis of breast cancer in Addis Ababa, Ethiopia: a cross-sectional study. BMJ Open. 2019;9(11):e032228.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsaf B, Jocelyn F, Hannah R, Ami K, Hong W, Jeremy HV, et al. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Global Health. 2019;4(Suppl 8):e001551.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas J, Hammer J. Quality of Primary Care in Low-Income Countries: Facts and Economics. Annual Review of Economics. 2014;6(Volume 6, 2014):525\u0026thinsp;\u0026ndash;\u0026thinsp;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanders D, Schaay N, Mohamed S. Primary Health Care. In: Quah SR, editor. International Encyclopedia of Public Health (Second Edition). Oxford: Academic Press; 2017. pp. 5\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEthiopia simplified version in international classification of disease (ESF-ICD11). In: Ethiopia MoH, editor Health Center edition ed2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTesfaw A, Getachew S, Addissie A, Jemal A, Wienke A, Taylor L, et al. Late-Stage Diagnosis and Associated Factors Among Breast Cancer Patients in South and Southwest Ethiopia: A Multicenter Study. Clin Breast Cancer. 2021;21(1):e112\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAragaw T, Eyerusalem G, Adamu A, Lesley T, Eva JK, Sefonias G. Clinical Profiles, Diagnosis and Treatment for Breast Cancer Patients in Hawassa Comprehensive Specialized and Teaching Hospital in Southern Ethiopia: Descriptive Analysis. Ethiop J Health Dev. 2023;37(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyele W, Addissie A, Wienke A, Unverzagt S, Jemal A, Taylor L, et al. Breast Awareness, Self-Reported Abnormalities, and Breast Cancer in Rural Ethiopia: A Survey of 7,573 Women and Predictions of the National Burden. Oncologist. 2021;26(6):e1009\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRayne S, Lince-Deroche N, Hendrickson C, Shearer K, Moyo F, Michelow P, et al. Characterizing breast conditions at an open-access breast clinic in South Africa: a model that is more than cancer care for a resource-limited setting. BMC Health Serv Res. 2017;17(1):63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhene-Yeboah M, Amaning E. Spectrum of complaints presented at a specialist breast clinic in kumasi, ghana. Ghana Med J. 2008;42(3):110\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHewage SA, Samaraweera S, Joseph N, Kularatna S, Gunawardena N, Presentation. Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country. Clin Oncol. 2022;34(9):598\u0026ndash;607.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSongiso M, Pinder LF, Munalula J, Cabanes A, Rayne S, Kapambwe S et al. Minimizing Delays in the Breast Cancer Pathway by Integrating Breast Specialty Care Services at the Primary Health Care Level in Zambia. JCO Global Oncol. 2020(6):859\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCherlin DS, Mwaiselage J, Msami K, Heisler Z, Young H, Cui Q et al. Breast Cancer Screening in Low-Income Countries: A New Program for Downstaging Breast Cancer in Tanzania. 2022;2022:9795534.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"primary health care, referral pattern, breast abnormalities, Global Breast Cancer Initiative, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-6202235/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6202235/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBreast cancer is the most commonly diagnosed cancer among women worldwide. At the primary health care level, understanding the magnitude of different breast abnormalities and current referral practices can improve patient-centred health care services, enhance patient education and awareness, and encourage interdisciplinary collaboration to enhance breast cancer outcomes, in line with the World Health Organization Breast Cancer Global Initiative (GBCI) Pillar One Goal. Thus, this study aims to explore the burden of breast-related abnormalities and their clinical features during presentation, diagnosis, treatment, and referral practices at the primary health care level in Ethiopia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA facility-based retrospective record analysis was conducted in 2022. All documented cases of breast abnormalities among women at outpatient departments of 17 primary health care facilities were included.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf all women who presented at outpatient departments, breast abnormalities were estimated at 5 per 1,000 women patients. The proportion of suspected diagnoses of breast cancer among women with breast-related complaints was 7.5% (n\u0026thinsp;=\u0026thinsp;25/335). Among women with breast-related complaints, half (50.7%, n\u0026thinsp;=\u0026thinsp;170) presented with a complaint of breast pain, and approximately half (47.2%, n\u0026thinsp;=\u0026thinsp;158) presented to the health facility within \u0026lt;\u0026thinsp;1 month from the onset of symptoms. More than half of the women (63.0%, n\u0026thinsp;=\u0026thinsp;211) were diagnosed with breast infection/mastitis. A total of 57.1% (n\u0026thinsp;=\u0026thinsp;194) of women with breast complaints were treated with antibiotics and pain medication. The proportion of women who received surgical treatment at primary hospitals was 2.6% (n\u0026thinsp;=\u0026thinsp;14). Overall, the study found a 6.0% (n\u0026thinsp;=\u0026thinsp;20) referral rate and 23.0% (n\u0026thinsp;=\u0026thinsp;101/436) incomplete patient record.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWomen in Ethiopia often present to primary health care facilities with breast pain and suspected mastitis. In this study, a suspected diagnosis of breast cancer was found in 1 in 13 cases. This highlights the need for diagnostic services, and coordination to distinguish between benign conditions and serious malignant diseases. Strengthening primary health care services in terms of symptom recognition, referral communication, and documentation is essential to achieve the GBCI goal to contribute to the reduction of breast cancer mortality.\u003c/p\u003e","manuscriptTitle":"Clinical features, diagnosis, and referral of patients with breast abnormalities in primary health care settings in rural Ethiopia: a retrospective record analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 10:02:44","doi":"10.21203/rs.3.rs-6202235/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-10T14:41:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T17:02:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-02-05T16:48:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-02T07:09:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-01T14:53:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122190650008488962076903446129510945289","date":"2025-04-25T21:11:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23009396790944267093246623776742652721","date":"2025-04-23T08:21:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280596565251148046908118840975617672203","date":"2025-04-21T21:57:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32476357539937844073755766728577702852","date":"2025-04-19T14:18:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-19T08:13:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-09T15:08:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-20T07:54:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-20T07:32:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-03-20T07:31:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a033f369-521d-406f-bb5f-ecc4a430d926","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:02:00+00:00","versionOfRecord":{"articleIdentity":"rs-6202235","link":"https://doi.org/10.1186/s12875-026-03255-z","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2026-03-11 15:58:22","publishedOnDateReadable":"March 11th, 2026"},"versionCreatedAt":"2025-05-06 10:02:44","video":"","vorDoi":"10.1186/s12875-026-03255-z","vorDoiUrl":"https://doi.org/10.1186/s12875-026-03255-z","workflowStages":[]},"version":"v1","identity":"rs-6202235","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6202235","identity":"rs-6202235","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}