Bridging knowledge gaps in breast cancer prevention: Insights from Ethiopia

Abstract

This editorial comment on the article by Agidew et al in the recent issue of the World Journal of Clinical Oncology. Breast cancer remains a growing challenge in Ethiopia, where high mortality results from low awareness, delayed diagnosis, and restricted healthcare access. Agidew et al report that women with a family history of breast disease exhibit significantly higher levels of knowledge (83.9% vs 10.5%), more positive attitudes (49% vs 32.1%), and greater engagement in preventive practices (74.1% vs 16.7%). However, with 69%-79% of women living below the poverty line, socioeconomic barriers severely limit preventive actions. Education, income, and community health insurance emerge as key predictors of health behaviors. We propose integrated interventions including deploying community-based approaches, culturally tailored education, and artificial intelligence-powered education tools, to bridge knowledge gaps and transform awareness into action. This multifaceted strategy offers a scalable model for resource-limited settings globally, addressing both individual awareness and structural barriers to improve breast cancer outcomes.

Key Words: Breast cancer prevention; Health equity; Socioeconomic determinants; Global health; Ethiopia

Core Tip: In Ethiopia, a study reveals that family history (FH) significantly boosts awareness and preventive practices among women, with those reporting FH demonstrating 83.9% knowledge compared to only 10.5% among those without. However, 69%-79% of participants live below the poverty line, underscoring critical socioeconomic barriers. Education, income, and insurance emerge as strong predictors of positive outcomes, suggesting that expanding community health insurance could be a pivotal strategy. This editorial advocates for deploying community-based approaches, culturally tailored education, and AI-powered education tools, to bridge knowledge gaps in resource-limited settings and transform awareness into action globally.

INTRODUCTION

Breast cancer remains a critical global health challenge. According to GLOBOCAN 2022, female breast cancer is the second most common cancer worldwide, with 2.3 million new cases annually, and the leading cause of cancer-related deaths among women[1]. The disease shows notable disparities between high-income countries (HICs) and low- and middle-income countries (LMICs). While HICs have reduced mortality through early detection and advanced treatment, LMICs like Ethiopia face rising incidence and mortality rates[1]. Notably, Ethiopia’s breast cancer mortality rate is twice that of the United States despite a 60% lower incidence, a disparity driven by low awareness, delayed diagnosis, and limited healthcare access[1].

Breast cancer is a significant heterogeneous disease with a multifaceted etiology involving genetic, environmental, and lifestyle factors. A recent population-based study found that pathogenic variants in 12 established breast cancer–predisposition genes in 5.03% of case patients and in 1.63% of controls[2]. Individuals with a family history (FH) of breast cancer, particularly those with an affected first-degree relative, face significantly higher risk[3]. Early-stage breast cancer can be cured with local-regional therapies like surgery and radiotherapy, with or without systemic treatments, while advanced breast cancer with distant metastases remains incurable even with systemic therapy management[4]. In Ethiopia, 71% of breast cancer patients diagnosed at stages III or IV, significantly increasing mortality risk[5]. While screening helps detect cancer early, individuals in LMICs demonstrate varying levels of knowledge, attitudes, and preventive practices regarding breast cancer.

This editorial comment on the article by Agidew et al[6] in a recent issue of the World Journal of Clinical Oncology, focusing on the interplay between FH, socioeconomic factors, and breast cancer prevention behaviors in Ethiopia, with implications for similar resource-limited settings worldwide.

INSIGHTS FROM ETHIOPIA STUDY

A recent study by Agidew et al[6] in the World Journal of Clinical Oncology offers critical insights into how FH of breast disease shapes knowledge, attitudes, and preventive practices among reproductive-age women in Northeast Ethiopia. By focusing on a rural region with scarce data, this study highlights the role of personal experience in driving health behaviors and identifies actionable socioeconomic factors for public health strategies in resource-limited settings[6].

Agidew et al[6] employed validated questionnaires and systematic sampling to assess differences between women with and without FH of breast disease[6]. Their findings demonstrated that women with FH demonstrated significantly higher levels of knowledge (83.9% vs 10.5%), more positive attitudes (49% vs 32.1%), and greater engagement in preventive practices (74.1% vs 16.7%) compared to their counterparts without FH. These disparities suggest that direct exposure to breast disease within a family serves as a powerful motivator, fostering awareness and proactive behaviors that might otherwise remain dormant in the absence of personal relevance.

Beyond the influence of FH, the study found educational status, monthly income, and community health insurance as significant predictors of knowledge, attitudes, and preventive practices. Women with secondary or higher education, those living above the poverty line, and those with health insurance were far more likely to exhibit favorable outcomes across all three domains. These findings align with global evidence linking social determinants to health literacy and preventive behaviors. Additionally, their findings highlight a critical economic disparity in this region, where 69.2% of women with FH and an even higher 78.9% without FH live below the poverty line, creating substantial barriers that prevent most women from translating awareness into actionable healthcare decisions.

This study reveals that women with FH of breast disease demonstrate better knowledge, attitudes, and preventive practices regarding breast cancer. These women could serve as effective community advocates for awareness. However, significant socioeconomic barriers exist, with 69%-79% of women living below the poverty line. Education level, income, and health insurance status strongly predict health outcomes, suggesting that community health insurance expansion could help bridge the gap between awareness and action. These findings reflect broader challenges in low and middle-income countries like Ethiopia, where breast cancer accounts for 33% of female cancers but healthcare systems remain primarily focused on communicable diseases rather than cancer prevention and treatment.

While this study advances understanding of breast cancer prevention in LMICs, there are several limitations warrant attention. First, the study’s cross-sectional design limits causal links between FH and breast cancer awareness. Longitudinal studies could track women over time to determine if FH directly enhances knowledge and practices or reflects factors like healthcare access. Qualitative methods, such as interviews or focus groups, combined with surveys, could uncover cultural beliefs and barriers missed by quantitative data. Community trials testing educational strategies could identify effective approaches, especially for women without FH. Culturally tailored tools, validated with local input, would improve measurement of knowledge, attitudes, and practices. Using observed skills assessments, such as direct evaluations of breast self-examination, or relying on clinical records rather than self-reports would enhance reliability. Despite female interviewers, social desirability bias may persist; anonymous surveys or mixed-methods approaches could address this. Finally, implementation science could adapt and scale interventions within Ethiopia’s resource-constrained healthcare system, translating findings into practice.

Second, reliance on American Cancer Society guidelines raises questions about applicability to Ethiopia’s sociocultural context. International guidelines often reflect Western healthcare contexts and may not fully account for the unique cultural, social, and healthcare realities in Ethiopia. Future work should focus on adapting these guidelines to incorporate local health beliefs, communication practices, and social structures. For instance, educational campaigns could integrate Ethiopia's communal decision-making structures by training respected community leaders, religious figures, or "health ambassadors" to disseminate information. Leveraging oral traditions, such as storytelling or radio dramas in local languages, could make messages more relatable than text-heavy materials. Furthermore, preventive practices like self-exams should be reframed within culturally acceptable norms. In rural areas, community health workers could teach self-examination during maternal health visits, normalizing it as part of holistic care. Collaborations with traditional healers could also help in recognizing early signs and referring patients, thereby building trust within the community.

Third, a puzzling negative link between education status and knowledge, attitude, and preventive practices suggests possible data errors or confounding, requiring further clarification. These findings contradict established literature and the authors' own conclusions, which state that higher education is associated with better outcomes. This discrepancy raises questions about potential data errors, statistical analysis issues, or unidentified confounding variables. Clarification from the authors on these contradictory findings is essential before their results can reliably inform interventions.

Fourth, a notable demographic imbalance exists between the study groups. Women with a FH of breast disease were predominantly rural residents (76.2%), while the non-FH group had a majority of urban residents (56.5%). This substantial rural/urban distribution difference could significantly confound the results, as urban residents typically have better access to healthcare information and services. The authors did not adequately address this potential confounder in their multivariate analysis, making it difficult to determine whether the observed differences in knowledge, attitudes, and practices are truly attributable to FH or simply reflect urban/rural disparities in healthcare access and education.

Agidew et al's findings represent a clear call to action for breast cancer prevention in Ethiopia and similar settings. While FH naturally heightens awareness, effective public health strategies must extend this vigilance to all women[6]. Targeted educational programs should be paired with practical measures, including accessible screening services and expanded health insurance coverage, to ensure knowledge transforms into preventive action.

In Ethiopia's context, where healthcare systems face the dual burden of infectious and chronic diseases with limited resources, these findings offer valuable direction. They highlight that effective breast cancer control requires both individual empowerment through education and systemic improvements in healthcare access. The evidence from Wollo provides a foundation that policymakers, healthcare providers, and researchers must now build upon with context-appropriate interventions that address both awareness and the socioeconomic barriers that currently prevent action.

Reports from HICs reveal distinct patterns. For example, Lin et al[7] found no significant association between FH and cancer attitudes in Ohio, United States (P = 0.11), with education level emerging as the dominant predictor of preventive behaviors[7]. Similarly, Ahmed et al[8] found a belief-action gap among Saudi healthcare providers, with 91.4% endorsing screening while actual uptake remained low.

Social determinants further shape these outcomes. Agidew et al[6] demonstrated that health insurance coverage strongly predicted preventive practices (Adjusted odds ratios = 4.59)[6], aligning with Lin et al’s emphasis on education[7]. Despite these findings, structural barriers persist in Agidew et al’s Ethiopian cohort, 69.2% of FH-positive and 78.9% of FH-negative women lived below the poverty line[6]. Meanwhile, Sayed et al’s meta-analysis reported that clinical breast examination training improved early-stage detection in LMICs [relative risk (RR) = 1.44], though its impact on mortality remained inconclusive (RR = 0.88)[8,9]. These disparities highlight a critical contrast: While FH drives awareness in Ethiopia, factors like education, systemic healthcare access, and healthcare provider training are central to shaping outcomes in other regions.

Emerging technologies like artificial intelligence (AI) chatbots, such as Claude, ChatGPT, and Gemini, offer complementary solutions for LMICs. Recent studies show these AI chatbots can outperform physicians and surgeons in specific knowledge domains[10-12]. Furthermore, AI chatbots have significant potential as cancer education tools for conditions such as myeloma and prostate cancer[12,13]. These technologies hold particular promise in LMICs where access to quality healthcare is limited[14]. First, AI can provide reliable information on breast cancer prevention and screening. Haver et al[15] evaluated ChatGPT’s performance in answering common questions about breast cancer prevention and screening[15]. They found that ChatGPT provided appropriate responses for 22 out of 25 questions (88%)[15]. These results indicate that ChatGPT has the potential to serve as a valuable tool for disseminating patient education on breast cancer prevention and screening. In addition, Haver et al[16] examined ChatGPT's ability to simplify breast cancer prevention information by asking it to simplify answers to 25 common questions. The simplified responses demonstrated significant improvements in reading ease and readability, along with a reduced word count[16]. These findings underscore ChatGPT's potential to enhance accessibility. Second, AI can effectively disseminate health messages at low cost. Winterstein et al[17] utilized a Generative AI application to create a virtual persona, "Wanda" for promoting cancer prevention on Instagram[17]. They created five posts addressing modifiable cancer risk factors, such as tobacco use, unhealthy diet, sun exposure, alcohol consumption, and HPV infection, and used both custom targeted and automated advertising strategies with a total budget of €100[17]. The campaign reached 9902 users at an average cost of €0.013 per reach, with the most efficient intervention costing €0.006 per reach[17]. The findings demonstrated that combining generative AI with targeted advertising can effectively disseminate health messages at low cost and minimal time investment, pointing to the promising role of AI-driven influencers in scalable digital health communication. In Ethiopia, where breast cancer is considered the most common cancer among women and a significant portion of cases are diagnosed at late stages[1,5], integrating AI-driven education with community health campaigns could bridge knowledge gaps exacerbated by limited healthcare provider access. These digital solutions could be particularly effective when deployed alongside traditional community-based interventions.

CONCLUSION

To transform awareness into action, Ethiopia could implement strategies such as expanding health insurance, offering culturally tailored education, utilizing AI-powered education tools, and improving healthcare provider training. Community-based organizations and local partnerships are essential. Trusted community health workers can extend breast health education, particularly in rural areas where many women with a FH reside. Religious institutions, women’s groups, and breast cancer survivors can help normalize discussions about breast health and act as effective ambassadors. Moreover, engaging traditional healers, who are often the first point of contact for health concerns, can establish reliable referral pathways to formal healthcare. This community-centered approach, combined with structural healthcare reforms, offers a practical model to bridge the gap between awareness and action, ultimately improving outcomes for women regardless of FH.