Breast cancer is the most common invasive cancer in women globally. In Ghana, it is the commonest cancer type among women [1]. Breast cancer is also the primary cause of cancer death among women globally [2]. Comorbidity is prevalent among cancer patients. Breast cancer development, staging, treatment and prognosis are affected by comorbidity [3]. Over a century ago, hyperglycemia and diabetes were first linked to breast cancer. Incidence reports since the 1950s, have also described women with breast cancer as having higher rates of diabetes than do healthy women [4][5]. Also, it has been observed that Tamoxifen may increase diabetes incidence through its oestrogen-inhibiting effects. Regardless of the cancer type, hypertension has been found to be the most prevalent chronic condition among cancer survivors [6] and can influence prognosis and survival [7][8]. This frequency keeps increasing with an aging population. Breast cancer development, staging, treatment and prognosis are affected by comorbidity [3].

In Ghana, breast cancer is the leading malignancy [9]. In 2007, breast cancer accounted for 15.4% of all malignancies, with this number increasing annually [10]. Roughly 70% of women diagnosed with breast cancer in Ghana are in the advanced stages of the disease resulting in lower chances of survival [11]. The incidence and prevalence of comorbidities among such female patients becomes alarming as it affects the survival rate, proper management and Quality of Life (QoL). Indeed, the diagnosis and treatment of breast cancer although demanding, can further trigger overwhelming challenges to basic principles, beliefs, goals of women, and alter their sense of identity and psychological functioning [12][13]. While early detection and treatment, along with advances in treatment are expected to result in better rates of survival, problems related to the treatment can cause negative effects on health related QoL. Today, QoL of patients is considered an important issue in the treatment of women with breast cancer [14][15][16]. This study therefore sought to assess the prevalence of comorbidities among breast cancer patients and also determine the overall QoL in breast cancer patients in Kumasi, Ghana.

Three hundred and seventy (370) female breast cancer patients were conveniently recruited onto the study. In order to determine the required sample size, the formula: n?=?Z2PQ/d2 was used, where, Z?=?1.96, P?=?prevalence of breast cancer from a previous study (and d?=?margin of error i.e. 0.05. Thus, the calculated sample size was n?=?329. With the minimum number to be enrolled being 329, we recruited 370 individuals in this study.

• Having being diagnosed with breast cancer
• Women more than 25 years with various stages of breast cancer
• Being indicated for breast cancer surgery and any other treatment regimens

• Difficulty in understanding the questionnaire.
• Unwillingness to participate

Well-structured questionnaires were administered to the respondents. Using the questionnaires, socio-demographical and clinical information were obtained from the participants. The information provided was verified from the patient’s hospital records. For the QoL assessment, the questionnaires used included the EORTC QLQ-C30 and the EORTC QLQ-BR23.

A convenient sampling method was used to recruit subjects for the study. The case records of all women with a diagnosis of breast cancer were screened for eligibility on the day they turned up for their appointments with their primary physicians. The researchers approached the eligible participants to explain the study aim and obtain their written consent. The recruitment was in the form of a face-to face interview with the participants.

Ethical approval for the study was obtained from the committee on Human Research, Publication and Ethics (CHRPE) (CHRPE/AP/252/16 and CHRPE/AP/270/16) of the School of Medical Sciences (SMS), Kwame Nkrumah University of Science and Technology (KNUST) as well as Research and Development board of the Komfo Anokye Teaching Hospital.

The data collected was entered into Microsoft Excel and analyzed using GraphPad Version 6. Independent t-test and ANOVA tests were used to assess the relationship between normally distributed variables. Mann-Whitney and Kruskal-Wallis tests were used to analyze non-parametric distributed variables. Descriptive statistics were used to present demographic characteristics and QOL. Normally distributed categorical variables were expressed as mean ±SD and non-parametric categorical variables expressed as median (IQR). A statistical significant level was set at p< 0.05 for all tests.

The socio-demographical characteristics of the respondent are given in Table 1. Most of the respondents (33.0%) were between ages 41–50 years while 18.1% were < 40 years of age. More than half (81.1%) of the respondents had been living with breast cancer for less than five years. With respect to marital status, high proportions (60.0%) of the women were married while 18.1% were divorced. Majority (40.0%) had primary education, half (50.0%) were unemployed, 41.1% were employed, 1.9% were on retirement while 7% were on pension. A high proportion of the respondents (71.1%) were in their post-menopausal stage. A greater percentage (85.9%) had no family history of breast cancer. Also majority of the respondents were neither alcoholic (98.1%) nor smokers (98.9%). More than half (51.9%) did not indulge in regular exercise. Only 48.1% actively engaged in exercise.

The distribution of obesity and blood pressure indices among the respondents is given in Table 2. With respect to BMI, majority of the respondents (44.1%) were normal, whereas 28.9% and 25.9% were overweight and obese respectively. Forty percent of the respondents had normal blood pressure levels, 25.9% were pre-hypertensive while 34.1% had high blood pressure. The mean systolic and diastolic values both were in the pre-hypertensive range.

One hundred and twenty-six (34.1%) of the respondents had comorbidities while 65.9% did not. Out of the 34% who presented with comorbidities, 82% had only one comorbidity, 15% had two comorbidities with one respondent (3%) presenting with three comorbidities.

A summary of the comparison of anthropometric measures and blood pressure between breast cancer patients with and without comorbidities is given in (Table 3). For the anthropometric measures, there was a statistically significant variation in the BMI and mean weight of the respondent with comorbidities compared to those without (p< 0.05). In all, respondents with comorbidities had increased BMI (29.3±5.34) and weight (72.4±14.9) than those without comorbidities although they were both overweight. The mean systolic (146±27.6) and diastolic (90.6± 17.5) blood pressures were significantly higher in the respondents with comorbidities than those without (p < 0.05).

A comparison of the socio-demographic and lifestyle characteristics between patients with and those without comorbidities is given in (Table 4). Statistical significant difference was observed when age (p=0.003), employment status (p=0.026) and menopausal status (p=0.003) were compared between patients with comorbidities and those without comorbidities. Majority of respondents without comorbidities (34.8%) were between 40–50 years whereas most of those with comorbidities (53.2%) were above 60 years. With respect to employment status, a higher proportion of the respondents without comorbidities were employed (48.0%) while most of their counterparts with comorbidities (56.5%) were unemployed.

The EORTC-QLQ Scale Scores and level of quality of life perceived by breast cancer patients is presented in Table 5. The average perception of quality of life by participants was 65.87±27.28. Two hundred and forty-one (65.1%) of the women perceived themselves to have a good quality of life with 13% having a poor quality of life perception. The participants recorded a healthier function in the order; social functioning (88.9%), 76% for both cognitive functioning and emotional functioning, physical function (74%) and role function (72.9%) with means of 80.73, 82.94, 75.93, 75.87 and 70.35 respectively. Participants were found to have considerable symptomatic problems in terms of finance with a median of 100 (67.0). Fatigue and pain symptoms were also relatively high with medians of 22 (0.0–33) and 17 (0.0–62.8) respectively.

The EORTC-QLQ-BR23 scale scores and level of quality of life perceived by breast cancer patients is presented in Table 6. On the QLQ-BR23, the study participants had the best function in body image (90%) and sexual function (83%) with means of 87.12±25.65 and 81.68±27.49 respectively. Participants recorded poor sexual enjoyment and future perspective function (mean of 61.83±28.25 for both). Systemic therapy side effects were the most challenging symptom recorded by participants and followed by Arm symptoms with a median of 11.0 (0.0–56).

Presence of comorbidities among breast cancer patients is a matter of great worry, as it affects proper management and QoL. This study determined the prevalence of comorbidities and overall QoL among breast cancer patients at Komfo Anokye Teaching Hospital, in Kumasi Ghana. There is a general consensus that comorbidity is common in patients presenting with cancer, but no study has come from Ghana reporting the magnitude. In this current study, 34.1% of the study respondents presented with comorbidities (Figure 1). Edwards et al., reported that, in the United States, patients with breast cancer had prevalence of comorbidity of 32.2% [17]. More than half, 53% of the respondents who presented with comorbidities were above 60 years (Table 4). It has been established that breast cancer incidence cum the risk of comorbidities increases with age [18][19]. Thus having a comorbidity at an older age could serve as a risk factor, predisposing a patient to breast cancer especially in the case of diabetes and hypertension [20]. Comorbidities is most prevalent in older adults and the aged, majority of our study participants were older than 40 years this might in part explain the observed higher prevalence of comorbidity in this category of patients. Additionally, it is common knowledge that cancer and chronic comorbid conditions share similar predisposing factors. Comorbidities tend to be increased in individuals living with increased levels of financial difficulty or poverty [21][22] as observed from our study only 41. 1% of our respondents were gainfully employed.

This study further observed that majority of the respondents were either pre-hypertensive or hypertensive. The mean blood pressure readings for respondents with comorbidities were also significantly higher than those without comorbidities. Mash (2010) also made similar observation from their study in which they attributed the increase in hypertension to lifestyle factors, including physical inactivity, a salt-rich diet through processed and fatty foods and alcohol and tobacco use [23]. In Ghana, The Ministry of Health (MOH) in 2005 reported a high prevalence of hypertension in adults above 45 years in Ghana (MOH, 2005). All the respondents were urban dwellers, and Addo et al., reported that the prevalence of hypertension in the urban societies of many developing countries like Ghana, is presently as high as that in the developed countries [24]. Souza et al., in a systematic review found that a high prevalence of hypertension in cancer patients is due to similar risk factors between hypertension and cancer [25]. The high prevalence of hypertension may be ascribed lifestyle factors as well as to the worry and fear associated with breast cancer diagnosis and treatment which can predispose a non-hypertensive breast cancer patient to hypertension especially if the patient is not counseled adequately.

A previous study has reported obesity to be related to prognosis in patients with breast cancer [26]. In this study, majority of the participants were overweight as well as obese (Table 2). This is in line with a cross-sectional study by Amoah in Ghana which revealed the overall crude prevalence of overweight and obesity to be 23.4% and 14.1% respectively among adults aged 25 years and above [27]. Moreover, in an epidemiological study conducted among Ghanaians by Biritwum et al., [28]. The prevalence of overweight and obesity among these women could be attributed to the general lack of physical activity, sedentary occupations, unbalanced diets, higher educational level and urban dwelling.

In this current study, there was a higher proportion of the cancer patient between the ages 40–50 years (33.0%), followed by those above 60 years (30%) with most of the women (71.1%) being postmenopausal. This finding is similar to reports from a retrospective study among Ghanaians by Edmund et al., and in a survey study by Ghartey et al., [29][30]. Most of the women from this current study did not have a family history of breast cancer prior to their diagnosis (Table 1). Only 14.1% of women diagnosed with breast cancer have a first-degree female relative (daughter, mother or sister) with the disease. Research by Collaborative Group on Hormonal Factors in Breast Cancer [31] reported that majority of women with breast cancer do not have a family history of the disease which conforms to the findings of our current study. This suggests that the aetiology and risk of breast cancer among Ghanaians is beyond merely hereditary patterns.

The EORTC QOL-C30 scores were high for physical functioning (74%), role functioning (74%), emotional functioning (76%), cognitive functioning (76%) and social functioning (89%) indicating a satisfactory level of these functions. These findings match up with reports from a cross-sectional study by Lobo et al., in Portugal on breast cancer patients who showed satisfactory functional scores [32]. Participants, however, had low symptoms scores for pain (25%), fatigue (19%), insomnia (19%), nausea/vomiting (9%), dyspnea (8%), constipation (3%), diarrhea (7%) and appetite loss (14%), (Table 5). Financial problems were a common problem amongst participants. Moreover, less than half of our study participants were actively employed. Lobo et al., in their study also reported that patients faced similar financial issues [32]. Breast cancer treatment regimens were very expensive and most participants complained greatest about treatment cost during the recruitment. To mitigate the cost of breast cancer treatment, we advocate for an increment in the cost allocated to breast cancer treatment in order to reduce the out-of-pocket payment made by the breast cancer patients.

Evaluation of participants with EORTC-QLQ BR23 showed patients with healthier functional scales but low symptom scale. Scores were high for body image (90%), sexual functioning (83%), sexual enjoyment (78%) and future perspective (78%). Lower scores were recorded for the symptom scale; systemic therapy side effects (7%), breast symptoms (16%), arm symptoms (22%) and upset by hair loss (14%), (Table 6). Systemic therapy side effects were the worst challenging symptom recorded by participants which could be due to the adverse effects implicated by adjuvant therapies. Earlier studies conducted on breast cancer patients, a global quality of life nearer to 100 (thus >70) was considered reasonable or satisfactory by women [32][33]. The global quality of life (65.87) though fairly good was unsatisfactory as considered by the women. In most cancer treatment, the presence of other comorbidities is seldom taken into consideration and this can have a possible adverse effect on the prognosis, QoL and overall survival, it is therefore suggested that treatment strategies must take into account the interaction and co-existence of cancer with other comorbidities for improved prognosis and overall QoL. Although the aforementioned findings in this study concur with several other authors, the limitations of the results of this study are related to the cross-sectional design that does not allow establishing relations of cause and effect.

Comorbidities were present in 34% of the breast cancer patients. Obesity, overweight, diabetes and hypertension were the most prevalent comorbidities. Overall, the quality of life (QoL) of the breast cancer patients was moderate but with high symptom scales and score as well as financial constraints. The presence of comorbidities affects breast cancer treatment, QoL, prognosis, as such, screening for occurrence of comorbidity in breast cancer patients should be made a priority and a part of routine medical care with extra attention given to patients that present with comorbidities with the aim of improving their prognosis and QoL.

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