Breast cancer is a real problem in Africa, and particularly in Côte d’Ivoire, where it is the leading cancer in women [1] . Its incidences vary from 31.9/100,000 in East Africa to 42.1/100,000 in West Africa, from 26.7 - 45.4/100,000 in Asia to 57.2/100,000 in South America; and from 92.6/100,000 in Western Europe to 95.1/100,000 in North America [2] . In 2022, 2,296,840 new cases of breast cancer were recorded worldwide, with 660,103 deaths attributable to it [2] . Mortality from breast cancer has been declining for some thirty years in the most industrialized countries [3] . Unfortunately, in Africa, 50% of women who die from breast cancer do not reach the age of fifty [4] . This finding is attributed partly to early diagnosis and improved treatment in the industrialized countries [3] . In Côte d’Ivoire, 3306 new cases were recorded in 2020, including 1785 deaths [5] . These figures are largely underestimated, due to a lack of resources to diagnose the disease nationwide [6] . Factors associated with late diagnosis include the lack of financial resources (36%), the sociocultural habits of the population (41.1%) and misdiagnosis (7.1%) [5] . The risk of breast cancer is increased by around 25% in women currently using oral contraceptives in Europe and North America [7] . Exogenous hormones and endocrine disruptors have also been implicated in the increased incidence of breast cancer [8] [9] . Genetic factors represented by family history of breast cancer and genetic mutations also play a role in the occurrence of the disease [10] . Available data on female breast cancer in Côte d’Ivoire come mainly from studies carried out in Abidjan, the economic capital city of Côte d’Ivoire. There is very little data concerning people affected by breast cancer living outside Abidjan, notably in Bouaké. The aim of the present study was to determine the epidemiological, radiological and pathological characteristics of female breast cancer in Bouaké.

The mean age of patients in the present study was 43.8 ± 11.0 years, in line with that reported by several authors in Côte d’Ivoire [12] - [14] . Elsewhere in Africa, average ages ranging from 44.1 to 47.8 years have been reported [15] - [17] . The 40 - 55 age group was the most represented, which is in agreement with a previous report from Côte d’Ivoire by Aka et al. [14] . Pre-menopausal patients represented almost 3/4 of the study population. This finding is in contrast with data from developed countries, where breast cancer is more often detected at an advanced age or during the post-menopausal period [18] . For instance, in the UK, over 80% of breast cancers are diagnosed in post-menopausal women [19] . This difference may be explained by the race of the patients. Indeed, various studies have highlighted a certain predisposition of black women to develop breast cancer at a young age [20] [21] . This assertion is supported by Pleasant [22] who also revealed an increased risk of endometrial cancer, in addition to the susceptibility of black women to breast cancer. In black Africans, the late onset of breast symptoms would justify the discovery of malignancy at a later age [5] . Very few patients used contraceptive drugs compared to their European counterparts. In Europe, contraception is widely available to all whereas, that is not the case in Côte d’Ivoire is limited [23] [24] . Previous reports have shown a contraceptive use rate of 14% in 2012, 21% in 2017 and 22.5% in 2020 [23] [24] . As highlighted by Coulibaly et al. [25] , there remains some sociocultural obstacles to the use of modern contraception in Côte d’Ivoire. These obstacles include the lack of reliable and reassuring information on contraception, the apprehension about its side effects, the illiteracy, the dominant power of the male partner in the decision-making process and the religious prohibitions [25] . These difficulties are also encountered in several other African countries such as the Democratic Republic of the Congo, Morocco, Niger and Senegal [26] - [29] . The BIRADS 4 group was frequently identified among the patients after mammography testing. It corresponds to the presence of suspicious abnormalities with a potential of malignancy ranging from 2% to 95% that require a pathology exploration [30] . Luo et al. [31] . have demonstrated the value of mammography in predicting breast cancer in patients grouped into BIRADS 4 or 5, highlighting the good discriminatory power of that analysis in front of malignant or benign breast tissue lesions. The most frequently diagnosed histological type was the non-specific infiltrating carcinoma. This finding has also been reported in many countries [17] , notably in Burkina Faso [16] and Mali [32] . In Côte d’Ivoire, Touré et al. [33] also found that 89.3% of breast cancers were non-specific infiltrating carcinomas. The non-specific infiltrating carcinoma is the most common histological type worldwide, with a frequency ranging from 77% to 88% on the African continent [34] as well as Asia with frequencies ranging from 80% to 94.5% [35] . The Nottingham grade II prevailed in this study, as reported by several authors in both developing and developed countries [16] [36] [37] . Once the diagnosis of breast carcinoma has been established, major challenges appear. Indeed, in Africa in general and in Côte d’Ivoire particularly, there are problems related to the geographical and financial access to healthcare. Aka et al. [14] investigated the direct economic cost of breast cancer for the patients. They showed that the cost of chemotherapy was on an average estimate of $3121 (US dollars) per patient before radiotherapy cost which stood at $1714 per patient [14] . One of the limitations of the present study is that hormone assays were not carried out, in particular the dosage of the serum levels of estrogen (estradiol II), progesterone, GnRH (gonadotrophin-releasing hormone), FSH (follicle-stimulating hormone), LH (luteinizing hormone) and prolactin. Some studies have found a link between blood levels of estrogen and androgen and the development of breast cancer in pre-menopausal women [38] - [41] . However, no link has been established between the blood levels of progesterone and the development of breast cancer [38] [39] .

This study describes the epidemiological, radiological and pathological aspects of female breast cancer in Bouaké. The keys features were an affected population with an average age of 43.8 years with a pre-menopausal status that does not contraceptive drugs. The BIRADS 4 group predominated, and the non-specific infiltrating carcinoma was overwhelmingly observed. No statistically significant relationship was found between the carcinoma type and the menopausal status, nor between the carcinoma type and the use of contraceptive drugs. It is therefore essential to reinforce the city of Bouaké with an independent institution dedicated to the fight against cancer which harbors all the needed specialized services in one place while providing free treatment for the patients.

Our thanks go to the staff of the peripheral screening sites, pathology, gynecology, medical oncology, and radiology of the Teaching Hospital of Bouaké, as well as the Roche Hoffmann Laboratories in Côte d’Ivoire.

This study was supported by the Coalition for Implementation of Research in Global Oncology (CIRGO) of the therapeutic route of patients to the pathological diagnosis.

The ethical approval of the protocol and written consent of the participants were secured. All procedures were approved by the National Ethics Committee of Côte d’Ivoire under the authorization number (142-23/MSHPCMU/CNESVS-km). The anonymity and data confidentiality were ensured.