Financial, geographic, laboratory and sociocultural barriers to histopathological confirmation of breast cancer in Niger: a multicenter retrospective study

Background Histopathological confirmation is the cornerstone of breast cancer diagnosis and is essential for tumour classification, biomarker assessment and evidence-based treatment planning. However, access to pathology services remains limited in many low-resource settings. This study aimed to determine the rate of histopathological confirmation among women with cytologically diagnosed breast cancer and to identify factors associated with failure to obtain histopathological confirmation in Niger. Methods We conducted a retrospective multicenter study in the two national referral hospitals providing specialized breast cancer care in Niger between January 2020 and December 2024. Women with malignant fine-needle aspiration cytology (FNAC) were included. Sociodemographic, clinical, diagnostic and treatment data were extracted from medical records. Patients were classified according to the availability of histopathological confirmation. Factors associated with failure to obtain histopathological confirmation were evaluated using multivariable logistic regression. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were calculated. Results A total of 674 women with cytologically diagnosed breast cancer were included. Only 172 (25.5%) subsequently underwent histopathological confirmation, whereas 502 (74.5%) were managed without histological confirmation. Multivariable analysis identified : Age < 50 years (AOR 3.24; P < 0.001), rural residence (aOR 3.40; P < 0.001), absence of formal education (aOR 2.36; P = 0.003), consultation delay > 6 months (aOR 1.80; P < 0.001), advanced breast cancer stage (III-IV) at diagnosis (aOR 2.76; P < 0.001), axillary lymph node involvement (aOR 2.78; P < 0.0001), and primary management in a periphery hospital (aOR 4.5 ; P < 0.001) as independent predictors of failure to obtain histopathological confirmation. During the study period, pathology services in Niger were characterized by limited laboratory capacity, prolonged turnaround times, absence of immunohistochemistry and hormone receptor testing, and highly centralized diagnostic facilities. Conclusions Histopathological confirmation remains insufficient among women with cytologically diagnosed breast cancer in Niger, representing a major gap in the breast cancer diagnostic pathway. Strengthening pathology services, expanding laboratory capacity, improving access to diagnostic investigations and introducing routine immunohistochemistry should be prioritized to improve diagnostic completion and facilitate guideline-concordant breast cancer care. These findings provide evidence to support implementation of the World Health Organization Global Breast Cancer Initiative in low-resource settings.