PURPOSEFeasible and effective strategies are needed to facilitate earlier diagnosis of breast cancer in low-income countries. The goal of this study was to examine the impact of health worker breast health training on health care utilization, patient diagnoses, and cancer stage in a rural Rwandan district.METHODSWe conducted a cluster randomized trial of a training intervention at 12 of the 19 health centers (HCs) in Burera District, Rwanda, in 2 phases. We evaluated the trainings’ impact on the volume of patient visits for breast concerns using difference-in-difference models. We used generalized estimating equations to evaluate incidence of HC and hospital visits for breast concerns, biopsies, benign breast diagnoses, breast cancer, and early-stage disease in catchment areas served by intervention versus control HCs.RESULTSFrom April 2015 to April 2017, 1,484 patients visited intervention HCs, and 308 visited control HCs for breast concerns. The intervention led to an increase of 4.7 visits/month for phase 1 HCs (P = .001) and 7.9 visits/month for phase 2 HCs (P = .007) compared with control HCs. The population served by intervention HCs had more hospital visits (115.1 v 20.5/100,000 person-years, P < .001) and biopsies (36.6 v 8.9/100,000 person-years, P < .001) and higher breast cancer incidence (6.9 v 3.3/100,000 person-years; P = .28). The incidence of early-stage breast cancer was 3.3 per 100,000 in intervention areas and 0.7 per 100,000 in control areas (P = .048).CONCLUSIONIn this cluster randomized trial in rural Rwanda, the training of health workers and establishment of regular breast clinics were associated with increased numbers of patients who presented with breast concerns at health facilities, more breast biopsies, and a higher incidence of benign breast diagnoses and early-stage breast cancers.

PURPOSE The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings. METHODS To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda. RESULTS Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda. CONCLUSION A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.

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Cancer care providers at Queen Elizabeth Central Hospital in Malawi identified a need for educational materials for their low-literacy patients. Global Oncology, a nonprofit focused on improving cancer care, research, and education in resource-limited settings, partnered with THE MEME to develop cancer patient educational materials (PEMs). The goal of the project was to create clinically relevant and culturally appropriate low-literacy PEMs to improve clinical care, support services, and patient adherence in resourcelimited settings. The team also aimed to develop a product strategy and business model for long-term sustainability. The article introduces the challenge from a global health perspective and the ways design can have a significant impact. It presents the collaborative process of developing the "Cancer and You" booklet for multiple cultural contexts and focuses on the results of a pilot study in Haiti evaluating the efficacy of the design in simplifying complex medical information, facilitating patient education, and improving communication.

Purpose In low-income countries, most women with breast cancer present with advanced-stage disease. To facilitate earlier diagnoses of symptomatic disease, feasible and effective early detection strategies are needed. We assessed health care use and patient outcomes from a randomized pilot study of an early detection program in Burera, a rural Rwandan district, where the Butaro Cancer Center of Excellence (BCCOE) is located. Methods The intervention included training for community health workers in breast health, training for health center (HC) nurses in the evaluation of breast concerns, and weekly breast clinics at HCs and BCCOE. Twelve of 18 eligible HCs were randomly assigned to receive the intervention—seven beginning in April and May 2015, and five in November and December 2015—and six served as controls for the entire study period. We abstracted HC and hospital records of patients seen between April 2015 and April 2017 and used generalized linear models to compare the incidence of biopsies, breast cancer diagnoses, and early-stage diagnoses in the geographic sectors served by intervention versus control HCs. Results Overall, 276,282 person-years were in intervention sectors and 302,856 in control sectors. Of patients, 1,500 patients sought care at intervention HCs for breast concerns versus 600 at control HCs. Three hundred eighteen patients that were referred from intervention HCs were evaluated at BCCOE compared with 62 from control HCs. The biopsy rate was 36.6 per 100,000 person-years from intervention sectors versus 8.9 per 100,000 from control sectors ( P < .001). Breast cancer was diagnosed in 19 of 101 patients from intervention HCs who underwent biopsy (18.8%) compared with 10 (37.0%) of 27 patients from control HCs. Breast cancer incidence was 6.9 per 100,000 in intervention sectors versus 3.3 per 100,000 in control sectors ( P = .35). Nine patients from intervention HCs had early-stage disease (47.4%) versus two from control HCs (20.0%). The incidence rate of early-stage breast cancer was 3.7 per 100,000 in intervention sectors versus 0.7 per 100,000 in control sectors ( P = .08). Conclusion Over 2 years, our early detection program was associated with more patients referred for hospital-level evaluation and requiring biopsies. Most patients referred by intervention HCs had benign conditions; however, there was a trend toward a higher incidence of early-stage breast cancer among patients from intervention regions. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Lydia E. Pace Stock or Other Ownership: Firefly Health