Breast cancer incidence and mortality are rapidly increasing in low-and middle-income countries like Uganda. Shifting the proportion of women presenting with late-stage breast cancer to earlystage breast cancer (downstaging) at the time of diagnosis would substantially improve survival and efficient use of available resources. Imaging The World (ITW) conducted a pilot study in Uganda where trained village health teams (VHTs) promoted breast cancer awareness in the Kamuli District (Uganda). As a result, 212 women with self-detected lumps presented to the community health center level III (Nawanyago HCIII) for a clinical breast examination (CBE). Patients with masses on CBE were examined with breast ultrasound by a certified sonographer trained in breast imaging. Women with ultrasound-detected masses were referred to a regional health center for further evaluation. Of the 212 women, 44 (21%) had a palpable mass by CBE, 11 (28%) examined by ultrasound were recommended for biopsy, and four breast cancers were diagnosed. Providing ultrasound scanning at Nawanyago HCIII reduced the number of women travelling to the referral hospital by 75%. As a result of breast cancer awareness and ultrasound studies, we were able to diagnose breast cancer at an earlier stage than would be otherwise possible. This pilot project supports locally available breast ultrasound as a resource-appropriate strategy to downstage breast cancer in a low-income country. I S S N 2 3 7 2 -8 4 1 8 in large numbers of patients. Therefore, given the resources, the most resource-appropriate strategy seems to be downstaging through health awareness leading to increased rates of BSE and CBE.According to the Breast Health Global Initiative (BHGI) guidelines, resource-appropriate strategies to downstage breast cancer in Uganda should include increased breast health awareness, so women begin to practice BSE and present early to their providers after self-detecting a lump (9, 10). It is also important to train the providers in breast health to obtain appropriate history and physical examination including a proper CBE. Both BSE and CBE have the potential for a high false-positive rate and are, therefore, no longer recommended in countries where screening mammography is available (11-13). But, with one publically available mammography unit in the country, screening mammography is not a feasible option for most Ugandan women, particularly rural women. Ultrasound is more widely available, even in rural areas, and has the ability to characterize palpable masses detected by CBE as those requiring biopsy versus those that can safely be managed by imaging or clinical follow-up (14).In accordance with the World Health Organization's recommendations to reduce the global burden of breast cancer (15), Imaging The World (ITW) developed a resource-appropriate strategy to downstage breast cancer. ITW is a non-profit organization with a global team of volunteers who provide ultrasound training, equipment and technology in LMICs to improve and sustain health outcomes...

Maternal and child health conditions, many of which can be detected by ultrasound, represent the highest burden of disease in Uganda. Imaging the World (ITW) is a not-for-profit organization which integrates high quality, affordable ultrasound services into rural health facilities. Of all the challenges faced with implementation of ITW programs in Uganda, lack of sensitization to ultrasound represented the greatest barrier. The Village Health Team (VHT) is an existing public health "train the trainer" model, sponsored by the Uganda Ministry of Health, that provides public health training to community volunteers. Trained VHT members were recruited to help with ultrasound community outreach and education. These VHT members were successful in achieving dramatic community acceptance and increased utilization of ultrasound services in rural communities. This has led to significant contributions in improving population health in low-resource settings.

Purpose: To describe the methodology and initial experience behind creation of an ultrasoundguided percutaneous breast core biopsy program in rural Uganda. Methods and Materials: Imaging the World Africa (ITWA) is the registered non-governmental organization division of Imaging the World (ITW), a not-for-profit organization whose primary aim is the integration of affordable high-quality ultrasound into rural health centers. In 2013, ITWA began the pilot phase of an IRB-approved breast care protocol at a rural health center in Uganda. As part of the protocol's diagnostic arm, an ultrasound-guided percutaneous breast core biopsy training curriculum was implemented in tandem with creation of regionally supplied biopsy kits. Results: A surgeon at a rural regional referral hospital was successfully trained and certified to perform ultrasound-guided percutaneous breast core biopsies. Affordable and safe biopsy kits were created using locally available medical supplies with the cost of each kit totaling $10.62 USD. Conclusion: Successful implementation of an ultrasound-guided percutaneous breast core biopsy program in the resource-limited setting is possible and can be made sustainable through incorporation of local health care personnel and regionally supplied biopsy materials. Our hope is that ITWA's initial experience in rural Uganda can serve as a model for similar programs in the future.