Breast cancer early detection and diagnostic capacity in Uganda

Abstract

BACKGROUND: Greater than 80% of women presenting for breast cancer treatment in Uganda have late-stage disease, which is attributable to a dysfunctional referral system and a lack of recognition of the early signs and symptoms among primary health care providers, and compounded by the poor infrastructure and inadequate human capacity. Improving the breast health care system requires a systemic approach beginning with situational analysis to identify systematic gaps that prevent sustainable improvements in outcome. METHODS:The authors performed a situational analysis of the breast health care system using methods developed by the Breast Health Global Initiative. Based on their findings, they developed a series of recommendations for strengthening the health system for the early diagnosis of breast cancer based on clinical detection, referral, tissue sampling, and diagnosis. RESULTS: Deficits in the recognition of breast cancer signs and symptoms, the underuse of clinical breast examination as a diagnostic and/or screening tool, the centralization of diagnostic tests (radiology and pathology), reliance on excisional biopsies rather than needle biopsies, and a lack of trained professionals and knowledge of the referral system all contribute to significant health system delays. CONCLUSIONS: To strengthen referral networks and improve the early diagnosis of breast cancer in Uganda, national referral hospitals should provide educational programs to primary health care providers in community health centers (CHCs), at which the majority of women first present with symptoms. At secondary district-level facilities in which imaging and tissue sampling can be performed, the capacity for diagnostic testing could be increased through task shifting of basic interpretation (abnormal vs normal) from specialists to nonspecialists using networking technology to facilitate remote oversight from specialists at the national referral hospitals. Cancer 2020;126:2469-2480.

Situational analysis of breast health care systems: Why context matters

“…As of January 2020, a total of 5 BHGI assessments have been performed in Tanzania, Brazil, Uganda, Panama, and India (Table 3). 39‐47 Assessment reports have included analysis of the questionnaire data as well as data regarding breast cancer mortality and incidence rates (when available), stage distribution from national and regional facilities, and exisiting peer‐reviewed literature concerning breast cancer epidemiology in the country or region. A review of governmental policies, state and private insurance rates versus out‐of‐pocket payments for services, workforce shortages, and health system organization also is included.…”

Receptor-Defined Breast Cancer in Five East African Countries and Its Implications for Treatment: Systematic Review and Meta-Analysis

“…Similar to other regions of the world, most BC among East African women had invasive ductal histology. Preventive health care and BC screening are limited or nonexistent in East Africa, 7 , 13 , 90 leading to BC diagnoses at advanced stages and higher grades. Although mammography screening has been linked to reduced BC mortality in US women, 91 , 92 timely access to BC diagnosis and treatment among symptomatic women in East Africa would likely improve BC mortality.…”

“…Primary care physicians, nurses, and other healthcare professionals are in short supply, and credentialed specialists in oncology are rare. 6 , 7 There is limited or no access to radiation, 8 which constrains the possibility for breast-conserving surgery even among women with early-stage BC. Many cancer medications routinely used in HIC for treatment, palliative care, or to control adverse effects of treatment are unavailable, and supplies of available less expensive medications fall short of need.…”

“… 9 - 11 Cancer treatment, such as chemotherapy, is confined to a few locations in an entire country in East Africa and care at these sites may not conform to current standards for diagnosis and treatment. 7 , 12 There is no system for routine preventive care or early detection of BC. Women seek care in response to breast symptoms.…”

A phased approach to implementing the Breast Imaging Reporting and Data System (BI‐RADS) in low‐income and middle‐income countries

“…However, similar to imaging, CBEs in LMICs mostly are performed by nonphysician health care professionals who lack sufficient clinical experience in CBE 5 and tend to overcall subtle clinical findings, thereby leading to a high false‐positive rate (ie, abnormal CBE with benign imaging and/or histologic findings) 12,13 . In countries that lack established monitoring systems for breast diagnosis, health care providers do not receive follow‐up on their referrals for women with abnormal physical examinations, and in rare cases with available follow‐up, the long delay between the initial clinical visit, imaging, and follow‐up visit makes the follow‐up too remote for the information to positively impact their clinical skills 14 …”