Minimizing Delays in the Breast Cancer Pathway by Integrating Breast Specialty Care Services at the Primary Health Care Level in Zambia

Abstract

PURPOSE In Zambia, more than two-thirds of female patients with breast cancer present with late-stage disease, leading to high mortality rates. Most of the underlying causes are associated with delays in symptom recognition and diagnosis. By implementing breast care specialty services at the primary health care level, we hypothesized that some of the delays could be minimized. METHODS In March 2018, we established a breast care specialty clinic for women with symptomatic disease within 1 of the 5 district hospitals in Lusaka. The clinic offers breast self-awareness education, clinical breast examination, breast ultrasound, ultrasound-guided breast biopsy, surgery, referral for chemoradiation, follow-up care, and electronic medical records. RESULTS Between March 2018 and April 2019, of 1,790 symptomatic women who presented to the clinic, 176 (10%) had clinical and/or ultrasound indications for histologic evaluation. Biopsy specimens were obtained using ultrasound-guided core-needle procedures, all of which were performed on the same day as the initial visit. Of the 176 women who underwent biopsy, 112 (64%) had pathologic findings compatible with a primary breast cancer, and of these, 42 (37%) were early-stage (stage I/II) disease. Surgery for early-stage cancers was performed at the district hospital within 2 weeks of the time of definitive pathologic diagnosis. Patients with advanced disease were referred to the national cancer center for multimodality therapy, within a similar time frame. CONCLUSION Breast care specialty services for symptomatic women were established in a district-level hospital in a resource-constrained setting in Africa. As a result, the following time intervals were minimized: initial presentation and performance of clinical diagnostics; receipt of a definitive pathologic diagnosis and initiation of surgery; receipt of a definitive pathologic diagnosis and referral.

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

“…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. 14 , 93 - 99 In our study, the overall proportion of grade 3 BC was 55%, and did not vary by proportion of receptor combination subtypes. In the United States, the proportions of grade 3 tumors were markedly different by subtype: 17% HR+/HER2−; 46% HR+/HER2+; 67% HER2-enriched; and 75% TNBC.…”

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

“…In Zambia, decentralized models of service provision that connect different levels of care present an effective alternative to comprehensive cancer centers, a common model of care in LMICs, while repurposing existing care pathways ( Box 3 ). 118 …”

“…A breast cancer clinic was established at primary care level in a district hospital. 118 Symptomatic women from surrounding primary care facilities including rural health posts, health centers, and other district hospitals are assessed at the clinic. Initially, an existing cervical cancer prevention program was used to direct eligible women for assessment and generate awareness of the new service among primary care providers.…”

“…These decentralized care pathways improved timeliness and access to diagnosis and treatment services by integrating provision with existing care pathways. 118 The intervention has been accompanied by workforce development, which was identified as a barrier to cancer care delivery in Zambia. 109 …”

Leveraging a matrix of stakeholders to facilitate access to chemotherapy for women’s cancers in the Democratic Republic of the Congo

“…Such is the case in the Democratic Republic of the Congo, a fragile, conflict and violence-affected nation whose population of 84 million people, >70% of whom live on less than $1.90/day, has no access to established cancer care facilities [12,13]. Armed with previous experience in successfully establishing women's cancer care services in highly resource-constrained African environments [14][15][16][17][18][19], we set out to disrupt the prevailing status quo and establish women's cancer care services in a private sector healthcare facility (Biamba Marie Mutombo Hospital, BMMH) in the capital city of Kinshasa. Herein we describe the challenges and experiences of establishing the chemotherapy infusion unit.…”