Pilot Educational Intervention and Feasibility Assessment of Breast Ultrasound in Rural South Africa

Role and knowledge of nurses in the management of non-communicable diseases in Africa: A scoping review

BACKGROUND

31.4 million people in low- and middle-income countries die from chronic diseases annually, particularly in Africa. To address this, strategies such as task-shifting from doctors to nurses have been proposed and have been endorsed by the World Health Organization as a potential solution; however, no comprehensive review exists describing the extent of nurse-led chronic disease management in Africa.

AIMS

This study aimed to provide a thorough description of the current roles of nurses in managing chronic diseases in Africa, identify their levels of knowledge, the challenges, and gaps they encounter in this endeavor.

METHODS

We performed a scoping review following the key points of the Cochrane Handbook, and two researchers independently realized each step. Searches were conducted using five databases: MEDLINE, PyscINFO, CINAHL, Web of Science, and Embase, between October 2021 and April 2023. A descriptive analysis of the included studies was conducted, and the quality of the studies was assessed using the Downs and Black Scale.

RESULTS

Our scoping review included 111 studies from 20 African countries, with South Africa, Nigeria, and Ghana being the most represented. Findings from the included studies revealed varying levels of knowledge. Nurses were found to be actively involved in managing common chronic diseases from diagnosis to treatment. Facilitating factors included comprehensive training, close supervision by physicians, utilization of decision trees, and mentorship. However, several barriers were identified, such as a shortage of nurses, lack of essential materials, and inadequate initial training.

CONCLUSION

There is significant potential for nurses to enhance the screening, diagnosis, and treatment of chronic diseases in Africa. Achieving this requires a combination of rigorous training and effective supervision, supported by robust policies. To address varying levels of knowledge, tailored training programs should be devised. Further research is warranted to establish the effectiveness of nurse-led interventions on population health outcomes.

The Potential of Adding Mammography to Handheld Ultrasound or Automated Breast Ultrasound to Reduce Unnecessary Biopsies in BI-RADS Ultrasound Category 4a: A Multicenter Hospital-Based Study in China

The appropriate management strategies for BI-RADS category 4a lesions among handheld ultrasound (HHUS) remain a matter of debate. We aimed to explore the role of automated breast ultrasound (ABUS) or the second-look mammography (MAM) adjunct to ultrasound (US) of 4a masses to reduce unnecessary biopsies. Women aged 30 to 69 underwent HHUS and ABUS from 2016 to 2017 at five high-level hospitals in China, with those aged 40 or older also accepting MAM. Logistic regression analysis assessed image variables correlated with false-positive lesions in US category 4a. Unnecessary biopsies, invasive cancer (IC) yields, and diagnostic performance among different biopsy thresholds were compared. A total of 1946 women (44.9 ± 9.8 years) were eligible for analysis. The false-positive rate of category 4a in ABUS was almost 65.81% (77/117), which was similar to HHUS (67.55%; 127/188). Orientation, architectural distortion, and duct change were independent factors associated with the false-positive lesions in 4a of HHUS, whereas postmenopausal, calcification, and architectural distortion were significant features of ABUS (all p < 0.05). For HHUS, both unnecessary biopsy rate and IC yields were significantly reduced when changing biopsy thresholds by adding MAM for US 4a in the total population (scenario #1:BI-RADS 3, 4, and 5; scenario #2: BI-RADS 4 and 5) compared with the current scenario (all p < 0.05). Notably, scenario #1 reduced false-positive biopsies without affecting IC yields when compared to the current scenario for ABUS (p < 0.001; p = 0.125). The higher unnecessary biopsy rate of category 4a by ABUS was similar to HHUS. However, the second-look MAM adjunct to ABUS has the potential to safely reduce false-positive biopsies compared with HHUS.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

OBJECTIVES

To systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries (LMICs).

DESIGN

A systematic review of published evidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses.

DATA SOURCES

A comprehensive search of published literature was conducted. In addition, relevant grey literature sources and bibliographical references of included studies were searched for potentially eligible evidence.

STUDY SELECTION

Studies published between January 2010 and November 2020 were eligible for inclusion. To be eligible, studies had to report on interventions/strategies targeted at women, the general public or healthcare workers, aimed at improving the timely diagnosis of breast and/or cervical cancers in LMIC settings.

DATA EXTRACTION AND SYNTHESIS

Literature search, screening, study selection, data extraction and quality appraisal were conducted by two independent reviewers. Evidence was synthesised and reported using a global taxonomy framework for early cancer diagnosis.

RESULTS

From the total of 10 593 records identified, 21 studies conducted across 20 LMICs were included in this review. Most of the included studies (16/21) focused primarily on interventions addressing breast cancers; two focused on cervical cancer while the rest examined multiple cancer types. Reported interventions targeted healthcare workers (12); women and adolescent girls (7) and both women and healthcare workers (3). Eight studies reported on interventions addressing access delays; seven focused on interventions addressing diagnostic delays; two reported on interventions targeted at addressing both access and diagnostic delays, and four studies assessed interventions addressing access, diagnostic and treatment delays. While most interventions were demonstrated to be feasible and effective, many of the reported outcome measures are of limited clinical relevance to diagnostic timeliness.

CONCLUSIONS

Though limited, evidence suggests that interventions aimed at addressing barriers to timely diagnosis of breast and cervical cancer are feasible in resource-limited contexts. Future interventions need to address clinically relevant measures to better assess efficacy of interventions.

PROSPERO REGISTRATION NUMBER

CRD42020177232.

Clinical Utility of a Hand-Held Scanner for Breast Cancer Early Detection and Patient Triage

PURPOSE

Globally, breast cancer represents the most common cause of cancer death among women. Early cancer diagnosis is difficult in low- and middle-income countries, most of which are unable to support population-based mammographic screening. Triage on the basis of clinical breast examination (CBE) alone can be difficult to implement. In contrast, piezo-electric palpation (intelligent Breast Exam [iBE]) may improve triage because it is portable, low cost, has a short learning curve, and provides electronic documentation for additional diagnostic workup. We compared iBE and CBE performance in a screening patient cohort from a Western mammography center.

METHODS

Women presenting for screening or diagnostic workup were enrolled and underwent iBE then CBE, followed by mammography. Mammography was classified as negative (BI-RADS 1 or 2) or positive (BI-RADS 3, 4, or 5). Measures of accuracy and κ score were calculated.

RESULTS

Between April 2015 and May 2017, 516 women were enrolled. Of these patients, 486 completed iBE, CBE, and mammography. There were 101 positive iBE results, 66 positive CBE results, and 35 positive mammograms. iBE and CBE demonstrated moderate agreement on categorization (κ = 0.53), but minimal agreement with mammography (κ = 0.08). iBE had a specificity of 80.3% and a negative predictive value of 94%. In this cohort, only five of 486 patients had a malignancy; iBE and CBE identified three of these five. The two cancers missed by both modalities were small—a 3-mm retro-areolar and a 1-cm axillary tail.

CONCLUSION

iBE performs comparably to CBE as a triage tool. Only minimal cancers detected through mammographic screening were missed on iBE. Ultimately, our data suggest that iBE and CBE can synergize as triage tools to significantly reduce the numbers of patients who need additional diagnostic imaging in resource-limited areas.

The role of dissemination and implementation science in global breast cancer control programs: Frameworks, methods, and examples

Global disparities in breast cancer outcomes are attributable to a sizable gap between evidence and practice in breast cancer control and management. Dissemination and implementation science (D&IS) seeks to understand how to promote the systematic uptake of evidence-based interventions and/or practices into real-world contexts. D&IS methods are useful for selecting strategies to implement evidence-based interventions, adapting their implementation to new settings, and evaluating the implementation process as well as its outcomes to determine success and failure, and adjust accordingly. Process models, explanatory theories, and evaluation frameworks are used in D&IS to develop implementation strategies, identify implementation outcomes, and design studies to evaluate these outcomes. In breast cancer control and management, research has been translated into evidence-based, resource-stratified guidelines by the Breast Health Global Initiative and others. D&IS should be leveraged to optimize the implementation of these guidelines, and other evidence-based interventions, into practice across the breast cancer care continuum, from optimizing public education to promoting early detection, increasing guideline-concordant clinical practice among providers, and analyzing and addressing barriers and facilitators in health care systems. Stakeholder engagement through processes such as co-creation is critical. In this article, the authors have provided a primer on the contribution of D&IS to phased implementation of global breast cancer control programs, provided 2 case examples of ongoing D&IS research projects in Tanzania, and concluded with recommendations for best practices for researchers undertaking this work.

Ultrasound for Breast Cancer Detection Globally: A Systematic Review and Meta-Analysis

PURPOSE

Mammography is not always available or feasible. The purpose of this systematic review and meta-analysis is to assess the diagnostic performance of ultrasound as a primary tool for early detection of breast cancer.

MATERIALS AND METHODS

For this systematic review and meta-analysis, we comprehensively searched PubMed and SCOPUS to identify articles from January 2000 to December 2018 that included data on the performance of ultrasound for detection of breast cancer. Studies evaluating portable, handheld ultrasound as an independent detection modality for breast cancer were included. Quality assessment and bias analysis were performed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Sensitivity analyses and meta-regression were used to explore heterogeneity. The study protocol has been registered with the international prospective register of systematic reviews (PROSPERO identifier: CRD42019127752).

RESULTS

Of the 526 identified studies, 26 were eligible for inclusion. Ultrasound had an overall pooled sensitivity and specificity of 80.1% (95% CI, 72.2% to 86.3%) and 88.4% (95% CI, 79.8% to 93.6%), respectively. When only low- and middle-income country data were considered, ultrasound maintained a diagnostic sensitivity of 89.2% and specificity of 99.1%. Meta-analysis of the included studies revealed heterogeneity. The high sensitivity of ultrasound for the detection of breast cancer was not statistically significantly different in subgroup analyses on the basis of mean age, risk, symptoms, study design, bias level, and study setting.

CONCLUSION

Given the increasing burden of breast cancer and infeasibility of mammography in certain settings, we believe these results support the potential use of ultrasound as an effective primary detection tool for breast cancer, which may be beneficial in low-resource settings where mammography is unavailable.

Assessment and Improvement Strategies for a Breast Cancer Early Detection Program in Rural South Africa

Purpose To assess and develop solutions for an ultrasound-based breast cancer early detection program in rural South Africa 1 year after implementation. Methods A WHO-endorsed RAD-AID Radiology Readiness Assessment was used to evaluate clinic resources. In addition, 5 weeks of observation identified resource deficiencies and reviewed existing documentation methods. On the basis of stakeholders' input and the BI-RADS, we developed new documentation systems. Training was followed by a survey that assessed feasibility and provider acceptance. Results Resource limitations included lack of computers, unpredictable electrical supply, and inconsistent Internet. The assessment revealed incomplete documentation of breast clinical examinations and history, breast lesions, and follow-up. Furthermore, limitations negatively affected communication among providers. Three solutions were developed: a paper patient history form, a paper clinical findings form, and a computerized patient-tracking data base compliant with BI-RADS. Three nurses, three nursing assistants, and one counselor completed the survey. Seventy-one percent indicated positive general attitudes, and 100% agreed that the documentation system is easy and useful and improves overall quality of care, follow-up, decision making; access to clinical information; and communication between clinicians and patients. Five of the seven providers reported that the system increased visit time, but three of those five believed that the process was valuable. Conclusion Implementation of a breast cancer early detection program in resource-limited regions is challenging, and continual assessment is essential. As a result of identified needs, we developed a documentation system that was broadly accepted. Future steps should focus on increasing efficiency, evaluation of provider attitudes long term, and clinical effect.

Prevention of cervical and breast cancer mortality in low- and middle-income countries: a window of opportunity

Breast and cervical cancer are the two most common women’s cancers worldwide. Countries have invested for decades in early detection programs for breast and cervical cancer through screening, community education, and opportunistic case detection by health professionals. However, effectiveness in low- and middle-income countries (LMICs) has been limited due to low coverage, insufficient laboratory capacities for diagnosis, health information systems (HIS) that are not designed to track patients or monitor program performance, barriers that inhibit women’s uptake of services, and inadequate treatment options. Even where some screening activities exist, there has not been sufficient attention to ensuring completion of appropriate diagnosis and treatment after women receive a positive screening test result or report symptoms suggesting cervical or breast cancer. Because of this failure to provide adequate follow-up care, these women miss the potential benefit from early detection and have a higher than average risk to develop cancer or progress to more advanced cancer stages that could have been avoided. There are several critical steps in a woman’s journey from good health to elevated cancer risk, then to cancer prevention or diagnosis, and finally to treatment. There is a window of opportunity that extends from the time a positive finding is identified—by a cervical or breast screening test or recognition of a breast abnormality—to the point when cervical precancer treatment is delivered or a treatment plan for diagnosed breast cancer is initiated. Building on existing health systems and adapting measurable, affordable, and culturally acceptable interventions can achieve a lasting impact. If women can successfully navigate this window of opportunity, they can avoid progression to cervical cancer or greatly reduce the need for invasive treatments for breast cancer and improve their chances for survival and improved quality of life. We propose several actions that can lead us on the path towards reduction of this cancer burden.