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Pace LE, Dusengimana JMV, Keating NL, Hategekimana V, Rugema V, Bigirimana JB, Costas-Chavarri A, Umwizera A, Park PH, Shulman LN, Mpunga T. Impact of Breast Cancer Early Detection Training on Rwandan Health Workers' Knowledge and Skills. J Glob Oncol 2019; 4:1-10. [PMID: 30241228 PMCID: PMC6223427 DOI: 10.1200/jgo.17.00098] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose In April 2015, we initiated a training program to facilitate earlier diagnosis of breast cancer among women with breast symptoms in rural Rwanda. The goal of this study was to assess the impact of the training intervention in breast cancer detection on knowledge and skills among health center nurses and community health workers (CHWs). Methods We assessed nurses’ and CHWs’ knowledge about breast cancer risk factors, signs and symptoms, and treatability through a written test administered immediately before, immediately after, and 3 months after trainings. We assessed nurses’ skills in clinical breast examination immediately before and after trainings and then during ongoing mentorship by a nurse midwife. We also examined the appropriateness of referrals made to the hospital by health center nurses. Results Nurses’ and CHWs’ written test scores improved substantially after the trainings (overall percentage correct increased from 73.9% to 91.3% among nurses and from 75.0% to 93.8% among CHWs (P < .001 for both), and this improvement was sustained 3 months after the trainings. On checklists that assessed skills, nurses’ median percentage of actions performed correctly was 24% before the training. Nurses’ skills improved significantly after the training and were maintained during the mentorship period (the median score was 88% after training and during mentorship; P < .001). In total, 96.1% of patients seen for breast concerns at the project’s hospital-based clinic were deemed to have been appropriately referred. Conclusion Nurses and CHWs demonstrated substantially improved knowledge about breast cancer and skills in evaluating and managing breast concerns after brief trainings. With adequate training, mentorship, and established care delivery and referral systems, primary health care providers in sub-Saharan Africa can play a critical role in earlier detection of breast cancer.
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Affiliation(s)
- Lydia E Pace
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jean-Marie Vianney Dusengimana
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Nancy L Keating
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Vedaste Hategekimana
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Vestine Rugema
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jean Bosco Bigirimana
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Ainhoa Costas-Chavarri
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Aline Umwizera
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Paul H Park
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Tharcisse Mpunga
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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O'Neil DS, Keating NL, Dusengimana JMV, Hategekimana V, Umwizera A, Mpunga T, Shulman LN, Pace LE. Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda. J Glob Oncol 2017; 4:1-11. [PMID: 30241207 PMCID: PMC6180813 DOI: 10.1200/jgo.2016.008672] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda's first public cancer center. PATIENTS AND METHODS We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis. RESULTS Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor-positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up. CONCLUSION Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival.
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Affiliation(s)
- Daniel S O'Neil
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Nancy L Keating
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jean Marie V Dusengimana
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Vedaste Hategekimana
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Aline Umwizera
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Tharcisse Mpunga
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lydia E Pace
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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