Implementation research: including breast examinations in a cervical cancer screening programme, Rwanda

Objective

To evaluate whether integrating breast and cervical cancer screening in Rwanda's Women's Cancer Early Detection Program led to early breast cancer diagnoses in asymptomatic women.

Methods

Launched in three districts in 2018-2019, the early detection programme offered clinical breast examination screening for all women receiving cervical cancer screening, and diagnostic breast examination for women with breast cancer symptoms. Women with abnormal breast examinations were referred to district hospitals and then to referral hospitals if needed. We examined how often clinics were held, patient volumes and number of referrals. We also examined intervals between referrals and visits to the next care level and, among women diagnosed with cancer, their initial reasons for seeking care.

Findings

Health centres held clinics > 68% of the weeks. Overall, 9763 women received cervical cancer screening and clinical breast examination and 7616 received breast examination alone. Of 585 women referred from health centres, 436 (74.5%) visited the district hospital after a median of 9 days (interquartile range, IQR: 3-19). Of 200 women referred to referral hospitals, 179 (89.5%) attended after a median of 11 days (IQR: 4-18). Of 29 women diagnosed with breast cancer, 19 were ≥ 50 years and 23 had stage III or stage IV disease. All women with breast cancer whose reasons for seeking care were known (23 women) had experienced breast cancer symptoms.

Conclusion

In the short-term, integrating clinical breast examination with cervical cancer screening was not associated with detection of early-stage breast cancer among asymptomatic women. Priority should be given to encouraging women to seek timely care for symptoms.

Clinical Diagnoses and Outcomes After Diagnostic Breast Ultrasound by Nurses and General Practitioner Physicians in Rural Rwanda

PURPOSE

To scale up early detection of breast cancer in low- and middle-income countries, research is needed to inform the role of diagnostic breast ultrasound performed by nonradiologists in resource-constrained settings. The authors examined 2-year clinical follow-up and outcomes among women who underwent diagnostic breast ultrasound performed by nonradiologist clinicians participating in a breast ultrasound training and mentorship program at a rural Rwandan hospital.

METHODS

Imaging findings, management plans, and pathologic results were prospectively collected during the training using a standardized form. Data on follow-up and outcomes for patients receiving breast ultrasound between January 2016 and March 2017 were retrospectively collected through medical record review.

RESULTS

Two hundred twenty-nine breast palpable findings (199 patients) met the study's eligibility criteria. Of 104 lesions initially biopsied, 38 were malignant on initial biopsy; 3 lesions were identified as malignant on repeat biopsy. All 34 patients ultimately diagnosed with cancer received initial recommendations for either biopsy or aspiration by trainees. The positive predictive value of trainee biopsy recommendation was 34.8% (95% confidence interval, 24.8%-45.0%). The sensitivity of trainees' biopsy recommendation for identifying malignant lesions was 92.7% (95% confidence interval, 84.2%-100%). Of 46 patients who did not receive biopsy and were told to return for clinical or imaging follow-up, 37.0% did not return.

CONCLUSIONS

Trained nonradiologist clinicians in Rwanda successfully identified suspicious breast lesions on diagnostic breast ultrasound. Loss to follow-up was common among patients instructed to return for surveillance, so lower biopsy thresholds, decentralized surveillance, or patient navigation should be considered for patients with low- or intermediate-suspicion lesions.

Health system costs of a breast cancer early diagnosis programme in a rural district of Rwanda: a retrospective, cross-sectional economic analysis

OBJECTIVES

This study aimed to quantify the health system cost of the first 2 years of a Breast Cancer Early Detection (BCED) programme in a rural district in Rwanda. We also aimed to estimate the cost of implementing the programme in other districts with different referral pathways and identify opportunities for enhanced cost efficiency.

DESIGN

Retrospective, cross-sectional analysis using time-driven activity-based costing, based on timed patient clinical encounters, retrospective patient data and unit costs of resources abstracted from administrative and finance records.

SETTING

The BCED programme focused on timely evaluation of individuals with breast symptoms. The study evaluated the health system cost of the BCED programme at seven health centres (HCs) in Burera district and Butaro Cancer Centre of Excellence (BCCOE) at Butaro District Hospital.

OUTCOME MEASURES

Health system costs per patient visit and cost per cancer diagnosed were quantified. Total start-up and recurring operational costs were also estimated, as well as health system costs of different scale-up adaptations in other districts.

RESULTS

One-time start-up costswere US$36 917, recurring operational costswere US$67 711 and clinical costswere US$14 824 over 2 years. Clinical breast examinations (CBE) at HCs cost US$3.27/visit. At BCCOE, CBE-only visits cost US$13.47/visit, CBE/ultrasound US$14.79/visit and CBE/ultrasound/biopsy/pathology US$147.81/visit. Overall, clinical cost per breast cancer diagnosed was US$1482. Clinicalcost drivers were personnel at HCs (55%) and biopsy/pathology supplies at BCCOE (46%). In other districts, patients experience a longer breast evaluation pathway, adding about US$14.00/patient; this could be decreased if ultrasound services were decentralised.

CONCLUSION

Clinical costs associated with BCED services at HCs were modest, similar to other general outpatient services. The BCED programme's start-up and operational costs were high but could be reduced by using local trainers and virtual mentorship. In other districts, decentralising ultrasound and/or biopsies to district hospitals could reduce costs.

Presenting Symptoms and Stage at Diagnosis Among Women Diagnosed With Breast Cancer Through a Combined Breast Cancer and Cervical Cancer Screening Program in Rwanda

PURPOSE

There is interest in leveraging cervical cancer (CC) screening to facilitate early breast cancer (BC) detection in low- and middle-income countries (LMIC). We sought to determine whether adding clinical breast exams (CBE) to CC screening led to early BC diagnoses among asymptomatic women in Rwanda's Women's Cancer Early Detection Program (WCEDP). The WCEDP provided CBE to women aged 30-49 who were receiving CC screening, as well as any individual with breast symptoms.

METHODS

The WCEDP was launched in three Rwandan districts (total population 1.3 million) in July 2018, August 2018 and May 2019 respectively. This analysis included patients presenting to health centers (HCs) through December 31, 2019. Follow-up data were collected through April 2021 using clinicians' weekly reports, patient navigator referral data, and the cancer hospital's electronic medical record. We determined patients' initial symptoms from HC records, patient interviews, and phone surveys.

RESULTS

Nine thousand seven hundred sixty-three women received CC screening and CBE together; 7,616 additional women received CBE alone. Five hundred eighty-five women were referred from HCs to a district hospital (DH) for abnormal CBE; 200 were referred from the DH to the referral hospital. Twenty-nine women were diagnosed with BC; of these 19 (66%) were 50 or older and 23 (79%) had stage III/IV disease. Median interval from HC visit to referral hospital visit was 19 days (IQR 11.0-26.0). Among the 23 women with BC for whom we could identify their reason for initial HC presentation, all had sought care for breast symptoms. The remaining six had advanced-stage disease and symptomatic tumors at diagnosis.

CONCLUSION

During the initial rollout of this combined BC and CC screening program, no BC was diagnosed among asymptomatic women and 2/3 women diagnosed with BC were older than the target CC screening age. Adding CBE for all women receiving CC screening in LMIC may be low-yield. Given the high proportion of late-stage diagnoses, community awareness of early BC symptoms, high-quality CBE and timely referrals are important areas of focus.

Health System Costs of a Breast Cancer Early Diagnosis Program in a Rural District of Rwanda

PURPOSE

Low-and-middle-income countries require information about effective and pragmatic strategies to facilitate earlier breast cancer diagnoses. A Breast Cancer Early Detection (BCED) program training health workers and establishing breast clinics in Burera District, Rwanda was associated with increased evaluation of breast symptoms and higher incidence of early-stage breast cancer. We examined the program's cost from the health system perspective.

METHODS

The BCED program's first phase started in 2015 and included seven health centers (HCs) and Butaro Cancer Center of Excellence (BCCOE), the cancer referral center at Butaro Hospital. Patient volume and diagnoses from 2015 to 2017 were abstracted from existing databases. We retrospectively reviewed administrative data to identify start-up and ongoing operational costs. Using Time-Driven Activity-Based Costing, clinical costs per patient visit were estimated based on HC and BCCOE visits for breast health care observed in 2021.

RESULTS

Over the first 2 years, there were 1,010 HC visits for breast symptoms, 210 referrals to BCCOE, and 10 breast cancers diagnosed. The BCED program's total cost was $119,511, comprising of start-up costs ($36,917), recurring operational costs ($67,711) and clinical costs ($14,883). Clinical breast assessment (CBA) at HCs cost $3.27/visit. At BCCOE, CBA-only visits cost $13.47, CBA/ultrasound cost $14.79, and CBA/ultrasound/biopsy cost $147.81. Overall, the clinical cost per breast cancer diagnosed was $1,488. The primary cost drivers were personnel at HCs (55%) and biopsy supplies at BCCOE (46%). In other districts, patients must go to their local HC and district hospital before referral to BCCOE, adding about $14.00/patient.

CONCLUSION

The BCED program's cost at HCs was modest, similar to other outpatient HC services. Hospital-level care was more expensive and requiring multiple visits for biopsies increased costs. Start-up and operational costs could be reduced by using local trainers and virtual/mobile mentorship. For scalability in other districts, decentralizing ultrasound and/or biopsies to district hospitals could reduce costs.

Training Nonradiologist Clinicians in Diagnostic Breast Ultrasound in Rural Rwanda: Impact on Knowledge and Skills

OBJECTIVE

To assess the effectiveness of diagnostic breast ultrasound training provided for general practitioners and nurses in Rwanda via intensive in-person and subsequent online supervision and mentorship.

METHODS

Four breast radiologists from Brigham and Women's Hospital trained two general practitioner physicians and five nurses in Rwanda over 9 total weeks of in-person training and 20 months of remote mentorship using electronic image review with emailed feedback. Independently recorded assessments were compared to calculate the sensitivity and specificity of trainee assessments, with radiologist assessments as the gold standard. We compared performance in the first versus second half of the training.

RESULTS

Trainees' performance on written knowledge assessments improved after training (57.7% versus 98.1% correct, P = .03). Mean sensitivity of trainee-performed ultrasound for identifying a solid breast mass was 90.6% (SD 4.2%) in the first half of the training (period 1) and 94.0% (SD 6.7%) in period 2 (P = .32). Mean specificity was 94.7% (SD 5.4%) in period 1 and 100.0% (SD 0) in period 2 (P = .10). Mean sensitivity for identifying a medium- or high-suspicion solid mass increased from 79.2% (SD 11.0%) in period 1 to 96.3% (SD 6.4%) in period 2 (P = .03). Specificity was 84.4% (SD 15.0%) in period 1 and 96.7% (SD 5.8%) in period 2 (P = .31).

DISCUSSION

Nonradiologist clinicians (doctors and nurses) in a rural sub-Saharan African hospital built strong skills in diagnostic breast ultrasound over 23 months of combined in-person training and remote mentorship. The sensitivity of trainees' assessments in identifying masses concerning for malignancy improved after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.

Cluster Randomized Trial to Facilitate Breast Cancer Early Diagnosis in a Rural District of Rwanda

PURPOSE

Feasible and effective strategies are needed to facilitate earlier diagnosis of breast cancer in low-income countries. The goal of this study was to examine the impact of health worker breast health training on health care utilization, patient diagnoses, and cancer stage in a rural Rwandan district.

METHODS

We conducted a cluster randomized trial of a training intervention at 12 of the 19 health centers (HCs) in Burera District, Rwanda, in 2 phases. We evaluated the trainings’ impact on the volume of patient visits for breast concerns using difference-in-difference models. We used generalized estimating equations to evaluate incidence of HC and hospital visits for breast concerns, biopsies, benign breast diagnoses, breast cancer, and early-stage disease in catchment areas served by intervention versus control HCs.

RESULTS

From April 2015 to April 2017, 1,484 patients visited intervention HCs, and 308 visited control HCs for breast concerns. The intervention led to an increase of 4.7 visits/month for phase 1 HCs (P = .001) and 7.9 visits/month for phase 2 HCs (P = .007) compared with control HCs. The population served by intervention HCs had more hospital visits (115.1 v 20.5/100,000 person-years, P < .001) and biopsies (36.6 v 8.9/100,000 person-years, P < .001) and higher breast cancer incidence (6.9 v 3.3/100,000 person-years; P = .28). The incidence of early-stage breast cancer was 3.3 per 100,000 in intervention areas and 0.7 per 100,000 in control areas (P = .048).

CONCLUSION

In this cluster randomized trial in rural Rwanda, the training of health workers and establishment of regular breast clinics were associated with increased numbers of patients who presented with breast concerns at health facilities, more breast biopsies, and a higher incidence of benign breast diagnoses and early-stage breast cancers.

Integrating breast cancer screening into a cervical cancer screening program in three rural districts in Rwanda

2025

Background: In low-income countries where mammography is not widely available, optimal strategies to facilitate earlier breast cancer detection are not known. We previously conducted a cluster randomized clinical trial of clinician trainings in Burera District in rural Rwanda to facilitate earlier diagnosis among symptomatic women; 1.3% of women evaluated at intervention health centers (HCs) were diagnosed with cancer. Early stage breast cancer incidence was higher in intervention areas. Subsequently, Rwanda Biomedical Centre, Rwanda’s national health implementation agency, adapted the program in 3 other districts, offering screening clinical breast exams (CBE) to all women aged 30-50 years receiving cervical cancer screening and any other woman requesting CBE. A navigator facilitated patient tracking. We sought to examine patient volume, service provision and cancer detection rate in the adapted program. Methods: We abstracted data from weekly HC reports, facility registries, and the referral hospital’s electronic medical record to determine numbers of patients seen, referrals made, biopsies, and cancer diagnoses from July 2018-December 2019. Results: CBE was performed at 17,239 visits in Rwamagana, Rubavu and Kirehe Districts (total population 1.34 million) over 18, 17 and 7 months of program implementation respectively. At 722 visits (4.2%), CBE was abnormal. 571 patients were referred to district hospitals (DH); their average age was 35 years. Of those referred, 388 (68.0%) were seen at DH; 32% were not. Of those seen, 142 (36.6%) were referred to a referral facility; 121 of those referred (85.2%) actually went to the referral facility. Eighty-eight were recommended to have biopsies, 83 (94.3%) had biopsies, and 29 (34.9% of those biopsied; 0.17% of HC visits) were diagnosed with breast cancer. Conclusions: Integrating CBE screening into organized cervical cancer screening in rural Rwandan HCs led to a large number of patients receiving CBE. As expected, patients were young and the cancer detection rate was much lower than in a trial focused on symptomatic women. Even with navigation efforts, loss-to-follow-up was high. Analyses of stage, outcomes, patient and provider experience and cost are planned to characterize CBE screening’s benefits and harms in Rwanda. However, these findings suggest building health system capacity to facilitate referrals and retain patients in care are needed prior to further screening scaleup. In the interim, early diagnosis programs targeting symptomatic women may be more efficient and feasible.

Impact of Breast Cancer Early Detection Training on Rwandan Health Workers' Knowledge and Skills

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.

Impact of an Early Detection Program on Breast Cancer Services, Incidence, and Stage in Rural Rwanda

Purpose

In low-income countries, most women with breast cancer present with advanced-stage disease. To facilitate earlier diagnoses of symptomatic disease, feasible and effective early detection strategies are needed. We assessed health care use and patient outcomes from a randomized pilot study of an early detection program in Burera, a rural Rwandan district, where the Butaro Cancer Center of Excellence (BCCOE) is located.

Methods

The intervention included training for community health workers in breast health, training for health center (HC) nurses in the evaluation of breast concerns, and weekly breast clinics at HCs and BCCOE. Twelve of 18 eligible HCs were randomly assigned to receive the intervention—seven beginning in April and May 2015, and five in November and December 2015—and six served as controls for the entire study period. We abstracted HC and hospital records of patients seen between April 2015 and April 2017 and used generalized linear models to compare the incidence of biopsies, breast cancer diagnoses, and early-stage diagnoses in the geographic sectors served by intervention versus control HCs.

Results

Overall, 276,282 person-years were in intervention sectors and 302,856 in control sectors. Of patients, 1,500 patients sought care at intervention HCs for breast concerns versus 600 at control HCs. Three hundred eighteen patients that were referred from intervention HCs were evaluated at BCCOE compared with 62 from control HCs. The biopsy rate was 36.6 per 100,000 person-years from intervention sectors versus 8.9 per 100,000 from control sectors ( P < .001). Breast cancer was diagnosed in 19 of 101 patients from intervention HCs who underwent biopsy (18.8%) compared with 10 (37.0%) of 27 patients from control HCs. Breast cancer incidence was 6.9 per 100,000 in intervention sectors versus 3.3 per 100,000 in control sectors ( P = .35). Nine patients from intervention HCs had early-stage disease (47.4%) versus two from control HCs (20.0%). The incidence rate of early-stage breast cancer was 3.7 per 100,000 in intervention sectors versus 0.7 per 100,000 in control sectors ( P = .08).

Conclusion

Over 2 years, our early detection program was associated with more patients referred for hospital-level evaluation and requiring biopsies. Most patients referred by intervention HCs had benign conditions; however, there was a trend toward a higher incidence of early-stage breast cancer among patients from intervention regions.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Lydia E. Pace Stock or Other Ownership: Firefly Health

Clinical Impact of Diagnostic Breast Ultrasound Performed by Generalist Doctors and Nurses in Rwanda

Purpose

Diagnostic breast ultrasound (US) can be an important tool for the early detection of breast cancer in low-resource settings where efficient strategies to refine the likelihood of malignancy among palpable breast masses are needed. However, the feasibility and clinical role of breast US in such settings has not been described. We trained four general practitioners and five nurses in diagnostic breast US at a rural Rwandan district hospital that serves as a cancer referral facility. We examined management plans, biopsy rates, and patient diagnoses after trainee breast US to determine the impact on clinical care.

Methods

We abstracted US assessment forms and medical records to determine outcomes from trainee US during 21 months of in-person and electronic training by Boston-based radiologists. We examined management plans, biopsy rate, cancer detection rate, rate of benign diagnoses, and cancers diagnosed among patients discharged after initial evaluation.

Results

Between January 2016 and September 2017, 307 patients had trainee-performed diagnostic breast US. After US, 158 (51%) were recommended to undergo biopsy, 30 (10%) were recommended to have aspiration/drainage, 49 (16%) were recommended for clinical/US surveillance, one (0.3%) was referred elsewhere, 65 (21%) were discharged, and four—all with no abnormalities on US—had missing recommendations. Of those recommended for initial biopsy, 151 patients (96%) underwent biopsy at that time. Fifty-six patients (37%) were diagnosed with breast cancer, 44 (30%) with fibroadenoma, and 50 (33%) with other benign diagnoses. Among those with breast masses on US (n = 255), 149 patients (58%) underwent biopsy and 55 (22%) were diagnosed with cancer. As of November 2017, all patients ultimately diagnosed with cancer had had a biopsy at their initial visit. No patients who had been discharged or were receiving surveillance had been subsequently diagnosed with cancer.

Conclusion

Diagnostic breast US by general practitioners and nurses has been a useful tool for the evaluation of breast lesions at a rural Rwandan facility and has helped avoid biopsy for 42% of patients with breast masses on US. Clinical follow-up is ongoing to assess longer-term outcomes and examine cancer detection rates and loss-to-follow-up rates among patients not initially biopsied.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Lydia E. Pace Stock or Other Ownership: Firefly Health Sughra Raza Honoraria: Fujifilm Medical Services Travel, Accommodations, Expenses: Fujifilm Medical Services

Early Clinical Impact of Diagnostic Breast Ultrasound Performed by General Practitioners and Nurses in Rwanda

Background: Diagnostic breast ultrasound (US) could be an important tool for early detection of breast cancer in low-resource settings, where efficient strategies to refine the likelihood of malignancy among palpable breast masses are needed. However, the feasibility and clinical role of diagnostic ultrasound in such settings has not been described. We trained 4 general practitioner doctors (GPs) and 5 nurses in diagnostic breast US at a rural district hospital in Rwanda that serves as a cancer referral facility. Aim: Assess management plans, biopsy rates and patient diagnoses after nurse- and GP-performed breast ultrasounds to determine the impact of diagnostic US on clinical care. Methods: We reviewed outcomes from trainees' ultrasounds during 21 months of in-person and electronic training and mentorship by Boston-based radiologists. Trainees' US assessments and management plans were recorded on structured clinical forms. Patient diagnoses and follow-up were extracted from medical records using a standardized data collection form. Among patients who received breast US, we examined a) clinicians' management plans; b) biopsy rate; c) cancer detection rate; c) rate of benign diagnoses; d) cancers diagnosed among patients who were sent home after initial evaluation. Results: Between January 1, 2016 and September 30, 2017, 307 patients with breast concerns had a diagnostic breast US and a documented trainee US assessment. Of these, following their initial US, 158 (51%) were recommended to receive a biopsy, 30 (10%) were recommended to have aspiration/drainage, 49 (16%) were recommended for clinical or US surveillance, 1 (0.3%) was referred to another facility, 65 (21%) were discharged, and 4 (all with no abnormalities on US) had missing recommendations. Of those recommended for biopsy at initial presentation, 151 (96%) had a biopsy at that time. 56 (37%) were diagnosed with breast cancer, 37 (25%) with fibroadenoma, 7 (5%) with lactating adenoma, and 50 (33%) with other benign diagnoses. Among those with breast masses on US (n=255), 149 (58%) received a biopsy and 55 (22%) were diagnosed with cancer. As of November 23, 2017, all patients ultimately diagnosed with cancer had had a biopsy at their initial visit, and no patients who had been discharged or recommended for clinical or radiographic surveillance had been subsequently diagnosed with cancer. Conclusion: Diagnostic breast US by GPs and nurses has been a useful tool in the evaluation of breast lesions, including palpable masses, at a rural cancer facility in Rwanda. Early findings suggest that it has allowed avoidance of biopsy for 42% of patients with breast masses noted on US. Clinical follow-up and evaluation are ongoing to assess longer-term patient outcomes, cancer detection rates among patients who are not initially biopsied, and rates of follow-up among patients recommended to have clinical or radiographic surveillance.

Impact of Training on Rwandan Health Care Staffs’ Skills in Diagnostic Breast Ultrasound

Purpose

Ultrasound (US) is a key tool in the evaluation of palpable breast masses and helps to refine the likelihood of malignancy and need for additional diagnostic studies. US is available in many low-resource settings, but there is little expertise. We launched a breast US training program for general practitioners (GPs) and nurses at a rural Rwandan district hospital that is a cancer referral facility. We assessed the skills of the GPs and nurses in diagnostic breast US after intensive training.

Methods

Four breast radiologists from Boston trained five nurses and four GPs in Rwanda over 9 weeks of in-person training and 21 months of weekly remote mentoring using electronic image review and feedback. During the in-person training, trainees and radiologists evaluated patients separately. Remote assessments were based on emailed image sharing. We compared lesions with radiologist and trainee assessments to calculate trainee sensitivity using the radiologist assessments as the gold standard.

Results

Of 323 breast and axillary lesions assessed by trainees and radiologists, 279 were breast lesions. Of these, 114 (41%) were evaluated by radiologists in person and 165 (59%) through e-mail. Two hundred thirty-seven lesions (85%) were determined to be breast masses by radiologists, 164 of these as solid masses, 25 complex solid/cystic, 15 definite or probable cysts, 31 normal lymph nodes, and two other masses. The sensitivity of trainees’ assessments in identifying solid masses was 90.2% (95% CI, 85.9% to 94.9%) overall. Among trainees who scanned ≥ 10 lesions, mean sensitivity was 90.6% in the first 14 months and 94.0% in the second 9 months, after in-person training ( P = .3, paired t tests). In cases in which radiologists and trainees perceived solid masses (n = 148), trainees’ sensitivity was 81.4% (95% CI, 72.3% to 90.5%) for detecting suspicious masses or probably benign but in need of additional evaluation ( v benign with no additional evaluation needed). Among trainees who scanned ≥ 10 lesions, sensitivity was 79.1% in the first 14 months and 96.2% in the second 9 months ( P = .03, paired t tests).

Conclusion

Nurses and GPs in a rural sub-Saharan African facility built strong skills in diagnostic US with in-person training and remote electronic mentoring. The sensitivity of assessments for identifying suspicious masses demonstrated significant improvement after sustained mentorship. Assessment of the impact of the training on patient care and outcomes is ongoing.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Sughra Raza Honoraria: Fujifilm Medical Services Travel, Accommodations, Expenses: Fujifilm Medical Services

Impact of In-Person and Electronic Training by Breast Radiologists on Rwandan General Practitioners' and Nurses' Skills in Diagnostic Breast Ultrasound

Background: Ultrasound (US) is a key tool in evaluation of palpable breast masses and can help refine the likelihood of malignancy and the need for further diagnostic studies. US technology is available in many low-resource settings, but there are few specialized radiologists. We launched a diagnostic breast ultrasound training program for general practitioner doctors (GPs) and nurses at a rural Rwandan district hospital that serves as a cancer referral facility. Aim: Assess GPs' and nurses' skill in diagnostic breast ultrasound over 23 months of intensive in-person and online supervision and mentorship. Methods: 4 rotating breast radiologists from Brigham and Women's Hospital trained 5 nurses and 4 doctors in Rwanda over 9 weeks of in-person training and 21 months of weekly remote case consultations and mentorship using electronic review of images with emailed feedback. During in-person trainings, trainees and radiologists evaluated patients separately, while radiologists' electronic assessments were based on emailed images and assessments from trainees. Among breast lesions with documented radiologist and trainee assessments, we compared written trainee and radiologist assessments to calculate the sensitivity of trainee assessments, with radiologist assessments as the gold standard. We used paired t-tests to examine whether the sensitivity varied between the first 14 months (stage I) and the last 9 months (stage 2), after the final in-person training. Results: Of 323 breast and axillary lesions assessed by trainees and radiologists, 279 were breast lesions. Of these, 114 (41%) were evaluated by radiologists in-person, and 165 (59%) through electronic evaluation. 237 (85%) were determined to be breast masses by the radiologists, with 164 of these solid masses, 25 complex solid/cystic lesions, 15 definite or probable simple cysts, 31 normal intramammary lymph nodes, and 2 other masses. Sensitivity of trainees' assessments for identifying a solid mass was 90.2% (95% CI 85.9-94.9) overall. Among trainees who scanned ≥ 10 lesions each, mean sensitivity was 90.6% in stage I, and 94.0% in stage 2 ( P = 0.3). In cases where both radiologists and trainees perceived solid masses (n=148), trainees' assessments had a sensitivity of 81.4% (95% CI 72.3-90.5) overall for detecting masses suspicious for malignancy, or probably benign but needing further evaluation (versus benign with no further evaluation needed). Among trainees who scanned ≥ 10 lesions each, sensitivity was 79.1% during stage I and 96.2% during the stage 2 ( P = 0.03). Conclusion: Nurses and GPs in a rural sub-Saharan African facility built strong skills in diagnostic ultrasound over 23 months of combined in-person training and distance learning via electronic case reviews. The sensitivity of their assessments for identifying masses concerning for malignancy showed significant improvement after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.