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.

A Ten-Year Experience of Treating Chronic Myeloid Leukemia in Rural Rwanda: Outcomes and Insights for a Changing Landscape

PURPOSE

In describing our ten-year experience with treating chronic myeloid leukemia (CML) as part of the Glivec Patient Assistance Program (GIPAP) in rural Rwanda, we evaluate (1) patient characteristics and treatment outcomes, (2) resource-adapted management strategies, and (3) the impact of diagnostic capacity development.

METHODS

We retrospectively reviewed all patients with BCR-ABL-positive CML enrolled in this GIPAP program between 2009 and 2018. Clinical data were analyzed using descriptive statistics, Kaplan-Meier methods, proportional hazards regression, and the Kruskal-Wallis test.

RESULTS

One hundred twenty-four patients were included. The median age at diagnosis was 34 (range 8-81) years. On imatinib, 91% achieved complete hematologic response (CHR) after a median of 49 days. Seven (6%) and 12 (11%) patients had primary and secondary imatinib resistance, respectively. The 3-year overall survival was 80% (95% CI, 72 to 87) for the cohort, with superior survival in imatinib responders compared with those with primary and secondary resistance. The median time from imatinib initiation to CHR was 59 versus 38 days (P = .040) before and after in-country diagnostic testing, whereas the median time to diagnosis (P = .056) and imatinib initiation (P = .170) was not significantly different.

CONCLUSION

Coupling molecular diagnostics with affordable access to imatinib within a comprehensive cancer care delivery program is a successful long-term strategy to treat CML in resource-constrained settings. Our patients are younger and have higher rates of imatinib resistance compared with historic cohorts in high-income countries. High imatinib resistance rates highlight the need for access to molecular monitoring, resistance testing, and second-generation tyrosine kinase inhibitors, as well as systems to support drug adherence. Hematologic response is an accurate resource-adapted predictor of survival in this setting. Local diagnostic capacity development has allowed for continuous, timely CML care delivery in Rwanda.

Nephroblastoma Treatment and Outcomes in a Low-Income Setting

PURPOSE

Nephroblastoma is a highly curable pediatric cancer that requires multidisciplinary care. Few reports have assessed long-term treatment outcomes in low-resource settings using a task-shifting model of care. We report outcomes of a large cohort and factors associated with survival.

METHODS

We performed a retrospective chart review of all patients with nephroblastoma presenting to the Butaro Cancer Center of Excellence in Rwanda between July 2012 and June 2018.

RESULTS

In total, 136 patients were identified and treated according to International Society of Pediatric Oncology guidelines for low-income settings. Median age at diagnosis was 39.7 months (interquartile range, 25.3-61.8 months); 56.6% were female. Sixty-one (44.9%) patients presented with stage I-III disease, 35 (25.7%) with stage IV disease, and 6 (4.4%) with stage V disease; the remainder were unstaged (n = 34; 25.0%). Most patients completed surgery (n = 97; 71.3%) and postoperative chemotherapy (n = 82; 60.2%); 17 patients received radiotherapy. With a median follow-up time of 18.1 months, 44.9% of patients were alive, 41.9% had died, 8.8% were lost to follow-up, and 4.4% were referred for palliative care or declined further care at the end of the study. Three-year overall survival was 57.5% (95% CI, 48.1 to 65.8) for the entire cohort, and 80.1% (95% CI, 66.8 to 88.5) and 44.0% (95% CI, 26.8 to 60.0) for stages I-III and IV-V, respectively.

CONCLUSION

We demonstrate that patients with nephroblastoma can be successfully treated in a low-resource setting. Survival remains lower than in high-income countries, in part due to early deaths, contributing to approximately 30% of patients not being medically able to receive surgical intervention. Next steps include the development of strategies that focus on earlier diagnosis, supportive care during the early phases of therapy, and efficient and timely transitions between specialties for multimodal care.

Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes

OBJECTIVE

Most cervical cancer cases and deaths occur in low- and middle-income countries, yet clinical research from these contexts is significantly underrepresented. We aimed to describe the treatment quality, resource-driven adaptations, and outcomes of cervical cancer patients in Rwanda.

METHODS

A retrospective cohort study was conducted of all patients with newly diagnosed cervical cancer enrolled between April 2016 and June 2018. Data were abstracted from medical records and analyzed using descriptive statistics, Kaplan Meier methods, and Cox proportional hazards regression.

RESULTS

A total of 379 patients were included; median age 54 years, 21% HIV-infected. A majority (55%) had stage III or IV disease. Thirty-four early-stage patients underwent radical hysterectomy. Of 254 patients added to a waiting list for chemoradiation, 114 ultimately received chemoradiation. Of these, 30 (26%) received upfront chemoradiation after median 126 days from diagnosis, and 83 (73%) received carboplatin/paclitaxel while waiting, with a median 56 days from diagnosis to chemotherapy and 207 days to chemoradiation. There was no survival difference between the upfront chemoradiation and prior chemotherapy subgroups. Most chemotherapy recipients (77%) reported improvement in symptoms. Three-year event-free survival was 90% with radical hysterectomy (95% CI 72-97%), 66% with chemoradiation (95% CI 55-75%), and 12% with chemotherapy only (95% CI 6-20%).

CONCLUSIONS

Multi-modality treatment of cervical cancer is effective in low resource settings through coordinated care and pragmatic approaches. Our data support a role for temporizing chemotherapy if delays to chemoradiation are anticipated. Sustainable access to gynecologic oncology surgery and expanded access to radiotherapy are urgently needed.

Abstract 46: Clinical Outcomes and Quality Metrics of Cervical Cancer Treatment in Rwanda

Purpose: Cervical cancer is a leading cause of cancer-related mortality in Africa. As treatment capacity expands, it is critical to evaluate outcomes and identify targets for quality improvement. We describe a cohort of cervical cancer patients at Butaro Cancer Center (BCCOE) in rural Rwanda, many co-managed by gynecologic specialists at the national referral hospital and a subset referred for definitive chemoradiotherapy plus brachytherapy (CRT) in Nairobi based on available funds and estimated curability.

Methosd: We conducted a retrospective cohort study of all patients with cervical cancer seen at BCCOE between 6/2016 and 6/2018. Data were extracted from clinical charts and analyzed using descriptive statistics and Kaplan Meier method.

Results: 377 patients were included; median age 54 years, 21% HIV positive. Most patients (85%) had squamous cell carcinoma. A majority (67%) had stage III or IV disease at presentation. Several early stage patients underwent radical hysterectomy (n=34). 114 (30%) received CRT, representing 45% of eligible candidates. Of these, 30 (26%) received upfront CRT after a median 126 days from diagnosis, and 83 (73%) received “temporizing” carboplatin/paclitaxel while awaiting CRT, with a median 56 days from diagnosis to chemotherapy. Patients sent for upfront CRT were younger (p <0.001) and more likely stage II (p <0.001). Nevertheless, there was no survival difference between upfront CRT versus temporizing chemotherapy before CRT. Most chemotherapy recipients (77%) reported improvement in symptoms. Estimated 3-year overall survival was 94% with radical hysterectomy (95% CI 63-99%), 66% with CRT (95% CI 54-75%), 11% with chemotherapy only (95% CI 5-19%), and 7% with no treatment (95% CI 2-17%) (p<0.001).

Conclusion: Multi-modality treatment of cervical cancer is effective in low resource settings through coordinated care and pragmatic approaches. Our data support a role for temporizing chemotherapy if delays to CRT are anticipated. Expanded and timely access to radiation is urgently needed.

Citation Format: Victoria Umutoni, Cyprien Shyirambere, Ethan Katznelson, Cam Nguyen, Jean Bosco Bigirimana, Aline Umwizerwa, Alan Paciorek, Lisa Bazzett-Matabele, Diomede Ntasumbumuyange, Scott Triedman, Lawrence Shulman, Tharcisse Mpunga, Rebecca DeBoer. Clinical Outcomes and Quality Metrics of Cervical Cancer Treatment in Rwanda [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 46.

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.

Treatment of Hodgkin Lymphoma With ABVD Chemotherapy in Rural Rwanda: A Model for Cancer Care Delivery Implementation

PURPOSE

Hodgkin lymphoma (HL) is highly curable in high-income countries (HICs), yet many patients around the world do not have access to therapy. In 2012, cancer care was established at a rural district hospital in Rwanda through international collaboration, and a treatment protocol using doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiotherapy was implemented.

METHODS

We conducted a retrospective cohort study of all patients with confirmed HL seen at Butaro Hospital from 2012 to 2018 to evaluate quality indicators and clinical outcomes.

RESULTS

Eighty-five patients were included (median age, 16.8 years; interquartile range, 11.0-30.5 years). Ten (12%) were HIV positive. Most had B symptoms (70%) and advanced stage (56%) on examination and limited imaging. Of 21 specimens evaluated for Epstein-Barr virus, 14 (67%) were positive. Median time from biopsy to treatment was 6.0 weeks. Of 73 patients who started ABVD, 54 (74%) completed 6 cycles; the leading reasons for discontinuation were treatment abandonment and death. Median dose intensity of ABVD was 92%. Of 77 evaluable patients, 33 (43%) are in clinical remission, 27 (36%) are deceased, and 17 (22%) were lost to follow-up; 3-year survival estimate is 63% (95% CI, 50% to 74%). Poorer performance status, advanced stage, B symptoms, anemia, dose intensity < 85%, and treatment discontinuation were associated with worse survival.

CONCLUSION

Treating HL with standard chemotherapy in a low-resource setting is feasible. Most patients who completed treatment experienced a clinically significant remission with this approach. Late presentation, treatment abandonment, and loss to follow-up contribute to the discrepancy in survival compared with HICs. A strikingly younger age distribution in our cohort compared with HICs suggests biologic differences and warrants further investigation.

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.

Sociodemographic factors associated with cancer treatment completion among women with breast cancer at Butaro Cancer Center of Excellence (BCCOE) in Rwanda

e19220

Background: Many barriers exist to delivering comprehensive breast cancer care in low-income countries. We examined sociodemographic factors associated with treatment completion among women receiving care for breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda’s first public cancer facility. Methods: We retrospectively measured treatment completion rates in women with early and locally advanced breast cancer diagnosed at BCCOE between July 1, 2012 and December 31, 2016. We defined treatment completion as receipt of surgery, 4 cycles of chemotherapy, and initiation of hormonal therapy for estrogen receptor positive (ER+) breast cancer. We used logistic regression to examine associations between socio-demographic and clinical factors and treatment completion. Travel time was estimated using a geographic information systems model using the WHO tool AccessMod 5.0. Results: Of 212 eligible women, 138 (65%) had surgery and 141 (66%) received 4 cycles of chemotherapy. Among 139 women with ER+ cancer, 59% initiated hormonal therapy. Overall 56% received all indicated treatment including surgery, chemotherapy, and hormonal therapy (if ER positive); 44% did not complete indicated treatment. Women who lived closer to the hospital ( <50 minutes travel time) were more likely than other women to complete treatment (OR 4.2; 95% CI 1.1-15.1). Women with early-stage disease were also more likely than women with locally advanced disease to complete treatment (OR 2.2, 95% CI 1.1-4.4). Among 100 women with available information about ubudehe (Rwandan social categorization used as a proxy for socioeconomic status), rates of treatment completion were higher for women who were eligible for social support (ie: transportation support or insurance subsidy) than women who were not (74% v. 63%), although this difference was not statistically significant (p= 0.51). Conclusions: Significant barriers exist for breast cancer patients receiving treatment in this low resource setting; nevertheless, over half of the patients completed therapy. Interventions are needed to facilitate care for women with long travel times and locally advanced disease to reduce disparities in outcomes for this population of patients. Further research is needed to determine the role of social support in treatment completion.

Barriers to timely surgery for breast cancer in Rwanda

BACKGROUND

Ensuring timely and high-quality surgery must be a key element of breast cancer control efforts in sub-Saharan Africa. We investigated delays in preoperative care and the impact of on-site versus off-site operation on time to operative treatment of patients with breast cancer at Butaro Cancer Center of Excellence in Rwanda.

METHODS

We used a standardized data abstraction form to collect demographic data, clinical characteristics, treatments received, and disease status as of November 2017 for all patients diagnosed with breast cancer at Butaro Cancer Center of Excellence in 2014 to 2015.

RESULTS

From 2014 to 2015, 89 patients were diagnosed with stage I to III breast cancer and treated with curative intent. Of those, 68 (76%) underwent curative breast operations, 12 (14%) were lost to follow-up, 7 (8%) progressed, and 2 declined the recommended operation. Only 32% of patients who underwent operative treatment had the operation within 60 days from diagnosis or last neoadjuvant chemotherapy. Median time to operation was 122 days from biopsy if no neoadjuvant treatments were given and 51 days from last cycle of neoadjuvant chemotherapy. Patients who received no neoadjuvant chemotherapy experienced greater median times to operation at Butaro Cancer Center of Excellence (180 days) than at a referral hospital in Kigali (93 days, P = .04). Most patients (60%) experienced a disruption in preoperative care, frequently at the point of surgical referral. Documented reasons for disruptions and delays included patient factors, clinically indicated treatment modifications, and system factors.

CONCLUSION

We observed frequent delays to operative treatment, disruptions in preoperative care, and loss to follow-up, particularly at the point of surgical referral. There are opportunities to improve breast cancer survival in Rwanda and other low- and middle-income countries through interventions that facilitate more timely surgical care.

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.

Barriers to Timely Surgery for Breast Cancer in Rwanda

Abstract 81

Purpose

Surgery is the mainstay of treatment for nonmetastatic breast cancer. Little is known about the quality of breast surgical care in sub-Saharan Africa. Research at the Butaro Cancer Center of Excellence (BCCOE), Rwanda’s first public cancer center, has suggested that access to timely surgery is inadequate, but barriers have not been systematically examined. The aim of the current study was to gain an understanding of the barriers to breast cancer surgery among patients who were diagnosed at BCCOE by investigating delays and interruptions in care.

Methods

We used a standardized chart abstraction instrument to collect demographic, treatment, and outcome data as of November 2017 for all patients who were diagnosed with breast cancer at BCCOE in 2014 and 2015. We recorded all visits and treatments received until surgery, disease progression, or loss to follow-up for all patients with stage I to III breast cancer.

Results

During 2014 and 2015, 91 patients were diagnosed with stage I to III breast cancer and were treated with curative intent—67 patients (74%) underwent surgery, with 22 undergoing surgery at BCCOE and 45 elsewhere. Of the 24 patients with no surgery, 16 were lost to follow-up and eight experienced disease progression before surgical evaluation. Median time from diagnosis to surgery was 103 days (range, 30 to 826 days) for patients without neoadjuvant chemotherapy (NAC) and 268 days (range, 108 to 794 days) for patients with NAC. We defined surgical delays as > 120 days from diagnosis without NAC or > 365 days from diagnosis if NAC was administered. Of the 67 patients who had surgery, 26 patients (39%) experienced delays. When documented, reasons for delay included patient factors, such as social and/or financial issues (n = 5), seeking alternate treatment (n = 2), refusing referral to Kigali (n = 3), or any surgery (n = 1); system factors, such as surgeon nonavailability (n = 1); and changes in clinical status, such as pregnancy (n = 5), treatment-associated adverse events (n = 4), or the need for a second surgical opinion (n = 2). Unexplained failure to complete the initial surgical referral (n = 5) and missed NAC treatment appointments (n = 6) were frequent contributors. Some patients had multiple reasons for delay. For five patients, there was no documented explanation.

Conclusion

We observed high rates of loss to follow-up, surgical delays, and lapses in care at the point of surgical referral. Identification of the barriers to completing referrals could guide strategies for improving access to timely surgery. Efforts are needed to address social and financial barriers and explore patients’ refusals to undergo surgery.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.