Implementation strategies to decentralize breast ultrasound services and facilitate timely breast cancer diagnoses in Rwanda

Brigham And Women'S Hospital, Boston MA

Investigators

Abstract

PROJECT SUMMARY Breast cancer cases and deaths are rising rapidly in low- and middle-income countries (LMIC), including in sub-Saharan Africa, where most women with breast cancer are diagnosed with advanced-stage disease. Largely because of late-stage presentations, breast cancer survival in sub-Saharan Africa is poor. To address these global breast cancer inequities, the World Health Organization has emphasized the need for expanded access to breast cancer diagnostics in LMIC, and particularly calls for decentralizing diagnostic testing to primary- and secondary-level health facilities while maintaining care quality. Diagnostic breast ultrasound (U/S) is an evidence-based intervention that is essential in evaluation of palpable breast abnormalities, including for determining which lesions require biopsy. However, diagnostic breast U/S is typically only provided by radiologists, of whom there is a profound shortage in sub-Saharan Africa; further, radiologists are typically based at urban referral hospitals. This impedes access for low-income rural patients in particular, limiting quality, equity, timeliness and efficiency of breast evaluation and contributing to diagnostic inefficiencies and delays. To address this issue, Rwanda’s chief health implementation agency (Rwanda Biomedical Centre) has called for decentralized provision of breast U/S at district hospitals through task-shifting to non-radiologist clinicians. Supportive supervision is regarded as essential for successful task-shifting. However, scalable strategies for clinical supervision of non-radiologist clinicians to ensure sustained provision of high-quality decentralized breast ultrasound have not been investigated. Our preliminary work training a small group of non-radiologist clinicians in Rwanda suggests that virtual support through electronically shared images and asynchronous feedback is feasible and potentially beneficial after intensive training. However, supervision with real-time teleultrasound technology could be more effective in facilitating sustained ultrasound provision and quality in a broader population of district hospital clinicians receiving shortened in-person training. The objective of this research project is to compare 2 implementation strategies (teleultrasound supervision and asynchronous virtual feedback) to facilitate decentralized breast ultrasound at Rwandan district hospitals. In Aim 1 we will conduct a hybrid Type 2 implementation-effectiveness trial to compare the strategies’ impact on penetration of guideline-concordant diagnostic breast ultrasound (implementation effectiveness). In Aim 2 we will compare the strategies’ impact on trainee-performed breast U/S image quality (clinical effectiveness). In Aim 3 we will estimate the implementation strategies’ costs and cost-effectiveness in facilitating high-quality breast U/S, as well as exploring downstream cost offsets associated with decentralized breast U/S. This project will be embedded in Rwanda’s national Women’s Cancer Early Detection Program at government- funded health facilities. It will directly inform breast cancer diagnosis pathways in Rwanda and shape the workforce and credentialing processes for breast U/S. In addition, this project will contribute to global understanding of feasible, contextually appropriate and effective strategies to increase access to breast cancer diagnostic services through task-shifting in LMIC– a topic of major global interest in light of rapidly rising breast cancer incidence and mortality in LMIC. This project aligns with the National Cancer Institute’s special interest in implementation research related to cancer control in low- and middle-income countries and its commitment to pursuing equity in global cancer control.