PURPOSE Breast cancer (BC) is detected at late stages in sub-Saharan Africa. We piloted a BC early-detection program in Eswatini aimed at increasing breast health knowledge and clinical skills. We also aimed to determine the proportion of patients with breast abnormalities who completed referral to breast specialty clinics. METHODS Nurses and counselors from five human immunodeficiency virus and/or antiretroviral therapy clinics underwent training in BC and clinical breast examination (CBE). We compared knowledge and skill examinations completed before, immediately after, and 90 days after training. Nurses then screened female clinic patients ≥ 18 years for breast symptoms, examined those with symptoms, and referred women with CBE abnormalities to a surgeon or the national breast clinic. Consenting women were contacted at 30 and 60 days after screening to determine if they had completed referral. RESULTS In 2019, 44 nurses underwent training. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training knowledge examinations were 17.5 (16-19), 20 (19-21), and 20 (19-21), respectively. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training skills examinations were 10 (7-11), 23 (21.5-25), and 23 (22-24), respectively. Compared with pretraining scores, post-training scores were significantly improved ( P < .0001 for all comparisons). From June 2019 to April 2020, a total of 9,502 clinic patients were screened for breast symptoms: 150 (2%) underwent CBE, 93 (62%) were referred for further evaluation, and 88 (97%) were included in the study. Of those, 54 (61%) completed referral. Referral completion was not associated with age, employment, relationship status, or prior experiences related to BC. CONCLUSION The program's training curriculum improved breast health knowledge and clinical skills. Efforts are needed to improve patients' receipt of recommended evaluation for breast abnormalities.
Purpose: Women living with HIV (WLHIV) are living longer and are at increasing risk for breast cancer (BC). Earlier detection of BC is essential to reduce late-stage diagnosis and BC mortality in sub-Saharan Africa, the region most heavily impacted by HIV. We implemented a pilot BC early detection program in Eswatini HIV clinics and studied patients' compliance with referral for evaluation of breast abnormalities. Methods: Nurses at five Eswatini HIV clinics were trained to ask all WLHIV aged ≥18 years about breast symptoms, to offer clinical breast exam (CBE) to symptomatic women, and to refer for further evaluation if appropriate. Referred, consenting patients completed baseline demographic questionnaires and questionnaires at 30- and 60-days post-enrollment, regarding referral outcomes. We used chi-squared testing to identify patient characteristics associated with completing referral. Results: From June 2019-April 2020, 9,502 WLHIV were screened for breast symptoms: 150 (1.6%) underwent CBE; 93 (62.0%) of those were referred for further evaluation; and 90 (96.7%) were enrolled in the evaluation. Of enrolled WLHIV, median age was 39 (range: 20-65) years, 54 (61.0%) reported completing referral. Referral completion was not associated with age, employment status, relationship status, or various prior experiences related to BC (all p>0.05). Of those who completed referral, 42 (80.7%) reported having no illness identified, 3 (5.8%) reported a new BC diagnosis, 1 (1.9%) reported a breast abscess, and 6 (11.5%) were still undergoing evaluation; diagnosis was missing for 2. The most common reasons cited for not completing referral were cost of transport or care, conflicting employment-related commitments, other conflicting commitments, and the breast clinic not accommodating the patient upon presentation. Conclusion: In this pilot BC screening program, 60% of WLHIV completed referral for further evaluation. Efforts to improve compliance with referral could focus on reducing the time and cost entailed by obtaining specialized breast care. Citation Format: Daniel O'Neil, Sifiso Nxumalo, Cebisile Ngcamphalala, G Tharp, Judith Jacobson, Harriet Nuwagaba-Biribonwoha, Xolisile Dlamini, Alfred Neugut, Tiffany Harris. Compliance with Referral for Evaluation of Breast Abnormalities among HIV-Clinic Patients in Eswatini [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 24.
PURPOSE Breast cancer (BC) incidence is rising in sub-Saharan Africa, and approximately 75% of cases are diagnosed at stages III and IV. Women living with HIV, who are surviving longer with antiretroviral use, are also increasingly affected. Survey data suggest that primary care providers often fail to recognize early-stage BC. We trained nurses from 5 antiretroviral clinics in Eswatini to assess breast abnormalities and evaluated our curriculum’s effectiveness in improving BC knowledge and skills. METHODS The 2-day curriculum covered breast physiology, benign pathology, and BC. Clinical breast exam and management were taught using mannequins and standardized patient scenarios, with emphasis on prompt referral for biopsy. After training, mentoring was provided every 2 to 4 weeks at each study clinic. A written examination of BC knowledge (maximum score, 23 points) and an observed examination of practical clinical skills (maximum score, 28 points) were administered before training, immediately after training, and 90 days after training. Pre- and post-training scores were compared using Wilcoxon signed-rank tests. RESULTS Forty-four nurses, with a median of 10 years of experience, underwent training; only 5 nurses (11%) reported prior BC education. All nurses completed the pre- and immediate post-training exams, and 38 completed the 90-day post-training exams. Median scores on pre-, immediate post-, and 90-day post-training knowledge exams were 17.5 (interquartile range [IQR], 16-19), 20 (IQR, 19-21), and 20 (IQR, 19-21), respectively. Median scores on pre-, immediate post-, and 90-day post-training practical exams were 10 (IQR, 7-11), 23 (IQR, 21.5-25), and 23 (IQR, 22-24), respectively. Compared with pretraining scores, immediate post- and 90-day post-training scores on both exams were significantly improved ( P < .0001 for all comparisons). CONCLUSION Our curriculum produced a sustained improvement in nurses’ BC-related knowledge and clinical skills, including identification of possible early cancers. Our results resemble those among similarly trained Rwandan nurses, suggesting that the curriculum may generally benefit front-line health care providers and patients in sub-Saharan Africa.
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