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

Abstract

PURPOSEFeasible 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.METHODSWe 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.RESULTSFrom 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).CONCLUSIONIn 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.

Interventions to improve early detection of childhood cancer in low‐ and middle‐income countries: A systematic review

“…Using a cluster randomized controlled trial design, Pace et al reported on the efficacy of a training program for health workers in Rwanda targeting the early diagnosis of breast cancer. Compared to the control group, health centers receiving the intervention experienced a statistically significant increase in breast cancer referrals (1484 visits [increase of 7.9 visits/month] vs 308 visits; P = .007) and an increase in incidence of early stage disease (3.3/100 000 vs 0.7/100 000 person‐years; P = .048) in intervention areas 35 . Other studies have also demonstrated the efficacy of training community health workers in the early detection and referral of breast and cervical cancer 35–41 .…”

“…Compared to the control group, health centers receiving the intervention experienced a statistically significant increase in breast cancer referrals (1484 visits [increase of 7.9 visits/month] vs 308 visits; P = .007) and an increase in incidence of early stage disease (3.3/100 000 vs 0.7/100 000 person‐years; P = .048) in intervention areas 35 . Other studies have also demonstrated the efficacy of training community health workers in the early detection and referral of breast and cervical cancer 35–41 . Whether such interventions in the adult cancer space can translate effectively to improvments in the early detection of childhood cancers in LMICs is a subject for future research.…”

“…Use of social media (Facebook, Twitter), 29,30 awareness through social events, 31 policy advocacy campaigns reaching out to organized groups within the community, 32 national social marketing compaigns, 33 and an increase in incidence of early stage disease (3.3/100 000 vs 0.7/100 000 person-years; P = .048) in intervention areas. 35 Other studies have also demonstrated the efficacy of training community health workers in the early detection and referral of breast and cervical cancer. [35][36][37][38][39][40][41] Whether such interventions in the adult cancer space can translate effectively to improvments in the early detection of childhood cancers in LMICs is a subject for future research.…”

“…35 Other studies have also demonstrated the efficacy of training community health workers in the early detection and referral of breast and cervical cancer. [35][36][37][38][39][40][41] Whether such interventions in the adult cancer space can translate effectively to improvments in the early detection of childhood cancers in LMICs is a subject for future research. is thus dependent on cancer type and jurisdiction.…”

Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

“…Given the prevalence of cervical cancer in Rwanda, and the complexity of the current cervical cancer treatment pathway that requires multi-institutional referrals, building strategies to improve community knowledge about cervical cancer, screen women for cervical cancer, connect them to care and help them navigate the health system will be imperative. At BCCOE, a training program was initiated in Burera District in 2015 to facilitate earlier diagnosis of breast cancer and has been shown to improve community health workers’ and health center nurses’ knowledge and skills in evaluating and managing breast concerns, increase the number of women visiting a health center for a breast concern, and increase the incidence of early stage breast cancer [ 29 30 ]. At the Ministry of Health’s request, this model was expanded to additional districts and to include cervical cancer screening in 2018.…”