Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process

Abstract

PURPOSE The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings. METHODS To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda. RESULTS Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda. CONCLUSION A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.

Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer

“…This study adds to a growing body of literature that characterizes the surgical and systemic treatment care continuum for patients treated in cancer programs in LICs. These efforts are leading to the emergence of context-specific quality metrics to guide meaningful quality improvement efforts [ 37 – 39 ]. Ongoing efforts at HUM are focused on identifying and supporting vulnerable patients, as well as systematically tracking where patients are in the care pathway to ensure retention in care and receipt of timely care.…”

Forty-Five Years of Research and Progress in Breast Cancer: Progress for Some, Disparities for Most

“…For example, in Rwanda, a low-income country of 12.5 million in East Africa, the Ministry of Health in collaboration with US institutions established the Butaro Cancer Center of Excellence (BCCOE), Rwanda's first public cancer facility in the country. 14 Breast cancer is the most common cancer treated there, with approximately 1,800 cases treated between 2012 and 2019. The services are covered by a national health insurance program and subsidized through charitable contributions.…”

“…The services are covered by a national health insurance program and subsidized through charitable contributions. 14 , 15 Over 7 years, 35% of early-stage patients received surgery within 60 days of biopsy or completion of neoadjuvant chemotherapy, and 68% of early-stage patients received chemotherapy, whereas 99% had indications for chemotherapy on the basis of national protocols. 15 No one received radiation despite 44% of cancer being locally advanced and most meeting criteria for postmastectomy radiation.…”

“… 15 Rwanda has also initiated programs to improve early detection. The training of community health workers in breast cancer screening is one such effort that has been shown to increase the rate of early-stage cancer diagnoses, 14 and increasing availability of radiation may improve options for breast conservation to further incentivize women to present earlier.…”

“…Research to identify quality measures for breast cancer care is invaluable and must be incorporated into these models as countries grapple with the burden of cancer. 14 Such measures will vary by population and health care system and should be carefully weighed against cultural and quality of life factors associated with breast cancer treatment to improve outcomes. The resource-stratified treatment tables and process metrics developed by the Breast Health Global Initiative and others provide structures for a comprehensive approach to set priorities deliberately to establish a minimum standard of care with the rational and equitable use of existing resources.…”