Implementation of a large‐scale breast cancer early detection program in a resource‐constrained setting: real‐world experiences from 2 large states in India

Abstract

BACKGROUND:The Breast Health Initiative (BHI) was launched to demonstrate a scalable model to improve access to early diagnosis and treatment of breast cancer. METHODS: A package of evidence-based interventions was codesigned and implemented with the stakeholders, as part of the national noncommunicable disease program, through the existing primary health care system. Data from the first 18 months of the BHI are presented. RESULTS: A total of 108,112 women received breast health education; 48% visited the health facilities for clinical breast examination (CBE), 3% had a positive CBE result, and 41% were referred to a diagnostic facility. The concordance of CBE findings between health care providers and adherence to follow-up care improved considerably, with more women visiting the diagnostic facilities and completing diagnostic evaluation within 1 month from initial screening, and with only 9% lost to followup. The authors observed a clinically meaningful decrease in time to complete diagnostic evaluation with biopsy, from 37 to 9 days. CONCLUSIONS:The results demonstrate the feasibility and effectiveness of implementing a large-scale, decentralized breast cancer early detection program delivered through the existing primary health care system in India.

State of the Science of Scale-Up of Cancer Prevention and Early Detection Interventions in Low- and Middle-Income Countries: A Scoping Review

“…They noted that CFIR was a useful and practical tool for researching health system implementation success determinants and that its unique methodology allowed for the comparison of constructs across different implementation efficiencies. Arrossi et al, 42 using the RE-AIM framework, Poor communication about follow-up visits from providers to patients 33 Commuting costs and because of poor communication 43 Expansion of participants and program 38 Missed repeat cryotherapy at 1 year for those who tested VIA-positive 47 Embarrassment by female patients being screened by a male doctor 38 Lack of information Little knowledge about the disease HPV and the HPV vaccine 52 Breast cancer 32 Low participant compliance Low screening uptake or adherence 32 Varied compliance within specific subgroups (higher socioeconomic status of the participants in terms of education levels and employment status) 39 Lack of access and resources High costs of service and financial concerns 34,45 No insurance 35 Health facility…”

“…Lay person clinic assistants were hired to help nurses with filing medical records, recording upcoming appointments, and calling patients in advance to remind them of upcoming follow-up appointments 43 ; in November 2010 and 2012, two mobilization days (Saturdays) were set to either update vaccination for girls who already took the first or second doses or to vaccinate girls who missed the first vaccination. Five hundred nurses and 10 doctors to conduct the interviews were recruited, and the project holidays HPV-free was launched 52 ; an intense social communication campaign was launched with radio and television advertisements to increase awareness regarding these preventive services among IMSS affiliates 32 ; the program used a training curriculum adapted from the WHO's IARC 43 ; women in each household reached was educated on cervical and breast cancer prevention and HPV 37 Use evaluative and iterative strategies The program used a training curriculum adapted from the WHO's IARC 43 ; developed indictors to be monitored throughout the activity 44 ; assessed data from women attending CC screening; this paper highlights the essential performance findings of the program with regards to the participation and performance indicators for the past 5 year 53 ; SSV was to identify any gaps in the beginning of the program and find any appropriate solution 30 ; review progress of each community health center; the CHCs were also required to submit monthly progress reports to the CDC of the district. The local CDC was responsible for the quality control of the whole process of the screening program 39 ; capacity building in monitoring and evaluation 45 ; created a context-appropriate implementation plan for breast cancer care delivery 32 ; we have conducted a situational assessment of breast health services in both states using the BHGI BCI2.5 toolkit 32 ; we established a robust monitoring and evaluation system at the onset of the program, so that all key data needed for decision-making could be captured in a timely and reliable manner.…”

“…Five hundred nurses and 10 doctors to conduct the interviews were recruited, and the project holidays HPV-free was launched 52 ; an intense social communication campaign was launched with radio and television advertisements to increase awareness regarding these preventive services among IMSS affiliates 32 ; the program used a training curriculum adapted from the WHO's IARC 43 ; women in each household reached was educated on cervical and breast cancer prevention and HPV 37 Use evaluative and iterative strategies The program used a training curriculum adapted from the WHO's IARC 43 ; developed indictors to be monitored throughout the activity 44 ; assessed data from women attending CC screening; this paper highlights the essential performance findings of the program with regards to the participation and performance indicators for the past 5 year 53 ; SSV was to identify any gaps in the beginning of the program and find any appropriate solution 30 ; review progress of each community health center; the CHCs were also required to submit monthly progress reports to the CDC of the district. The local CDC was responsible for the quality control of the whole process of the screening program 39 ; capacity building in monitoring and evaluation 45 ; created a context-appropriate implementation plan for breast cancer care delivery 32 ; we have conducted a situational assessment of breast health services in both states using the BHGI BCI2.5 toolkit 32 ; we established a robust monitoring and evaluation system at the onset of the program, so that all key data needed for decision-making could be captured in a timely and reliable manner. A centralized digital dashboard allowed for real-time monitoring of key indicators 32 ; all sites participated in intensive QA monitoring 33 ; conduced semi-structured interviews with 36 staff members of 20 NGO-based VIA programs 31 ; assessed data from women attending CC screening 46 Provide interactive assistance An experienced gynecologist conducted monitoring visits at the triage centers to ensure adequate implementation of clinical procedures 38 ; experts from the pilot site reviewed all cervical images centrally and mentored providers during monthly site visits.…”

“…The local CDC was responsible for the quality control of the whole process of the screening program 39 ; capacity building in monitoring and evaluation 45 ; created a context-appropriate implementation plan for breast cancer care delivery 32 ; we have conducted a situational assessment of breast health services in both states using the BHGI BCI2.5 toolkit 32 ; we established a robust monitoring and evaluation system at the onset of the program, so that all key data needed for decision-making could be captured in a timely and reliable manner. A centralized digital dashboard allowed for real-time monitoring of key indicators 32 ; all sites participated in intensive QA monitoring 33 ; conduced semi-structured interviews with 36 staff members of 20 NGO-based VIA programs 31 ; assessed data from women attending CC screening 46 Provide interactive assistance An experienced gynecologist conducted monitoring visits at the triage centers to ensure adequate implementation of clinical procedures 38 ; experts from the pilot site reviewed all cervical images centrally and mentored providers during monthly site visits. Each scaled-up site was monitored monthly 33 ; BHI personnel monitored program logistics 38 ; core group of local gynecologists from MUSOM underwent specialized training and continuous mentorship from visiting North American gynecologists to become skilled at colposcopy, biopsy, and LEEP 43 ; supportive supervision visits to mentor and support providers; training of data managers on data extraction and cross-check methodology to improve data quality.…”

Barriers and challenges in providing standard breast cancer care in low resource settings

“…These include low-cost core needle biopsy technique, low-cost SLNB technique and clinical breast examination etc. [18][19][20] These validated low-cost alternatives deserve to be included in various guidelines and National Cancer Control Plan (NCCP) of each country.…”