Promoting Clinical Breast Evaluations in a Lower Middle–Income Country Setting: An Approach Toward Achieving a Sustainable Breast Health Program

Abstract

PurposeTo promote a systems-based approach for the early detection and downstaging of breast cancer at presentation in the remote mountainous region of Gorno Badakhshan Autonomous Oblast (GBAO), Tajikistan, by introducing breast cancer awareness into the community and training health care professionals in clinical breast evaluation (CBE).MethodsThrough a public-private partnership between the Ministry of Health, the Aga Khan Health Services, Tajikistan, and the Aga Khan Health Board, we organized breast cancer screening in the community and trained family medicine doctors (FMDs) and family medicine nurses (FMNs) in CBE. We identified and trained CBE master trainers, who, in turn, systematically trained FMNs to conduct CBEs in each of the remote regional clinics.ResultsBetween 2014 and 2017, 47 FMDs (85% of all FMDs in GBAO), 166 FMNs (55% of all FMNs in GBAO), and six master trainers were trained. Of 3,556 women who were screened, abnormal CBEs were noted in 696 of them (20%). Of the last 1,101 CBEs that were performed by trainee FMNs, with secondary CBEs by master trainers, the rate of abnormal CBEs plateaued at 9%. A total of 18 women were diagnosed with breast cancer—2.6% of abnormal CBEs and 0.5% of all screened women.ConclusionA dual-pronged approach of community awareness and CBE training of health care professionals, supported by CBE master trainers, offers a sustainable approach for the early detection of breast pathology. We observed anecdotal evidence of clinical early-stage detection over time with improved CBE proficiency and community acceptance. Sustaining this program will require advocacy by health care providers and a responsive public policy to support the early detection and treatment of breast cancer across the region.

Achieving and Sustaining Change Through Capacity Building Train-the-Trainer Health Initiatives in Low- and Middle-Income Countries: A Systematic Review

“…28,43 The studies that did demonstrate change at higher levels showed improved networks, procedures, and policy. 26,27,[29][30][31][32][33][34][35]37,38,40,[44][45][46] Theoretically and practically, little evidence supports the view that only providing training to a group of individuals will genuinely build capacity. 12 This suggest that although existing evidence indicates that T3 modalities are effective in engendering sustainable change at the foundational level, it is limited in autonomously affecting the organizational and institutional levels.…”

“…The T3 training spanned various health topics, including mental health, disaster management, chronic diseases, infection control, occupational health and safety, improvement in medical procedures and processes, and health leadership development. The prominent topic area revolved around maternal and child health (see 26,27,29,46 All but two studies demonstrated change effect at their respective levels. The studies exhibiting no change consisted of examining change attributed to reducing organizational or institutional mortality or case fatality rates.…”

“…Approximately 70% of studies did not specify barriers to achieving and sustaining change. [27][28][29][30][31][32][33][35][36][37]40,42,43,45,46 However, of those studies that did, Resources and Context were the primary limitations. 25,26,34,38,39,41,44 Most interventions that listed Resources as a barrier noted limited access to or ability to acquire materials to support training.…”

When Is a Suboptimal Approach to Cancer Screening Better Than None?

“…The feasibility of CBE has been established in LICs. 35,37 Our argument is not that CBE is a good screening tool but that it is a more pragmatic choice than mammography in LICs. For screening programs to be effective and affordable, high-quality treatment must be available.…”

“…Preliminary data from trials in low-income settings suggest that CBE screening can lead to downstaging of breast cancer, although its effect on mortality hasn't been shown. 34,35 Because a substantial proportion of women in LICs present with late-stage breast cancer, 29,36 for women like Ms P and others in LICs, downstaging is critical.…”