Making an impact: Day #1 of the ITW Breast Imaging Protocol
August 11, 2013
It is possible that Monday August 11, 2013 marked the first time ever that breast diagnostic ultrasound images were obtained in rural Sub-Saharan Africa and transmitted for remote interpretation. Sister Angela, Rogers Kalende, a sonographer from ECUREI, and I began scanning patients at Nawanyago Health Centre III (HC III)early in the morning and continued until well after dark. A successful breast health educational outreach program initiated by Imaging the World Africa (ITWA), collaborating with the local Village Health Team (VHT) and conducted earlier this year, resulted in significant community engagement in this project, with over 100 women coming to the HC III for a breast problem. Each patient received a clinical breast examination performed by trained health providers – those with a palpable breast mass, then received a diagnostic breast ultrasound scan followed by the ITW protocol scan. Rogers interpreted the scans in real time and there was a secondary interpretation performed by a breast imager in the USA. Both interpreters agreed with each other on all cases. All of the ITW protocol images sent for remote interpretation were sent as de-identified images, that is, patient confidentiality was maintained in the same fashion that we use in the USA. In consultation with the Ugandan Ministry of Health and many involved in the health care sector in Uganda to establish best practices, Imaging the World Africa, a registered NGO in Uganda, has been using this same process for obstetric ultrasound for the last several years, making low-cost, safe and high quality early diagnosis available at the point of care.
Patients who had diagnostic breast ultrasound performed were then counseled based on the results of the scans. We were pleased to find that most women with palpable lumps had benign-appearing masses, with only a few that had more worrisome findings. The women with more worrisome findings, known as BI-RADS Category 4 or 5, were counseled to go for additional diagnosis and treatment at Kamuli Mission Hospital. Women who had negative or benign-appearing exams were also counseled.
Working with local and worldwide experts and under the supervision of Ugandan Drs. Alphonsus Matovu and Moses Galukande, a breast health care algorithm has been developed by ITWA that navigates a woman from the village through all of the steps in her care when a breast lump is detected and/or a breast cancer is diagnosed. This includes a multidisciplinary approach in Uganda, with radiologists, sonographers, surgeons, pathologists, oncologists, counselors, breast care coordinators and even volunteer breast cancer survivors involved. Most women diagnosed with cancer will have to go to Kampala (the capital) for treatment, and this closed-loop navigation system helps to break down a lot of the barriers to care that women coming from the village face.
Until now, most women found to have breast cancer in Uganda already have advanced disease by the time they are diagnosed. There has been no good way for a woman in remote Uganda to access quality care for breast problems near her home or to manage the costs and logistics of traveling a great distance for treatment. The primary goal of the ITWA breast imaging pilot program is to identify women with palpable breast masses early in the disease process, and to diagnose breast cancer at an early stage, thus reducing cancer-associated morbidity and mortality. Finding early stage disease should also reduce the overall cost-burden, also improving the likelihood that women will seek treatment. Based on today’s turnout at Nawanyago, we will undoubtedly have the opportunity to make a profound impact on many women and their families and communities as we move forward. As an ITW volunteer, I am proud of the achievements we have made thus far and look forward to many more in the coming days.
Chris Stark, MD