Breast cancer early detection and diagnostic capacity in Uganda

From the Duggan Group, Public Health Sciences Division

Uganda has a breast cancer age-standardized incidence and mortality rate of 21.3 per 100,000 population and 10.3 per 100,000 population, respectively. Majority of women in Uganda, a low-income country, are diagnosed at stage III or stage IV, when breast cancer is more difficult to treat, and the outcome of survival is significantly lower. Dr. John R. Scheel, the lead author, elaborated on the high levels of breast cancer survival and mortality in Uganda. “In the US 5-year survival rates from breast cancer are close to 90% - i.e., 90% of women diagnosed with breast cancer are alive after 5 years. In Uganda, rates are closer to 50%: 1 in 2 women with breast cancer will die of their disease, as they are usually diagnosed with breast cancer when it is advanced, and chances of a cure, low,” he said.

Therefore, it’s necessary to increase the accommodations for early detection of breast cancer survival statistics by early diagnosis or screening programs. It’s beneficial to enhance access to care, timely diagnosis, and breast cancer treatment. The Duggan group, from the Division of Public Health Sciences, performed a situational analysis to inform the planning of appropriate evidence-based and resource-appropriate interventions to increase the women’s access to care.  The Duggan group performed the first comprehensive analysis of Ugandan health care system by assessing their breast cancer delivery system and facilitating structured interviews with stakeholders in Uganda. Also, their development of early detection strategy aligned with the National Comprehensive Cancer Network (NCCN) guidelines for clinical workup of invasive breast cancer. The article is published in Cancer.

The Breast Health Cancer Assessment Questionnaire was used to collect data from 35 Ugandan health care facilities.  The questionnaire assessed breast cancer screening and early detection practices, the detection of breast cancer stages, surgical availability, pathology, and treatment. Interviews were conducted with 60 stakeholders who were involved in breast cancer management, survivorship, and policy development. The interviews clarified standard of care practices for breast cancer and attitudes towards treatment, early detection, and diagnosis.

The Ugandan health care system is organized into 7 levels and managed by the Ministry of Health.  The following is a summary of the lack of breast cancer screening and early detection practices among the 7 levels of the health care system.  Level 1:  Village health teams (VHTs) do not receive breast cancer awareness training. Level 2:  Outpatient clinics are staffed with midwives and a health assistant; they do not perform breast cancer services. Level 3 and 4: The physical extenders (PE) spend one week observing physicians in a women’s health clinic. Therefore, they are not extensively trained, and may not refer women to a higher level of care.  Level 5: Women with positive ultrasound findings must travel to level 6 or level 7 facilities for biopsies or image-guided fine-needle aspiration (FNA). This is associated with expenses and delays. Patients must also transport their own samples to a pathology laboratory. Level 6: Facilities had at least 1 functioning ultrasound machine; but little to no accommodations for image analysis. There are rarely full-time radiologists on staff. Level 7:  This level includes privately funded hospitals. Ugandan patients must pay for services or have private health insurance. Therefore, level 7 is beyond the reach of most women in Uganda.


Graphical Representation of a Health center in Uganda
Health center in Uganda Image from Dr. John Scheel

Dr. Scheel explains the limitations in health care delivery illustrated in the photos above, “The photos above show typical health centers where most women receive their health care. They are usually staffed by midlevel providers who have been trained to recognize and treat infectious diseases. Women with breast complaints are usually suspected to have mastitis, and treated with antibiotics, or pain related to menses, and treated with an aspirin equivalent. These women receive no follow-up or diagnostic imaging, for example mammography or ultrasound - unless they return to the same clinic for a referral to a higher-level clinic. These delays add to the risk of late stage diagnosis when treatment is less effective and outcomes poor.”

The Duggan group outlined a broad framework that recommends changes in breast health care at a system level that aligns with the NCCN guidelines for clinical evaluation for invasive breast cancer. The following is a summary.  Level 1 and 2: VHTs and dispensary staff should be educated to recognize the signs and symptoms of breast cancer. They should also know which level of care to refer the breast cancer patient, level 5 or level 6. Level 3 and 4: Training for clinical breast examinations (CBE) should be increased and utilized more extensively. Level 5: Triage capacity can be increased by increasing the number of ultrasound instruments and trained sonographers. Women with abnormal tissue sampling can be referred to level 6. Level 6 and 7: Increase the number of ultrasound instruments, increase accommodations for image-guided biopsies and cytologic interpretation. 

Dr. Scheel comments on this study’s significant contributions, “This study brought multiple stakeholders across the spectrum of breast health in Uganda together. This project started conversations about how to collaborate and plan a future breast cancer symposium to start prioritizing breast cancer related activities.  We also leveraged the Breast Health Global Initiative’s (BHGI) resource stratified guidelines and novel work (funded by the Fred Hutch among others) to develop a stepwise methodology (phased implementation) for guiding the translation of resource‐appropriate breast cancer control guidelines into real‐world practice.”

Dr. Scheel concludes: “This manuscript describes the organization of the Ugandan health system and the capacity at each of these levels related to breast cancer detection, diagnosis, and treatment. This study also identified gaps and opportunities to improve breast cancer outcomes. We surveyed breast cancer diagnostic capacity across the 7 levels of the Ugandan health care system starting with local dispensaries up to UCI and describe a systematic method of health system capacity building to increase women’s access to early breast cancer diagnosis.”

This research was supported the Breast Health Global Initiative (BHGI) Global Summit and funded by grants from the Fred Hutchinson Cancer Research Center.

Fred Hutch/UW Cancer Consortium members Catherine Duggan, John R. Scheel, and Benjamin Anderson contributed to this work.

Scheel JR, Giglou MJ, Segel S, Orem J, Tsu V, Galukande M, Okello J, Nakigudde G, Mugisha N, Muyinda Z, Anderson BO. Breast cancer early detection and diagnostic capacity in Uganda. Cancer. 2020 May 15;126: 2469-80