Abstract
Breast imaging capacity in Tanzania is currently very limited. In a country of almost 60 million people, mammographic units are exceedingly rare. The few existing units are compromised by lack of maintenance and quality control and extremely limited technologist training. Breast cancer incidence continues to increase in East Africa, while the ability to accurately diagnose and differentiate benign and malignant breast disease remains a challenge. However, as ultrasound technology improves and becomes more affordable, there is increased access to devices including hand-held point of care ultrasound. Additionally, there has been a recent expansion in the training of academic radiologists in Tanzania, creating an opportunity for possible sustainable improvement of breast imaging and intervention. Our initial efforts at the Muhimbili Academic Medical Center (MAMC) included social media advertising for symptomatic and asymptomatic women, followed by screening (clinical breast exam) and subsequent ultrasound imaging of symptomatic women. We then initiated a workflow for ultrasound-guided breast intervention, performed biopsies, reviewed results by local pathologists, and brought the postbiopsy patients back for radiologic–pathologic correlation, wound assessment, and coordination of follow-up and treatment.
Breast cancer prevalence continues to increase in the developing world.
Challenges to breast imaging and intervention in Tanzania include lack of available high-quality mammography, while ultrasound is available and relatively high quality.
In Tanzania, differentiating between benign and malignant disease remains a challenge both from a clinical and imaging standpoint.
Our collaboration included breast imaging, primarily by ultrasound, for symptomatic women, followed by ultrasound-guided biopsy, radiology–pathology correlation, and discussing results with patients.
Introduction
In the developed world, breast radiologists are familiar with the anxiety of patients during the process of screening, diagnostic work-up, breast biopsy, and the possibility of a breast cancer diagnosis. Fortunately, sophisticated and patient-centric care, timely and accurate diagnosis, and a multidisciplinary approach to therapy are generally available. In the developed world, the paradigm for screening, diagnosis, and treatment for breast malignancy is perhaps the most sophisticated in all of cancer care. Radiologists play a role in preserving the quality of breast imaging, diagnosing minimally invasive disease, and caring for breast cancer patients.
In the developing world, the landscape is vastly different (1). While our specific intervention is directed to Tanzania, many challenges and opportunities are generalizable within neighboring East African community members of Kenya, Uganda, Tanzania, and Rwanda, as many cultural beliefs are borrowed from country to country due to intermarriage and open borders. Cultural beliefs towards healthcare and other social activities are similar among these countries (2).
As denoted in the Breast Health Global Initiative (BHGI) of 2005, women of low- and middle-income countries face numerous challenges (3,4). The Tanzania Breast Assessment Report of 2017 documents barriers affecting the screening and treatment of breast cancer at many levels. Institutional barriers include the lack of standardized protocols within healthcare institutions, limited healthcare facilities, limited breast-specific treatment expertise, lack of image-guided intervention, and limited availability of sophisticated multimodality therapies. Examples of individual barriers include travel logistics to receive care and the inability to pay for healthcare services, among others (5). A study of breast cancer knowledge and perception in Kenya noted poor knowledge of signs and symptoms of breast cancer, fear of stigma associated with a breast cancer diagnosis, fear of community and/or marital isolation, a preference for traditional healers, and inadequate access to services due to poverty (2).
These multilevel challenges for patients in developing countries likely contribute to the increasing incidence of breast cancer (6). When comparing rates of breast cancer, age standardized incidence, and mortality rates, and according to the Tanzania Breast Healthcare Assessment Report of 2017, the lifetime risk for presenting with breast cancer is currently approximately 1 in 20, and approximately half of those diagnosed will die of the disease (5). These statistics emphasize the need for improved early diagnosis and treatment for breast cancer in developing countries to include sub-Saharan African nations (6,7). Additionally, Vierra et al. systematically reviewed Pubmed articles related to breast cancer and breast cancer screening in developing countries (1). They note that while the incidence of breast cancer in developing countries is lower than in developed countries, breast cancer patient morbidity and mortality rates are higher due to late diagnosis, economic and logistical constraints, and a limited organized framework.
The updated National Comprehensive Cancer Network (NCCN) harmonized breast cancer guidelines for sub-Saharan Africa in 2017, and it is useful in beginning to understand diagnostic and treatment considerations for breast cancer in Africa. The use of clinical and physical breast examination with the added use of ultrasound, mammography, and ultrasound image-guided core biopsy is of paramount importance in the diagnostic assessment of various breast cancers and precursors as a set of treatment algorithms (8).
An important factor hindering the progress in breast cancer diagnosis and treatment, is a lack of adequately trained personnel. In this regard, continued advocacy and training of radiologists, pathologists, and surgeons on ultrasound-guided core biopsy in patients with palpable breast lumps may increase the rate of timely and accurate diagnosis, which could positively affect the currently poor outcomes data.
Yale New Haven Hospital (YNHH), Dartmouth Hitchcock Medical Center (DHMC), Muhimbili Academic Medical Center (MAMC), and Muhimbili National Hospital (MNH) have collaborated on a number of projects in both diagnostic and interventional radiology. Teams from North America travel to Tanzania, in two-week increments, and teach a myriad of topics. During the most recent trip in February 2019, in collaboration with Tanzanian medical and radiology staff, a training course for ultrasound-guided breast intervention at MAMC was initiated. This article outlines the initial work leading up to and during this intervention.
Preparation
On prior teaching trips, Tanzanian radiology residents received lectures on various topics surrounding breast disease and ultrasound-guided intervention and participated in breast intervention workshops utilizing gelatin and chicken breast “phantoms” (Figure 1). These lectures and workshops created a foundation for the introduction of ultrasound-guided 14-gauge automated core-needle biopsy to the Tanzanian women’s health portfolio. Until now, breast cancer diagnosis in Tanzania has been limited to fine needle aspiration (FNA) without image guidance (primarily performed by pathologists) and open surgical biopsy.
Preintervention biopsy workshop using chicken breasts as a phantom.
Preparations for the February 2019 teaching trip included compiling breast-specific lecture topics, acquiring 14-gauge automated biopsy capability, communicating with multiple departments at MNH and MAMC for collaboration, and devising a schedule and proposed workflow (Figure 2). In addition, utilization of local (Tanzanian) resources and supplies was maximized, with the goal being to optimize the transition to fully independent Tanzanian physician care. Supplies were acquired by a combination of procurement by Tanzanian hospitals and donations from private donors and radiology departments in the United States.
Workflow for the intervention.
Intervention
Recruitment and Selection of Patients
In the time between the most recent prior preparation trip and the intervention, Tanzanian radiologists and residents organized multiple “breast camps,” defined as targeted medical breast outreach programs offered to the general population at no patient cost. These camps were advertised largely on social media platforms, including Facebook, Twitter, Instagram, and Whatsapp, through the Road2IR handle, and by poster advertisements (Figure 3). According to the StatCounter website, in August 2019 the social media use statistics for the general population were as follows: Facebook 53%, Pinterest 21%, Twitter 13%, YouTube 6%, and Instagram 5.5% (9). Additionally, television and local radio advertisements and word of mouth were used to generate interest and participation. These weekend camps included focused patient history and clinical breast exams to identify patients for further imaging and possible biopsy. Prospective patients were screened by physical exam by medical providers, including radiology faculty and/or residents and local breast surgeons, in an effort to provide a high-yield pool of patients for possible intervention.
Poster disseminated through social media. An invitation in Swahili for women to attend a no-cost “breast camp” at MAMC.
A total of 114 women and 2 men presented for evaluation. Patients who had negative clinical examinations were discharged home and advised on the breast screening program; all women above the age of 40 were educated on breast self-examination, availability of clinical breast exam, and breast self-examination technique.
Of the 114 female patients, 25 had positive breast examinations, which included breast lumps, suspicious nipple discharge, breast pain, and abnormal breast appearance, and were subsequently scheduled for specialized treatment that included targeted breast imaging and consideration of ultrasound-guided biopsy. The schedule ran for two weeks under the supervision of the visiting attending breast radiologists and residents from various U.S. universities. During this two-week period, an additional 17 patients who had abnormal clinical breast examinations were referred to the radiology department by other physicians from various departments in the facility at MAMC.
Imaging and Biopsy
The 25 patients from the breast screening camp and the 17 additional referral patients were scheduled for ultrasound and limited mammography to consider possible ultrasound-guided core-needle biopsy. As noted above, mammographic evaluation is extremely limited in Tanzania, and therefore the training efforts were focused almost exclusively on ultrasound (10). While breast ultrasound has not been commonly performed in Tanzania to date, trainees and faculty are generally well acquainted with ultrasound imaging for other organ systems, with ultrasound playing a relatively larger role in imaging when compared to the United States.
The Tanzanian faculty and residents, which included the radiology, pathology, and surgical departments, underwent a two-day training and simulation of ultrasound-guided biopsy. The patients who had presented with possible breast pathology received diagnostic ultrasound. As needed for diagnostic decision-making prior to possible biopsy, 2D digital mammograms were also utilized. Imaging demonstrated cysts and/or galactoceles in six patients and potentially malignant findings in 30 patients, who then underwent ultrasound-guided biopsy. Six patients were lost to follow-up before imaging.
Based on prior experience, the desires of the local facilities, and personnel, the workflow was structured, and the interventions were accomplished at the academic hospital campus at MAMC. While this facility has the advantage of providing state-of-the-art hospital infrastructure, including modern ultrasound and mammography capabilities, there are challenges with this location. Unlike the academic medical center (MNH), which is located centrally in Dar es Salaam, MAMC is situated 36 kilometers away from the city center and remains difficult to reach for both patients and staff.
As is commonly seen with new workflow implementation, numerous challenges were encountered. Similar to any large hospital system, creating buy-in from hospital leaders was essential. The general concept and approach were discussed with the directors of the two major hospitals in Dar es Salaam, MNH, and MAMC. All steps of the training intervention were accomplished by coordination and close collaboration between visiting radiologists and Tanzanian residents and faculty, following a team concept for training and hands-on teaching. In an effort to increase interdepartmental communication, clinicians from other departments, including pathology and breast surgery, were involved in lectures and hands-on ultrasound biopsy sessions.
The MAMC radiology department includes four examination rooms, each containing a dedicated ultrasound machine. One room was assigned exclusively for diagnostic breast imaging and a second adjacent room for ultrasound-guided biopsy. An initial challenge included the adequate setup of the procedure room, using supplies brought from the United States combined with those available on site. Unlike patient encounters in the developed world, patients generally arrived in the morning and often waited for many hours as the team worked through the training and workflow process.
In Tanzania, imaging is performed primarily by the radiology trainee or faculty. Tanzanian and U.S. radiology residents and faculty were paired up for both scanning and procedures. For every patient interaction, the patient’s age, demographics, and a brief history were obtained using the available paper record, as electronic medical records (EMRs) are not yet fully developed. Depending on symptoms and patient age, one or both breasts were scanned by ultrasound. Abnormalities were documented in real time by the teams, as ultrasound images cannot currently be uploaded or stored in a picture archiving computer system (PACS). The ultrasound teams catalogued the size of the abnormalities with real-time teaching accomplished in the ultrasound parameters of the findings as well as possible approaches to ultrasound-guided intervention. Axillary evaluation was accomplished in some cases depending on the index lesion and level of concern.
Although relatively inexpensive by U.S. standards, each patient was required to prepay (approximately U.S. $35) for the combination of procedure, equipment, and pathology assessment. This was a subsidized fee during this intervention period. For the patients who could not afford to pay for the examination and/or intervention, they were assigned to a social worker and had their fees waived by the hospital. The average approximate yearly income in Tanzania is approximately U.S. $6800.
At the conclusion of each patient evaluation, the resident presented findings and suggested a plan to U.S. and Tanzanian faculty before proceeding with the intervention.
The next step was to move the patient to the designated biopsy room for the intervention. Time and effort were spent optimizing every intervention, as every step provided a training opportunity. As breast imaging and intervention represented uncharted territory for both Tanzanian trainees and faculty, the 11 residents and staff rotated through the process, allowing for equal exposure to all the steps involved. Table and tray preparation, sterile technique, needed supplies, patient positioning, and workflow organizing were emphasized during every procedure. Due to the low fixed-height exam table, the seated biopsy technique was employed. Ultrasound-guided local anesthesia with lidocaine, trocar use, and core-needle biopsy sampling with 14-gauge spring-loaded biopsy devices were performed by Tanzanian faculty and trainees. Although skilled in the techniques of ultrasound imaging at other body locations, the logistics and coordination of ultrasound-guided biopsy and the challenges specific to breast lesions were discussed. This included a specific focus on hand-eye coordination in biopsy sampling and the handling of the specimens (Figure 4).
Hand-eye coordination in biopsy sampling and specimen handling is practiced with active coaching.
Pathologic Examination and Patient Follow-up
The biopsied specimens were placed in formalin and accessioned by the pathology technicians, and subsequently analyzed by Tanzanian pathology residents and faculty. After performing biopsies, residents and staff were tasked with following up on results and discussing those results with patients. Of the patients seen, 43.3% were diagnosed with invasive breast cancer or ductal carcinoma in-situ (Table 1). Patients generally received results within a week and were then brought back to discuss the results and next steps, including referral to hospital surgeons for further management of the breast pathology. The patients who had benign findings were generally discharged home and asked to consider annual breast cancer screening if over the age of 40. As the ultrasound images cannot currently be stored, retaining patient information in relation to the findings was a challenge. The patient database was used to accomplish correlation with history, along with repeat real-time ultrasound scanning to confirm location and radiologic and pathologic concordance at the follow-up appointment. This was also an opportunity to check for postbiopsy complications.
Chart Showing Breast Pathologies After Biopsy
| Biopsy Outcome | N (%) |
|---|---|
| Invasive ductal carcinoma | 8 (26.7%) |
| Ductal carcinoma in situ | 3 (10.0%) |
| Non-specific benign breast tissue | 4 (13.3%) |
| Fibroadenoma | 6 (20%) |
| Tubular adenoma | 2 (6.7%) |
| Adenosis | 3 (10%) |
| Phyllodes tumor | 1 (3.3%) |
| Invasive lobular carcinoma | 1 (3.3%) |
| Ductal hyperplasia | 1 (3.3%) |
| Non-specific malignant disease | 1 (3.3%) |
| Total | 30 (99.9%) |
| Biopsy Outcome | N (%) |
|---|---|
| Invasive ductal carcinoma | 8 (26.7%) |
| Ductal carcinoma in situ | 3 (10.0%) |
| Non-specific benign breast tissue | 4 (13.3%) |
| Fibroadenoma | 6 (20%) |
| Tubular adenoma | 2 (6.7%) |
| Adenosis | 3 (10%) |
| Phyllodes tumor | 1 (3.3%) |
| Invasive lobular carcinoma | 1 (3.3%) |
| Ductal hyperplasia | 1 (3.3%) |
| Non-specific malignant disease | 1 (3.3%) |
| Total | 30 (99.9%) |
Chart Showing Breast Pathologies After Biopsy
| Biopsy Outcome | N (%) |
|---|---|
| Invasive ductal carcinoma | 8 (26.7%) |
| Ductal carcinoma in situ | 3 (10.0%) |
| Non-specific benign breast tissue | 4 (13.3%) |
| Fibroadenoma | 6 (20%) |
| Tubular adenoma | 2 (6.7%) |
| Adenosis | 3 (10%) |
| Phyllodes tumor | 1 (3.3%) |
| Invasive lobular carcinoma | 1 (3.3%) |
| Ductal hyperplasia | 1 (3.3%) |
| Non-specific malignant disease | 1 (3.3%) |
| Total | 30 (99.9%) |
| Biopsy Outcome | N (%) |
|---|---|
| Invasive ductal carcinoma | 8 (26.7%) |
| Ductal carcinoma in situ | 3 (10.0%) |
| Non-specific benign breast tissue | 4 (13.3%) |
| Fibroadenoma | 6 (20%) |
| Tubular adenoma | 2 (6.7%) |
| Adenosis | 3 (10%) |
| Phyllodes tumor | 1 (3.3%) |
| Invasive lobular carcinoma | 1 (3.3%) |
| Ductal hyperplasia | 1 (3.3%) |
| Non-specific malignant disease | 1 (3.3%) |
| Total | 30 (99.9%) |
Conclusion
There are several challenges to implementing image-guided breast diagnosis in Tanzania, including limited access to care, affordability, time away from family, and the ability to receive treatment after diagnosis. However, as care improves from a basic level to a more sophisticated model, ultrasound-guided intervention may offer an opportunity as the tool of choice for image-guided diagnosis, as improving access to ultrasound technology coincides with a significant increase in the number of trained Tanzanian radiologists. As previously determined in the developed world, imaged-guided core-needle biopsy offers an accurate, well-tolerated, and relatively inexpensive option for this purpose.
Our intervention introduced our Tanzanian colleagues to the process of image-guided breast intervention, with an interest in a continuing service, pivoting towards improving access to care, diagnosis of early stage disease, and providing a window into future advances in treatment.
The intervention reported here was limited in time and scope but provided an example of what may be possible in the future. The hope is that local radiologists can eventually continue the process independently. Furthermore, this intervention was an opportunity to emphasize protocols for the imaging and diagnosis of breast cancer and other breast diseases using BI-RADS (11). A secure tracking and follow-up system for the patients who have been seen in the program will need to be established in order to create an adoptable and self-sustaining system. The ultimate goal is to create a model that can be easily replicated throughout sub-Saharan Africa.
Funding
None declared.
Conflict of interest statement
None declared.
