Early experience scaling up a breast cancer early detection initiative integrated with cervical cancer screening in...

Late-stage breast cancer contributes to a growing number of deaths in sub-Saharan Africa (SSA) but few studies examine scalable early detection strategies. Following small-scale pilots, in 2020 Rwanda launched an adapted Women's Cancer Early Detection Programme (WCEDP), integrating clinical breast exam (CBE) for symptomatic patients with cervical cancer screening. A WCEDP-specific electronic health record (EHR) was developed to facilitate patient tracking.

We used the RE-AIM implementation science framework to retrospectively evaluate implementation of breast cancer early detection within the WCEDP over 12 months in the first three scale-up districts (population: 2 009 888), using routinely-collected electronic and paper data from 15 health centres and 3 hospitals. We examined the WCEDP's Reach in the target population, Effectiveness linking patients to care, Adoption by facilities and fidelity to the Implementation protocol.

Regarding Reach, average weekly health centre visits for CBE increased from 18 to 33 post-WCEDP launch; of 1688 women receiving CBE through the WCEDP, 12.0% were ≥50 years. Regarding effectiveness, among 383 women referred to district or referral hospitals, 157 (40.9%) had no documented referral facility visit. Of those seen at a referral facility, median days from health centre to district hospital visit and from district to referral hospital visit were 6 (IQR 1.8-14.8) and 8 (IQR 5.0-40.5) respectively. Among the 36 patients receiving biopsy, 72.2% were biopsied within 60 days of initial presentation. In terms of adoption, 79 clinicians were trained in cancer early detection, with 69.6% remaining at WCEDP facilities after 3 years. Regarding implementation fidelity, WCEDP clinics were held 52.6% of weeks. EHR data quality was inconsistent, with half of patients seen at district hospitals for breast care lacking EHR documentation.

Breast cancer early detection services can be implemented in resource-constrained SSA health facilities. Integration with cervical cancer screening may be a promising strategy. However, investing in data systems is critical to support programme evaluation and high-quality care.