Using patient navigation to reduce time to diagnosis of breast cancer in Uganda

J Am Coll Radiol. 2024 Mar 8:S1546-1440(24)00273-4. doi: 10.1016/j.jacr.2024.03.006. Online ahead of print.

Abstract

Objective: The Ugandan Ministry of Health adopted the Breast Imaging-Reporting and Data System (BI-RADS) as standard of care in 2016. We performed a medical audit of breast ultrasound practices at four tertiary-level hospitals to assess interpretive performance. We also determined the effect of a low-cost navigation program linking breast imaging and pathology, on percent of patients completing diagnostic care.

Methods: We retrieved 966 consecutive diagnostic breast ultrasound reports, with complete data, performed on women aged >18 years, presenting with symptoms of breast cancer between 2018-2020 from participating hospitals. Ultrasound results were linked to tumor registries and patient follow-up. A medical audit was performed according to the American College of Radiology BI-RADS Atlas, 5th edition, and compared to results from a prior audit performed in 2013. At Mulago hospital, we piloted an intervention based on patient navigation, cost sharing, and same day imaging/tissue sampling/pathology.

Results: 888 (91.9%) of breast ultrasound examinations were eligible for inclusion. Compared to 2013, the post-intervention cancer detection rate increased from 38 to 148.7 cancers/1,000 examinations; Positive Predictive Value (PPV)2 from 29.6% to 48.9%; and PPV3 from 62.7% to 79.9%. Specificity decreased from 90.5% to 87.7%, and sensitivity from 92.3% to 81.1%. Mean time from tissue sampling to receipt of a diagnosis decreased from 60 days to 7 days. The intervention increased the percentage of patients completing diagnostic care from zero to 100%.

Discussion: Efforts to establish a culture of continuous quality improvement in breast ultrasound require robust data collection that links imaging results to pathology and patient follow-up. Interpretive performance met BI-RADS benchmarks for palpable masses, except sensitivity. Our resource appropriate strategy linking imaging, tissue sampling, and pathology interpretation decreased time to diagnosis and lost to follow-up rates and improved the precision of the audit.

Keywords: BI-RADS; Breast ultrasound; Low- and middle-income countries (LMICs); Uganda; audit; diagnostic breast imaging; patient navigation.