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

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.