The burden of breast cancer is rising rapidly in low- and middle-income countries (LMICs), where most women
with breast cancer are diagnosed with advanced-stage disease. Largely because of late-stage presentations,
despite lower age-standardized incidence of breast cancer in sub-Saharan Africa, the region’s breast cancer
mortality rates are higher than the United States’. We previously studied an intervention to facilitate timely
evaluation of breast symptoms in a single Rwandan district (Burera District) which increased the number of
women receiving evaluation for breast symptoms and increased early-stage diagnoses. However, effective
strategies to scale-up breast cancer early diagnosis programs in resource-constrained primary health
care systems are not well-understood. Particular challenges for scaling early diagnosis include integration of
clinical breast assessment with other primary care services and facilitating timely, reliable linkage of patients
with concerning breast findings to higher levels of care. The objective of this research project is to study
implementation successes and challenges of Rwanda Biomedical Centre’s (RBC’s) scale-up of the Burera
intervention to other districts. To facilitate scaleup, RBC has adapted the program to integrate breast cancer
awareness-raising and evaluation of symptomatic women into a cervical cancer screening initiative and is
utilizing a tablet-based electronic medical record to facilitate patient tracking. This project will evaluate
implementation of this adapted scaleup initiative, and facilitators of and barriers to successful implementation.
In Aim 1 we will use the RE-AIM framework to retrospectively examine the WCEDP’s reach, effectiveness,
adoption and facilities’ implementation fidelity over the program’s first year. In Aim 2, we will use qualitative
methods guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify
health workers’ perceptions of fit, feasibility and acceptability of the WCEDP and inner and outer context
factors influencing success. We will also interview women diagnosed with breast cancer through the WCEDP
to explore fit, acceptability, and participation barriers and facilitators. Understanding the implementation
successes and challenges of this adapted model will inform further adaptations that can be studied in a larger
research project and linked to longer-term outcomes. This project aligns with the National Cancer
Institute’s special interest in implementation research related to cancer control in LMICs and its
commitment to pursuing equity in global cancer control.
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