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J Glob Oncol. 2018 Sep;(4):1-10. doi: 10.1200/JGO.17.00098.

Impact of Breast Cancer Early Detection Training on Rwandan Health Workers' Knowledge and Skills.

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Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA.



In April 2015, we initiated a training program to facilitate earlier diagnosis of breast cancer among women with breast symptoms in rural Rwanda. The goal of this study was to assess the impact of the training intervention in breast cancer detection on knowledge and skills among health center nurses and community health workers (CHWs).


We assessed nurses' and CHWs' knowledge about breast cancer risk factors, signs and symptoms, and treatability through a written test administered immediately before, immediately after, and 3 months after trainings. We assessed nurses' skills in clinical breast examination immediately before and after trainings and then during ongoing mentorship by a nurse midwife. We also examined the appropriateness of referrals made to the hospital by health center nurses.


Nurses' and CHWs' written test scores improved substantially after the trainings (overall percentage correct increased from 73.9% to 91.3% among nurses and from 75.0% to 93.8% among CHWs ( P < .001 for both), and this improvement was sustained 3 months after the trainings. On checklists that assessed skills, nurses' median percentage of actions performed correctly was 24% before the training. Nurses' skills improved significantly after the training and were maintained during the mentorship period (the median score was 88% after training and during mentorship; P < .001). In total, 96.1% of patients seen for breast concerns at the project's hospital-based clinic were deemed to have been appropriately referred.


Nurses and CHWs demonstrated substantially improved knowledge about breast cancer and skills in evaluating and managing breast concerns after brief trainings. With adequate training, mentorship, and established care delivery and referral systems, primary health care providers in sub-Saharan Africa can play a critical role in earlier detection of breast cancer.

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