Adding Triage Ultrasound to a Breast-Cancer Detection Model in Peru

Background: The rising breast-cancer burden in middle-income countries is straining the capacity of health systems to provide early detection and diagnostic services. To bring these services to women in a northern region of Peru, community education and clinical breast exam (CBE) by midwives was introduced as a method for screening asymptomatic women and evaluating women with symptoms; if positive, women were evaluated further by fine needle aspiration (FNA) by a trained physician at a local hospital. Aim: During the pilot phase, this early detection program resulted in increased demand for cytopathology services, invasive procedures for patients, delays in results, and high rates of benign findings. We added basic triage ultrasound (US), performed and interpreted by general physicians at a local hospital, to further evaluate women with a positive CBE and reduce the number of unnecessary FNAs. We aim to evaluate the changes in the FNA rate. Methods: PATH worked with an expert radiologist to develop a breast-US training program that included: teaching physicians to perform and interpret breast US using a triage algorithm based on the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) and a standardized checklist to document clinical and US findings. The triage algorithm was reviewed and validated by oncologists at Peru's national cancer institute, and later introduced in ten networks in northern Peru. Results: After adding triage ultrasound in 2015, a total of 133 CBE+ women received US at the local hospital; 73 women had a finding on US indicating a need for FNA biopsy, and all received it. Eleven of these women were subsequently diagnosed with breast cancer. Without triage US, all 133 CBE+ women would have received FNA. This represents a 55% decrease (60/133) in FNA biopsies. Conclusion: Triage ultrasound, as part of a resource-adapted model of breast screening, combined with FNA sampling increases the ability of general physicians to manage CBE+ women locally, thereby reducing health system burdens and assuring that patients at highest risk receive timely referrals to a specialized hospital. Triage ultrasound reduces the biopsy rate following a positive CBE. As ultrasound technology becomes more accessible and less expensive, we anticipate there will be an even more significant role for it in early detection models.