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Improving Breast Cancer Outcomes for African Women

July 31, 2019
by Jane E. Dee

For Melissa Durand, MD, interest in a medical service mission was piqued several years ago when she attended a grand rounds lecture sponsored by the Department of Radiology & Biomedical Imaging at Yale School of Medicine (YSM). The talk mentioned volunteer opportunities with, the nonprofit group that works to improve medical imaging and radiology in developing and emerging countries.

Wanting to learn more, Durand attended a RAD-AID national conference at the World Health Organization in Washington, D.C.

“All of their presentations were so inspiring,” said Durand, an assistant professor of radiology & biomedical imaging at YSM.

After meeting one of RAD-AID’s breast program directors, Durand signed on as a volunteer for a 2019 trip to Ghana, West Africa.

For eight days in early June, Durand volunteered at Ghana’s second-largest teaching hospital, the 1,200-bed Komfo Anokye Teaching Hospital (KATH) in Kumasi, the regional capital of the Ashanti Region that serves a population of about 5 million people.

Breast cancer is the most common cause of female cancer deaths in Ghana, where the five-year survival rate is estimated to be 25%. In the United States, the survival rate is 90%. Many of the breast cancer patients treated at KATH are young women in their 30s and 40s.

“The survival rate is low; people were presenting in late stage,” Durand said. “At Yale we have a weekly tumor board with surgeons, radiologists, and oncologists to talk about cases that are 1 centimeter in size. There, we saw tumors that were 10 centimeters, and in younger women.”

Often, a woman will not come to the hospital until she feels a lump, she said.

Durand conducted a radiology readiness assessment survey for RAD-AID, outlining the hospital’s breast imaging needs. As RAD-AID’s breast imaging lead for Ghana, she plans to return to KATH next year to, among other things, teach its radiologists and surgeons to perform ultrasound-guided biopsies, and to establish a system for biopsy record-keeping.

“What’s so attractive about the experience is that you feel you are changing something for the better,” she said.

In the meantime, RAD-AID is in talks with the vendor Hologic to donate a Viera portable ultrasound unit to the teaching hospital.

A week before leaving for Africa, Durand mentioned her trip to Judith Abaidoo, a mammography technologist at Yale New Haven Hospital’s Shoreline Medical Center.

“I said, ‘You’re going to Ghana? That’s my country!’” Abaidoo said.

Abidoo received her training at Korle-Bu Teaching Hospital in Accra. Working as a new radiographer in the early 1990s, she walked into a room where a male radiographer was performing a mammogram. “Afterwards I went to the director of the program and asked why was this man doing mammograms because there are girls here who could be trained to do it,“ Abaidoo said.

The director took her up on her idea, training Abaidoo and another student. “We were among the first group of women to do mammograms in Ghana. That was more than 20 years ago,” she said.

One of the challenges to improving breast cancer outcomes for African women is overcoming traditional beliefs and cultural barriers, Durand said. Some women rely on traditional healers and prayer, and will only go to a doctor when those methods fail, she said. But by then the cancer has likely become more advanced and harder to treat. Transportation and long travel distances also are barriers to receiving care, she said.

Still, the hospital is busy, with up to 50 patients visiting its Breast Care Centre each day. But the process can be time-consuming. If an examination shows the need for an ultrasound, the patient must return to the center for a follow-up appointment a week later. And if the ultrasound reveals a tumor that requires a biopsy, the patient must return for a third appointment.

Less than half of the patients who need an ultrasound or a biopsy return for these procedures, Durand said. Cost is one reason. While the national insurance program covers breast cancer treatment, the work-up to get a diagnosis of breast cancer is not. “As such, the cost of the tests can be prohibitive,” she said.

As a mammography technologist in Ghana, Abaidoo participated in outreach programs, talking about breast health to women at their churches.

During this time, one of her patients was a nurse whose younger sister had been Abaidoo’s childhood friend. “I was working when the head of the department called for me. He had a patient he wanted me to do a mammogram on,” she recalled.

“She had full-blown breast cancer. She died less than two months after that mammogram,” Abaidoo said. “Screening was still not common then, but she was a nurse, so it broke my heart.”

While more women in Ghana are being screened for breast cancer, the procedure is expensive, she said. “The people who can afford it are doing it. The women who can’t afford it only come when they feel a lump.”

Among the physicians Durand met through RAD-AID was Lisa Newman, MD, chief of the Section of Breast Surgery at Weill Cornell Medicine and New York-Presbyterian who traveled to Ghana at the same time Durand was there, and who runs a clinical trial at KATH. Newman’s research has shown that Ghanaian women have the highest frequencies of triple-negative breast cancer in Africa. In the United States, African American women have a higher incidence of triple-negative breast cancer when compared to Caucasian women. According to Newman, the patterns make sense if you look at maps of the transatlantic slave trade that brought Africans from West Africa to serve as slaves in the U.S. Colonies. Their descendants, some of today’s African American women, are the result of that diaspora, Durand explained.

Newman also has co-authored a recent study that identified a set of gene variants that originated in Sub-Saharan West African populations that might explain why African American women have worse breast cancer outcomes than Caucasian women.

Before she left Ghana, Durand and Newman visited a slave fortress on the coast of Ghana where Africans were imprisoned before crossing the Atlantic. Several weeks after her return to Yale, Durand was still visibly moved by what she saw there.

“You can’t believe something like that happened,” she said.

In her radiology readiness assessment for RAD-AID, Durand outlined the lack of supplies such as biopsy devices, marker clips and sterile probe covers, as well as a lack of functioning imaging equipment. The breast cancer center has not had a working mammography unit for six years, as its sole unit never worked due to a software malfunction. There is no image-guided biopsy capability; biopsies on late-stage tumors are done by feel. Ultrasound can help the radiologists target a tumor if it cannot be felt, Durand said.

“The need for image-guided procedures is also critical because as patients begin to present at earlier stages, which is the goal, these smaller masses will be more difficult to biopsy free-hand,” she said.

In addition to an ultrasound, KATH has an MRI Center with a 1.5T MRI unit that had been used once. A new CT scanner is expected to be purchased soon, and there are plans to install a PACS system, Durand said.

“RAD-AID could best support breast imaging at KATH by training radiologists in image-guided procedures, and supporting the purchase of a working mammography unit, preferably one with digital breast tomosynthesis, as well as an additional ultrasound unit,” Durand said. “A mobile unit would be very useful for taking breast screening and awareness programs directly to communities.”

Durand recently gave a short talk about her trip to the department’s breast section. “Many of our technologists expressed interest in helping out in some way. Many even want to come to Ghana to help share their expertise in performing ultrasound and mammography, which will come in handy if we are able to move things forward with KATH getting their mammography unit replaced,” Durand said.

“We have such a talented group of people in breast imaging at Yale. It made me really happy to see their enthusiasm to help.”

Submitted by Angel Machon on July 29, 2019