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Women wait for screening services at a clinic in Tanzania. Photo courtesy of The Medical Women Association of Tanzania.

Time to ACT - Implementing strategies for breast cancer control in Africa

October 25, 2019 by Crystal Cazier
Crystal Cazier speaks to Dr. Anne Rositch of Johns Hopkins Bloomberg School of Public Health about a research study she's leading to implement strategies for breast cancer control in Africa.

Crystal interviews Dr. Anne Rositch, Assistant Professor, Epidemiologist and Implementation Scientist at the Johns Hopkins Bloomberg School of Public Health. Dr. Rositch is the principle investigator of the research study Time to ACT - Implementing strategies for breast cancer control in Africa, which the Bush Institute supports through the generous giving of the National Breast Cancer Foundation. The study is also funded with a grant from Susan G. Komen.

In Breast Cancer Awareness month, we explore the landscape of breast cancer care in sub-Saharan Africa and how Dr. Rositch is collaborating with communities, healthcare workers, the Tanzanian government, and other stakeholders to improve breast cancer control and care in the region.

Crystal Cazier: What is the landscape like for breast cancer care in sub-Saharan Africa? What are some of the challenges?

Dr. Anne Rositch: Breast cancer is currently more common in high-income countries, but incidence is increasing rapidly in low- and middle-income countries. As countries develop economically, we see lifestyle changes that contribute to breast cancer risk – poor diet, less physical activity, having children later in life, and less breast feeding. As incidence of breast cancer is increasing, so is mortality. Why is breast cancer so fatal? There is a lack of early detection programs, little awareness of breast cancer, and limited capacity for diagnosis and treatment. When you combine changes in lifestyle with lack of infrastructure, you have the perfect storm. We must work on changing lifestyle factors that contribute to breast cancer risk, while at the same time improve infrastructure for early detection, diagnosis, and treatment for better outcomes.

CC: Tell us about the Time to ACT study.

AR: With that landscape in mind, in 2017, the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) enlisted the help of partners including the Bush Institute and Susan G. Komen to facilitate a workshop for the development of breast cancer guidelines. I was part of that workshop. The objective was to prepare Tanzania’s plan for combatting breast cancer. The plan focuses on clinical breast examinations for symptomatic women.

It was around that time that I developed the idea for this study. The Ministry wanted to be more proactive about breast cancer, but I knew needed more data to inform plans to improve early detection and care. This is not a typical research study — we took a more agnostic approach, allowing each phase of the study to inform the next. We knew that we needed to know more about local context when it came to breast cancer and started there.

The Time to ACT study has three phases: 1. Assess the local context for breast cancer awareness, education, and infrastructure; 2. Couple data on the local context with evidence-based interventions; and, 3. Test implementation strategies to improve breast cancer control and care. We have completed the first two phases of the study and are now on the third phase.

CC: Why is this study important?

AR: When we have a better understanding of breast cancer control broadly, we can increase awareness, early detection, diagnosis, and treatment. Understanding the full landscape is essential if we are going to ultimately reduce breast cancer mortality. This study takes a step back and looks at local context first. In Tanzania, there has been limited research to understand both the community perspective and context and the perspective of clinical providers – what breast cancer risk factors and symptoms to look for. This is a multi-level approach to assess breast cancer awareness, the priority they place on breast cancer, and the barriers to care.

These are things we can work on together to facilitate better breast cancer care.

We took all this information from women in the community, healthcare providers, and in-depth interviews from other stakeholders to help inform interventions for breast cancer care. Supported by data and stakeholders’ perspectives, we have now identified evidence-based interventions that we will test in the third phase of study, where we are now.

CC: What intervention(s) will you be testing?

AR: The intervention is a standardized clinical pathway at a zonal hospital, the highest-level hospital in the Tanzanian healthcare system. If we can improve care there, we can get more women through the system more efficiently. The clinical pathway includes more diagnostics and a tumor board for comprehensive care planning for women with breast cancer.

CC: What have you already learned?

AR: From data collection, we identified barriers to care including personal barriers such as finances, but also knowledge barriers such as low levels of awareness of breast cancer, its risk factors, and symptoms. If a woman doesn’t know what the symptoms of breast cancer are, she doesn’t seek care immediately.

We also learned that providers are aware of breast cancer but would like more education and training on breast cancer, especially how to identify it, and what they can do at their facility. Finally, we have done an extensive medical chart review and estimated the time it takes a woman to obtain treatment once she presents to care. This is an important marker so we can reduce time from diagnosis to treatment.

CC: What do you hope to learn from this study?

AR: Now that we’ve put together an intervention, we hope to see if we can get the hospital system to work better for women with breast cancer. We lose a lot of women to the healthcare system and those that do remain in care face long wait times and a very complex system. We hope our interventions will help retain women to get complete diagnosis and treatment in a timely manner.

The tumor board will also improve treatment planning and patient outcomes. Our hope is that now that physicians can better diagnose breast cancer, they can provide comprehensive and complete treatment that leads to better survival for breast cancer patients.

CC: How can the findings of this study change the options for breast cancer control in Africa? What are the practical implications of the study?

AR: We are hoping for two things. From a research perspective, we hope the cancer research community will see the design of this study as valuable. The research design of our study allows adaptation for future phases of research based on what was learned in the previous phases. It also emphasizes working with the community and stakeholders to inform future phases of research.

We also want to figure out what options and tools are already available and how we make them really work – for women, for the healthcare system, and for the providers. How can clinical breast examinations get more women into care and get that care to work for more women. We then take these tools and learnings and apply them to real life to improve options for women in care and provide training for diagnostic tools and treatment planning. Improving these will result in better and more sustainable outcomes for women in Tanzania and similar settings.


Crystal Cazier
Crystal Cazier

Crystal Cazier serves as Program Manager for the Global Health Initiative and for Evaluation and Research at the George W. Bush Institute. In this role, she helps coordinate the Bush Institute’s involvement in The Partnership to End AIDS and Cervical Cancer, a collaboration of the Bush Institute, PEPFAR, and UNAIDS that works with eight countries in sub-Saharan Africa to prioritize HIV-positive women in national cervical cancer prevention and control programs. She also serves on the research and evaluation team which supports programming across the Bush Institute.

Before joining the Bush Institute, Crystal worked as a Clinical Research Associate at Carle Cancer Center in Urbana, Illinois where she managed budgetary and contractual negotiations for both pharmaceutical and government-sponsored clinical trials. 

Crystal received her undergraduate degree from the University of Illinois in Urbana-Champaign and is currently pursuing a Master of Public Health at the University of Texas Health Science Center.

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