Breast Ultrasound Program Aids Ugandan Care

After completing a series of proof-of-concept studies, researchers with Imaging the World (ITW) in Burlington, VT, and Naalya, Uganda, are implementing an ultrasound-based healthcare pilot program designed to bring breast cancer diagnosis and treatment to underserved areas of Uganda.

Currently, the non-profit organization operates obstetric ultrasound imaging programs at 11 Ugandan rural health clinics. “Our goal this summer is to expand the imaging program to offer ultrasound to patients with palpable breast masses,” says Kristen DeStigter, MD, cofounder of ITW and vice chair of the Department of Radiology at the University of Vermont and Fletcher Allen Health Care in Burlington.

Breast cancer is the second most common form of cancer in Ugandan women (behind cervical cancer). The peak age for diagnosis in the country is 30–39 years, the incidence is increasing, and more than 75% of breast cancer patients are diagnosed with stage III or IV disease.

“Many women are diagnosed with advanced disease and receive only palliative care,” says DeStigter. “Women in Uganda often don't go to a doctor when they feel a lump because diagnostic facilities are too far away, or they fear surgery, or they just assume a diagnosis of breast cancer is a death sentence.”

To address these concerns, ITW has worked closely with the Ugandan Ministry of Health and Ugandan doctors to develop a breast-care algorithm to guide clinicians and patients from ultrasound evaluation in a remote, rural setting to treatment in the country's capital. The program relies on the use of portable ultrasound machines to capture images, which are then compressed on a laptop computer and sent via Internet and cell phone networks.

“The unique component of our program is that we train local midwives at clinics in remote areas to generate ultrasound images by following a standardized, volumetric scanning methodology,” says DeStigter. “Then, we transmit those images to a referral hospital where trained experts read the scans. Offering this service in remote areas is a real paradigm shift in how ultrasoundenabled healthcare is delivered.”

Ginger Merry, MD, MPH, the project manager and a breast imaging fellow at Northwestern Memorial Hospital in Chicago, IL, says pilot studies conducted in 2011 involved training 3 midwives to generate scans and 3 doctors to perform ultrasound-guided biopsies.

To test the validity of the ITW ultrasound scanning protocol, a separate study at the University of Vermont is comparing it to traditional breast ultrasound performed by professional sonographers. Early results show the approach is well suited for use in rural Africa.

“While mammography remains the gold standard for breast imaging, ultrasound is more practical for under-resourced settings,” says Merry. “There are very few mammography machines in Uganda. In addition, several studies have shown that ultrasound is more sensitive than mammography in younger women with dense breast tissue, and African women develop breast cancer at a younger age when women may have denser breasts. Therefore, ultrasound may be the most appropriate imaging tool for these women.”

In March 2013, ITW worked with Ugandan healthcare leaders to firm up the patient education and community outreach aspects of the algorithm. During a 3-year prospective study set to start in August, ITW researchers will train midwives, sonographers, and doctors in using the algorithm; educate patients and communities; and establish an electronic tracking system to generate data that can contribute to a viable breast cancer registry in the country.

“Our goal is for the program to become a sustainable model in Uganda as well as expandable to other countries,” says DeStigter.

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