The Value Chain for Breast Cancer in Botswana

Abstract

Breast cancer is the leading cancer killer of women globally, with an estimated 22.2 million cases in Africa alone by 2030. However, the mortality to incidence ratio is much higher in low and middle income countries (LMICs), including Africa, relative to high income countries (HICs). The value chain for breast cancer, meaning all the essential steps required to improve outcomes, is long and complex. In order to effect positive change for breast cancer in LMICs, understanding this value chain and improving each component must be achieved to elevate the standard of care. This value chain consists of education and awareness, screening, evaluation for suspected cancer, multimodality treatment, and long-term follow-up. This thesis presents work in 3 of these domains: screening, evaluation for suspected cancer, and long-term follow-up. Regarding screening, we analyzed the outcomes from a cohort of over 6000 women who were screened using clinical breast exams regarding number of cancers diagnosed, time to diagnosis, and the burden of diagnostic testing performed. For evaluation of suspected cancer, we conducted a landscape analysis to get feedback from key stakeholders regarding a novel diagnostic device for breast cancer and evaluated feasibility of using the device for people with varying degrees of lab skill. Lastly, we evaluated long-term effects of HIV status on change in quality of life among women surviving at least 18 months. Each of these projects contributes to a critical component of the value chain for breast cancer in Botswana. The diagnostic portion of the value chain, screening through definitive diagnosis, could be substantially improved in terms of quality and timeliness by efforts presented here.