Over 21,000 women screened for breast cancer in Ethiopia thanks to decentralized services

The problem

Breast cancer is the most prevalent cancer in Ethiopia, accounting for around 20 percent of the national cancer burden and a third of all cancer deaths among women.[1] Starting in 2018 and with the support of CHAI, the American Cancer Society (ACS), the Norwegian Cancer Society, and the Norwegian Pink Ribbon Campaign, the Ethiopian government expanded breast cancer treatment services from just two hospitals in the capital city, hundreds of miles from most patients, to 20 hospitals across the country to increase access to services. As a result, over 6,000 women benefited from decentralized treatment at regional hospitals, dramatically reducing waiting time to start treatment from several months to just a week after diagnosis.

Nevertheless, over 70 percent of women in Ethiopia are still diagnosed at advanced stages of the disease when their chances of survival are diminished.[2] Because of a lack of awareness of the disease, the absence of screening programs at primary healthcare levels, weak referral pathways, and limited access to diagnostic services, many women start receiving the help they need when it is too late. Logistical challenges also further cause delays in the start of treatment. Before a woman can start treatment, a confirmatory diagnosis is required; a tissue sample is taken from her and sent for laboratory tests, which are typically only conducted at comprehensive hospitals if she manages to make it to the facility at all. Many women cannot afford the transportation costs to facilities for preliminary examinations.

In 2021, the government of Ethiopia renewed its partnership with CHAI and other partners to enhance early detection of breast cancer by strengthening screening and diagnostic capabilities at the primary healthcare level and improving linkages to care.

Map of breast cancer treatment service hospitals in Ethiopia

The Approach

CHAI supported the Ministry of Health in establishing early detection programs for breast cancer at five regional hospitals and 87 primary-level facilities in their catchment areas. Our support focused on:

• Training non-specialist health workers (e.g., general doctors, nurses, midwives) to conduct a clinical breast examination (CBE), a simple and cost-effective screening method recommended by the World Health Organization (WHO) in resource-constrained settings.[3]
• Training general doctors at primary hospitals to obtain a tissue sample with fine needle aspiration, a method that minimizes the need for complex equipment and extensive lab processing.[4]
• Strengthening referral pathways so that a suspected breast cancer case detected at a primary facility is quickly and correctly referred to higher-level hospitals where diagnosis and treatment are available.

Per the model guidelines, all women aged 20 and above who visit a primary hospital are offered a CBE. If any abnormality is detected, the patient undergoes a fine needle aspiration to obtain a sample of tissue. The collected samples are then sent to a referral regional hospital where a trained pathologist assesses them, leveraging the existing sample transportation system used for HIV and tuberculosis. The average lab processing time of fine needle aspiration samples has dropped from five to three days since the start of the program before a patient can receive their final diagnosis. When a patient receives a positive diagnosis, they are immediately referred for further care.

The results

In the first 1.5 years of the program alone, over 21,000 women have accessed screening services, and close to 1,000 women have been referred for further tests, thanks to decentralized and accelerated diagnostic services.

Transformational change

The program has demonstrated that when health services such as breast cancer screening are brought closer to communities, it empowers more women to get screened sooner, increasing the chances of breast cancer being caught early while it is still curable. The easy access to facilities means that women reduce unnecessary transport expenditures and time away from families and jobs, and can take better care of their health.