Lawrence Shulman, MD

Creating healthcare infrastructure and training health care professionals in Rwanda to ensure that previously underserved women receive quality screening and treatment for breast cancer.

Impact

Breast cancer is a major public health concern in low- and middle-income countries such as Rwanda, where women have a much higher risk of dying from their disease. This is due, in part, to delayed and late-stage diagnoses. By focusing on training and infrastructure, Drs. Shulman and Shyirambere have developed effective strategies to integrate early detection services into the health care system in rural Rwanda and reduce time to treatment. To date, the team has trained hundreds of Rwandan health care workers in ways to educate patients about breast cancer, perform high-quality breast exams, utilize ultrasound to identify those who may have cancer, and refer patients for timely diagnosis and treatment. Their program has provided breast exam screening to thousands of patients and expanded into four districts in the country, leading to significant improvement in patient outcomes. They are now working to expand these efforts to reach more women with the goal of reducing breast cancer deaths in Rwanda and other low-income countries and shaping national cancer control policy.

Progress Thus Far

One of their major innovations has been the development of a tablet-based electronic medical record that allows clinicians to share information across facilities and identify patients who have missed visits and re-engage them in care. This mobile platform also helps patients navigate the health care system and obtain timely care and maximize any follow-up care. Drs. Shulman and Shyirambere have developed and implemented a Women’s Cancer Early Detection Program Learning Collaborative in two key districts and 19 health centers in Rwanda. This Collaborative focuses on clinical mentorship, local leadership, and building a culture of data-driven practice improvement. In addition, Drs. Shulman, Shymirambere, and their colleagues are seeking to offer U.S.-driven advancements in diagnostic curriculum to Rwandan radiologists. To accomplish this, they have engaged a local leader and radiologist as a trainer to serve as a liaison. The team has leveraged their success with virtual mentorship and employed previously trained Rwandan medical staff to implement virtual and in-person ultrasound training and mentorship to other radiologists. These efforts will help to decentralize breast ultrasound expertise from cancer hospitals in Rwanda to smaller district hospitals.

What’s next

The team will continue to expand their clinical trials program to other districts in Rwanda and evaluate the program’s impact on the health system and patients. Refinement of their patient navigation model to improve its delivery, address barriers to care, and facilitate patient re-engagement is ongoing. While ultrasound imaging is successfully being decentralized, the team will develop an ultrasound skills metric that can be used to determine which non-radiologist clinicians possess the necessary skills to perform breast ultrasound. Simultaneously, Drs. Shulman and Shymirambere will develop and implement a training program for non-radiologist clinicians at district hospitals to perform ultrasound-guided core needle biopsy. These studies will expand the cadre of Rwandan clinicians with U.S. diagnostic skills and bring these important diagnostic services closer to patients’ homes and facilitate accessible, timely, and high-quality breast cancer care.