Date of Award

9-2025

Degree Type

Dissertation

Degree Name

Master of Medicine (MMed)

First Advisor

Dr. Miriam Mutebi

Second Advisor

Dr. Roselyter Rianga

Department

General Surgery (East Africa)

Abstract

Introduction 

Breast cancer represents the most commonly diagnosed cancer in women. In Kenya, it constitutes 20% of all cancer diagnoses as well as the second most common cause of cancer related death in the country, with a 5-year survival between 40.1% and 64%. There exists heterogeneity in the delivery of breast cancer care despite the presence of guidelines that can standardize care and that have been contextualized for Sub-Saharan Africa. There is paucity of data on barriers and facilitators of guideline-concordant breast cancer surgical care.

Setting 

The Aga Khan University Hospital Nairobi.

Aim 

The purpose of this study was to outline the barriers and facilitators to implementing breast cancer surgery guideline-concordant care in Kenya.

Methodology 

We designed the study as a sequential mixed method study with an initial survey on REDCap followed by virtual in-depth interviews. Both the quantitative and the qualitative data targeted general and breast surgeons through the Surgical Society of Kenya. The survey was a 35-question semi-structured questionnaire exploring the spectrum of care from pre-surgical diagnosis to surgical and post-surgical management. This was done to gain an understanding of the surgical care landscape in Kenya. This was followed by the qualitative part of the study which involved virtual in-depth interviews with an 8-question interview guide. The interview was administered to 16 general and breast surgeons that were purposively sampled. A deductive approach was used in thematic analysis with pre-existing themes. MAXQDA 24 software was utilized to perform the analysis. Ethical clearance was given by the Institutional Scientific Ethics Review Committee.

Results 

The survey managed to recruit 47 general surgeons and 4 breast surgeons to respond. This constituted a 51% response rate among the targeted 100 active members of the surgical Society of Kenya. There was good availability of ultrasound (50,98%), mammography (38,75%) and radiographers (44,85%). Only 3 (6%) surgeons used no breast cancer guidelines. The most used guidelines were the NCCN guidelines. Only half (25,49%) utilized core needle biopsy in 75% to 100% of patients. Furthermore, 13 (25%) respondents had >6 weeks delay from diagnosis to surgical intervention and 17 (33%) made management decisions without MDT or oncologist input. There was limited utilization of breast conserving therapy with 40 (78%) offering it only in 0% to 25% of cases. About half (25,49%) of the surgeons performed sentinel node biopsy in a negative axilla in 0% to 25% of cases. Dual modality localization was only used by 4 (8%) surgeons. Only 1 respondent reported lack of confidence in axillary lymph node dissection. Almost all surgeons (46, 90%) were able to access radiotherapy services. Breast reconstruction could be offered by half of the respondents (26,51%).

13 general surgeons and 3 breast surgeons were interviewed with representation from different regions of the country. The main patient-related barriers were lack of knowledge and perceptual challenges as well as financial inaccessibility to services. Recommendations to improve these revolved around increasing health financing and improving patient education. Health-worker numbers, knowledge and skill were the main health-worker related barriers. Limited MDT utilization was also noted to be a health-care worker related barrier to guideline concordant care. It emerged that increasing human resource for breast cancer surgical care and improving their skills through training were the main facilitators, as well as increasing MDT utilization. The main system barriers were lack of infrastructure and equipment for breast cancer investigation and care. More investment from governance structures would mitigate this barrier.

Conclusion 

We found that inadequate patient education, limited health-care financing, lack of infrastructure and limitations in guideline adaptation to different contexts constitute the main barriers to breast cancer surgical care. Hence, improving patient education, increasing investment in healthcare financing and infrastructure, training more breast cancer surgical care providers and development of context specific guidelines were the proposed ways to enhance guideline-concordant breast cancer surgical care.

First Page

1

Last Page

117

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