PROJECT SUMMARY The burden of breast cancer is rising rapidly in low- and middle-income countries (LMICs), where most women with breast cancer are diagnosed with advanced-stage disease. Largely because of late-stage presentations, despite lower age-standardized incidence of breast cancer in sub-Saharan Africa, the region’s breast cancer mortality rates are higher than the United States’. We previously studied an intervention to facilitate timely evaluation of breast symptoms in a single Rwandan district (Burera District) which increased the number of women receiving evaluation for breast symptoms and increased early-stage diagnoses. However, effective strategies to scale-up breast cancer early diagnosis programs in resource-constrained primary health care systems are not well-understood. Particular challenges for scaling early diagnosis include integration of clinical breast assessment with other primary care services and facilitating timely, reliable linkage of patients with concerning breast findings to higher levels of care. The objective of this research project is to study implementation successes and challenges of Rwanda Biomedical Centre’s (RBC’s) scale-up of the Burera intervention to other districts. To facilitate scaleup, RBC has adapted the program to integrate breast cancer awareness-raising and evaluation of symptomatic women into a cervical cancer screening initiative and is utilizing a tablet-based electronic medical record to facilitate patient tracking. This project will evaluate implementation of this adapted scaleup initiative, and facilitators of and barriers to successful implementation. In Aim 1 we will use the RE-AIM framework to retrospectively examine the WCEDP’s reach, effectiveness, adoption and facilities’ implementation fidelity over the program’s first year. In Aim 2, we will use qualitative methods guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify health workers’ perceptions of fit, feasibility and acceptability of the WCEDP and inner and outer context factors influencing success. We will also interview women diagnosed with breast cancer through the WCEDP to explore fit, acceptability, and participation barriers and facilitators. Understanding the implementation successes and challenges of this adapted model will inform further adaptations that can be studied in a larger research project and linked to longer-term outcomes. This project aligns with the National Cancer Institute’s special interest in implementation research related to cancer control in LMICs and its commitment to pursuing equity in global cancer control.

PROJECT NARRATIVE Incidence of and mortality from breast cancer are rising rapidly in low- and middle-income countries, which bear a disproportionate number of the world’s breast cancer deaths. Facilitating earlier breast cancer diagnoses is critical to reduce preventable breast cancer deaths in LMICs, but how to deliver scalable early diagnosis services in resource-limited primary care settings is not known. This project will examine implementation successes and challenges of adapted scaleup of a breast cancer early diagnosis program in Rwanda in order to inform further adaptations and guide cancer policies and practice.