Quality of care and surgical outcomes in breast cancer management at Muhimbili National Hospital

Abstract

Background: Breast cancer is ranked 2nd in number of new of cases worldwide while is 4th in cancer mortality globally, while in Tanzania it is ranked fourth overall and second to cervical cancer among female patients with cancer. The use of breast self-examination with screening mammography has resulted in early diagnosis and standardised care with improved outcome. While algorithm for work up of breast cancer patients has been proposed, how this is implemented and its outcomes in Tanzania has been poorly investigated. Even though the infrastructure to improve breast cancer services from investigations to treatment are available, uniformity in patients’ pathways might differ hence the difficulty in measuring survival and outcome. Standardising such pathways will ensure each patient receives stage specific care with expected improved outcome and ease of measuring efficiency of interventions offered. Objective: To assess the quality of implementation of evidence-based management of Breast cancer patients and outcomes of Modified Radical Mastectomy at Muhimbili National Hospital. Methodology: A prospective cohort study of MRM patients was carried out at MNH in 2019. Patients who had received an MRM for confirmed breast cancer were recruited over a six months period. Information gathered includes investigations ordered, Provision of NACT, surgery type and complications post-surgery. A multi-centerdata collection tool adopted from Global Surgery Collaborativewas used to gather information and variables entered in to SPSS version 24 where cleansing and coding was done. Descriptive statistics were summarized into proportions and continuous variables into means with association between variables determined by using Chi-squared test or Fisher’s exact test. An association with P-value less than 0.05 will be considered significant. The study was conducted after being approved by MUHAS IRB. Results:66 breast cancer patients who had MRMwere recruited. The mean age was 48.17±13.15 with only 3 (4.5%) being male. Invasive Ductal carcinoma was the most predominant seen in 59 (89.4%). Most of the patient at the time of surgery were Stage 3 by 95.5% while the rest were Stage 2. Chest x-rays and abdominal ultra sound was done in all patients, while only 14(21.2%) had a mammography performed. Seroma and SSI were the reported complications affecting 40.9% and 18.2% respectively. Overweight was found to significantly relate with the development of SSI, p-value 0.011 while previous history of smoking related with seroma development, p-value 0.029. Surgical mortality was reported in 3(4.5%) of the patients. Conclusion:Breast cancer patients undergoing MRM at MNH are under investigated, which might result in under treatment when immunohistochemistry for hormonal status and Her2/Neo expression are not part of the treatment plan. Similarly, with majority being stage 3 cancers, it could result in over-treating stage four patients that could have been picked by CT and MRI. Recommendation: Introduction of Breast Cancer clinical pathway that eliminates and variability in the preoperative workup of a patient,also keeps track of the patient postoperative outcome. This is also improves record keeping with and offers easier institutional sharing of information to further improve on the outcome of patients.Finally, a clinical pathway set will ensure equitable utilization of available resources to all patients in different treatment institutions beyond Muhimbili National Hospital.