Breast Care in Malawi: the problem

Malawi is one of the poorest countries in the world. Breast cancer is an increasing problem. Globocan estimates there are about 750 new cases every year, but most of these do not reach secondary care, and the majority of those that do present at a very late stage of the disease. Within two years, 80% of them will have died - we aim to change this.

Healthcare in Malawi

Malawi has universal, free at the point of delivery healthcare across the Government sector, through a network of Central Hospitals, District Hospitals, Community Hospitals and Health Clinics. However, it is very poorly resourced, one of the factors contributing to the low life expectancy at birth of 61/67 (m/f) years.

Malawi Breast Group: the proposed solution

In March 2018 the five breast surgeons of Malawi came together to plan how to provide specialist breast care to all Malawians. We decided to establish three Centres of Breast Excellence, one at the main Central Hospital in each of the three Regions, to coordinate services across the Region reaching to the 27 District Hospitals on a hub and spoke model.

Central hubs: progress so far

A triple assessment clinic had begun at Queen Elizabeth Central Hospital in the Southern Region in February 2017. The second clinic started in December, at Kamuzu Central hospital in Lilongwe, Central Region. The surgeon at Mzuzu Central Hospital in the north plans to start her one-stop clinic later in 2018.

Clinic resources:

Each clinic is run by a consultant surgeon (all Malawian general surgeons are generalists, but may have a special interest) who assesses each patient, arranges ultrasound scan, and where necessary, takes a core biopsy. There is currently no mammography. Biopsies are read during the following week, patients are discussed at the oncology multidisciplinary team meeting and a care plan agreed. Patients will generally have either neoadjuvant chemotherapy, or proceed straight to mastectomy and axillary lymph node dissection. There is at present no radiotherapy in Malawi.

Three pillars:

We aim to establish universal access to specialist breast care on a regional basis, on a hub and spoke model to the three Central Hospital Centres.

We will provide education to clinicians across the regions, to recognise breast cancer early, and refer appropriately to the specialist service, to avoid delays in diagnosis and treatment.

We plan to devise breast education and awareness programmes in conjunction with the Women's Health Programme and various voluntary organisations.

Our needs:

We work within the government healthcare system and intend that the universal service will be coordinated through this service, incorporating public and private facilities, so that the standards of excellence practised will be available to all Malawians. Some costs will be offset by private revenue, but within the government sector where most of our patients are cared for, day to day medical services frequently suffer from shortages, and items such as disposable biopsy forceps are not supplied.

We need to build a breast facility to provide inpatient and outpatient services in each region. Each will be integrated within the campus of the existing central hospital, and will be designed individually to integrate with these facilities. For example, the Blantyre centre will need to incorporate clinics, imaging, operating theatre, wards and high dependency unit, as well as academic and conference facilities, and laboratory services.

In Malawi there are four digital mammogram machines which were donated from India in 2012, but were never commissioned. We are currently negotiating with the Department of Health and anticipate that these will be operational within the next few weeks, one in each of the central hospital breast centres. We hope to procure a mobile triple assessment van to reach out to people who cannot come to the Central Hospitals which will locate the fourth machine, as well as an ultrasound scanner which will need to be purchased, along with other necessary equipment.

We are already focussing on the next generation, and teach undergraduate medical students in the Malawi College of Medicine in a programme which is engaged with in great enthusiasm. However, we have no programme to teach breast care to clinicians, nurses and other health care workers. There is one breast care nurse in the country, but he has had no specialist training. Thus, we would wish to establish a comprehensive breast education programme across all sectors, to include in-house, in country, and educational visits.

We are constantly reminded about the low awareness about breast cancer from the advanced cancer which presents at our clinics. We want to incorporate a breast awareness programme across the country with the women's health programme and voluntary organisation, and will need to secure funding for this.

We recognise an urgent need to understand the characteristics of breast cancer in Malawi, and determine how best to manage it. We therefore plan to work to protocols and have joint audit across the county. To do this, we need an electronic data system. In addition, we need to establish a research programme, which we would hope will contribute to further understanding breast cancer, and our management of breast disease in Malawi, but also across the African continent.

We plan to explore all options for funding these initiatives, but a major component of this is UK-based funding. If you would like to donate to us in any other way, please contact us directly, but otherwise we are most grateful for your JustGiving donation. With sincere thanks, Malawi Breast Group: Dr Briony Ackroyd-Parkin, Dr Kondwani Chalulu, Dr Carlos Varela, Dr Chifundo Kajombo, Dr Judith Mkwaila, Dr TK Itaye-Kamangira.