Breast Cancer Screening and Early Diagnosis Action Plan 2021-2025

Objectives

Kenya’s Breast Cancer Action Plan 2021–2025 provides a resource-appropriate framework for reducing the breast cancer burden through prevention, early detection, timely diagnosis, treatment linkage and supportive care. Its central aim is to ensure that women with breast cancer are diagnosed earlier and promptly connected to further management.[1]The plan prioritises screening and early diagnosis because prevention alone cannot avert most breast cancers.[2]

• Increase Clinical Breast Examination and mammography coverage among eligible women to at least 30% by 2025.[1]
• Ensure that at least 90% of symptomatic women are linked to evaluation and management within 60 days of their first contact with a health worker.[3]
• Improve access to screening, diagnostic, treatment, palliative, rehabilitation and supportive services across levels of care.[1]
• Reduce modifiable risk through healthy weight, diet, physical activity, breastfeeding, and reduced alcohol and tobacco use.[4]
• Strengthen five result areas: governance and policy; demand creation, community education and engagement; workforce training and professional development; service delivery; and monitoring, evaluation and research.[3]
• Integrate breast cancer prevention, screening and early diagnosis within Universal Health Coverage, primary health care, cervical screening, family planning, maternal and child health, HIV and non-communicable disease services.[5][6]

The strategy adopts a phased, resource-stratified approach for Kenya’s largely screening-naive population.[7]Clinical Breast Examination is positioned as the principal initial detection and triage intervention in lower-resource settings, with mammography used chiefly for diagnostic assessment and triple assessment of suspicious lesions rather than initial population-wide screening.[5]Mammography remains the preferred screening method for average-risk women where service capacity permits.[8]

• Promote breast health awareness, self-awareness and prompt assessment of symptoms among women and men.[7]
• Use age-appropriate screening recommendations, including regular Clinical Breast Examination from age 25 and mammography-based screening for relevant older age groups.[8]
• Strengthen early diagnosis through clinical evaluation, imaging, pathology, staging and referral for multimodality treatment.[9]
• Establish rapid diagnostic capacity, including same-day imaging and biopsy where appropriate, to reduce delays to surgical intervention and treatment.[10]
• Improve quality through pathology, breast imaging and clinical audit systems, adherence to national guidelines, and workforce competency development.[11][12]

Implementation

The Ministry of Health leads implementation with counties, health facilities, the National Cancer Control Programme, the National Cancer Institute of Kenya, referral hospitals, professional bodies, training institutions, regulators, partners, community structures and private-sector providers.[1][10]Implementation is organised through an action matrix that assigns activities, indicators, responsible entities and timeframes, supported by national and county governance structures and county breast cancer committees.[3][11]

• Establish Breast Cancer Centres of Excellence at three national referral hospitals and rapid diagnostic units with histopathology services at county referral hospitals.[13]
• Activate mammography services in all 47 county referral facilities and develop referral pathways for patients, specimens, psychosocial support and treatment.[13]
• Provide hormonal testing for oestrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 through national referral and selected county facilities.[13]
• Develop one-stop rapid diagnostic breast clinics at level 5 facilities and above, offering triple assessment for symptomatic women.[10]
• Equip Clinical Breast Examination, imaging and biopsy services with appropriate infrastructure, consumables, information systems, radiation protection and trained personnel.[13][14][15]

Service delivery begins at community and primary-care level, where Community Health Volunteers, Community Health Extension Workers and other frontline personnel promote prevention, breast awareness, self-examination, screening uptake and referral.[5][1]Dispensaries and health centres provide Clinical Breast Examination, identify possible symptoms and refer clients with abnormal findings.[8]Secondary facilities provide experienced clinical assessment, ultrasound for women younger than 35 years, mammography for women older than 35 years, and tissue diagnosis using fine-needle aspiration or core biopsy.[16]Tertiary services provide definitive treatment, palliative care, rehabilitation and prioritised surgical management.[16]

• Develop and distribute locally appropriate information, education and communication materials, using simple language, relevant images and target-group involvement.[17]
• Conduct mobile outreach, personalised screening invitations, workplace programmes and sustained mainstream and social-media campaigns.[18]
• Engage cancer survivors, community and religious leaders, media, opinion leaders and community welfare groups in advocacy, education and demand creation.[19]
• Train primary-care clinicians in breast awareness, self-examination, Clinical Breast Examination, diagnosis, management and referral.[1]
• Build specialist capacity in breast imaging, image-guided biopsy, pathology, onco-pathology, data management and patient navigation, including through fellowships and continuing professional education.[20][21]
• Integrate breast cancer content into undergraduate and postgraduate health-training curricula.[22]

Governance actions include quarterly technical working group meetings, stakeholder mapping and annual review forums, county technical support, quality-assurance teams, resource mobilisation, and inclusion of breast cancer activities in county annual work plans, county integrated development plans, Universal Health Coverage packages and insurance benefits.[11][23]Public-private partnerships are intended to expand access to screening, diagnosis and treatment through service agreements and linked public and private facilities.[6]

Operational learning draws on the 2019 Nyeri County breast screening pilot, which highlighted limited specialist staffing, service cost barriers, low mammography utilisation, uncollected results and weak linkage of women with suspicious lesions to biopsy and treatment.[9][17]The plan therefore emphasises sustained awareness, patient navigation, follow-up databases, treatment linkage, quality improvement and information management rather than screening activity alone.[17][24]

Monitoring & Evaluation

The Action Plan establishes a monitoring, evaluation and accountability system for breast cancer screening and early diagnosis, combining process, outcome and impact indicators with national and county targets, quality assurance, routine data management, audits and periodic assessments.[3][13][25]

• Measure screening and early-diagnosis performance against targets to achieve at least 30% Clinical Breast Examination and mammography coverage by 2025, and link at least 90% of symptomatic women to evaluation and management within 60 days of first contact with a healthcare worker.[1]
• Track annual screening coverage progressively towards 20% of the eligible population, alongside annual Clinical Breast Examination for women aged 25 years and above and annual mammography for women aged 40 to 55 years.[26]
• Monitor service outputs across levels of care, including community referrals, Clinical Breast Examination, imaging, fine-needle aspiration, core biopsy, screening mammography, down-staging, treatment outcomes and follow-up.[8][27]
• Use key performance indicators, data sources, assigned responsible entities and implementation timeframes within the implementation matrix to support delivery accountability.[28][3]
• Strengthen screening data management, train health records and information personnel, calculate selected screening, diagnosis, treatment and follow-up indicators, and improve timely monthly reporting for counties and other stakeholders.[1][13]
• Conduct baseline, mid-term and end-term assessments, including data collection, analysis and dissemination, and monitor implementation continuously to identify progress and gaps and reprioritise subsequent actions.[16][6]
• Establish quality assurance and improvement processes for Clinical Breast Examination, breast imaging, pathology and treatment, including annual screening and quality-of-care audits, pathology quality assurance, breast-imaging standards and multidisciplinary review of discordant clinical, imaging and biopsy findings.[16][11][12]
• Require mammography-centre medical outcomes audits, with an audit interpreting physician at each centre who interprets at least 960 mammograms every 24 months.[15]
• Use annual progress reports, audit reports, guideline dissemination records, stakeholder-meeting outputs and action tracking to report on governance, quality improvement and guideline implementation.[11][23]
• Monitor demand creation through information-material distribution, community forums, sensitisation sessions, advocacy activities, mobile outreaches, screening invitations, facility linkages, media outputs and workplace programmes.[19][18]
• Track workforce development through training-needs assessments, supportive supervision, training materials, trainers, Community Health Volunteers, radiographers, sonographers, radiologists, pathologists, laboratory staff and curriculum integration.[29][20][21][22]
• Monitor service readiness and continuity through multidisciplinary teams, specialist availability, laboratory and imaging turnaround times, accreditation, equipment and consumable stocks, stock-out days, patient databases, navigation, psychosocial support and referrals to the National Cancer Registry.[30][31][24]
• Assign overall implementation responsibility to the Ministry of Health, with county health committees measuring and reporting indicators through the Kenya Health Information Management System and customised monitoring and evaluation frameworks; the National Breast Cancer Technical Working Group is to support continuous performance monitoring and data use.[25][32]
• Track 2025 targets including 25,000 health-care workers trained in Clinical Breast Examination, 500 radiographers and radiologists trained, histopathology available in 40 county referral facilities, and breast imaging available in 15% of health facilities.[32]
• Assess outcome targets for 2025 of 50% invitation coverage, 30% participation and screening coverage, 50 positive findings per 1,000 women screened, a 25% biopsy rate at Centres of Excellence, advanced cancer detection reduced to 40%, treatment initiation increased to 90%, and mortality of 17.1 deaths per 100,000 women.[32]
• Recognise evidence from the Nyeri County pilot showing gaps in continuity of care: six months after the pilot, 33% of mammography reports had not been collected and only 22 of 49 clients with suspicious lesions had undergone biopsy and been linked to treatment.[17]

Costing & Financing

The Action Plan includes a 2021-2025 costing annex and identifies resource mobilisation, integration into national and county plans, insurance coverage and partnerships as financing mechanisms; however, the supplied material provides only selected cost estimates and does not specify a total programme budget, currency, financing sources, funding gap or economic assumptions.[28][23][33]

• Allocate a stated subtotal of 56,115,000 for governance and policy activities during 2021-2025, including governance integration, stakeholder engagement, quality assurance and guideline adherence.[33]
• Fund demand creation and community engagement activities, including information materials, Community Health Volunteer engagement, advocacy, mobile outreaches, screening invitations and sustained media campaigns.[33]
• Mobilise resources by incorporating breast cancer activities into annual work plans and county integrated development plans, developing an investment case, and including screening, early diagnosis and management in Universal Health Coverage and insurance benefit packages.[23]
• Recognise major non-costed resource requirements, including specialised personnel, mammography and imaging infrastructure, pathology and tissue-sampling capacity, commodities, tele-radiology and telepathology systems, patient navigation and psychosocial support.[14][15][30][31][24]
• Address access barriers associated with the cost of mammography services, while using community strategies described as cost-effective for awareness creation and screening invitations.[9][17]
• Prioritise Clinical Breast Examination in lower-resource settings because it has lower technical requirements and is more widely implementable than mammography.[34]