Identifying the Barriers and Facilitators to Guideline-Concordant Breast Cancer Surgical Care in Kenya: A Sequential Mixed Method Study

Breast cancer constitutes 20% of all cancer diagnoses as well as the second most common cause of cancer related death in the country. There exists heterogeneity in breast cancer care despite the presence of standardized guidelines. There is paucity of data on barriers and facilitators of guideline-concordant breast cancer surgical care. We sought to outline the barriers and facilitators to guideline-concordant breast cancer surgical care in Kenya.A sequential mixed method study with an initial survey followed by in-depth interviews was conducted. We targeted general and breast surgeons through the Surgical Society of Kenya. The survey was a 35 question semi-structured questionnaire census. The in-depth interview guide had 8 questions administered to purposively sampled respondents.47 general and 4 breast surgeons responded to the survey. There was good availability of ultrasound (50,98%), mammography (38,75%) and radiographers (44,85%). Only 3 (6%) surgeons used no guidelines with NCCN as the most commonly used. 13 (25%) respondents had >6 weeks delay from diagnosis to surgical intervention and only 16 (31%) made management decisions with an MDT (Multi-disciplinary team) in all their patients. 40 (78%) respondents offered breast conserving therapy to only 0% to 25% of patients who met criteria. 25 (49%) surgeons performed sentinel node biopsy in a negative axilla in 0% to 25% of cases.13 general and 3 breast surgeons were interviewed.  The main patient-related barriers were lack of knowledge, perceptual and financial barriers. Recommended facilitators included increasing health financing and patient education. Health-worker training and limited MDT utilization were the main health-worker related barriers. The main system barriers were lack of infrastructure and equipment while more investment from governance structures would mitigate this. Improving healthcare worker training and increasing MDT utilization, when integrated with patient education, increased financing and infrastructural development will improve guideline concordant breast cancer care.