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The Challenge of Breast Cancer in Low- and Middle-income Countries
expertise in reading cytology slides.
37
When available, core needle preferred initial treatment of LABC is systemic therapy; if optimal
biopsy is preferable to excisional biopsy for diagnosis because it is chemotherapy and evaluation are not available, primary MRM is
minimally invasive and does not limit subsequent definitive surgical acceptable. However, it should be recognised that without systemic
procedures. Sentinel lymph node (SLN) biopsy, while developed in the therapy, surgery alone for LABC is unlikely to improve outcome. After
context of high-income countries, can actually be used by breast responding to systemic therapy, most LABC patients will require an
surgery teams in lower-income settings at low cost when the technique MRM followed by radiation therapy.
is restricted to the use of blue dye without radiotracer.
38
The availability
of predictive tumour markers, especially ER testing, is critical to proper Inflammatory breast cancer should be initially managed with
selection of cancer therapy when endocrine therapies are available, pre-operative drug therapy irrespective of resource level. Standard pre-
although quality assessment of immunohistochemical (IHC) testing is operative therapy includes anthracycline-based chemotherapy. The
important to avoid false-negative results. addition of sequential taxane after anthracycline-based chemotherapy
improves pathological responses and breast-conservation rates, but
Treatment may not improve survival. The high cost and lack of clear survival
benefit do not justify taxane use at limited resource levels for metastatic
Surgical Therapy and inflammatory cancer. CMF combination chemotherapy is less
The ability to perform modified radical mastectomy (MRM) is the mainstay potent than anthracycline and taxanes, but may be used in its classic
of locoregional treatment at the basic level of breast healthcare.
31
While the schedule in LMCs because of lower costs and lesser complications. The
MRM (total mastectomy plus level I/II axillary lymph node dissection) is role of pre-operative endocrine therapy remains to be better defined,
considered fundamental surgical training in high-income countries, but appears to be feasible and acceptable in elderly women.
surgeons from LMCs may have had less exposure to the procedure and may
not be knowledgeable about the operation’s proper technical execution. Healthcare Systems
Breast-conserving surgery can be provided as a limited resource but requires Poorer outcomes in LMCs may relate to their healthcare systems having
proper breast-conserving radiation therapy planning. If this is unavailable, a limited capacity for successful early detection, diagnosis and
patients should be transferred to a higher-level facility for radiation. treatment of breast cancer. Impediments to better outcomes include
deficits in public education and awareness, insufficient numbers of
Systemic Therapy appropriately trained healthcare workers, limited access to
For adjuvant therapy in stage I–III breast cancer, chemotherapy becomes screening/treatment facilities, inadequate supplies of necessary drugs
available at the limited level beginning with anthracyclines in stage II at the and timeliness of treatment after diagnosis.
basic level.
31
The provision of endocrine therapy requires relatively few
specialised resources, but ideally necessitates the knowledge of hormone Public Education
receptor status to ensure treatment of patients most likely to benefit. HER2- Obstacles to improving cancer care arise from multiple sources, including
targeted therapy is very effective in tumours that overexpress the HER2/neu deficits in public knowledge and awareness, social and cultural barriers,
oncogene, but cost largely prevents the use of this treatment in LMCs. challenges in organising healthcare and insufficient resources. Early
breast cancer detection improves outcome in a cost-effective fashion
Tamoxifen is recommended for patients with ER-positive tumours in (assuming that treatment is available), but requires public education to
LMCs. Aromatase inhibitors (AIs) give better results than tamoxifen and foster active patient participation in diagnosis and treatment.
are recommended for countries with enhanced and maximal resources,
but cost constraints make tamoxifen a very reasonable alternative to AIs. Professional Education and Training
Despite its benefits for disease control, no overall survival benefit has The education of healthcare professionals, trusted traditional healers,
been attributed to AIs over tamoxifen. Hormonal therapy should be used governmental agencies, women and the general public about breast
after surgery for at least five years. health and breast cancer detection, diagnosis, and treatment is central to
the provision of high-quality breast cancer care.
Radiation Therapy
Radiation therapy resources are insufficient in LMCs. There is a need to Cancer Centre Organisation
provide the necessary equipment but also to improve quality, technique The use of multidisciplinary teams for the management of breast cancer
and resource utilisation in an optimal and sustainable fashion. Radiation in general, and LABC in particular, is strongly recommended and should
therapy can be delivered with a cobalt-60 unit or a linear accelerator be available wherever breast cancer patients are treated.
41
In LMCs where
(linac) along with other quality assurance tools. Although linac is some or several subspecialists are unavailable, the team approach should
considered to be the preferred therapy in most settings, telecobalt be adapted to include only two to four members (e.g. a surgeon, a
machines are a reasonable alternative in LMCs. Of note, linac requires radiologist, a pathologist and a medical and/or radiation oncologist).
consistent electricity for powering and water for cooling the equipment. Every effort should be made to have local pathologists available. Patient
Applying safe and effective treatment requires well-trained staff, advocates may play an important role in encouraging the set-up of
support systems, geographical accessibility and the initiation and multidisciplinary teams and can serve a special role in strengthening
completion of treatment without undue delay.
26
patient navigation through a given healthcare system.
Management of Locally Advanced Disease Radiation Facilities
LABC and metastatic breast cancer (MBC) are the most common The current supply of megavoltage radiotherapy machines (cobalt-60
stages at presentation (60–80% of cases) in most LMCs.
11,39,40
The or linear accelerator) is only 18% of the estimated need in some parts
ASIA-PACIFIC ONCOLOGY & HAEMATOLOGY 33
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