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The Challenge of Breast Cancer in Low- and Middle-income Countries
Breast Health Global Initiative Summits 2002 and 2005 methods of information delivery and follow-up will depend on financial and
The first evidence-based guidelines were developed at the 2002 BHGI Global personnel resources. While the magnitude of absolute risk reduction based
Summit, ‘International Breast Healthcare Guidelines for Countries with Limited on risk factor management is somewhat unclear, any of these health
Healthcare Resources,’ for: early detection; diagnosis; and treatment. These behaviors can reduce risk for other chronic diseases, so they may be of high
guidelines, published in 2003, describe healthcare disparities at different interest for general public health in both LMCs and high-income countries.
economic levels and outline principles for programmatic improvement in
breast health services as applied to LMCs.
15–18
Early Detection
While prevention is ideal, these strategies will not eliminate breast cancer
At the 2005 BHGI global summit, the previous BHGI guidelines were updated incidence in LMCs, which remains the most prominent cancer among
and expanded into a flexible comprehensive framework for improving the women even in countries that lack the most common ‘Westernized’ breast
quality of healthcare delivery based on outcomes, cost, cost-effectiveness, and cancer risk factors.
33
Public education is a key first step because early
the use of healthcare services. The 2005 guidelines addressed: early detection detection cannot be successful if the public is unaware of the problem or
and access to care;
19
diagnosis and pathology;
20
cancer treatment and has adverse misconceptions about the value of early detection. Social and
allocation of resources;
21
and healthcare systems and public policy.
22
The cultural barriers to early breast cancer detection must be considered in any
stepwise, systematic approach to healthcare improvement outlined context where early detection programs are being established. Public
by the 2005 BGHI panels involved a tiered system of resource allotment education must include health education messages conveying the idea that
defined using four levels—basic, limited, enhanced, and maximal—based breast cancer is curable in the majority of women when it is detected early,
on the contribution of each resource toward improving clinical outcomes. diagnosed accurately, and treated correctly.
During the BHGI summits, several key points were identified or demonstrated.
23
Breast cancer screening modalities include breast self-examination (BSE),
First, early breast cancer detection improves outcome in a cost-effective clinical breast examination (CBE), and screening mammography. Screening
fashion, assuming that treatment is available.
24
Second, the effectiveness of mammography is the single modality that has been shown to improve
early detection programs requires public education to foster active individual breast cancer mortality in prospective randomized trials, but its cost is
participation in diagnosis and treatment.
25
Third, clinical breast examination prohibitive in many settings.
34
When screening mammography is employed
combined with diagnostic breast imaging (breast sonography with or without in LMCs, target populations and screening intervals need to be selected in
diagnostic mammography) can facilitate cost-effective tissue sampling a way that is judged to be optimal for the overall population and within the
techniques for cytological or histological diagnosis.
20
Fourth, breast cancer scope of available resources. Breast cancer carries poorer prognosis in young
treatment with partial mastectomy and radiation requires more healthcare patients and its frequency in women below 40 years of age is 20% in Turkey
resources and infrastructure than mastectomy, but can be provided in a and up to 30% in developing Asian countries.
4,35
Thus, screening younger
thoughtfully designed limited-resource setting.
26
Fifth, the availability and women in LMCs requires more attention and resources to implement.
29
administration of systemic therapy are critical to improving the survival of
breast cancer patients. Sixth, estrogen-receptor testing allows patient selection Diagnosis
for hormonal treatments (tamoxifen, oophorectomy), which is better for Obtaining a patient’s history, specific both to the breast disease and to
patient care and allows the proper distribution of services. Seventh, general health, provides important information for clinical assessment of
chemotherapy, which requires a substantial allocation of resources and breast disease and comorbid disease that might influence breast cancer
infrastructure, is needed to treat LABC, which represents the most common therapy choices.
30
Focused CBE and complete physical examination provide
clinical presentation of disease in low-resource countries. Furthermore, when guidance as to the extent of disease, the presence of metastatic disease,
chemotherapy is unavailable, patients presenting with locally advanced, and the patient’s ability to tolerate more aggressive therapeutic regimens.
hormone-receptor-negative cancers can receive only palliative therapy.
21
Breast imaging, initially with ultrasound and, at higher resource levels, with
Breast Health Global Initiative Summit 2007 diagnostic mammography, improves pre-operative diagnostic assessment,
The BHGI guidelines published in 2006
17,20–22
were re-examined, revised, and and also permits image-guided needle sampling of suspicious lesions.
extended at the third global summit held on October 1–4, 2007 and hosted Diagnostic mammography and magnetic resonance imaging (MRI), while
by the American Society of Clinical Oncology (ASCO) in Budapest, Hungary.
27
helpful for breast-conserving surgery, are not mandatory in LMCs when
Specific attention was paid to guideline implementation in LMCs in the areas these resources are lacking.
36
Additional imaging studies (plain chest
of prevention,
28
early detection,
29
diagnosis,
30
and treatment,
31
and special and skeletal radiography, liver ultrasound) facilitate metastatic work-up and
discussion was directed at healthcare systems
32
in LMCs as the foundation therefore patient treatment selection. Selected laboratory studies (blood
through which breast healthcare and all healthcare is supported. chemistry profile, complete blood counts) are required for the safe
administration of cytotoxic chemotherapy, which is a basic-level resource
Prevention for the treatment of node-positive, estrogen-receptor (ER)-negative, and
Health behaviors that may reduce the risk for breast cancer include locally advanced disease.
prolonged lactation, regular physical activity, weight control, avoiding
excess alcohol intake, avoiding prolonged use of exogenous hormone The choice of sampling procedures (fine-needle aspiration biopsy [FNAB],
therapy, and avoiding excessive radiation.
28
These behaviors, while not core needle biopsy, or excisional biopsy) should be based on the availability
proved in clinical trials to reduce risk, are likely to be beneficial. Information and access to cytopathologists/pathologists in each medical community and
on them can be provided as a prevention strategy in LMCs, although the the training and experience of the available pathology specialists. FNAB
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