Page 0039

GLOBAL CANCER POLICY-MAKING

disseminated1-3. In 2002, the World Health Organization conservation trials required preoperative diagnostic

(WHO) pointed out that these guidelines have limited utility in mammography for entry in the study10,11. Certainly, in

4

resource-constrained countries . They fail to include countries where screening mammography is commonly

implementation costs and provide no guidance as to how an employed and non-palpable, non-invasive cancers are often

existing system could be improved incrementally towards an diagnosed, diagnostic mammography is critical for

ideal delivery system based on available resources. determining the extent of disease in the breast to properly

Guidelines for LMIC must offer practical solutions to the select patients for breast conserving surgery versus

implausibility of applying cancer guidelines developed for mastectomy. However, in LMIC where women present with

high-resource countries to LMIC. Guidelines from high- palpable disease at the time of diagnosis, a preoperative

resource countries may be inappropriate for a number of mammogram may not be essential for selecting patients for

reasons, including inadequate numbers of trained health care breast conserving surgery. Nadkarni, Badwe and colleagues

providers; inadequate diagnostic and treatment infrastructure reviewed their institutional experience in Mumbai, India to

such as pathology, pharmacy, infusion centres, and assess how often diagnostic mammography added to clinical

microbiology laboratories; lack of drugs; lack of radiographic assessment in the selection of patients for breast conserving

film; and inadequate transportation systems. Thus, in a surgery12. The investigators examined their experience in

country with limited resources, many barriers lie between the 2004 and found that if mammography had not been

average patient and the level of care dictated by guidelines performed in the 735 patients undergoing surgery, breast

applicable to high-resource settings. conservation would have been performed erroneously in only

38 (5%) patients (13 with impalpable multicentric disease, 25

Breast cancer as a model for resource-stratified with extensive microcalcifications). The remaining patients

guideline development were corrected assessed for breast conservation versus

As the world’s most common cancer among women, and the mastectomy on the basis of clinical assessment performed by

most likely reason that a woman will die of cancer around the an experienced surgeon. Furthermore, had breast

globe, breast cancer affects countries at all economic levels. conservation been attempted in the 38 patients with clinically

Each year, breast cancer is newly diagnosed in more than 1.1 occult disease, most (if not all) would have been recognized

million women, representing more than 10% of all new cancer and rectified postoperatively on the basis of positive surgical

cases. Breast cancer is becoming an increasingly urgent margins seen on final pathology. Thus, the availability of

problem in low-resource regions where incidence rates have diagnostic mammography cannot be asserted to be mandatory

5

been rising by up to 5% per year . Despite the common in countries lacking screening mammography, especially when

misconception that breast cancer is primarily a problem of patients commonly present with clinically obvious disease.

high-income countries, the majority of the 425,000 breast Established in 2002, the Breast Health Global Initiative

cancer deaths in 2010 occurred in developing (not developed) (BHGI) created an international health alliance to develop

countries6. The number of young lives lost is even more evidence-based guidelines for LMIC to improve breast health

disproportionate. In 2010, breast cancer killed 68,000 women outcomes. BHGI held four Global Summits to address health

aged 15–49 years in developing countries versus 26,000 in care disparities (Seattle, Washington, 2002)13, evidence-based

developed countries7. Countries with established and adequately resource allocation (Bethesda, Maryland, 2005)14, guideline

funded health care systems have higher breast cancer implementation (Budapest, Hungary, 2007)15 and optimizing

diagnosis rates, but also have improved breast cancer survival8. outcome (Chicago, 2010)16 as related to breast cancer in

Standards of care are defined by the environment in which LMIC. Modeled after the approach of the National

they are practiced. It is incorrect to assume that methods of Comprehensive Cancer Network (NCCN), BHGI developed

breast cancer diagnosis and treatment that have evolved in and applied a consensus panel process, now formally endorsed

high-income countries should directly translate into by the US Institute of Medicine, to create resource-sensitive

applications in LMIC. Some tools considered indispensable guidelines for breast cancer early detection17, diagnosis18,

tools by US or Western European standards are less useful in treatment19 and health care systems20 as related to breast

limited resource environments, because the more advanced health care delivery in LMIC.

stage of disease at diagnosis makes their findings less relevant.

For example, diagnostic mammography in high-income Principles of BHGI guideline development

countries is considered mandatory for the performance of To begin the guideline development process, two axioms were

9

breast conservation surgery , because the early breast adopted as principles in considering available evidence

CANCER CONTROL 2013 37

Index

  1. CANCER CONTROL 2013
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