GLOBAL CANCER POLICY-MAKING
regarding breast cancer early detection, diagnosis and ‰ Clinical breast examination combined with diagnostic
treatment. First, it was assumed that all women have the right breast imaging (breast ultrasound with or without
to access to health care, but that considerable challenges exist diagnostic mammography) can facilitate cost-effective
in implementing breast health care programmes when tissue sampling techniques for cytological or histological
resources are limited. Second, it was assumed that all women diagnosis;
have the right to education about breast cancer, but that it ‰ Breast conserving therapy with partial mastectomy and
must be culturally appropriate, and targeted and tailored to radiation requires more health care resources and
specific populations in need21. infrastructure than mastectomy, but can be provided in a
Breast cancer outcomes in LMIC correlate with the degree thoughtfully designed limited-resource setting;
to which 1) cancers are detected at early stages, 2) newly ‰ The availability and administration of systemic therapy are
detected cancers can be diagnosed correctly, and 3) critical to improving breast cancer survival;
appropriately selected multimodality treatment can be ‰ Estrogen receptor testing allows patient selection for
provided properly in a timely fashion. In LMC, the majority of hormonal treatments (tamoxifen, oophorectomy) which is
women have advanced or metastatic breast cancer at the time both better for patient care and allows proper distribution
of diagnosis. Based upon evidence-based review and of services;
consensus discussion, BHGI made four core observations13: ‰ Chemotherapy, which requires some allocation of
‰ Because advanced breast cancer has the poorest survival resources and infrastructure, is needed to treat node-
and is the most resource-intensive to treat, efforts aimed positive, locally advanced breast cancers, which represent
at early detection can reduce the stage at diagnosis, the most common clinical presentation of disease in low-
potentially improving the odds of survival and cure, and resource countries;
enabling simpler and more cost-effective treatment; ‰ When chemotherapy is unavailable, patients presenting
‰ There is a need to build programmes that are specific to with locally advanced, hormone receptor negative cancers
each country’s unique situation; can only receive palliative therapy.
‰ The development of cancer centres can be a cost-effective
way to deliver breast cancer care to some women when it is Guideline implementation
not yet possible to deliver such care to women nationwide; The BHGI Guidelines can be used to communicate
‰ Collecting data on breast cancer is imperative for deciding programmatic needs to hospital administrators, government
how best to apply resources and for measuring progress. officials and/or health care ministries. It is the thesis of BHGI
that these works create a framework for change, by defining
BHGI created and developed a stepwise, systematic practical pathways through which breast cancer care can be
approach for breast programme development based on improved in an incremental and cost-effective fashion14.
resource stratification. A tiered system of resource allotment However, guidelines do not in-and-of themselves improve
was defined using four levels – basic, limited, enhanced, and outcomes for women. Implementation is the critical step by
maximal – based on the contribution of each resource towards which the value of the guidelines may be measured. Pilot
improving clinical outcomes (Table 1). Based on these research and demonstration projects are needed both to
principles, BHGI invited international experts to review and determine the effectiveness of the guidelines, and to create
develop resource-stratified guideline tables for early evidence that will promote similar guideline implementation in
detection, diagnosis, treatment, and health care systems15. In other regions with similar resource constraints.
each area, a prioritization scheme was developed that BHGI examined common patterns in health care delivery in
considered both limitations in resources and corresponding low-22 and middle-23 resource settings to determine what
stage of disease at diagnosis to consider how systematic health system and patient-related barriers are contributing to
improvements can be developed in each area such as breast late-stage presentation and assess what strategies24 can be
cancer early detection (Table 2). During this analysis, a number applied to improve outcomes in an incremental fashion
of key points were identified and/or demonstrated: without exceeding realistic capacity within that system16. As
‰ Early breast cancer detection improves outcome in a cost countries progress to higher economic status, the rate of late
effective fashion assuming treatment is available. presentation is expected to decrease, and diagnostic and
‰ The effectiveness of early detection programmes requires treatment resources are expected to improve. Health care
public education to foster active patient participation in systems in LMIC share many challenges including national or
diagnosis and treatment. regional data collection, programme infrastructure and
38 CANCER CONTROL 2013