Optimisation of breast cancer management in low-resource and middle-resource countries: executive summary of the Breast Health Global Initiative consensus, 2010

Summary

The purpose of the Breast Health Global Initiative (BHGI) 2010 summit was to provide a consensus analysis of breast cancer control issues and implementation strategies for low-income and middle-income countries (LMCs), where advanced stages at presentation and poor diagnostic and treatment capacities contribute to lower breast cancer survival rates than in high-income countries. Health system and patient-related barriers were identified that create common clinical scenarios in which women do not present for diagnosis until their cancer has progressed to locally advanced or metastatic stages. As countries progress to higher economic status, the rate of late presentation is expected to decrease, and diagnostic and treatment resources are expected to improve. Health-care systems in LMCs share many challenges including national or regional data collection, programme infrastructure and capacity (including appropriate equipment and drug acquisitions, and professional training and accreditation), the need for qualitative and quantitative research to support decision making, and strategies to improve patient access and compliance as well as public, health-care professional, and policy-maker awareness that breast cancer is a cost-effective, treatable disease. The biggest challenges identified for low-income countries were little community awareness that breast cancer is treatable, inadequate advanced pathology services for diagnosis and staging, and fragmented treatment options, especially for the administration of radiotherapy and the full range of systemic treatments. The biggest challenges identified for middle-resource countries were the establishment and maintenance of data registries, the coordination of multidisciplinary centres of excellence with broad outreach programmes to provide community access to cancer diagnosis and treatment, and the resource-appropriate prioritisation of breast cancer control programmes within the framework of existing, functional health-care systems.

Introduction

Countries are classified economically by the World Bank by their gross national income per head as low income, middle income (subdivided into lower-middle and upper-middle), or high income.¹ For global health care, this classification provides a framework to assess what resources can be allocated to address the most urgent health-care issues. In the richest nations, gross national income per head is 100 times that in the poorest nations. However, national health-care expenditure per head is almost 200 times that in the poorest countries, suggesting that disparities in health-care delivery are significantly greater than are disparities in national wealth (table 1). The required out-of-pocket expenses are the largest in countries of low and lower-middle income, despite the fact that people in these countries have the least personal resources to cover these costs. With chronic diseases such as cancer, including breast cancer, the financial hardship of paying for health care could mean that patients and their families have to choose between health care and basic sustenance. Socioeconomic status is an independent predictor of breast cancer outcome in both high-income and low-income countries.2, 3

Poorer countries have lower life expectancy and larger infectious disease burden than do more developed countries. Globally, life expectancy varies by more than two decades, from less than 60 years in the lowest-resource countries to more than 80 years in the highest-resource countries. Health-care needs in the poorest countries with the lowest average life expectancies often centre on the management of the most common communicable diseases such as malaria, tuberculosis, waterborne diseases, and other infectious diseases. The major non-communicable diseases such as cardiovascular disease, cancer, chronic lung disease, and diabetes, which dominate the health-care needs of high-resource countries, are often left unaddressed in the poorest countries.⁴

WHO recognises the rising risks of non-communicable diseases in developing countries, noting that 80% of deaths from chronic disease occur in low-income and middle-income countries (LMCs).⁵ In 2005, WHO projected that global deaths from infectious diseases, maternal and perinatal disorders, and nutritional deficiencies combined would decrease by 3% over the next 10 years, while deaths due to non-communicable diseases would increase by 17% during the same period.⁵ The most common cancers will become increasingly common as communicable diseases are controlled and as populations age. 5·6 million people worldwide died from HIV/AIDS, tuberculosis, and malaria in 2002. During that year, 7·6 million people died from cancer.⁶ By the year 2020, 70% of the 16 million cancer cases are expected to arise in LMCs.⁷ Despite the rising cancer toll in these countries, global health policy statements such as the UN Millennium Development Goals and the 2006 agenda for the G8 Group of industrialised nations emphasise infectious diseases as a global health concern, but either make no reference to cancer at all, or instead only broadly reference non-communicable diseases as a group without any specific reference to cancer.⁸ As such, the global community, until recently, has paid little attention to cancer in developing countries.⁹

As the most common cancer in women worldwide, with more than 1 million new cases every year,¹⁰ and the most frequent global cause of female cancer mortality, breast cancer is a highly relevant disease for which systematic approaches to early detection, diagnosis, and treatment must be implemented to improve outcome.¹¹ Worldwide, breast cancer incidence and mortality are expected to increase by 50% between 2002 and 2020.¹¹ These rising cancer rates will be greatest in developing countries, and are projected to reach a 55% increased incidence and 58% increased mortality in fewer than 20 years.¹⁰ Age-specific breast cancer incidence and mortality rates have been increasing in low-income countries, especially in recent birth cohorts, which could relate to the adoption of lifestyles similar to those in developed countries.12, 13 Thus, the reported low incidence of breast cancer in developing countries today should not be used as a rationale for avoiding the creation of cancer programmes generally, or breast cancer programmes specifically. The establishment of breast cancer programmes should instead be regarded as appropriate preparation for an escalating disease that has highly significant ramifications for future global health.

The Breast Health Global Initiative (BHGI) held three global summits to address health-care disparities (Seattle, WA, USA; 2002), evidence-based resource allocation (Bethesda, MD, USA; 2005), and guideline implementation (Budapest, Hungary; 2007) as related to breast cancer in LMCs.11, 14, 15 Modelled after the approach of the National Comprehensive Cancer Network, BHGI developed and applied a consensus panel process, which is now formally endorsed by the Institute of Medicine,¹⁶ to create resource-sensitive guidelines for breast cancer early detection,¹⁷ diagnosis,¹⁸ treatment,¹⁹ and health-care systems²⁰ as related to health-care delivery for this disease in LMCs. The BHGI guidelines are intended to assist health authorities, policy makers, administrators, and institutions to prioritise resource allocation as breast cancer control programmes are implemented and developed in their resource-constrained countries.

This executive summary summarises the consensus findings of the fourth BHGI global summit that addressed issues and obstacles to breast cancer early detection, diagnosis, and treatment in low-resource²¹ and middle-resource countries.²² The summit also addressed the need for systematic approaches for problem solving and programme implementation.²³