Abstract
“It is evident that the time has come for the international scientific and advocacy organizations to take the measures necessary in highlighting breast cancer as the national priority in countries of limited resources”
As one of the major causes of morbidity, mortality and disease burden, breast cancer continues to receive significant attention. However, this attention is most conspicuous in resource-rich countries. In resource-limited countries, breast cancer has not yet been identified as a priority healthcare issue because infectious disease is still the major threat in these countries. There is also a remarkable diversity in the rate of economic growth, political and social conditions and the current status of the delivery of breast cancer care across the resource-limited countries. In addition, the emerging increase in the incidence rate of breast cancer by up to 5%/year is alarming and requires international attention. Breast cancer is becoming an urgent public health problem in resource-limited countries and requires comprehensive resource-appropriate strategies for breast cancer control and management, regardless of age, ethnicity, religion and nationality.
There has been significant improvement in breast healthcare over the past few decades, primarily due to advances in health research by diverse teams of basic scientists, physicians, pharmacists, industry, nurses and social workers. This research has involved inquiries regarding fundamental biological alterations in breast cancer, differences in diagnostic modalities and treatment options in various outcome studies. An increase in public awareness of breast cancer, an interest in women's health issues, advances in radiological imaging, the development of new chemotherapeutic agents and the availability of molecular genetic tests have brought remarkable opportunities to a new insight in breast cancer. These efforts have resulted in earlier breast cancer detection and better outcomes. However, at a global level, there are some countries in the world that have absolutely no ability to enjoy the advancements made in breast cancer detection and therapy. There are also significant numbers of medically underserved individuals in developed countries who have no access to breast healthcare and experience poor outcomes similar to those living in countries of limited resources. Access to optimal breast cancer care is a global challenge and requires a worldwide collaboration among those who have the power to implement the required changes. This editorial is designed to provide an overview of the challenges associated with breast cancer at the international level and to suggest interventions that may offer opportunities for improved breast healthcare among the medically underserved population.
Background information
Breast cancer remains a medical and social challenge, as well as a major public health problem. On a global level, it continues to be a devastating disease, for which no cause or cure has been found. Over 1.1 million women are diagnosed with breast cancer each year worldwide, and more than 410,000 of them die from this disease. Breast cancer accounts for 10% of all new cancer cases and more than 1.6% of all women's death around the globe [1–3].
Aside from the physical morbidity associated with breast cancer, this disease causes significant psychosexual impairment in a woman's lifetime. Breasts play an important role in a woman's sexuality and self-image. For some women, the loss of a breast to breast cancer is viewed as the loss of their sexual identity.
During the last several years, there have been significant advances in patient advocacy, early breast cancer detection and therapy. One milestone that has been achieved is increased public awareness of breast cancer. Many patients and survivors have been willing to share their pain and experiences very openly, while encouraging others to join them in the fight against this disease. Their efforts have been most effective in gaining increased funding for breast cancer research and in the emphasis on breast cancer screening and early detection [4–6]. Advances in breast imaging and genetics, the introduction of minimally invasive diagnostic and therapeutic procedures, and the discovery of molecular targeted therapy have resulted in significant progress in enhancing the quality of life for many breast cancer patients.
There has been a remarkable change in the fundamental understanding of breast cancer. This disease is no longer viewed as a single localized disease, with radical surgery as the only alternative therapy. Breast cancer is a heterogenous systemic disease that requires the attention of an integrated team of knowledgeable and interested physicians and healthcare providers who believe in a consolidated and multidisciplinary approach to breast healthcare. The magnitude of the importance of an integrated approach for breast cancer care has inspired the establishment of breast health centers, focused on fostering individualized therapy.
The above-mentioned progress has resulted in the reduction of the mortality rate from breast cancer in resource-rich countries. In the USA and Europe, as the result of screening mammography and the use of systemic chemotherapy and hormonal therapy, the mortality rate for breast cancer has been decreasing by 1–2%/year since the early 1990s [17]. By contrast, in resource-limited countries, the mortality rate from breast cancer has remained the same. Ironically, the incidence of breast cancer is higher in resource-rich countries; however, more women with breast cancer die of this disease in resource-limited countries [3].
These facts provide powerful evidence that improvement in breast cancer survival is achievable when appropriate resources are available and measures are in place to fulfil the task. In other words, it is possible to favorably impact breast cancer mortality by applying incremental changes in cancer care within a population. The barriers are numerous. Providing optimal breast healthcare to a geographically diverse population with different genetic backgrounds, social values, religious beliefs, lifestyle and economic status is a major task. There are also cultural and political influences that play important roles in this process.
Traditional beliefs and negative societal attitudes concerning breast cancer in resource limited countries significantly hinder a woman's access to appropriate medical care. The loss of a breast is a terrifying experience for a woman whose husband may divorce her because of the ‘bad genes’ that she has brought to the family and the fact that she is no longer considered sexually desirable [8–10]. Many societies with low income and limited medical resources are male-dominated. In these societies women have low social status and fewer personal resources. In these circumstances, other barriers include lack of or limited health insurance, lack of transportation to a medical facility, inability to take time off from work, inability to pay for childcare and the fear of abandonment by their husbands after a diagnosis of breast cancer is made [11–13].
These cultural taboos affect women's access to information, early detection and treatment. Associated with beliefs of fatalism, many women fall into social isolation and accept the poor outcomes. In resource-limited countries the knowledge of most women about breast cancer and its warning signs is very limited. This factor may also influence the delay in referral for treatment and increase in the incidence of late-stage disease presentation. Social fear of breast cancer, cultural taboos and myths and a lack of adequate public health educational resources are major obstacles in countries of limited resources. This has a major impact on early breast cancer detection and disease outcome. Implementation of breast cancer advocacy and public awareness programs similar to The European Breast Cancer Coalition (EUROPA DONNA) and the Komen Foundation and American Cancer Society in the USA are especially challenging. Limitations in financial support, social barriers and competing illnesses are factors that adversely affect the establishment of advocacy programs in limited-resource countries [11–13].
Access to care
The underlying differences in known risk factors, access to effective treatment and the influence of organized screening programs are the key factors in explaining the differences in the incidence, mortality and survival rates among different regions of the world [14,15]. A common feature across the world is the rising incidence of breast cancer ranging from 0.5–3%/year, with a projected number of 1.4–1.5 million in 2010 [1]. However, the emerging disparity in this long-term mortality trend is the result of the growing burden of breast cancer in resource-limited countries. This problem is attributed to the common presentation of the disease at late stage when the prognosis is poor.
It is difficult to argue with healthcare leaders of resource-limited countries who are focused on more urgent needs such as providing clean water, sanitation and treatment for infectious disease. However, it is possible to implement low-cost interventions that could make a difference [16].
Suggestions
There is no doubt that treating early stage breast cancer is more cost effective than treating late-stage disease. However, there is a broad variation in epidemiology between regions and significant differences in the cost structure of each area. The barriers to reform are numerous and often difficult to understand. The realization of the complexity of cancer care at an international level is a necessary initial step [17,18]. It is also critically important to recognize that the existing guidelines for optimal breast cancer early detection, diagnosis and therapy designed for resource-rich countries are not practical for resource-limited regions [19–21]. This limitation has also been confirmed by the WHO [22].
The alternative is to develop region-specific guidelines that realistically take into consideration the financial, political, cultural and social issues surrounding each resource-limited country. The concept of resource-appropriate strategies for optimal breast cancer care is central to the framework of any proposed guidelines.
The members of the Breast Health Global Initiative (BHGI) have already begun to achieve the above task. Co-sponsored by the Fred Hutchinson Cancer Research Center and the Susan G Komen Breast Cancer Foundation, BHGH is a program that strives to develop evidence-based, cost-effective and culturally sensitive guideline that are hoped to improve the quality of breast healthcare in countries of limited resources. The BHGI is an innovative international collaboration among a wide range of partners from different countries. As the result, a comprehensive set of resource- and stage-specific guidelines are developed that are applicable to all aspects of breast cancer management [17–30].
This process has involved reviews of the available reports in the literature, assembly of clinical observations, and the testimony of breast cancer patients. The guidelines were designed with a great deal of sensitivity to the existing diversity in the delivery of breast healthcare and with a sincere recognition of the current economic and cultural differences in countries of limited resources all over the world.
These guidelines are somewhat different from other guidelines that are traditionally developed. The most impressive characteristic of the proposed guidelines is the concept of stratification. In other words, the required essentials for the delivery of breast healthcare are based on the anticipated level of available resources in each economically diverse region.
This approach provides a realistic opportunity for every region of the world to make an effort to gradually improve their delivery of breast healthcare. This stepwise improvement is indeed a remarkable starting point, which will pave the way for a gradual progression to optimal care. The guidelines are only starting tools for those who are committed to making a change in the current status of breast healthcare. They are not meant to be interpreted as an established rule for which a different infrastructure and a wider participation of qualified individuals is required. The proposed guidelines by the BHGI are an introduction to the necessity for a movement at an international level to highlight the importance of optimal breast healthcare.
Implementation of these guidelines is an ambitious task and requires a significant amount of endurance to make sure that this message is heard by heads of governments, healthcare leaders, administrators, physicians, scientists, healthcare providers, nurses, social workers, technicians, industry, religious leaders and, more importantly, by the people of the world.
Future perspective
Breast cancer continues to remain a public health threat across the world. The innovation in early detection and therapy will impact the quality of life and reduces the mortality among patients in resource-rich countries. Breast cancer patients in resource-limited countries will become more aware of their right for access to a better quality of breast healthcare. The international advocacy movement will become more effective in enhancing knowledge regarding breast cancer among the public and healthcare providers. Together with assistance from the committed international breast cancer community, breast cancer will become a national public health priority in countries of limited resources. The challenge is how to accelerate the process against the time that is so essential to implement the change.