Reducing Breast Cancer Mortality in Poorer Countries

SEATTLE, Washington—In a new endeavor, an international group of experts is creating detailed guidelines for the screening, diagnosis, and treatment of breast cancer in countries and regions of the world with limited resources. The endeavor began with the Global Summit Consensus Conference and will lead to the publication, dissemination, and translation of the first edition of the guidelines next year.

"There has been a great deal of research defining how to do breast care when resources are without limit," said conference chair Benjamin O. Anderson, MD. "As a result, we know a lot about the disease and can make a very significant impact on it when we have the resources. What has never been done is sorting out, at a basic level, what to do when you don’t have those resources."

Dr. Anderson, associate professor of surgical oncology at the University of Washington Medical Center, and clinical medical director of the University of Washington’s Breast Care and Cancer Research Program, credits other groups and organizations, such as the World Health Organization, with laying the critical groundwork on which the guidelines will build.

More than 40 breast care and breast cancer experts from 16 countries participated in the conference, which was jointly sponsored by the University of Washington, the Fred Hutchinson Cancer Research Center, the Susan G. Komen Breast Cancer Foundation, the World Society for Breast Health, and the International Society for Breast Pathology.

Breast cancer is the third most common cancer worldwide and the leading cause of cancer-related death among women, Dr. Anderson told ONI in an interview. Women living in limited-resource countries have a lower incidence of breast cancer but poorer survival, compared with women living in countries with higher resource levels.

"The leading cause of higher breast cancer mortality appears to be diagnosis at more advanced stages combined with limited access to treatment," he said.

Sobering Statistics

Experts at the conference presented sobering statistics about the reality of breast care and breast cancer in limited-resource countries that highlight the need for guidelines. They described how women commonly or even typically present with stage III disease in many countries, how most women in regions of Pakistan who undergo mastectomy are later found to have benign breast conditions, how radiation therapy is nonexistent throughout much of Africa, and how Romanian physicians faced with tight budgets must decide how to best distribute chemotherapy and hormonal therapy among their patients.

The target audience for the guidelines will be health care providers, both at the national and community levels, Dr. Anderson said. But he emphasized that the expert group will be advocating for and speaking on behalf of women, and that certain related tenets will form the foundation of the guidelines.

"Human rights and women’s rights are an underlying theme of our guidelines," he said. These rights include a fundamental right of women to education about breast cancer and to early detection "as much as is feasible within their realm," he explained.

A Flexible Framework

When speaking of limited resources, one needs to address the often marked heterogeneity of resource distribution within a country and to think on a regional level as well, Dr. Anderson pointed out.

"Even in wealthy countries, there are pockets or regions where the resources are not available," he said. "Similarly, there are countries where the resources overall are limited, and yet there are cancer centers within these countries that are able to provide these services to the small number of people who have access to the centers."

The guidelines will, therefore, provide a flexible framework for implementing and expanding programs that can be tailored to each country’s and region’s unique circumstances. "We recognize that populations differ, social environments differ, the types of resources that can be made available differ among different parts of the world," Dr. Anderson said. "And so the solutions in two different parts of the world as to what is the next step may well be different."

The guidelines will be published in 2003 in the Breast Journal, which has an international readership, and will be disseminated through national and international organizations, he said.

"We hope, through written means, electronic means, and presentations, to disseminate this information and bring other people on board to help us with the next round of guidelines development," he said. Based on current plans, the guidelines will be updated every 2 to 3 years. He added that they will be translated into Spanish and French initially and into other languages thereafter.

"It’s clear that we will not be able to solve the global breast cancer problem in a single large step," Dr. Anderson said. "It is going to be small incremental steps in different parts of the world at different times that allow us to make advances. The guidelines will provide a framework by which these incremental steps can be made."