Global guidelines for breast health

An American woman who develops breast cancer might learn she has the disease following her annual mammogram. Or, acting on breast-health information from her doctor or the news media, she may discover a lump through self-examination. If she needs treatment, she'll have an 85 percent likelihood of surviving her disease; even greater if the cancer is detected early, as the majority of breast-cancer cases are in the United States.

For a woman living in an economically disadvantaged countries, the situation is very different. She probably has never had a mammogram. If she does find a breast lump herself, cultural perceptions of cancer and limited access to medical care may keep her from seeing a doctor until the cancer is advanced and hard to treat. It's likely any treatment she does receive won't be optimal for her condition.

These worlds-apart experiences are ones that Dr. Ben Anderson, a University of Washington breast surgeon, with a joint appointment in the Public Health Sciences Division, wants to change. In 2002, Anderson founded the Breast Health Global Initiative (BHGI), an international coalition of doctors, scientists, economists and policy makers that is developing guidelines to improve breast-cancer outcomes in resource-limited nations. Last month, more than 60 initiative representatives from five continents convened in Bethesda, Md., for the group's second Global Summit.

"In developed countries, we understand a great deal about how to treat breast cancer," said Anderson, also the director of the UW Breast Health Center. "We have effective guidelines for screening, diagnosis and treatment of breast cancer. The problem is that they cannot be applied in at least 80 percent of countries around the world due to inadequate health-care resources."

While breast cancer is the most common cause of cancer-related death among women worldwide, it is no longer the leading cause of cancer death for American women in this country, Anderson said. Breast-cancer death rates are highest among women in economically disadvantaged countries.

A roadmap for breast-health care

With an eye toward improving outcomes for breast cancer for all women, the group convened in 2002 to develop economically feasible, culturally appropriate breast-health guidelines based on the best scientific data. The initial guidelines, published in the Breast Journal in May 2003 and made freely available on the Web, focused on three areas in breast-cancer care delivery: early detection, diagnosis and treatment.

Recognizing that most resource-poor countries are unable to implement ideal breast health-care programs, the experts view the BHGI guidelines as a roadmap to help health ministries decide how to prioritize spending to ensure the greatest positive impact on breast health. The meeting in January focused on expanding and revising the guidelines, with an emphasis on developing specific recommendations for guideline implementation based on a country's available resources, using a stratified model defining "core", "limited", "enhanced" and "maximal" resource applications. Participants attended four consensus panels including early detection and access to care; diagnosis and pathology; cancer treatment and allocation of resources; and health-care systems and public policy. Each consensus panel will provide an updated guideline monograph to be published in the September/October issue of the Breast Journal and again to be made available for circulation on the Web.

"A major point of discussion in this year's Global Summit was that the most cost-effective way to improve treatment outcomes is to improve early detection of breast cancer," Anderson said.

Mammography is considered the best screening tool for early detection of breast cancer, but only the most economically privileged countries have the resources to offer screening mammography to women. Anderson said that even in the absence of mammography, the development of educational campaigns to promote breast awareness could make a significant impact on breast-cancer outcomes.

"In countries where women receive information about breast health, the average size of a tumor at diagnosis is smaller than in countries with little or no education or mass-media information about breast health," he said.

However, he said, initiative members recognize that cultural differences and attitudes toward cancer, particularly of the breast, may make it difficult to provide this information in some parts of the world.

The summit also hosted a meeting of the steering committee charged with determining how to help countries begin implementing the guidelines. Chaired by Dr. Gabriel Hortobagyi, professor and chairman of breast medical oncology at the M.D. Anderson Cancer Center, the BHGI Steering Committee is now defining plans and seeking funding to support pilot research projects, demonstration projects and educational programs based upon the BHGI guidelines.

Anderson said that breast cancer is an excellent model disease for addressing cancer outcome differences around the world.

"Breast cancer is a very treatable cancer," he said. "It's also a disease with a lot of complexities."

In particular, social stigmas associated with breast removal after cancer pose a number of challenges not seen with many other diseases.

"If we can solve the survival outcome differences for breast cancer, this will translate to many other cancers that have poorer survival rates in underdeveloped countries," he said.