As simple as it might sound, knowledge of median invasive tumor size provides a powerful indicator regarding the state of breast cancer detection.
—Benjamin O. Anderson, MD, FACS
As the world’s most common cancer among women, and the most likely reason around the globe that a woman will die of cancer, breast cancer affects countries at all economic levels. Despite the common misconception that breast cancer is primarily a problem of high-income countries, the majority of the 425,000 breast cancer deaths in 2010 occurred in developing (not developed) nations.
The number of young lives lost is even more disproportionate: In 2010, breast cancer killed 68,000 women aged 15 to 49 years in developing countries vs 26,000 in developed countries. If cancer will seriously be addressed as a global health issue, then breast cancer in low- and middle-income countries cannot be ignored.1
International Health Organizations and Cancer
The World Health Organization (WHO) reported that in 2008, an estimated 36 million of the 57 million global deaths were due to noncommunicable diseases (NCDs), principally cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, including 9 million deaths before age 60, nearly 80% of which occurred in developing countries. In response, the United Nations (UN) held a historic high-level meeting on September 19-20, 2011, to consider the prevention and control of noncommunicable diseases. The aim was to adopt “a concise, action-oriented outcome document that will shape the global agendas for generations to come.”
While the UN’s political declaration on noncommunicable diseases mentions cancer generally, it provides no specific reference to breast cancer as a leading problem or to cancer treatment priorities in practice. The document promotes “increased access to cost-effective cancer screening programs, as determined by national situations,” but otherwise gives no guidance about how diagnosed cancers should be managed.2
Why is this UN “action-oriented outcome document” largely silent on breast cancer? The organization embraced tobacco control, arguably the lowest hanging fruit of cancer prevention, and discussed the prevention of infection-associated cancers like cervical, liver, and stomach cancer through increased access to cost-effective hepatitis B virus and human papillomavirus vaccination. But UN statements have limited the discussion of common cancers that lack an infectious origin, like breast and colon cancers, to the modification of risk factors (unhealthy diet, obesity, and physical inactivity)—interventions that are unlikely to produce major shifts in outcome for these very common malignancies.
Prior to the UN summit, WHO released an executive summary, “Global Status Report on Noncommunicable Diseases 2010,” which outlines the core obstacles in addressing noncommunicable diseases in low- and middle-income countries.3 This analysis notes that biennial mammographic screening (from age 50–70 years) to downstage disease and breast cancer treatment of all stages are among the “best buys” for health-care interventions to tackle noncommunicable diseases. The report asserts that these breast cancer interventions could avert 19% of the cancer burden, and as such are “quite cost-effective.” However, the document’s editor and principal author, Ala Alwan, MD, who then served as WHO Assistant Director-General of Noncommunicable Diseases and Mental Health, concluded that breast cancer interventions are nonetheless impractical for poorer countries, both because of implementation costs and limited feasibility of treatment in the primary care setting in low- and middle-income countries.
Is this pessimistic perspective the end of the road for breast cancer in developing countries, or are there sequential steps that can be taken to address the most common cancer among women?
Breast Cancer Early-detection Strategies
Breast cancer screening has been a source of heated debate among health-care policymakers. The discussion about mammographic screening’s strengths, limitations, frequency, and target age group, which has relevance to high-income countries with established health-care infrastructures, has overshadowed more practical questions for addressing breast cancer outcomes in low- and middle-income countries.
Throughout the world, women in developing countries are most often first diagnosed with locally advanced (stage III) or metastatic (stage IV) cancer. These large palpable, visible, or ulcerated cancers are easily detected on inspection and clinical examination, obviating the value of detection on screening. These advanced cancers are more expensive to treat, less likely to respond to therapy, and most often prove incurable in any health-care setting. The critical questions, then, must not revolve around mammographic availability in low- and middle-income countries, but instead should focus on interventions whereby cancers can be diagnosed at less-advanced stages—so-called “clinical downstaging”—followed by adequate locoregional and systemic treatments.
Core Indicators for
The 2010 WHO report on noncommunicable diseases states that countries require a surveillance framework that monitors exposures (risk factors and determinants), outcomes (morbidity and mortality), and health-system responses (interventions and capacity). This WHO report recommends that standardized core indicators for each of the three components should be adopted and used for monitoring.
So what metrics are most relevant to breast cancer in low- and middle-income countries? Simply knowing the number of breast cancer cases and deaths provides no guidance about what health system responses are most needed in a given low- or middle-income environment. Useful health system metrics, like predictive tumor markers in treatment planning, should suggest practical solutions as next steps.
The Breast Health Global Initiative (BHGI) developed and published resource-stratified guidelines for breast cancer early detection, diagnosis, treatment, and health-care systems.4 Metrics recommended by that multidisciplinary international expert group include median invasive tumor size at initial diagnosis (the most basic tumor metric), and ratio of advanced-stage (stages III/IV) to early-stage (stages 0, I, II) disease at initial diagnosis (if higher-level staging information is available).
As simple as it might sound, knowledge of median invasive tumor size provides a powerful indicator regarding the state of breast cancer detection and sheds light for early detection strategies in low- and middle-income countries. Regions where median tumor size exceeds 3 to 4 cm are dominated by clinically detectable disease and therefore need to improve public knowledge about breast cancer and access to health-care facilities where cancer diagnoses can be made in an accurate and timely fashion. Practical interventions include outreach and public education about the signs and symptoms of breast cancer, the importance of early detection when it is still a small palpable mass or thickening, the promotion of breast self-examination, and the establishment of diagnostic tissue sampling and analysis to permit the accurate and timely diagnosis of clinically detectable disease. Image-detection of clinically occult cancers only becomes relevant when the median tumor size is less than 2 to 3 cm, and even then, the best methods for detection remain an important area of investigation. One size does not fit all.
It is crucial that WHO provide direct technical guidance to Member States about breast cancer as a relevant noncommunicable disease in low- and middle-income countries. Education about early detection, breast lumps, and self-examination is not a costly intervention and may help a woman seek treatment while it is still realistic, rather than waiting until the tumor is advanced and likely untreatable except through palliative care.
On April 19, 2012, the Union for International Cancer Control (UICC), working through the multi-organizational NCD Alliance, submitted recommendations to WHO regarding the prevention and control of noncommunicable diseases. Contained within this consensus document is the recommendation for “policies to support national programs for early detection of breast cancer that are appropriate and feasible for the population-need and resource setting and include, at a minimum, tumor size to be collected as part of the pathological assessment at diagnosis.”5
The Breast Health Global Initiative fully supports and endorses this recommendation to WHO and hopes that other organizations and oncology health professionals mirror this support of the BHGI framework for breast cancer core indicators in low-resource settings, by proposing inclusion of this indicator for breast cancer to their own governments and ministers of health. Such proposals are especially critical now, in this most important year for setting global targets and indicators for noncommunicable diseases. The decision of how to intervene with breast cancer will be made at the individual country level, and must be adapted to existing resources. For countries to make informed decisions on breast cancer control, they need meaningful data, including median tumor size at diagnosis. This is a key first step in assessing the real burden and options for solutions in addressing the most common life-threatening female cancer on earth. ■
Disclosure: Dr. Anderson reported no potential conflicts of interest.
Dr. Anderson is Director, Breast Health Global Initiative, Fred Hutchinson Cancer Research Center, and Professor of Surgery and Global Health-Medicine, University of Washington, Seattle.
1. Forouzanfar MH, Foreman KJ, Delossantos AM, et al: Breast and cervical cancer in 187 countries between 1980 and 2010: A systematic analysis. Lancet 378(9801):1461-1484, 2011.
2. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (A/RES/66/2). United Nations General Assembly. 66th session, agenda item 117. New York, United Nations, 2012.
3. Alwan A, Armstrong T, Bettcher D, et al: Global status report on noncommunicable diseases 2010. Geneva, WHO Press, 2012.
4. Anderson BO, Yip CH, Smith RA, et al: Guideline implementation for breast healthcare in low-income and middle-income countries: Overview of the Breast Health Global Initiative Global Summit 2007. Cancer 113(8 suppl):2221-2243, 2008.
5. Union for International Cancer Control: Follow-up to the UN High-level Meeting on NCDs. Available at http://www.uicc.org/advocacy/follow-un-high-level-meeting-ncds. Accessed May 7, 2012.