According to a report from the International Agency for Research on Cancer’s GLOBOCAN project, one woman dies every minute from breast cancer and one woman dies every 2 minutes from cervical cancer.1 The majority of these deaths occur in developing countries, where access to health care is limited and continuity of care is poor.2 Colombia is no exception. There, breast cancer and cervical cancer are the two leading causes of cancer-related death in women.2-4
Cali, Colombia
Poverty is related to inferior cancer outcomes.5 Cali, the third largest city in Colombia, is home to more than 2,500,000 individuals; 40% live in poverty.6,7
In Cali, 20 women per 100,000 are diagnosed with cervical cancer annually, an incidence twice that in the United States. Eight women per 100,000 die annually from cervical cancer, 4.5 times greater than mortality rates in the United States.1,8
Breast cancer also presents a significant threat. In Cali alone, 48 women per 100,000 are diagnosed annually, and 13.7 women per 100,000 die each year (30% higher than the national death rate).1,9 The incidence of breast cancer in Colombia is not greater than in the United States; however, Colombian women are diagnosed with advanced disease twice as often as North American women.1,10
The implications of late diagnosis are grave, including threats to family stability and socioeconomic viability as well as notable increases in mortality.11,12 The potential for improved outcome by providing early diagnosis and expedient treatment is significant.
A 2011 ruling by the Colombian government ensures that all Colombian women (regardless of income) are guaranteed state-sponsored health coverage.13 However, the existing health infrastructure is not adequately mobilized to meet the needs of all women requiring cancer care.
In response to this need in Cali, Partners for Cancer Care and Prevention, a 501(c)3 nonprofit organization based in Baltimore, launched its women’s health program in 2011. Using data from epidemiologic research, the group created a baseline profile of the sociodemography of prospective breast health patients in Cali (see sidebar). The organization then assessed the barriers to timely access, early detection, and high-quality treatment services, and created a plan of action, as highlighted below.
Barriers to Care
Physician Training: Each year, Colombia trains only a small number of surgical and medical oncologists. The number of trainees is not commensurate with the number of patients needing care. Moreover, regulations limit treatment of breast cancer patients by general surgeons.
Equipment Deficits/Customs Regulations: There is a limited supply of vital diagnostic equipment, including biopsy needles, a portable ultrasound to perform ultrasound-guided biopsies, and a gamma-detecting probe to perform sentinel node biopsies. In spite of this, Colombia’s national customs regulations prohibit importation of medical machinery over 5 years old.
Delayed Screening: Patients’ poor health literacy, limited financial resources, and insufficient knowledge of the HMO system that authorizes care constitute major obstacles. As a result, many do not enter into care until their cancer is advanced and requires more expensive and invasive intervention.
Impaired Patient Flow: More than 24 months may elapse from screening mammography, diagnostic procedures, and reporting of test results to actual diagnosis and initiation of treatment. Barriers to timely referral include:
- Patient (vs provider) accountability for communication of screening and diagnostic test results
- HMO denial of physician and patient petitions for treatment, and lengthy subsequent appeals processes
- Poor communication between providers within the local referral network
- Limited availability of providers, appointments, and equipment
Deficient Histopathologic Reporting: Review of 49 cases revealed insufficiently standardized histopathologic reporting leading to a lack of information necessary for timely implementation of appropriate treatment. Hormone receptor status, margins, and grade of differentiation are frequently omitted from such reports.
Plan of Action
Cali boasts a strong network of hospitals and health centers, local governmental support of cancer control, and a mobilized private sector. These interests are collaborating with the support and coordination of our pilot program.
Partners for Cancer Care and Prevention and collaborators have set clear pilot goals. In 2013, the team aims to provide 100% of women needing breast cancer diagnostic services with prompt, accurate diagnoses and linkage to care. Strategies include:
Patient Navigation: The pilot facility provides a critical point of entry into the health system for socioeconomically marginalized women. In 2013, Partners for Cancer Care and Prevention secured grant support from the Susan G. Komen Foundation to launch a patient navigation pilot initiative (which began in July 2013) to improve continuity and quality of breast cancer care and ensure that no woman who enters the facility for breast health services is lost to follow-up between screening, diagnosis, and treatment. Knowledge gained will be used to enhance treatment initiation, adherence, and success.
Facility Capacity: Partners for Cancer Care and Prevention, local hospital personnel, and local academic institutions have partnered to increase diagnostic and treatment skills of providers.
- Pathology: Based on international pathology reporting standards, local protocols for specimen collection, preparation, and documentation were assessed and revised.14 In addition, five hospital bacteriologists were trained in rapid fine-needle aspiration quality checks. Follow-up review and training will occur in 6 months.
- Health Professional Education: A week-long series of 21 breast disease management lectures was provided to hospital staff, including hands-on guidance in surgical/diagnostic techniques. In the coming year, Partners for Cancer Care and Prevention will support monthly remote grand rounds and training in evidence-based breast cancer management.
- Diagnostic/Treatment Capacity: Partners for Cancer Care and Prevention secured donations of medical supplies and equipment totaling $20,000 in 2012–2013, including a five-headed microscope for pathologist/cytologist quality control and training, which was donated to the partner facility for use in ongoing cancer program activities.
Program Needs
Currently, Partners for Cancer Care and Prevention seeks:
Educators: experienced nutrition, medical, nursing, and operations professionals with an interest in being a part of a replicable model program to sustain technical support and capacity-building efforts. The organization aims to fund one oncology fellowship based at the pilot site.
Research Partners: At both U.S. and Colombian academic institutions to document and disseminate program activities to advance knowledge on a broader scale.
Sponsors: Partners for Cancer Care and Prevention currently has partnerships with ReNew Life and the Susan G. Komen Foundation. The group welcomes interested corporate and independent partnership opportunities. ■
Dr. Sardi is Chief of Surgical Oncology and Director of The Institute for Cancer Care at Mercy Medical Center, Baltimore. He is also President and Co-founder of Partners for Cancer Care and Prevention, formerly known as the United Hands for Health Foundation.Ms. Joseph is Executive Director of Partners for Cancer Care and Prevention.
Disclosure: Dr. Sardi and Ms. Joseph reported no potential conflicts of interest.
References
1. International Agency for Research on Cancer: The GLOBOCAN project. Available at http://globocan.iarc.fr. Accessed July 23, 2013.
2. American Cancer Society: Global Cancer Facts and Figures, 2nd ed. Atlanta, American Cancer Society, 2011. Available at www.cancer.org. Accessed July 23, 2013.
3. Forouzanfar MH, Foreman KG, Delossantos AM, et al: Breast and cervical cancer in 187 countries between 1980 and 2010: A systematic analysis. Lancet 378:1461-1484, 2011.
4. Piñeros M, Gamboa O, Hernández-Suárez G, et al: Patterns and trends in cancer mortality in Colombia 1984-2008. Cancer Epidemiol 37:233-239, 2013.
5. Knaul FM, Frenk J, Shulman L, for the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries: Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. Boston, Harvard Global Equity Initiative, October 2011.
6. Populations, CO: The population of Cali, Colombia. Available at http://populations.co/populations-by-city/city-populations/cali/. Accessed July 23, 2013.
7. DANE: Boletin: Censo general 2005, perfil Cali, Valle del Cauca. 2010. Available at www.dane.gov.co. Accessed July 23, 2013.
8. Universidad del Valle: Registro Poblacional de Cáncer de Cali, Colombia; C53, Cuello Uterino. 2008. Provided by Fundación Hemato—Oncólogos, Cali, Colombia.
9. Universidad del Valle: Registro Poblacional de Cáncer de Cali, Colombia; C50, Mama. 2008. Provided by Fundación Hemato—Oncólogos, Cali, Colombia.
10. Piñeros M, Sánchez R, Cendales R, et al: Patient delay among Colombian women with breast cancer. Salud Pública de México 51(5):372-380, 2009.
11. Williams-Brennan L, Gastaldo G, Cole DC, et al: Social determinants of health associated with cervical cancer screening among women living in developing countries: A scoping review. Arch Gynecol Obstet 286:1487-1505, 2012.
12. De Boer AGEM, Taskila T, Ojajarvi A, et al: Cancer survivors and unemployment: A meta-analysis and meta-regression. JAMA 301:753-762, 2008.
13. Guerrero R, Amarís AM: Financing cancer care and control: Lessons from Colombia. Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries Working Paper and Background Note Series, No. 1, Harvard Global Equity Initiative, 2011.
14. Lester SC, Bose S, Chen YY, et al: Protocol for the examination of specimens from patients with invasive carcinoma of the breast. College of American Pathologists. Available at http://www.cap.org. Accessed July 23, 2013.
For more information about Partners for Cancer Care and Prevention, please visit the organization’s website (pfccap.org) or e-mail either Executive Director Rachel Joseph (rjoseph@pfccap.org) or President and Co-founder Dr. Armando Sardi, Director of the Institute for Cancer Care and Chief of Surgical Oncology at Mercy Medical Center, Baltimore (asardi@mdmercy.com).
