Understanding Breast Cancer Diagnosis and Treatment Disparities in Resource-Challenged Nations

A Conversation With Temidayo Fadelu, MD, MPH

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Temidayo Fadelu, MD, MPH

Temidayo Fadelu, MD, MPH

Cancer is the second leading cause of death in the Caribbean. Adding to this growing burden, many of the nations in this geographically spread region have under-resourced health-care systems and a lack of cohesive approaches to the delivery of cancer care. To shed light on the public health dilemma, The ASCO Post recently spoke with Temidayo Fadelu, MD, MPH, a medical oncologist at Dana-Farber Cancer Institute. Dr. Fadelu works with the Center for Global Cancer Medicine at Dana-Farber, which supports cancer programs in Rwanda and Haiti in collaboration with Partners in Health.

Education and Background

Please tell the readers a bit about your background and current position and work.

I was born and reared in Nigeria and came to the United States to attend college at Baylor University, where I earned a BA in biology and environmental studies. I received my medical degree from Yale University School of Medicine and did my internal medicine residency at the Hospital of the University of Pennsylvania. After residency, I moved to Rwanda for 2 years, working as Clinical and Programmatic Implementation Lead for a rural oncology program based at Butaro Cancer Center of Excellence in northern Rwanda.

I returned to the States to pursue a fellowship in medical oncology at Dana-Farber, during which I earned an MPH at the Harvard T.H. Chan School of Public Health. Currently, I do clinical work in the hospital, seeing patients with breast cancer, and spend the rest of my time working with the Center for Global Cancer Medicine at Dana-Farber. Much of my research centers on global inequities of care in resource-challenged regions of the world, with a particular emphasis on sub-Saharan Africa.

Barriers to Delivery of Quality Care in Haiti

You were part of a team of researchers looking into patient characteristics and outcomes in nonmetastatic breast cancer in Haiti. First, please give the readers a sense of the challenges faced by oncologists and their patients with cancer in Haiti.

Most of the cancer care delivery challenges faced in Haiti coincide with those of other resource-challenged nations. Haiti happens to be extremely poor, which exacerbates the challenges. One of Haiti’s biggest care challenges is the severe shortage of programs to train clinicians to care for patients with cancer, which is an initiative we are undertaking at the Center for Global Cancer Medicine. Due to Haiti’s fractured infrastructure, traveling long distances to the clinic is difficult. Plus, there is a large medical literacy deficit and a lack of national health insurance, which create a financial barrier to care for a majority of Haitians.

Moreover, there are very limited diagnostic pathology services available, and the few labs on the island have limited capacity to do even basic tissue-processing functions. Our study looked at breast cancer, which is the leading cause of cancer death among Haitian women. Not having the ability to quickly diagnosis and stage breast cancer makes the delivery of quality care challenging for Haitian women.

Effect of Late-Stage Diagnosis on Breast Cancer Outcomes

Please describe the goals and design of your study.

Although previous studies have found that most Haitian women with breast cancer are diagnosed at later stages, there are no thorough studies describing how late-stage diagnosis affects outcomes in these women with breast cancer. Our study identified a retrospective cohort of female patients with nonmetastatic breast cancer, and we conducted survival analyses to identify prognostic factors that may affect patient outcomes. The goals were twofold: to describe patients’ presenting features, along with their selected treatment and outcomes, and then to identify what factors might be put in place to create better outcomes.

We conducted the study from 2012 to 2016 at the University Hospital Mirebalais (HUM), which is a 350-bed public tertiary care government facility. To give a sense of the available services, HUM is one of only two institutions delivering comprehensive breast cancer treatment in Haiti, a country of 11 million people. Despite the challenges, one thing that helped our study was that HUM has electronic medical records with coded diagnoses, which enabled us to identify patients who might be a good fit for our research.

Operating in the Absence of Radiation Therapy

You noted that radiation therapy does not exist in Haiti, which creates a large void in breast cancer care. Please give the readers a sense of that clinical reality.

Needless to say, radiation therapy is a major component in breast care, but, nonetheless, there are elements of quality breast cancer care that can be provided in the absence of radiation therapy. Since clinicians in Haiti do not have radiation options, which rules out lumpectomy, they rely on more extensive surgical procedures; the current standard of care is a modified radical mastectomy. Consequently, in the absence of radiation therapy, we saw a greater-than-average recurrence rate in the cohort of younger women we studied. As one would expect, given Haiti’s economic condition, advanced imaging techniques are not readily available. In fact, HUM does not have access to a magnetic resonance imaging machine. Plus, along with the scarce radiologic services, there is a shortage of technicians trained in providing radiologic services.

‘Loss-of-Breast’ Stigma

What effect did a lack of radiation therapy have on the women with breast cancer you looked at?

The cultural stigma around the loss of a whole breast contributed to a significant loss to follow-up in those women scheduled for mastectomy. Moreover, I think there is a greater percentage of Haitian women who opt out of mastectomy because of this loss-of-breast issue than is shown by the results of our work. Unfortunately, our study also looked at women with nonmetastatic disease who would have had curative potential in mastectomy but chose not to because of the breast stigma.

Next Steps and Future Directions

Given the depth of economic and clinical challenges faced in Haiti, do you plan to continue studying this critical issue?

Yes, we’ve really just scratched the surface with this study. We did, however, lay the groundwork for future investigation. We identified some potential areas for improvement despite the limited available diagnostic and treatment capacity. For instance, strategies for optimizing breast cancer care at this facility may focus on increasing surgical resection rates, increasing the use of neoadjuvant chemotherapy among patients with locally advanced disease, and encouraging the initiation of adjuvant endocrine therapy in those with estrogen receptor–positive disease.

Despite the gaps and limitations in the system, delivery of curative breast cancer treatment in Haiti is possible, and we are looking at interventions that might help ease some of the patient-centric issues serving as barriers to entering the care system. We are also planning a study to understand, from the patient’s standpoint, the various barriers they face to access breast care. There are also many missed opportunities along the way before a patient presents at the clinic with breast cancer. The amount of work to rectify that major gap in care needs to be undertaken with the help of the Ministries of Health. 

DISCLOSURE: Dr. Fadelu has received institutional research funding from Celgene and Cepheid Inc.