Benjamin O. Anderson, MD, is the Director of the Breast Health Global Initiative (BHGI) and surgical oncologist and Director of the Breast Health Clinic at the University of Washington in Seattle. The ASCO Post recently spoke with Dr. Anderson about the conceptual framework of the risk-stratification program developed by BHGI, the challenges presented by cultural obstacles, and the power of advocacy worldwide.
A Conceptual Framework
What motivated you to try to improve health-care delivery for breast cancer in the developing world?
In the late 1990s, I was invited to participate in a breast cancer–related project in the Ukraine run by PATH [the global health nonprofit headquartered in Seattle]. It quickly became evident that the National Comprehensive Cancer Network (NCCN) guidelines we use in the United States do not apply to countries that lack fundamental resources and infrastructure. Like cancer guidelines from other high-income countries, the NCCN guidelines assume that all the necessary tools are available and can be deployed to optimize disease management.
The BHGI has developed a conceptual framework that addresses management of breast cancer globally and can be applied in individual countries with few health-care resources by Western standards, adjusting for local cultural and political realities.
Our risk-stratification program prioritizes available tools for managing breast cancer diagnosis and treatment according to the best evidence available. Keep in mind that the evidence comes from wealthier countries.
We defined four levels for allocation of resources: basic, limited, enhanced, and maximal. Surgery would be considered essential for survival. Chemotherapy is an example of a limited resource, not necessarily essential but would provide a major improvement in survival. Enhanced resources might not improve survival but would improve treatment options. Maximal resources, such as PET or MRI imaging, are not appropriate or relevant for low- and middle-income patients, since these modalities add significantly to infrastructure cost and complexity but do not directly improve survival.
The guidelines are now comprehensive, covering early detection, diagnosis, treatment by stage, health-care systems and supportive and palliative care. We are focusing on implementing what we have learned. The real value of our conceptual framework is that it allows people to think through problems that otherwise seem vast and insurmountable.
Resource Stratification
What projects have emanated from the work on risk-stratification?
Many countries are involved in the BHGI. In 2009, Lancet Oncology published our report on the Asian Oncology Summit, which used our framework to develop five guidelines for Asia.1
I am really excited about the upcoming third edition of Disease Control Priorities (DCP3), coordinated by the University of Washington Department of Global Health, funded by the Bill and Melinda Gates Foundation, and published by the World Bank. This evaluation tool provides an economic framework for health management in low and middle income countries.
DCP3 will be launched to coincide with World Cancer Day on February 15, 2015. For the first time, DCP3 will include a full volume focused on cancer, using a modified version of the BHGI resource-stratification framework, characterizing resources as basic, limited, and augmented. The concept of resource stratification is taking off, and the next step is how to implement it.
Cultural Understanding Is Key
What factors are key to its success?
Guidelines and interventions must be relevant to the countries you are trying to help. For some countries, they are trying to figure out how to get patients to come for medical care before they develop ulcerating breast masses. Late detection of breast cancer is the major problem in the developing world, not overtreatment of breast cancer, as commonly discussed in the United States.
Cultural understanding is another key factor. The BHGI framework needs to be implemented in the context of social and cultural norms within a given environment.
Cultural Obstacles
What obstacles have you encountered related to cultural beliefs?
Cancer fatalism is a huge obstacle. Some people believe that God has created cancer as an irreversible punishment, or that witchcraft has delivered the disease as a curse. If you believe that cancer is invariably fatal, why would you participate in a program aimed at early detection?
Other obstacles include fear of stigmatization. In some Sub-Saharan African countries, it is common that a husband would divorce a wife with cancer, stripping her of any claim to her home or marital property. This is a huge disincentive toward early breast cancer detection.
Power of Advocacy
Can advocacy play an important role?
Powerful advocates can change awareness and influence policy. Survivors can become advocates, so we have to produce survivors by focusing on early cancer detection, diagnosis, and treatment.
Advocacy may be the single most powerful tool in addressing breast cancer globally. It is not an add-on; it’s a core feature.
Focus on Radiation Therapy
How is radiation therapy being approached in countries with few resources?
In the poorest regions of the world, radiation therapy is absent or so limited that it is not available, according to a recent International Atomic Energy Agency (IAEA) report. Radiation oncologists are lobbying to bring radiation therapy to these countries.
Radiation therapy can be important for palliative care, as well as curative, and it is one of the few effective treatments for painful bone metastasis. This is important in countries where cancers are discovered at advanced stages. Also, cancer is the only disease for which radiation is a treatment.
A first step in low-resource countries is to develop a center for excellence with an infrastructure, which becomes a magnet for multidisciplinary treatment and training. Radiation therapy is often the beginning of that cancer center, because it attracts other specialists like surgeons and medical oncologists involved in both curative and palliative care.
Appropriate Tools
What are some of the issues in bringing radiation therapy to the developing world?
What we consider the best solutions may not be implementable in developing countries. However, tools we consider no longer appropriate may, in fact, be the only way to bring radiation therapy to these environments.
One of the simplest approaches is to use cobalt as a radioactive source, because it is renewable and does not require running water and electricity grids like linear accelerators do. However, many governments do not like cobalt, because it can be used in dirty bombs.
Developing Radiation Centers
Has anyone quantified the actual need for radiation therapy in developing countries with limited resources?
Two groups are working on this. Mary Gospodarowicz, MD, of Princess Margaret Hospital, Toronto, Canada, recently convened a Global Task Force for Radiotherapy in Cancer Control. And the IAEA is attempting to quantify the need and costs in different countries—one at a time. The goal is to develop radiation centers in these countries. The IAEA is interested in providing linear accelerators and related infrastructure to make radiation treatment practical and available.
Stepwise Progress
Are any of these countries interested in developing radiation centers?
A number of countries have recognized the importance of developing radiation centers, and their health-care ministries are trying to address this goal. A key concept is that our job is not to go into countries and fix cancer, but rather to provide the tools so people can address problems in their own countries in sustainable ways.
The IAEA is driving efforts on the ground, including its PACT [Program Action for Cancer Therapy] initiative. I feel positive about this work and other efforts by the IAEA. It is a very exciting time.
I think we are making stepwise progress in the delivery of cancer care, and radiation therapy is a component of that. Rome was not built in a day! ■
Disclosure: Dr. Anderson reported no potential conflicts of interest.
Reference
1. Consensus statements from the Asian Oncology Summit 2009. Lancet Oncol 10:1075-1127, 2009.
