Lydia Pace, MD, MPH
To shed light on this important issue, The ASCO Post recently spoke with Lydia Pace, MD, MPH, of the Division of Women’s Health, Brigham and Women’s Hospital, Boston, who has worked in Rwanda and studied the issues surrounding the rise in breast cancer in low- and middle-income countries, particularly in sub-Saharan Africa.
Road to Rwanda
Please share a bit of your background.
I’m a general internist. I trained in primary care and then did a fellowship in women’s heath at Brigham and Women’s Hospital. Through that fellowship, I went to work in the cancer center of the Butaro Hospital in the Burera district in Rwanda. I spent 3 years in Rwanda, which is how I became involved in studying the issues surrounding the rise of breast cancer in low- and middle-income countries, especially in sub-Saharan Africa.
Dearth of Cancer Registries
Given the infrastructural challenges in sub-Saharan Africa, how do you access and evaluate data related to breast cancer incidence in this region?
Access to high-quality incidence data in the developing world is limited, and there are no quick and easy answers to that question. However, in the medium- to long-term period, we need to develop population-based cancer registries, which would be the gold-standard way to ensure that we had high-quality data to guide program development. Currently, only about 2% of Africa’s population is covered by cancer registries.
In the short term, I think using facility-based data is a reasonable start, which is what we did in Rwanda. However, our facility-based data in Rwanda actually approximate the incidence rate using our facility as a model, which receives most of the nation’s patients. The long-range goal is to integrate data collection from multiple facilities.
More generally, if you think about maximizing facility-based data, it takes the development of thoughtful instruments, and ideally we would collect subsets of data using electronic medical records, which would also help improve care delivery.
Complicated Undertaking
Collaboration is needed in any large-scale cancer program. Do you get a sense that medical officials in Rwanda are on board with this initiative?
First, the only way any cancer-related program can be effective is with the support of the local government. For cancer services to reach low-level populations, they need to be integrated with existing public cancer care services and preferably with any existing insurance programs; and they need to be networked with existing tertiary cancer facilities. It’s a complicated undertaking, and for it to work, it needs to be integrated with all of the existing services.
Explaining the Trend
In your work, did you identify reasons for this upward trend in breast cancer?
We summarized data from GLOBOCAN, which are the most reliable contemporary estimates for incidence and mortality, at a national level, for 184 countries. We also looked at evidence form the Global Burden of Disease databank and a couple of other models. After data from all of those sources were evaluated, they suggested that breast cancer incidence and mortality are rising in low- and middle-income countries, especially in sub-Saharan Africa. The data are not granular enough to define the causes of this trend.
However, we do know that the incidence and mortality rates of breast cancer are simply increasing by keeping pace with the population growth. And the population in this region is aging, which puts more women in the at-risk category. Some hypothesize that rising incidence rates may reflect shifts in other risk factors known to increase breast cancer risk in developed countries, including lower fertility rates, age at first birth, underuse of breastfeeding, possibly dietary factors, and an increase in obesity. These factors could also be age-specific, but we don’t have enough data to definitively explain the trend, but it certainly makes sense.
Screening Challenges
Since many women in low- and middle-income countries areas present with late-stage disease, is there an opportunity to enhance screening programs?
There are some important issues with breast cancer screening in low- and middle-income countries. Globally, screening is an appealing strategy because it offers a promise of early detection and better survival outcomes. But breast cancer screening is not widely available in low- and middle-income countries, especially in sub-Saharan Africa. And because of several factors, widespread breast cancer screening will not be available in these areas in the foreseeable future.
Before you launch a widespread breast cancer–screening program, you must be able to enter every woman who is diagnosed with cancer into an affordable high-quality program that offers a full continuum of care. So the first step before launching a breast cancer–screening program is to develop treatment facilities that can properly manage the women who are diagnosed with the disease. To that end, we’re currently looking at what kind of treatment models best serve the populations in these challenged areas.
More Clinicians Needed
Please discuss some of the opportunities available to address the growing breast cancer burden in sub-Saharan Africa.
The first opportunity is to increase the availability of medical education on all levels. There is a dire shortage not only of oncologists, but also pathologists and second- and third-level providers, such as nurse practitioners and nurses. Skilled surgical oncology services are of vital importance in the treatment of early breast cancer, and these services are scarce. These areas also need more primary care providers on the front lines who can triage patients to their next step of care. In short, low- and middle-income countries areas need more health-care providers on every level and more treatment facilities.
Closing Thoughts
Would you like to share any closing thoughts?
The underserved cancer populations in low- and middle-income countries present difficult financial and structural challenges, which can only be met with a concerted international effort, such as the one put forth during the AIDS crisis. But positive change begins in increments. For instance, there is a group of physicians and nurses at the Butaro Cancer Center in Rwanda with whom I have worked for 5 years, and I’ve been humbled and awed by their commitment to their patients with cancer and training in oncologic services at the same time.
It’s important to note that well-mentored mid- and lower-level providers can deliver high-quality cancer care, and bringing them into the clinic requires less time and money than bringing in an oncologist. So that’s a goal that can be met in the short term. Furthermore, the ongoing accompaniment by Dana-Farber and Partners in Health along with oncologists from other institutions has been incredibly effective. From Rwanda, I would email oncologists back in the States almost daily, and we’d get valuable advice on tough cases. Most importantly, I saw first hand how generous programs like Dana-Farber’s can truly enhance the cancer-care delivery services in a resource-challenged country like Rwanda. ■
Disclosure: Dr. Pace reported no potential conflicts of interest.
