Global Analysis of National Health System Characteristics and Breast Cancer Mortality and Stage at Diagnosis

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In a global population-based study reported in The Lancet Oncology, Duggan et al identified national health system characteristics associated with reduced breast cancer mortality, including higher Universal Health Coverage Service Coverage Index (UHC Index) rating and increased number of public cancer centers per population with cancer.

As stated by the investigators, “In some countries, breast cancer age-standardized mortality rates have decreased by 2% to 4% per year since the 1990s, but others have yet to achieve this outcome.”

Study Details

In the study, national age-standardized breast cancer mortality rate estimates for women aged ≤ 69 years obtained from GLOBOCAN 2020 were correlated with a standardized national health system data from the World Health Organization Cancer Country Profiles 2020, including:

  • Health expenditure
  • The UHC Index
  • Dedicated funding for early detection programs
  • Breast cancer early detection guidelines
  • Referral systems
  • Cancer plans
  • Number of dedicated public and private cancer centers per 10,000 patients with cancer
  • Pathology services.

Data on TNM stage at diagnosis were obtained from individual national cancer registries and a systematic literature review covering 2010 to 2020.

Key Findings

Complete health system data were available for 148 countries. In unadjusted analysis, high-income vs low-income countries had higher values for: health expenditure (P = .0002), UHC Index (P < .0001), dedicated funding for early detection programs (P = .0020), breast cancer early detection guidelines (P < .0001), breast cancer referral systems (P = .0030), national cancer plans (P = .014), cervical cancer early detection programs (P = .0010), number of dedicated public (P < .0001) and private (P = .027) cancer centers per 10,000 patients with cancer, and pathology services (P < .0001).

In multivariate analysis including 141 countries, health system characteristics significantly associated with lower age-standardized breast cancer mortality rates consisted of: higher UHC Index levels (β= –0.12, 95% confidence interval [CI] = –0.16 to –0.08), indicating a 0.12-unit decline in age-standardized mortality per unit increase in UHC index; and increasing number of public cancer centers (β= –0.23, 95% CI = –0.36 to –0.10), indicating a 0.23-unit decline in age-standardized mortality rate with each additional public cancer center per 10,000 patients with cancer.

Analysis of 35 countries for which available breast cancer TNM staging data could be compared with mortality data showed that 20 exhibited mean reductions in age-standardized mortality rates of ≥ 2% per year for ≥ 3 consecutive years since 1990. In all 20 countries, ≥ 60% of patients with invasive breast cancer were diagnosed with stage I or II disease. This level of reduction was observed in some countries without population-based mammographic screening programs. Countries that did not exhibit this level of reduction included some high-income countries.

The investigators concluded, “Countries with low breast cancer mortality rates are characterized by increased levels of coverage of essential health services and higher numbers of public cancer centers. Among countries achieving sustained mortality reductions, the majority of breast cancers are diagnosed at an early stage, reinforcing the value of clinical early diagnosis programs for improving breast cancer outcomes.”

Benjamin O. Anderson, MD, of the Global Breast Cancer Initiative, World Health Organization, Geneva, is the corresponding author for The Lancet Oncology article.

Disclosure: The investigators reported receiving no funding for the study. For full disclosures of the study authors, visit

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