Breast cancer in Latin AmericaCazap, Eduardo; Buzaid, Antonio Carlos; Garbino, Carlos; de la Garza, Jaime; Orlandi, Francisco Javier; Schwartsmann, Gilberto; Vallejos, Carlos; Guercovich, Andres; ,
doi: 10.1002/cncr.23834pmid: 18837031
The incidence of breast cancer in Latin American countries is lower than that in more developed countries, whereas the mortality rate is higher. These differences probably are related to differences in screening strategies and access to treatment. Population‐based data are needed to make informed decisions. A 65‐question telephone survey that included 100 breast cancer experts from 12 Latin American countries was conducted in 2006 as an exploratory analysis of the current state of breast cancer treatment in these regions at both at the country level and at the center level. Greater than 90% of countries had no national law or guideline for mammography screening. The access rate to mammography was 66.3% at the country level and 47% at the center level. Variation in care based on level (country vs center) was indicated for the timing of treatment after diagnosis, timing from initial diagnosis to treatment, and the time from surgery to initial chemotherapy. However, the more sophisticated diagnostic testing for hormone receptors and biomarkers were available at most centers (>80%), and, overall, nearly 80% of patients started treatment within 3 months of diagnosis. Variation in care between breast cancer care at the center level versus the country level indicated a need for national cancer care programs. Alternative data collection strategies for understanding the state of breast cancer control programs in developing countries can help identify areas of improvement. Cancer 2008;113(8 suppl):2359–65. © 2008 American Cancer Society.
Breast cancer prevention in countries with diverse resourcesMcTiernan, Anne; Porter, Peggy; Potter, John D.
doi: 10.1002/cncr.23829pmid: 18837024
Breast cancer is the most common invasive cancer in women globally, and it affects more than 1 million women worldwide each year. It is a preventable disease in part, and primary care providers and public health programs play a key role in providing cancer preventive care. There are several health behaviors that may reduce the risk of breast cancer, including prolonged lactation; regular physical activity; avoiding overweight, obesity, and lifetime weight gain; avoiding excess alcohol intake; avoiding prolonged use of exogenous hormone therapy; and avoiding excessive radiation. These behaviors, although they have not been proven in clinical trials to reduce risk, are likely to be beneficial; information on them can be provided as a prevention strategy in countries of diverse means, although the methods of information delivery and follow‐up will depend on financial and personnel resources. Many of these health behaviors can reduce the risk for other chronic diseases and, thus, may be of great interest for general public health. In high resource level countries, additional prevention methods are available for high‐risk women, including selective estrogen response modulators and, for women at very high risk, bilateral prophylactic mastectomy and bilateral oophorectomy. Most women can benefit from advice and preventive care for reducing their risk for breast cancer. Cancer 2008;113(8 suppl):2325–30. © 2008 American Cancer Society.
Effective but cost‐prohibitive drugs in breast cancer treatmentBines, Jose; Eniu, Alexandru
doi: 10.1002/cncr.23837pmid: 18837028
New pharmacologic treatments for early‐stage breast cancer have been proven effective, but many of them are cost prohibitive in low economic settings. Differences in breast cancer mortality rates between developed and developing countries may be because of differences in screening and treatment options, some of which may be unavailable or limited by cost constraints in countries with limited resources. It is well recognized that treatment choices have to be made within budgetary constraints, and treatment guidelines that address the need to stratify treatment options by available resources have been published by the Breast Health Global Initiative. Practical treatment choices need to be made based on the best available cost–effective information. This article reviews new and emerging medical strategies that may improve the cost‐effectiveness equation. Cancer 2008;113(8 suppl):2353–8. © 2008 American Cancer Society.
Strategic health communication across the continuum of breast cancer care in limited‐resource countriesKreps, Gary L.; Sivaram, Rama
doi: 10.1002/cncr.23832pmid: 18837025
Strategic health communication is a critical component of healthcare that should be implemented across the continuum of care. Recognizing the importance of communication strategies and incorporating such strategies into healthcare policies, programs, and interventions is essential to the effective delivery of breast cancer care. The authors reviewed relevant literature and suggested practical evidence‐based strategies for effective communication interventions across the continuum of care for breast cancer patients, including early detection, diagnosis, treatment, survivorship, palliative care, and end‐of‐life care. Examples were provided from limited‐resource nations to support health communication recommendations. Cancer 2008;113(8 suppl):2331–37. © 2008 American Cancer Society.
Guideline implementation for breast healthcare in low‐ and middle‐Income countries: Treatment resource allocationEniu, Alexandru; Carlson, Robert W.; El Saghir, Nagi S.; Bines, Jose; Bese, Nuran Senel; Vorobiof, Daniel; Masetti, Riccardo; Anderson, Benjamin O.; ,
doi: 10.1002/cncr.23843pmid: 18837019
A key determinant of breast cancer outcome is the degree to which newly diagnosed cancers are treated correctly in a timely fashion. Available resources must be applied in a rational manner to optimize population‐based outcomes. A multidisciplinary international panel of experts addressed the implementation of treatment guidelines and developed process checklists for breast surgery, radiation treatment, and systemic therapy. The needed resources for stage I, stage II, locally advanced, and metastatic breast cancer were outlined, and process metrics were developed. The ability to perform modified radical mastectomy is the mainstay of locoregional treatment at the basic level of breast healthcare. Radiation therapy allows for consideration of breast‐conserving therapy, postmastectomy chest wall irradiation, and palliation of painful or symptomatic metastases. Systemic therapy with cytotoxic chemotherapy is effective in the treatment of all biologic subtypes of breast cancer, but its provision is resource intensive. Although endocrine therapy requires few specialized resources, it requires knowledge of hormone receptor status. Targeted therapy against human epidermal growth factor receptor 2 (anti‐HER‐2) is very effective in tumors that overexpress HER‐2/neu receptors, but cost largely prevents its use in resource‐limited environments. Incremental allocation of resources can help address economic disparities and ensure equity in access to care. Checklists and allocation tables can support the objective of offering optimal care for all patients. The use of process metrics can facilitate the development of multidisciplinary, integrated, fiscally responsible, continuously improving, and flexible approaches to the global enhancement of breast cancer treatment. Cancer 2008;113(8 suppl):2269–81. © 2008 American Cancer Society.
Guideline implementation for breast healthcare in low‐income and middle‐income countries Anderson, Benjamin O.; Yip, Cheng‐Har; Smith, Robert A.; Shyyan, Roman; Sener, Stephen F.; Eniu, Alexandru; Carlson, Robert W.; Azavedo, Edward; Harford, Joe
doi: 10.1002/cncr.23844pmid: 18816619
Breast cancer outcomes in low‐ and middle‐income countries (LMCs) correlate with the degree to which 1) cancers are detected at early stages, 2) newly detected cancers can be diagnosed correctly, and 3) appropriately selected multimodality treatment can be provided properly in a timely fashion. The Breast Health Global Initiative (BHGI) invited international experts to review and revise previously developed BHGI resource‐stratified guideline tables for early detection, diagnosis, treatment, and healthcare systems. Focus groups addressed specific issues in breast pathology, radiation therapy, and management of locally advanced disease. Process metrics were developed based on the priorities established in the guideline stratification. The groups indicated that cancer prevention through health behavior modification could influence breast cancer incidence in LMCs. Diagnosing breast cancer at earlier stages will reduce breast cancer mortality. Programs to promote breast self‐awareness and clinical breast examination and resource‐adapted mammographic screening are important early detection steps. Breast imaging, initially with ultrasound and, at higher resource levels with diagnostic mammography, improves preoperative diagnostic assessment and permits image‐guided needle sampling. Multimodality therapy includes surgery, radiation, and systemic therapies. Government intervention is needed to address drug‐delivery problems relating to high cost and poor access. Guideline dissemination and implementation research plays a crucial role in improving care. Adaptation of technology is needed in LMCs, especially for breast imaging, pathology, radiation therapy, and systemic treatment. Curricula for education and training in LMCs should be developed, applied, and studied in LMC‐based learning laboratories to aid information transfer of evidence‐based BHGI guidelines. Cancer 2008;113(8 suppl):2221–43. Published 2008 by the American Cancer Society.