The Breast Journal

Abstract: Breast cancer is the most common cause of cancer‐related death among women worldwide, with case fatality rates highest in low‐resource countries. Despite significant scientific advances in its management, most of the world faces resource constraints that limit the capacity to improve early detection, diagnosis, and treatment of the disease. The Breast Health Global Initiative (BHGI) strives to develop evidence‐based, economically feasible, and culturally appropriate guidelines that can be used in nations with limited health care resources to improve breast cancer outcomes. Using an evidence‐based consensus panel process, four BHGI expert panels addressed the areas of early detection and access to care, diagnosis and pathology, treatment and resource allocation, and health care systems and public policy as they relate to breast health care in limited‐resource settings. To update and expand on the BHGI Guidelines published in 2003, the 2005 BHGI panels outlined a stepwise, systematic approach to health care improvement using a tiered system of resource allotment into four levels—basic, limited, enhanced, and maximal—based on the contribution of each resource toward improving clinical outcomes. Early breast cancer detection improves outcome in a cost‐effective fashion assuming treatment is available, but requires public education to foster active patient participation in diagnosis and treatment. Clinical breast examination combined with diagnostic breast imaging (ultrasound ± diagnostic mammography) can facilitate cost‐effective tissue sampling techniques for cytologic or histologic diagnosis. Breast‐conserving treatment with partial mastectomy and radiation therapy requires more health care resources and infrastructure than mastectomy, but can be provided in a thoughtfully designed limited‐resource setting. The availability and administration of systemic therapies are critical to improving breast cancer survival. Estrogen receptor testing allows patient selection for hormonal treatments (tamoxifen, oophorectomy). Chemotherapy, which requires some allocation of resources and infrastructure, is needed to treat node‐positive, locally advanced breast cancers, which represent the most common clinical presentation of disease in low‐resource countries. When chemotherapy is not available, patients with locally advanced, hormone receptor‐negative cancers can only receive palliative therapy. Future research is needed to better determine how these guidelines can best be implemented in limited‐resource settings.

Abstract: As the largest cancer killer of women around the globe, breast cancer adversely impacts countries at all levels of economic development. Despite major advances in the early detection, diagnosis, and treatment of breast cancer, health care ministries face multitiered challenges to create and support health care programs that can improve breast cancer outcomes. In addition to the financial and organizational problems inherent in any health care system, breast health programs are hindered by a lack of recognition of cancer as a public health priority, trained health care personnel shortages and migration, public and health care provider educational deficits, and social barriers that impede patient entry into early detection and cancer treatment programs. No perfect health care system exists, even in the wealthiest countries. Based on inevitable economic and practical constraints, all health care systems are compelled to make trade‐offs among four factors: access to care, scope of service, quality of care, and cost containment. Given these trade‐offs, guidelines can define stratified approaches by which economically realistic incremental improvements can be sequentially implemented within the context of resource constraints to improve breast health care. Disease‐specific “vertical” programs warrant “horizontal” integration with existing health care systems in limited‐resource countries. The Breast Health Global Initiative (BHGI) Health Care Systems and Public Policy Panel defined a stratified framework outlining recommended breast health care interventions for each of four incremental levels of resources (basic, limited, enhanced, and maximal). Reallocation of existing resources and integration of a breast health care program with existing programs and infrastructure can potentially improve outcomes in a cost‐sensitive manner. This adaptable framework can be used as a tool by policymakers for program planning and research design to make best use of available resources to improve breast health care in a given limited‐resource setting.