The Breast Health Global Initiative (BHGI) applied an evidence-based consensus review process to the development of guidelines for breast cancer early detection, diagnosis, treatment and health care systems in low- and middle-income countries (LMCs). Breast cancer outcomes 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 and in a timely fashion. Cancer prevention through health behavior modification may influence breast cancer incidence in LMCs, although prevention strategies alone cannot eliminate the great majority of breast cancer cases. Diagnosing breast cancer at earlier stages will reduce breast cancer mortality, assuming that appropriate multimodality treatment is provided. Programs to promote breast self-awareness and clinical breast examination and resource-adapted mammographic screening are important steps in early detection. Obstacles to breast cancer early detection, diagnosis, and treatment occur in industrialized countries as well as LMCs. Understanding implementation in LMCs can inform policy makers in the U.S. on how to improve health care delivery in underserved communities, where the challenges mirror those of low-resource environments.
Breast cancer is the most common cause of cancer-related death among women worldwide, with case fatality rates highest in low- and middle-income countries (LMCs). Globally, breast cancer is the most common female cancer, comprising 23% of all cancers that are newly diagnosed, in more than 1.1 million women each year. More than 411,000 breast cancer deaths occur each year, accounting for more than 1.6% of female deaths from all causes. The annual global burden of new breast cancer cases is projected to be 1.5 million this year, with an ever-increasing majority from LMCs. Approximately 4.4 million women diagnosed with breast cancer in the last five years are currently alive, making breast cancer the single most prevalent cancer in the world.
In most LCMs, breast cancer incidence rates are increasing more rapidly than in regions where incidence rates are already high. Despite the younger age structure of most developing countries, LMCs already account for 45% of the incident breast cancer cases and cause 54% of the annual breast cancer deaths around the globe. Even assuming that there will be no change in underlying age-specific rates, a nearly 50% increase in breast cancer global incidence and mortality is anticipated between the years 2002 and 2020—due simply to the aging of current global populations. These rising cancer rates will be disproportionately greater among countries in the developing world, projected in LMCs to reach a 55% increased incidence and 58% increased mortality in fewer than 20 years. In reality these projected statistics probably underestimate future cancer rates, since the little data that is available from LMCs reveals increasing age-specific breast cancer incidence and mortality rates, especially among recent birth cohorts. This is especially true for urban women in LMCs and is partially attributable to the adoption of Western lifestyles.[4,5]
Evidence-based guidelines outlining optimal approaches to breast cancer detection, diagnosis, and treatment have been well-developed and disseminated in several high-resource countries.[6,7] However, these guidelines define optimal practice, and therefore have limited utility in LMCs. Optimal practice guidelines may be inappropriate for LMCs for numerous reasons, including inadequate personal resources, limited health care infrastructure, lack of pharmaceuticals, and cultural barriers. Hence, there is a need to develop clinical practice guidelines oriented specifically toward LMCs, and these guidelines need to take into consideration existing health care resources.
Cosponsored by the Fred Hutchinson Cancer Research Center and Susan G. Komen for the Cure, 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, with the aim of improving breast cancer outcomes. The BHGI held three Global Summits to address specific topics as they relate to breast cancer in LMCs: health care disparities (Seattle, Washington, 2002); evidence-based resource allocation (Bethesda, Maryland, 2005); and guideline implementation (Budapest, Hungary, 2007). Modeled after the approach of the National Comprehensive Cancer Network (NCCN), BHGI developed and applied a consensus panel process that is now formally endorsed by the Institute of Medicine (IOM)  to create resource-sensitive guidelines for breast cancer early detection, diagnosis, treatment  and health care systems  as related to breast health care in LMCs. These BHGI guidelines are intended to assist ministers of health, policymakers, administrators, and institutions in prioritizing resource allocation as breast cancer treatment programs are implemented and developed in their resource-constrained countries (Table 1).
The dominant paradigm in the medical community is that good research and publication should be sufficient to ensure the translation of scientific findings into general practice. Unfortunately, a landmark IOM report from 2001 clearly identified the failure of much scientific innovation to be translated into practice.[17,18] More recently, Rubenstein and Pugh separated the IOM’s second translational block — clinical research to practice — into two parts: clinical research to guidelines, and guidelines to practice. Implementation researchers maintain that the process is complex, and they have begun to identify factors and processes critical to the adoption of new technologies and practices. Although there has already been some research assessing readiness for change, it has usually focused on just one component, such as providers or health units, or has focused on intention without considering self-efficacy or environment. As a conclusion in her extensive review of the implementation literature, Greenhalgh notes the need for more research on system readiness for innovation and for more studies evaluating implementation of specific interventions.
A review of available information strongly suggests that research could play a crucial role in applying the experience and knowledge of high-income societies to the challenges of women and breast cancer throughout the world. A recent survey of oncology experts from Latin American countries found that 94% of the surveyed experts consider clinical-epidemiologic research development on breast cancer insufficient in their country. The main reasons identified were insufficient funding and lack of available time.
Very little research on guideline implementation has been done in LMCs. It is necessary to determine whether the basic frameworks and instruments described in high-income countries apply in these very different environments, and what adaptation is needed to make them both valid and feasible. A systematic program of research to develop appropriate readiness-assessment instruments and to identify effective implementation strategies is now needed in a variety of LMCs. As we move toward the adoption, implementation, and maintenance of the new evidence-based principles embodied in the BHGI guidelines, it is critical that careful evaluation is incorporated in the efforts, to ensure that lessons about effectiveness and efficiency are captured. It is precisely because resources are scarce in these countries that it is even more imperative that LMCs adopt effective practices as quickly as possible, and that implementation approaches are designed with limited resources in mind.
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