This effort has already brought important contributions to countries of low and middle incomes: the basic guidelines, which not only indicate how patients with breast cancer can be treated even with modest resources, but also provide a minimum level of care below which countries, governments and health care systems cannot even pretend that they provide care for women with breast cancer.
As I write these lines from my office overlooking the Texas Medical Center, arguably the most impressive collection of Health Institutions around the country, I realize how enormously privileged I am, and how fortunate my patients have been over the past three to four decades. I practice in a technologically advanced institution, with ample resources and with ready access to over 300 basic scientists within my institution and several hundred more just within blocks of my office. I have ready access to state-of-the-art technology before it becomes commercially available, and I have been able to assess the value of most experimental drugs developed for breast cancer years before FDA approval.
I have access to a fabulous medical and research library and subscribe to over 20 relevant scientific publications. The 10-year survival of patients with stage I breast cancer (which represents over 60% of our patients) approaches 90%, and for patients with positive lymph nodes it exceeds 75%. The 10-year survival of patients with metastatic breast cancer is 22%, and we are able to palliate the great majority with well-tolerated interventions.
However, my reality has no resemblance to the world outside of North America and Europe. Three out of four deaths from breast cancer occur in the rest of the world, in an environment where mammographic screening and early diagnosis are but a dream. Fine needle or core needle biopsies and sophisticated pathological analysis, including measurement of estrogen and progesterone receptors, HER2 and Ki-67 do not exist or are out of reach for the majority of mankind, as are modern radiotherapy, breast reconstruction and systemic therapies. While patients with primary breast cancer in our country receive primary treatments ranging in cost between $50,000 and $100,000, in much of the developing world, the health care allocation per capita is so low that even basic services are only intermittently available. And yet, breast cancer knows no borders, and what we learn about the disease in the Western world applies largely to the rest of the world.
Conversely, there are incredible opportunities for us to better understand the biology of breast cancer by integrating all women at risk and all women with breast cancer in modern translational and clinical research. Developing cost-effective diagnostic and therapeutic interventions for breast cancer is an imperative if we are to provide a basicum of care for those who do not have access to it today, and it is also an important mechanism to eventually determine the incremental benefits from our current therapies, where cost and cost-effectiveness are not part of the treatment selection. Expanding the “breast cancer market” to all patients around the world would also result in cost reductions as a result of bulk manufacture of medical equipment, drugs, and instrumentation. Most importantly, addressing the needs of women in countries of low or modest income levels is the right thing to do, and calls attention to the massive disparities in health care around the world. Calling attention to the AIDS epidemic has successfully brought drugs and treatment skills to many communities with very limited resources where AIDS is now a manageable disease. Breast cancer can be cured, and it is imperative to make the appropriate resources available globally for that purpose. The international community must come together to enhance the education and basic health care needs of the rest of the world.
For these reasons, the Breast Health Global Initiative is a critically important program. By bringing together experts in breast cancer, epidemiology, health care administration, health care policy, cancer prevention, and clinical and translational research, it creates an environment where cross-fertilization and productive interactions can develop. Individuals of these various backgrounds seldom come together in other forums, and their activities develop in parallel, never in synergy. This effort has already brought important contributions to countries of low and middle incomes: the basic guidelines, which not only indicate how patients with breast cancer can be treated even with modest resources, but also provide a minimum level of care below which countries, governments and health care systems cannot even pretend that they provide care for women with breast cancer. The hope is that the continued reinforcement and dissemination of these guidelines will bring attention to this problem, and more importantly to solutions that are within the means of most countries. Similar efforts would be helpful for other cancers, and other common illnesses that affect much of mankind. The global community needs to be aware of our common health challenges and needs to develop solutions that are universally applicable.
Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
1. Buzdar A, Hunt K, Buchholz TA, et al. Improving Survival of Breast Cancer Patients Over the Past 6 Decades – The University of Texas M. D. Anderson Cancer Center Experience. Proc 2010 Breast Cancer Symposium, Oct 1-3, 2010, Washington, D.C. p. 97
2. G. N. Hortobagyi, S. J. de la Garza, K. Pritchard, et al. ABREAST. ‘The global breast cancer burden: variations in epidemiology and survival., Clinical Breast Cancer. 2006;6:391-401.
3. Perkel, SJ: Financial modeling for global pricing: the NCCN breast cancer prototype. National Comprehensive Cancer Network. Oncology (Huntington). 1999;13(5A):73-74.
4. B. O. Anderson, R. Shyyan, A. Eniu, eet al. ‘Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines, Breast Journal. 2006;12: Suppl-15.