"Guidelines" for Breast Health Care and Cancer Treatment in Countries of Limited Resources

2002 GLOBAL SUMMIT CONSENSUS CONFERENCE
October 2 – 4, 2002
Seattle, Washington

MAJOR POINTS:

Overview

• All women have the right to access to health care, but considerable challenges exist in implementing breast health care programs when resources are limited.
• All women have the right to education about breast cancer, but it must be culturally appropriate, and targeted and tailored to the specific population.
• In countries with limited resources, most women have advanced or metastatic breast cancer at the time of diagnosis.
• Because advanced breast cancer has the poorest survival and is the most resource-intensive to treat, efforts aimed at early detection can reduce the stage at diagnosis, potentially improving the odds of survival and cure, and enabling simpler and more cost-effective treatment. These efforts are likely to have the greatest overall benefit in terms of both survival and costs.
• There is a need to build programs that are specific to each country's unique situation.
• The development of cancer centers can be a cost-effective way to deliver breast cancer care to some women when it is not yet possible to deliver such care to women nationwide.
• Collecting data on breast cancer is imperative for deciding how best to apply resources and for measuring progress.

Early Detection

• Early detection entails both early diagnosis in symptomatic women and screening in asymptomatic women.
• Key prerequisites for early detection are ensuring that women are supported in seeking care, and that they have access to appropriate, affordable diagnostic tests and treatment.
• The panelists propose the following action plan: 1) promote general activities to the empowerment of women to obtain health care, (2) develop infrastructure for diagnosis and treatment of breast cancer, (3) begin early detection efforts through breast cancer education and awareness, (4) when resources permit, expand early detection efforts to include mammographic screening.
• Public education and awareness can promote earlier diagnosis, and these goals can be achieved in simple and cost-effective ways, such as dissemination of messages through mass media.
• When resources become available for screening, they should be invested in screening mammography, as it is the only modality that has thus far been shown to reduce breast cancer mortality.
• While Clinical breast examination (CBE) and breast self-examination (BSE) are important components of routine breast care in countries with access to mammography; and are important for general breast health education in all countries. However, the evidence does not support the use of CBE and BSE as sole screening methods at this time, recognizing that data from the most extreme limited-resource settings are lacking.
• There is tremendous diversity among and within countries, and a program to promote early detection must therefore be tailored to each country's unique situation.

Diagnosis

• Accurate diagnosis avoids erroneous treatment for breast cancer, which can have devastating consequences for the woman and unnecessarily consumes resources.
• The panel distinguishes between a clinical diagnosis of breast cancer (one based on signs and symptoms and imaging findings) and a pathology diagnosis of breast cancer (one based on microscopic examination of cellular or tissue samples).
• All women should have a pathology diagnosis of breast cancer before they are given definitive treatment for the disease, no matter how strongly their clinical findings suggest cancer.
• Mastectomy should not be used to diagnose breast cancer, noting that accurate diagnosis can be made by less invasive means.
• Mammography and ultrasound also help determine the extent of disease within the breast, which is essential when breast-conserving therapy can be offered to women.
• Expertise in pathology was identified as a key requirement for ensuring reliable diagnostic findings.
• The tools for pathology diagnosis include fine needle aspiration biopsy, core needle biopsy, and standard surgical biopsy.
• The panel noted that each of these tools has potential benefits and limitations in the limited-resource setting, and concluded that the choice among them must be based on the available tools and expertise.

Treatment

• Local treatment of early-stage breast cancer involves either mastectomy or breast-conserving surgery followed by whole-breast irradiation.
• Substantial support systems are required to optimally and safely use breast-conserving approaches to local therapy or cytotoxic chemotherapy as systemic therapy.
• Cytotoxic chemotherapy also improves recurrence rates and survival with the magnitude of benefit decreasing with increasing age.
• Locally advanced breast cancer (LABC) accounts for at least half of all breast cancers in countries with limited resources and has a poor prognosis.
• The treatment of LABC requires multiple disciplines and is resource intensive.
• Most women with LABC will require a radical or modified radical mastectomy after neoadjuvant (preoperative) chemotherapy and/or hormonal therapy.
• In those women who cannot receive preoperative chemotherapy because of resource constraints, mastectomy with node dissection, when feasible, may still be considered in an attempt to achieve local-regional control.
• After local-regional therapy, most women should receive additional systemic chemotherapy.
• Ovarian ablation or suppression with or without tamoxifen is an effective endocrine therapy in the adjuvant treatment of breast cancer in premenopausal women with estrogen-receptor positive or unknown breast cancer.
• In postmenopausal women with estrogen and/or progesterone receptor-positive or unknown breast cancer, the use of tamoxifen or anastrozole are effective adjuvant endocrine therapies.
• Efforts to reduce the number of breast cancers diagnosed at an advanced stage thus have the potential to improve rates of survival while decreasing the use of limited resources.