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International breast health guidelines


Specific recommendations for improving breast-health care and cancer treatment in countries with limited resources have been published by the Breast Health Global Initiative (BHGI), an international coalition of doctors, scientists, policy makers and advocates led by Fred Hutchinson Cancer Research Center and the Susan G. Komen Breast Cancer Foundation.

"The Guidelines for International Breast Health and Cancer Control" are published as a 122-page supplement in the January-February 2006 issue of The Breast Journal. The material is available free of charge on the Internet on the BHGI website at

Benjamin O. Anderson, M.D., is chairman and director of BHGI, which he founded in 2002 to address the growing rate of breast cancer in developing nations and the need for such nations to provide more services to women.

"Many challenges in health care extend beyond the capacity of any one organization or sector to address effectively," he said. "This is especially true in a global world where traditional boundaries between what are ’public’ and ’private’ responsibilities have become blurred. The Guidelines for International Breast Health and Cancer Control is an example of what a collaborative, working global alliance can achieve."

Building on guidelines first published in 2003 to help developing nations find ways to make economically feasible and culturally appropriate care available to medically underserved women, "The Guidelines for International Breast Health and Cancer Control" expand and refine the earlier work by proposing an economically stratified approach to providing breast care based on available health-care resources, and a check-list format.

The BHGI Guidelines outline recommendations for breast health and cancer control in limited resource countries in four areas: Early Detection and Access to Care; Diagnosis and Pathology; Treatment and Allocation of Resources; and Health Care Systems and Public Policy. The Guidelines recommend, based on the country’s resource level, what level of care and/or service to provide and evaluation goals. Four panels of BHGI experts developed the Guideline recommendations using an evidence-based consensus approach.

Diana Rowden, international director of the Komen Foundation, said the Guidelines "provide an essential, practical tool in the fight against breast cancer in limited- resource countries as well as a plan to expand and improve health-care systems. We’re pleased to help make the Guidelines available to cancer researchers and advocates, health-care professionals, and policy makers around the world."

In an overview of the Guidelines published in The Breast Journal, Anderson and colleagues note that breast cancer is the most common cause of cancer-related deaths among women worldwide. Breast cancer is newly diagnosed in more than 1.1 million women annually; these cases represent 10 percent of all new cancer cases. Breast cancer deaths, at more than 410,000 annually, represent about 1.6 percent of all female deaths worldwide.

"Breast cancer is an urgent public-health problem in high-resource regions and is becoming an increasingly urgent problem in low-resource regions, where incidence rates have been increasing by up to 5 percent," the authors said.

Low-resource countries generally have not identified cancer as a priority health-care issue because infectious diseases are the predominant public-health threat, the study said. In these situations, cancer is most often treated when it is in its advanced stages, when treatment is most expensive and least successful. Cancer will become a greater health-care concern in low-resource countries as control of communicable diseases improves and life expectancy rises, the authors said.

While evidence-based breast-cancer guidelines exist for high-resource countries, they are of little value to poorer countries. "Current evidence about the value of earlier diagnosis and cost-effective diagnosis and treatment can nonetheless be applied to define evidence-based ’best practices with limited resources’ for breast health care for use in countries where access to medical care is marginal, breast-cancer awareness is marginal and cultural barriers to effective care exist," the researchers reported. Developing guidelines for nations with limited resources "is a crucial step toward improving breast health care and breast cancer in these regions," the study said.

The 2005 Guidelines offer a stepwise, systematic approach to health-care improvement using a tiered system of resource allocation on four levels – basic, limited, enhanced and maximal – depending on a country’s resources.

For example, in the area of breast-cancer early detection and access to care, the Guidelines suggest that countries with very basic health systems should educate women about performing breast self-examination to detect lumps. For countries with more but still-limited resources, the Guidelines recommend targeted outreach and education on clinical breast examination to women in at-risk groups, followed by ultrasound or mammography to confirm the discovery of suspected lumps. "We encourage ministries, cancer organizations, health professionals and patient networks across the world to actively engage in bridging the widening gap between what is and what could be," said Isabel Mortara, executive director of the International Union Against Cancer based in Geneva, Switzerland. UICC is an association of 270 cancer organizations in more than 80 countries, and a collaborating organization in the BHGI.

Rafael Bengoa, M.D., director of Health System Policies and Operations at the World Health Organization in Geneva, participated in the development of the Guidelines for Health Care Systems and Public Policy. He said, "In international development there are too many documents with ’should’ recommendations and too few on ’how’ to do things. Developing countries know the ’shoulds.’ They want support with the ’how.’ These Guidelines are about ’how’ to handle cancer and resources more effectively."

Leslie Sullivan | EurekAlert!
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