Benjamin O. Anderson

Cancer control planning has become a core aspect of global health, as rising rates of noncommunicable diseases in low-resource settings have fittingly propelled it into the spotlight. Comprehensive strategies for cancer control are needed to effectively manage the disease burden. As the most common cancer among women and the most likely reason a woman will die from cancer globally, breast cancer management is a necessary aspect of any comprehensive cancer control plan. Major improvements in breast cancer outcomes in high-income countries have not yet been mirrored in low-resource settings, making it a targeted priority for global health planning. Resource-stratified guidelines provide a framework and vehicle for designing programs to promote early detection, diagnosis, and treatment using existing infrastructure and renewable resources. Strategies for evaluating the current state and projecting future burden is a central aspect of developing national strategies for improving breast cancer outcomes at the national and international levels.

Low‐ and middle‐income countries (LMICs) are undergoing an increase in incidence of breast cancer, but have inadequate resources to implement mammographic screening. Clinical breast examination (CBE) has been suggested as an alternative to mammography in these settings. We compared the results of CBE screening by 47 midwives and 15 trained lay health workers to results of independently performed mammographic screening in an unscreened population of 1,179 women in Jakarta, Indonesia. Two hundred and eight‐nine (24.5%) of the screened women had a suspicious finding on CBE and/or mammography. Sixty‐nine (23.9%) of these women had both an abnormal CBE and mammogram; 98 (33.9%) had an abnormal CBE, but a normal mammogram; and 122 (42.2%) had a normal CBE and an abnormal mammogram. Fourteen breast cancers were diagnosed. Of these, 13 were identified by both mammogram and CBE. One breast cancer was identified from an abnormal mammogram, but had a normal CBE. One hundred and sixty‐seven (14.2%) of the CBEs required additional work‐up to diagnose 13 of the 14 cancers detected by mammography. In comparison, 191 (16.2%) of mammograms required additional work‐up to diagnose the 14 cancers. Unfortunately, only 42.8% of the women diagnosed with cancer returned for treatment. In an unscreened population in LMICs such as Indonesia, CBE is nearly as effective as mammography in detecting prevalent breast cancers. However identifying and overcoming barriers to appropriate treatment of women who are identified as having breast cancer are essential to the success of any screening program.

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.