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Breast Cancer Screening in a Global Context: The Security of Early Detection and the Inequity of Implementation

One of my family members was recently diagnosed with breast cancer. A few days after her diagnosis, she sent me her pathology reports. They said that her cancer was ductal carcinoma in-situ, invasive, high grade (grade 3), estrogen positive, and HER2 positive. I’m certainly no oncologist. Most days I’m really just trying to wrap my head around general medicine. But it sounded like her cancer was potentially an aggressive one. That night, I got on my computer in attempt to educate myself about her pathology. Her cancer was in its early stages, but the fact that it was high grade meant it could spread quickly. The ER positivity was a good thing, but the HER2 positivity meant that she would probably need chemotherapy. I was certainly scared. But I was also relieved because it was detected early on. Because of that, her prognosis was good.

In contrast to my family member, for other people in many other parts of the world, there’s no such thing as the security of early detection. The statistics reflecting this are somewhat staggering. Breast cancer is the most common cancer in women in both in the developing and the developed world. However, the differences in survival rates are profound – 80% in North America, Japan, and Sweden, 60% in middle-income countries, and 40% in low-income countries.1 Both late disease presentation and lack of access to diagnostic and therapeutic options contribute to this dismal disparity.2

The conundrum of access to screening and treatment is certainly not new to global health. The Breast Health Global Initiative has opted to tackle the issue by creating a set of four recommendations for breast cancer screening and treatment based on the level of country resources. Below is a table that walks through the different “levels” and the types of tests and treatments recommended for each.

table

Table adapted from Yip et al “Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries.”

As I read through this table, what struck me was the stark difference between the clinical implications of these recommendations. A clinical breast exam has a sensitivity of 54%. In contrast, mammograms are the only screening modality shown to reduce mortality of breast cancer. They have a sensitivity of 85%. The different sensitivities of these two tests translates into significant diagnostic and therapeutic outcomes,  the most significant one being that it’s much more common for women in low and middle income countries to die from breast cancer.

At first glance, the BHGI recommendations seem inherently inequitable. The WHO defines equity as the “absence of avoidable or remediable differences among groups of people.” This definition begs the question of whether or not the differences in the BHGI recommendations are in fact avoidable. One of their main goals is to create guidelines that are feasible for countries to carry out. This is certainly a step towards equity, but it is far from equitable. Women in high resource settings have the security of early detection, while women in low resource settings simply become more aware of why early detection is important.

In low and middle-income countries, breast cancer is becoming more common. This is thought to be from multiple factors, including changes in dietary habits, childbearing patterns, and exogenous hormone exposure.3 With this trend, we would be remiss to not continue investigating how to make the BHGI recommendations truly equitable and to give all women the opportunity to seek timely treatment that will allow them to survive breast cancer.

  1. WHO: Breast Cancer, Prevention and Control. http://www.who.int/cancer/detection/breastcancer/en/
  2. Anderson, BO et al. “Breast Cancer Issues in Developing Countries: An Overview of the Breast Health Global Initiative.” World J Surg (2008) 32:2578-2585.
  3. Yip et al. “Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries: Early Detection Resource Allocation. Cancer. October 15, 2008/Volume 113/Number 8.
This entry was posted in BMC.

One comment on “Breast Cancer Screening in a Global Context: The Security of Early Detection and the Inequity of Implementation

  1. Great piece, Andrea! In particular, I think you highlight a huge ethical tension in the development of evidence-based guidelines – we want people to have guidelines (they simplify clinical reasoning, all the more important when you have a huge burden of patients), and these have to reflect the actual resources available at a given location. But accepting these limitations in planning can spill over into acceptance of the underlying inequity, as you note.

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