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Challenges for breast cancer screening in low-‐resource countries
Vivien Tsu, PhD MPH Associate Director, Reproduc@ve Health Program Abstract: Congress track: 1 Disclosure of Interest: None to declare
PATH/Glenn Aus@n
World Cancer Congress, Melbourne December 2-‐6, 2014
Outline
• Background • Screening op@ons • Innova@ve model in Peru • Implica@ons and next steps
Page 2 Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Breast cancer trends are worrying
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1990 2010 2030
Thou
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Estimated number of breast cancer deaths
More developed
Less developed
• Numbers are going up, especially in developing countries.
• Mortality rates are higher in poorer countries and growing faster.
Page 3 Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Reasons for rising rates in low-‐ and middle-‐income countries are similar to other NCDs
• Increasing life expectancy—women are living longer. • Changing lifestyles—urbaniza@on, less physical ac@vity, higher calorie and fat diets.
• Plus changing reproduc@ve behaviors—fewer children, star@ng later, less breasXeeding.
Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Is mammography a good op@on?
• In middle-‐income countries, where equipment exists but is limited: • Use for diagnosis first, then for screening as capacity increases.
• Ensure quality—training, maintenance, record-‐keeping.
• In low-‐ and middle-‐income countries with li^le or no equipment, mammography is NOT a feasible op@on for screening and diverts resources that can be used be^er elsewhere.
Page 5 Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Breast awareness, NOT breast self-‐exam (BSE)
• There is li^le evidence of BSE effec@veness and it takes @me to teach and reinforce.
• Awareness of breast changes and of danger signs and symptoms—when linked with access to services and educa@on about the ability to survive breast cancer—CAN make a difference.
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Clinical breast exam (CBE)—a viable op@on
• Clinical breast exam: includes pa@ent history, visual inspec@on, and breast palpa@on.
• With one-‐day competency-‐based training, including supervised hands-‐on prac@ce, CBE can be very effec@ve.
• Especially useful in previously unscreened popula@ons, where there are many prevalent masses that are already big enough to feel.
• Two possible roles: 1) Managing women with breast problems; 2) Screening women without symptoms.
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Class demonstra@on
Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Innova@ve program in rural Peru
Community-‐based Breast Health Project, 2011-‐present • Goal: To introduce and evaluate a new model of care for women in low-‐resource areas, based on: • Outreach by community health promoters.
• Clinical breast exam (CBE) by midwives. • Fine needle aspira@on (FNA) biopsy by local doctors.
• Part of major cancer ini@a@ve by government of Peru.
LA LIBERTAD
LIMA
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Peru
Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Breast cancer care model, La Libertad
Regional Cancer Ins@tute (Trujillo)
• Diagnos@c mammography • Pathology • Surgery • Chemotherapy • Radiotherapy
La Fora Reference Hospital
Health centers
• FNA biopsy taken
• Community educa@on • CBE
Photos courtesy of Ben Anderson
Page 9 Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Validated components are being scaled up • Service delivery model: Community educa@on,
screening by clinical breast exam, diagnos@c triage by fine needle aspira@on, referral to regional cancer hospital.
• Validated curricula: For building health worker capacity.
• Communica@on materials: For community and pa@ents.
• Pa@ent naviga@on: Trained volunteers to support pa@ents and families through a fragmented system.
• Health informa@on systems: Adapted for pa@ent and program monitoring.
Page 10 Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Implica@ons and next steps
• Breast health care must be tailored to the available human, financial and infrastructure resources.
• New approaches should be carefully tested, refined, and validated before scaling up. • It is cri@cal to ensure links between screening, diagnos@c pathways, and treatment are func@onal.
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Next steps: • Add more elements of care: survivor support groups, ultrasound for triage before biopsy, basic treatment at local hospitals ajer staging at cancer hospital.
• Mobilize communi@es to support women’s a^endance at screening and care. • Geographic expansion within Peru and to other countries, including in Africa.
Vivien Tsu Challenges for breast cancer screening in low-‐resource countries
Thank you!
Vivien Tsu, PhD, MPH Associate Director, Reproduc@ve Health Program, [email protected]
And to our donors: • Norwegian Cancer Society/Norwegian Breast Cancer Society • Susan G. Komen for the Cure®
And collaborators: • Peru Na@onal Cancer Ins@tute (INEN) • Regional Cancer Ins@tute (IREN-‐Norte) • Ministry of Health (MINSA), par@cularly at the regional level in Trujillo
• Union for Interna@onal Cancer Control (UICC) • Breast Health Global Ini@a@ve (BHGI)
Vivien Tsu Challenges for breast cancer screening in low-‐resource countries Page 12
