Almost 70 percent of all breast cancer deaths now occur in low-income countries. In the first part of our series “The Shifting Burden,” we look at how community is key to tackling the disease in countries that are ill-prepared and underfunded.
Breast cancer is no longer a disease of the wealthy. Incidence rates are shifting, and of the estimated 1.7 million women who will be diagnosed with breast cancer in 2020, most will be in the developing world.
But global health policy is yet to catch up. The World Health Organization (WHO) estimates that worldwide more than 508,000 women die each year due to breast cancer – significantly more than the 438,000 people killed by malaria in 2015, for example. And yet, the money available for cancer prevention and treatment in the developing world is only a fraction of the sums spent on diseases such as HIV, TB and malaria.
At the moment, the incidence of breast cancer cases is still higher in the developed than the developing world, due in part to longer female lifespans and lifestyle factors. But studies show incidence rates are increasing in low-income countries. And a huge discrepancy in survival chances means the majority of breast cancer deaths – a devastating 69 percent – occur in the developing world.
According to The Cancer Atlas compiled by the American Cancer Society, the Union for International Cancer Control (UICC), the WHO and the International Agency for Research on Cancer, even though Nigeria has the highest incidence rate of any developing African country on the list, it sits at 58th place among all the countries ranked. However, it is in third place for mortality per 100,000 females.
It is clear that the disease burden of breast cancer in the developing world is disproportionately large. So why are so few women getting the treatment they need?
One reason breast cancer claims so many more lives in the developing world is that more than four-fifths of women in low-income settings don’t get a diagnosis until their disease is in its later stages, often too late for curative care. In high-income countries, by contrast, the same proportion of breast cancer patients seek medical help with early stage disease and are potentially curable.
“One of the key issues I come across is that women see the cancer center as a place you go to die,” says Julie Torode, deputy CEO at the Union for International Cancer Control (UICC). “We need to try and engage a new generation to see breast cancer as something they can take control of. We can’t prevent it completely but there are things women can do if they find their breast cancer early to increase their likelihood of surviving for a long time.”
Despite the oft-cited – and false – trope that there is no word for cancer in most of Africa’s 2,000 or so languages, women in the developing world are not ignorant of breast cancer, particularly if they have already witnessed a neighbor or relative dying of the illness. The issue is around finding the right kind of help.
“When you look at some of the research, women have known they’ve got a problem, they’ve presented to a primary healthcare post or a mobile clinic, but they’ve not got to someone who’s said, ‘This is suspicious, go here to get it sorted,’” Torode says. She cites a study done in Ethiopia that showed women going to over seven different healthcare providers until they got to the point where they received appropriate follow-up. In places where cancer sufferers first turn to traditional healers before seeking medical care, diagnosis and treatment often come too late.
UICC member Breast Without Spot – a Nigerian initiative so called to send the message that normal breasts have no lumps, lesions or anomalies – aims to dispel the myths around breast cancer that stop women from asking doctors for help. “Fellow Nigerians are still of the opinion that cancer is a mysterious disease which is due to some diabolical reason, witchcraft, family enemies or poison,” says the campaign’s founder Ifeoma Okoye.
Another prevalent attitude that feeds the myths is that of “fatalism,” wherein women feel that they do not have any control over disease, life or death. In some cases, women believe that simply knowing they have breast cancer will cause them to die sooner.
Community engagement is key, says Okoye. So Breast Without Spot visits schools to show girls how to perform breast self-exams for signs of cancer, organizes annual screenings and provides a patient navigation system to enable the follow-up of positive-screened patients through diagnosis, treatment and support care. It also recruits and trains local advocates to raise awareness – and separate fact from fiction – in their own communities.
Closing the funding gap
Better education and more screening are solid steps toward reducing the number of breast cancer deaths across the developing world. But they can only go so far. “Mammography screening has been shown in many clinical studies to reduce breast cancer mortality by at least 20 percent. But sustainable funds, project management, physicians trained on breast cancer and affordable care need to be in place to support any screening program anywhere,” says Claire Goodliffe, women’s healthcare marketing director at GE Healthcare, which commissioned a report into thegrowing rates of breast cancer incidence in the developing world.
There is currently a funding gap of about $26 billion in the developing world to bring spending in countries with low breast cancer survival up to that of high-survival countries, and this will only increase as the overall burden of breast cancer cases shifts to vulnerable populations in ill-prepared, low-income countries.
The global healthcare agenda is starting to take notice. In 2011, theUN Political Declaration on the Prevention and Control of NCDsrecognized non-communicable diseases as a global health and development priority. The WHO’s NCD Global Monitoring Framework, which was adopted by the World Health Assembly in 2013, includes nine ambitious targets measured against 27 indicators, while the organization’s Global Action Plan for the Prevention and Control of NCDs 2013-2020 provides the roadmap for achieving this goal, with an overarching objective to reduce premature mortality from NCDs by 25 percent by the year 2025. Breast cancer-specific targets, actions and indicators include cancer planning and surveillance; timely treatment and palliative care policies.
With these targets in mind, some governments and organizations are getting proactive about fighting breast cancer in regions and communities that have long been neglected. In Peru, for example, since 2011 PATH has collaborated with partners on a community-based breast health program that reaches low-income women through awareness campaigns, locally available screenings and referrals. To help women navigate the health system, PATH developed a model that trains volunteers to support them. It is also collaborating with the Peru National Cancer Institute, the Regional Cancer Institute in Trujillo and the Ministry of Health to introduce a model of care to improve access and quality of breast cancer screening, diagnosis and referral for treatment at lower levels of the health system.
In Saudi Arabia, GE Healthcare joined with the government in 2012 to implement the kingdom’s first ever breast cancer screening program. To date, the program has screened more than 30,000 women, with over 170 showing as positive for breast cancer. In October 2014, it launched women’s health screening clinics in two Riyadh malls. Staffed by female healthcare professionals, technicians and health educators, the clinics aim to screen around 10,000 women for diseases including breast cancer in the next year.
An AstraZeneca-funded pilot program in Addis Ababa, Ethiopia takes a different approach to tackling the disease. Starting in 2005, the six-year program turned Tikur Anbessa Hospital into the country’s ﬁrst breast cancer treatment center. With a limited budget, the single-site project addressed the full range of needs from prevention and early detection to treatment and palliative care. Costs were far from prohibitive: project funds ranged from $200,000 to $500,000 per year and drug donations amounted to an additional $124,000.
The program’s impact went beyond what was anticipated, as treatment guidelines were developed and a referral system put in place, to create a hub-and-spoke system across the country. At project launch, there was only one oncologist and one radiotherapy unit in the country. By raising awareness of the facilities among healthcare professionals and providing training for other physicians, the program was able to reduce the time between diagnosis and surgery from 12-18 months in 2006 to three to six months in 2009.
While experts advocate for projects of this nature to be replicated and scaled up to other developing countries, there are often basic regulatory obstacles in the way. For example, the classification of morphine as a “specially controlled substance,” based on recommendations from the International Narcotics Control Board, is “a major problem in cancer treatment and care in developing countries,” according to the WHO.
As the conversation on the post-2015 development agenda gains momentum, there remain several challenges to getting quality prevention, early detection and treatment to breast cancer sufferers in the developing world. When taking into account its incidence and mortality rate, breast cancer still receives comparatively low levels of both attention and funding.
But just as successes in other realms of public health have seen dramatic drops in child and maternal mortality, health ministries and organizations are hoping that a shift in focus to the fight against breast cancer can bring outcomes for women in low-income countries in line with those for women in industrialized economies. Because the myth of cancer as a disease of the wealthy is proving to be a death sentence for growing numbers of women in the rest of the world.
More in this series: