Improving breast health in low- and middle-income countries
Breast cancer incidence is rising steadily in many low- and middle-income countries as women live longer and life styles are changing in ways that increase risk factors for breast cancer. As with many other diseases, the burden falls more heavily on poor, marginalized, and rural women due to their unequal access to screening and treatment. The importance of early detection and treatment of breast cancer is well recognized, since the cost and success of treatment is directly related to the stage of disease at the time of diagnosis. Affordable screening, diagnostic and treatment options, and resource-appropriate guidelines offer new opportunities to reach underserved populations with life-saving screening and treatment approaches that are effective and sustainable. Engaging communities in supporting appropriate-aged women in seeking breast cancer screening and following through with early treatment, as well as providing appropriate psychosocial support for women both during treatment and afterwards, has been shown to be critical to treatment success, survivorship, and quality of life.
Over the last 15 years, PATH has worked in several countries—including Ukraine, Ghana, and most recently Peru—to strengthen breast cancer early detection, diagnosis, treatment, and recovery.
According to the International Agency for Research on Cancer (IARC) database, Peru had an estimated 4,300 new cases of breast cancer and 1,365 deaths in 2008, with an age-standardized annual incidence rate of 34/100,000 women. However, these rates are rising as elsewhere in the developing world; in 2010 the Peruvian government estimated 5,643 new breast cancer cases.
In early 2011, the Community-based Program for Breast Health, Peru was initiated with generous support from the Norwegian Cancer Society, supplemented with PATH institutional funds. Two additional donors, including the Susan G. Komen for the Cure®, have also agreed to contribute to the project and support the geographic expansion of the pilot program.
PATH has been collaborating with the Peru National Cancer Institute (INEN), the Regional Cancer Institute in Trujillo (IREN-Norte), and the Ministry of Health (MINSA) 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. This innovative project brings together government and nongovernment partners to encourage creativity and problem-solving, while ensuring compliance with national standards, integration with existing systems, and attention to sustainability.
Progress to date
The project is being implemented in one health network within the region of La Libertad, Peru, as a Phase 1 effort to pilot the new model; Phase 2 would focus on technical support to the Peruvian government’s national scale-up of tested approaches. Donor funding has allowed us to expand the scope of the pilot phase to the entire Pacasmayo network. Health facilities in this network consist of a community hospital, four health centers, and five health posts. The target population for community awareness and screening with clinical breast exam (CBE) is women 40–59 years of age in the entire Pacasmayo network (23,885 females), although all women who come in asking for breast evaluation will be served. PATH is collaborating closely with INEN, IREN-Norte, and MINSA, particularly at the regional level (GERESA La Libertad) to ensure that the project work is implemented within the regular systems of the Ministry of Health as well as integrated into the Breast Health Technical Excellence Center that INEN is in the process of establishing.
At this time, the project has made substantial progress in synthesizing the various training materials into three comprehensive curricula that will provide a sustainable system for building service capacity to ensure women have access to breast health care. Materials follow the model developed by Peru’s Cervical Cancer Excellence Center, thus including a reference manual, a trainer’s guide, and a participant guide. These materials were validated in the CBE clinical trainings in April and May 2012, and were finalized by June 2012. In addition to the CBE and fine needle aspiration (FNA) curricula, health promotion materials for breast cancer screening and early treatment and a curriculum for training of community health promoters also have been developed and introduced.
PATH is also collaborating closely with Peruvian authorities on utilizing the existing health information system to capture data integral to the new model of care—specifically allowing for the accurate tracking of breast cancer screening, FNA diagnosis, and referral.
Finally, PATH conducted an assessment of needs and facilities in two phases. First, in March 2011, key project staff conducted a planning meeting and site visits with INEN counterparts in Peru. Second, PATH’s consultant coordinator assessed the status of facilities in August 2011 to better understand potential constraints and facilitating factors to implementation. The information gathered through these activities was instrumental to ensuring that the overall project plan was realistic and feasible.
This innovative project brings together a coalition of partners with highly complementary skills, resources, and interests. The community-based model of care being tested and refined in La Libertad is suitable for a broad range of settings, in Peru and elsewhere, where screening mammography will not be feasible for some years to come and where women have limited access to the first crucial steps in the diagnostic process. We cannot expect survival to improve if we do not raise awareness among women, build screening capacity among the primary care health workers who have the most contact with women, and create affordable and accessible diagnostic and treatment services to ensure that women reap the benefits of earlier detection.
PATH’s past breast cancer work