The Challenge of Breast Cancer in Low- and Middle-income Countries— Implementing the Breast Health Global Initiative Guidelines

US Oncological Review, 2008;4(1):76-9

Breast cancer is the most common cancer in women, accounting for 23% of all female cancers around the globe. There were an estimated 1.15 million cases diagnosed in 2002.1 There is marked geographical variation in incidence rates, being highest in the developed world and lowest in the developing countries in Asia and Africa. The highest age-standardized incidence is in North America, at 99.4 per 100,000 population, while the lowest is in central Africa, at 16.5 per 100,000.2 However, in most low- and middle-income countries (LMCs), incidence rates are increasing at a more rapid rate than in areas where incidence rates are already high. Global breast cancer incidence rates have increased by about 0.5% annually since 1990, but cancer registries in China are recording annual increases in incidence of 3–4%.1 In a population-based cancer registry in Western Turkey in 1992, breast cancer incidence and prevalence were 24.4/100,000 and 0.3%, respectively; cervical cancer was relatively rare (age-standardized incidence rate of 5.4).2 Breast cancer incidence has increased in Turkey, and the estimated number of breast cancer cases in 2007 was 44,253.3 The distribution of breast cancer incidence varies significantly among different regions of Turkey due to geographical, economic, social, and cultural factors.
The breast cancer incidence in Western Turkey (50/100,000 in 2000) is more than two times that of Eastern Turkey (20/100,000) due to ‘Westernized’ lifestyles (early menarche, late menopause, first birth >30 years of age, less breast-feeding, etc.) and other factors in the last decades.4,5 The prognosis of those with breast cancer is good, although globally it still ranks as the leading cause of cancer mortality among women. Favorable breast cancer survival rates in developed countries have been attributed to early detection by screening and timely and effective treatment.6 For example, women diagnosed with breast cancer between 1990 and 1992 and reported in the population-based case series from the Surveillance, Epidemiogy, and End Results (SEER) program (13,172 women) had an 89% five-year survival rate.7 In a study from Istanbul including 1,841 breast cancer patients, the five-year survival rate was 86%.8 In contrast, age-adjusted survival rates for breast cancer in less developed regions of Eastern Turkey average 60% and are as low as 46% in India and 32% in sub-Saharan Africa.1,4,5
Poorer survival in LMCs is largely due to the late presentation of the disease, which, when coupled with limited resources for diagnosis and treatment, leads to particularly poor outcomes.6 Of the over 15,000 new cases presenting for treatment each year in Turkey, 75% have locally advanced breast cancer (LABC) at diagnosis in Eastern Turkey.4 Compounding the problem of late diagnosis, breast cancer case fatality rates are high because LMCs typically lack major components of healthcare infrastructure and the resources necessary to implement improved methods for early detection, diagnosis, and treatment of breast cancer.8,9 Although low-resource countries have not identified cancer as a priority healthcare issue because infectious diseases and malnutrition are the predominant public health problems, as the control of communicable diseases improves and life expectancy rises, cancer care will become an important health issue.10
Evidence-based guidelines outlining optimal approaches to breast cancer detection, diagnosis, and treatment have been well developed and disseminated in several high resource countries.11–13 Optimal practice guidelines may be inappropriate to apply in LMCs for numerous reasons, including inadequate numbers of trained healthcare providers, inadequate diagnostic and treatment infrastructure, and cultural, societal, or religious barriers to women accessing the healthcare system. Thus, in a country with limited resources, many barriers exist between the average patient and the level of care dictated by guidelines applicable to high-resource settings.
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