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 3,952 new cases of breast cancer and 1,208 deaths in 2012, with an age-standardized annual incidence rate of 28 per 100,000 women. Most of these cases were detected at an advanced stage of disease.
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
- In 2011, PATH initiated a collaborative pilot demonstration of a model of care to improve access to and quality of breast cancer screening, diagnosis, and referral services. Notable results from this project include nearly 15,000 women participated in more than 900 educational sessions.
- More than 13,500 women received clinical breast exams.
- Training materials were developed and 48 health promoters, 36 midwives, 19 doctors, and 11 supervisors were trained.
- 321 breast abnormalities were found, 114 Fine Needle Aspiration (FNA) biopsies were performed, and 10 cancers were identified in women who then initiated treatment.
- Preliminary data show that adding breast ultrasound to the screening process has reduced the need for FNA by 65 percent.
- Patient navigation programs were created to strengthen the linkages from community to secondary and tertiary care levels—a program that INEN has taken up nationally and that is now being extended to cover palliative care.
- The process of changing the national health information system (HIS) to incorporate key breast care indicators was begun.
- INEN established a School of Excellence for the Prevention of Breast Cancer that will disseminate the training program and other elements of the model throughout the country.
Beginning in 2013, PATH partnered with the volunteer group Alianza de Apoyo al Instituto Nacional de Enfermedades Neoplasicas Norte (Alinen Norte). Together with a Community Action Board we developed a successful model of “patient navigation” for breast cancer patients in the La Libertad region in northwestern Peru, with the goal of ensuring better access to and completion of diagnostic, treatment, and rehabilitation services. This model is now being implemented nationally.
In 2016 and 2017, PATH collaborated with international and Peruvian experts to create a training curriculum and materials in palliative care for nurses. Because of this information, nurses are changing the way they interact with cancer patients and their families. Patients and caregivers feel identified in the materials and are eager to learn how to best deal with cancer treatment. In addition, PATH is researching end-of-life attitudes and beliefs, so that materials can reflect felt needs.
PATH has recently begun the scale up of the breast cancer early detection model in nine health networks in Trujillo. The teaching materials that were originally produced during a pilot study have been validated by Peruvian experts and were used extensively during 2017. Peruvian experts trained a significant number of individuals in early breast cancer detection during several workshops held in 2017. The total of 530 professionals were trained in a group that included 15 doctors, 382 midwives, 96 community health promoters, and 37 patient navigators. Thousands of Peruvian women will benefit from breast cancer screening and care provided by these professionals.
These same experts at the School of Excellence for the Prevention of Breast Cancer have planned trainings for 2018 in other regions of the country. There is continued enthusiasm for the model and its use.
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