Addressing equity and stigma in breast cancer care

Dr Fatima Cardoso, Director of the Breast Unit of the Champalimaud Clinical Center in Lisbon, offers an in-depth look at the challenges facing breast cancer control in LMICs.

Breast cancer has now surpassed lung cancer as the most common form of cancer and, in absolute numbers, leads to the highest number of deaths, according to the latest Globocan data. However, women in low- and middle-income countries (LMICs) have a much greater risk of dying from breast cancer due to late diagnosis and limited access to treatment and care. 

In high-income countries, 85-90% of cases are diagnosed as non-metastatic, which are generally curable if the person has access to the most important available treatments. Survival rates are above 70% and can rise above 90% depending on the stage of advancement of the tumour, as well as the subtype of breast cancer. 

In LMICs, 60-80% of all breast cancers are diagnosed at an advanced or metastatic cancer (Stage IV according to the UICC TNM classification), when the cancer is considered incurable although treatable. The reasons for this inequity are complex and go beyond merely lack of resources; lack of awareness about the disease as well as stigma and cultural contexts also play a role.

Dr Fatima Cardoso is a Medical Oncologist and Director of the Breast Unit of the Champalimaud Clinical Centre in Lisbon, Portugal. She is also the President of the ABC Global Alliance and the Chair of the ABC International Consensus Conference and Guidelines, as well as Chair of the SPARC Selection Advisory Group. In this interview with UICC, she offers insight into the issue of the global inequity in breast cancer control and how it can be addressed.

Dr Cardoso, could you first touch upon the issue of lack of resources in LMICs for breast cancer care, in particular with respect to treatment?

Metastatic breast cancer is currently incurable. However, with access to appropriate treatment and disease control, as is the case in most high-income countries, patients can live on average up to three years; the survival highly depends on the subtype and availability of treatments, with the highest being HER2+ breast cancer.  

In LMICs, where innovative targeted agents are not available (but only chemotherapy agents) – median survival drops to one year. More recent treatments such as biological and targeted therapies are expensive and difficult to access, despite the fact that some of them are on the WHO list of essential medicines. Also, even in countries where these treatments are available, they are generally reserved for cancers that are diagnosed at an earlier stage and not for metastatic disease because of lack of resources.

What are some of the actions that must be taken to improve access to life-saving treatments?

Actions need to be taken at all stages of the cancer continuum. First, countries must invest in early detection and make it a priority. We also need to increase awareness about breast cancer and its risks, improve access to primary care and invest in the education of primary care physicians on the early signs and symptoms of breast cancer. 

The second emphasis must be on reducing the time between when a person is diagnosed and when he or she starts treatment. People living in remote areas with care often wait six to nine months, at which point the disease has progressed even further and is harder to treat. We need to shorten the referral time and commence treatment earlier with surgery, radiotherapy, essential medicines, as appropriate.

The third focus must be on helping LMICs fight communicable diseases, another onerous health problem for these countries where non-communicable diseases such as cancer are skyrocketing. They are fighting on two fronts.

In terms of reaching remote populations, could you tell us about the Hard-to-reach communities ABC/mBC toolkit, a solution developed by ABC Global Alliance in collaboration with and Pfizer to address critical unmet need?

The toolkit available on the ABC Global Alliance website hosts the Initiative Repository, which showcases projects from around the world where effective help has been provided to hard-to-reach populations on an accessible budget. 

While the projects are generally onsite and hands-on, many also use new communication tools to put patients in contact with experts without needing to travel. They provide solutions to reaching out and providing information, raising awareness, enabling women to detect early signs of breast cancer. They also look at supportive care, how to improve the quality of life for patients suffering from pain. Not only is death more common in LMICs, but it is death with suffering, which is inaccessible since pain control is rather inexpensive.  

For instance, the “Reusable Wounds Kits for malignant fungating breast wounds” project saw a team of Australian volunteer nurses travel to Timor Leste to provide reusable kits that allowed women to self-manage wounds caused by metastatic breast cancer. The project outlines the unmet needs, the key components, the challenges, how the kits were developed and the cost.

Projects also address stigma and fear around cancer, and specific cultural contexts where people may favour only traditional healers and not seek timely care from a specialist. Or, for instance, the stigma surrounding morphine to treat pain, which is not expensive but its use is often limited, because of fears of diversion to recreational use. We also need to fight to overcome these barriers to using appropriate symptom and pain control.

How has the Seeding Progress and Resources for the Cancer Community (SPARC) MBC Challenge driven progress in reducing cancer incidence and inequity in accessing quality care?

This initiative developed with the support of Pfizer and UICC provides grants for projects in LMICs that address specific needs of MBC patients. Projects address educational as well as onsite, raising awareness, improving information, scaling up early detection and overcoming stigma and the mistrust on nurses and physicians, the fear of looking for treatment and the tendency to go to healers.

The additional benefit of SPARC is that grantees make connections amongst themselves and exchange experiences, providing support in implementing projects, which can be the most difficult.

Are there promising technological innovations that can also increase a patient’s chances of accessing timely care in LMICs? 

There are, but there are also limitations in technological innovations. Mobile units for mammography, while not particularly new, can help reach remote populations. But they are not a priority in low-income countries, where the focus should be on treating advanced breast cancer and on raising awareness and early detection. 

There have been advances in radiotherapy, but its use is very limited in many countries. This is not just because of the machinery itself, since high-income countries can make older machines available as they acquire new ones, but these require trained technicians to use and maintain them as well as qualified physicians to manage the treatment. The problem is more often the implementation of the technology, not the technology itself.

However, new digital tools can improve communication between the patients and the healthcare providers facilitating control symptoms and provision of  better health for people with cancer. This is where I see the biggest innovation and chance of closing the care gap.

How can the international community assist in implementing the three pillars of WHO’s new breast cancer initiative – health promotion, timely diagnosis and comprehensive treatment and supportive care – for instance through greater availability of essential medicines?

The ABC Global Alliance is one of the partners in this initiative, which tries to tackle the barriers that exist at every step when looking to scale up services. It addresses early detection, referral procedures and treatment, and outlines best buys in treatment – not just the most recent and most expensive, but adapted to the income level of the country.

The most difficult challenges remain those related to distance. Even if care is provided for free, patients still need to find a place to stay and take time from work and away from their families. The idea of the initiative is to offer solutions so that countries can see how they can best meet their needs.

Last update: Wednesday 13 October 2021Share Tags:  Equity innovation WHO Breast Cancer Initiative ABC Global Alliance SPARC MBC Challenge