Advancing early detection of breast cancer in resource-limited settings - Workshop Report

Workshop Report

Advancing early detection of breast cancer in resourcelimited settings

20 October 2022

Geneva, Switzerland

This workshop was organised by the Union for International Cancer Control in collaboration with the WHO Global Breast Cancer Initiative, as part of the World Cancer Congress 2022 and is supported by the UICC Breast Cancer Programme.

Introduction

On the occasion of the 2022 World Cancer Congress, UICC and the World Health Organization (WHO) hosted a three-hour workshop to support progress in advancing the early detection of breast cancer in resource-limited settings.

Many cases of cancer in lower-income regions are diagnosed at an advanced stage, when they are much harder to treat effectively. Improving the early detection of breast cancer will contribute to saving 2.5 million lives by 2040 according to the targets laid out by the WHO Global Breast Cancer Initiative (GBCI).

This interactive workshop aimed at:

• Building the knowledge of key breast cancer actors on evidence-based strategies to improve early diagnosis in low and middle-income countries (LMICs);

• Gathering input from civil society and the breast cancer community more broadly as to specific actions they could take to improve early detection, and support implementation of the GBCI recommendations.

In total, 62 participants from 37 countries participated in the workshop including leaders from civil society organisations, governments, academia, private sector and technical partners.

The workshop was interactive, including presentations, case studies, online polls, as well as group conversations. Assigned roundtables by region enabled participants to share their experiences, ideas and recommendations with peers from similar contexts, and in their shared language. The event was held primarily in English, but table discussions were also held in French and Spanish for Francophone Africa and Latin America participants, respectively.

Agenda

Welcome

Sabrina Zucchello, Senior Manager, Capacity Building, UICC

Early detection of breast cancer and the WHO Global Breast Cancer Initiative

Dr Benjamin Anderson, Medical Officer, Cancer Control, WHO

Screening and clinical breast examination in LMICs: What is evidence-based?

Dr Partha Basu, Deputy Branch, Head, Early Detection, Prevention and Infections Branch, IARC

Table discussion

The role of civil society in advocating for timely diagnosis: Case study from Brazil

Dr Maira Caleffi, Volunter President, FEMAMA Brazil

Table discussion

Implementing a National Cancer Control Plan for early detection of breast cancer: Barriers and key lessons

Dr Mary Nyangasi, Head of the National Cancer Control Programme, Ministry of Health of Kenya

Table discussion

Closing

Workshop: Advancing early detection of breast cancer in resource-limited settings

Sabrina Zucchello, lead of the UICC Breast Cancer Programme, welcomed participants and opened the workshop, inviting participants to share via an online poll the questions they would most like to explore in the workshop.

The most popular topics participants were interested in learning more about were mainly around the effectiveness of interventions for early detection and the implementation of early detection programmes:

“What is the most costeffective approach for the early detection of breast cancer in LMICs?”

“How can diagnostic pathways be simplified and decentralised while maintaining quality?”

“How can selfexamination and clinical breast examination help in the early detection of breast cancer, and how often should these be done?”

“How can early detection be implemented in rural areas, when mammographs and radiologists are unavailable?”

“When should populationbased screening mammography be supported at the national level?”

“What are realworld learnings from implementing early detection programmes at scale?"

Other topics mentioned in the poll touched upon how to include patient preferences into early detection programmes.

Early detection of breast cancer and the WHO Global Breast Cancer Initiative

Dr Benjamin Anderson, Medical Officer, Cancer Control, WHO, gave the opening presentation describing the current landscape of breast cancer globally, the importance of prevention and early detection, and provided an overview of the WHO GBCI.

Currently, breast cancer is the leading cause of cancer deaths among women worldwide. It is to be noted that, at the current rate, by 2040, 60% of the projected three million new breast cancer cases and 70% of the one million new deaths annually will occur in LMICs. However, when necessary measures are taken and sufficient resources are allocated, it can be observed that breast cancer five-year survival rates are over 90% in high-income countries (HICs). Unfortunately, these survival rates are significantly reduced in LMICs, for example, five-year survival rates are 66% in India and 40% in South Africa

In this context, Dr Anderson stressed that prevention and early detection are key to control breast cancer, and early detection programmes must be in adequation with the level of resources of a given country. Early diagnosis, or opportunistic screening (which is providing services to symptomatic women) has proven to be a costeffective and efficient strategy to diagnose breast cancer in limited settings.

The GBCI was designed to address the significant burden of breast cancer and aims at reducing global breast cancer mortality by 2.5% per year, thereby averting 2.5 million breast cancer deaths globally between 2020 and 2040.

The GBCI is comprised of three pillars:

Pillar 1: Health promotion for early detection

TARGET: 60% of invasive cancers are stage I or II at diagnosis

1A: Health Literacy: Breast health education to women ages 30 – 49 (linked to cervical cancer screening and women’s health education programming)

1B: Primary and Secondary Provider Education:

• WHO-PEN breast education modules for primary health care

• Clinical breast assessment (CBA) training for district facilities and providers

Pillar 2: Timely cancer diagnosis

TARGET: Evaluation, imaging, tissue sampling & pathology within 60 days

2A. Rapid Diagnosis Units (RDUs) deployed at secondary level facilities

2B. Tissue Pathology Services using standard and leapfrog methodology

2C. Patient Navigation Systems linking primary, secondary and tertiary care

Pillar 3: Comprehensive breast cancer management

TARGET: 80% undergo multimodality treatment without abandonment

3A. Timely access to quality multidisciplinary cancer treatment (surgery, radiation therapy, systemic treatment) completed with minimal abandonment:

• Multidisciplinary treatment planning based on resource adapted guidelines

• Patient navigation for surgery, radiotherapy and systemic therapy

• Systemic assessment to measure compliance and treatment abadonment

3B. Treated women are reintegrated into community minimizing financial toxicity:

• Follow-up care established at primary level

• Survivorship and palliative care available to women after treatment

Workshop: Advancing early detection of breast cancer in resource-limited settings

Dr Anderson also highlighted the challenges that the breast cancer community faces in achieving this objective and why urgent action is needed:

• Political will has been moving toward NCDs but has not past the ‘tipping point’

• Countries can have multiple parallel delivery systems that tend to lack unity

• Underserved communities are a ‘country within a country’.

He touched on findings that can influence the efforts to address the breast cancer burden in different contexts, highlighting the role that civil society plays as key partners in driving both patient education and political will.

These findings were echoed in the following presentations and table discussions of participants, as they explored steps to achieve the GBCI targets.

“With breast cancer now the most common cancer globally and the most likely reason a woman will die from cancer, countries need to embrace the concept of improving breast cancer outcomes if they are going to address cancer as a health priority.”

Dr Benjamin Anderson, Medical Officer, Cancer Control, WHO

Workshop: Advancing early detection of breast cancer in resource-limited settings

Screening and clinical breast

examination in LMICs:

What is evidence-based?

Dr Partha Basu, Head, Early Detection, Prevention and Infections Branch, IARC, presented the results of studies analysing the impact of clinical breast examination (CBE) and interventions to increase breast awareness on breast cancer staging and mortality.

The Mumbai randomised controlled trial study (Mittra, et al, BMJ, 372:n256, 25 Feb 2021) conducted over a period of 20 years highlighted that CBE conducted every two years by primary health workers significantly downstaged breast cancer at diagnosis and led to a significant reduction of mortality of nearly 30%. It also showed that increased breast awareness even without CBE was linked with improved diagnosis time.

Furthermore, the Trivandrum randomised controlled trial study (Ramadas, et al, ACS Journal, 2022) shows that CBE is a valuable tool for diagnosis of breast cancer in symptomatic women especially in areas where breast cancer screening programmes are not widely available.

Although there can be a high variability in performance in screening programmes, key take away messages on CBE include:

• CBE is a very useful tool in the assessment of symptomatic women

• CBE screening has demonstrated to contribute to downstaging of the disease and improved survival rates

• Breast awareness linked with improved access to prompt diagnosis and treatment may be equally effective.

Table Discussion

What would it take to achieve the target of 60% of invasive breast cancers diagnosed at stage I or II in the setting in which you operate?

Following Dr Basu’s presentation, the participants of the workshop, mainly composed of civil society representatives, discussed the key actions to take in order for LMICs to progress towards the first target of the GBCI. The discussions highlighted common themes across all tables and regions.

The main actions envisaged to accelerate progress in having 60% of breast cancers diagnosed at stages I or II include (in order of importance):

• Raise awareness and health literacy amongst the general public, involving survivors and advocates, and addressing stigma around the disease.

• Improve the availability of early diagnosis services for women through their formal inclusion in the health system (early diagnosis programme in the NCCP, availability of screening guidelines, declaring breast cancer as a national prioritiy, development of referral pathways) and adopting an integrated approach to educate and assess symptomatic women.

• Train the healthcare workforce on CBE and patient navigation.

The role of civil society in advocating for timely diagnosis: Case study from Brazil

Dr Maira Caleffi, Volunteer President, FEMAMA Brazil, illustrated GBCI’s second target on the 60 days interval to diagnosis by presenting how civil society has been instrumental in advocating for timely diagnosis in Brazil.

FEMAMA is a federation of organisations advocating for better access and adequate treatment accross the country. Three major laws have been enacted in Brazil as a result of the efforts of civil society including FEMAMA demonstrating the importance of advocacy in creating policy for breast cancer patients:

The 60 day law to access treatment (2012)

Between 2009 and 2011, approximately 65.4% of all new cases of cancer began treatment between 60 and 366 days from their date of diagnosis. The 60 day law established the standard that patients receiving care through the Brazilian insurance system must begin treatment within a maximum of 60 days from the date of the pathology report when the cancer was first diagnosed.

Table Discussion

Compulsory notification of cancer law (2018)

FEMAMA has been committed to implement a mandatory and unified cancer registration system since 2015. In 2018, through its advocacy efforts, it was mandated that new cases of cancer should be notified in real time in public and private networks of healthcare.

The 30 day law to receive diagnosis (2019)

Timely breast cancer diagnosis should reduce delays between the time a patient first interacts with the health system and the potential receipt of a diagnosis. With this in mind, the 30 day law established the maximum period of 30 days to receive a diagnosis after an exam was performed and when cancer is suspected.

Globally, as an overall standard, the WHO GBCI recommends 60 days as the maximum time for the diagnosis interval.

What would it take to achieve the target of 60 days to complete evaluation, imaging, tissue sampling and pathology in the setting in which you operate?

Discussions on this topic also show commonality across the different regions represented. The main actions identified by participants to support timely diagnosis in LMICs included (in order of importance):

• Build the capacity of healthcare workers. Primary care workers can be better trained on recognising symptoms, on patient navigation, and alternative models, such as nurses performing biopsies, should be explored. More pathologists and radiologists are also needed to improve the diagnosis interval. Finally, telemedicine and telepathology can help address the human resources gap.

• Work towards having a comprehensive policy in place supported by political will, with budget allocated for data and diagnostic services. Include the diagnosis interval of 60 days in the NCCP with relevant data and key performance indicators to monitor the progress, and ensure insurance coverage is available for cancer diagnosis.

• Develop the necessary infrastructure for timely diagnosis including: facilities, equipment, high quality pathology services with immunohistochemistry capacity, timely reporting and sample transportation. The importance of having rapid diagnosis pathways supported by patient navigation programmes was emphasised by several of the group discussions.

Implementing a National Cancer Control Plan

for early detection of breast cancer: Barriers and key lessons

Dr Mary Nyangasi, Head of the National Cancer Control Programme, Ministry of Health of Kenya described how the early diagnosis cancer action plan was elaborated and implemented in the country.

Dr Nyangasi gave background of the context in Kenya, which is similar to many LMICs, with nearly 70% of cancer cases diagnosed in advanced stages. In such contexts, structural barriers to screening include limited service availability, weak referral networks, human resource capacity, affordability of services and information management. Other barriers to access include sociocultural, personal and financial issues such as myths and misconceptions, poor linkages between health facilities and communities, poor health-seeking behavior, and high out-of-pocket expenditure due to lack of health insurance.

Kenya’s breast cancer screening and early diagnosis plan was issued in 2021 and recommends mammography as screening method alongside complementary methods (such as breast self-examination, CBE and ultrasound) as mammography is not widely available across the country. Magnetic resonance imaging is also recommended for selected high-risk groups. It is recommended that women in average risk groups are screened from ages 40-74 years, with women from 40-55 years screened every year and women from 56-74 years screened every two years.

Dr Nyangasi highlighted that controlling breast cancer is not only reliant on screening but requires a full spectrum of interventions from primary prevention to treatment.

Kenya’s Breast Screening and Early Diagnosis Cancer Action Plan

Key Highlights

Primary Prevention

Secondary Diagnosis

Diagnosis

Treatment

• Lifestyle modification

• High risk individuals: Chemoprevention, prophylactic surgery

• Clinical breast exam for early diagnosis

• Mammogram for screening

• Mammogram, ultrasound, biopsy

• Treatment (surgery, chemotherapy, radiotherapy)

Stage 1-4

• Supportive and palliative care as indicated

She also provided broader recommendations for implementing NCCPs including:

• Wider adoption of fiscal policies such as taxation on sugar-sweetened beverages, unhealthy foods and subsidies for healthy foods

• Sustained multisectoral coordination

• Sustained surveillance

• Prioritise strengthening of health systems for breast cancer screening, diagnosis and treatment

• Adoption of cost-effective interventions in the Universal Health Coverage (UHC) benefit package.

Table Discussion

What would it take to have early detection of breast cancer included in your country’s NCCP as well as a dedicated budget for this in the setting in which you operate?

With a majority of civil society organisations amongst the participants, table discussions focused on the importance of advocacy. The main actions identified in the order of importance were:

• Advocate to build political will. Patient advocates and civil society are recommended to work jointly to influence political will, and seek consensus with policymakers and medical societies to draft the NCCP together.

• Improve data collection for evidence-based advocacy. Need for data on the breast cancer burden in the country, an investment case demonstrating the effectiveness and a cost-benefit analysis of an early detection programme, and cancer registries to be able to better advocate for early detection.

• Build accountability around the NCCP, which includes strengthening its governance, the transparency of the NCCP (public access and understanding of what is funded), holding policy makers accountable, and putting the legislation in place to ensure that the NCCP will be implemented. Other points mentioned in the conversations related to the need to have screening and treatment integrated into UHC packages.

Workshop: Advancing early detection of breast cancer in resource-limited settings

Closing

The workshop closed with a Q&A session and online polls to assess learning and key take aways from participants. The Q&A session generated rich discussion that demonstrated the learning that had taken place during the workshop, and added further nuance and clarity regarding specific contexts or aspects of early detection.

“It is ok to use clinical breast examination for screening and it can be very effective”

“I learned about the GBCI and its targets”

More generally, over 36 answers were collected via the online poll, with main learning points highlighted by participants related to CBE as being an effective tool for early diagnosis; understanding the diagnosis interval recommended by GBCI, and the importance and relevance of law in cancer control:

“Law makes a difference and can help improve the diagnosis interval”

“Implementation of the NCCP is a must”

“Early diagnosis within 60 days reduces mortality”

“Any task is feasible after a clear and intelligent plan!”

“Attending the WCC Breast Cancer Workshop was a truly beneficial experience. What I found most valuable was learning about the evidence for the use of clinical breast examination (CBE) as a screening method, and knowing that there is real value in developing and sustaining its use in our resource-limited settings. In addition to sharing this knowledge with clinicians, we are planning to have training sessions with doctors and nurses on performing CBE to ensure the correct technique is used consistently, and women with suspicious findings are referred for further investigations without delay.”

Workshop: Advancing early detection of breast cancer in resource-limited settings

Dr Nazima Dharsee, Oncologist, Ocean Road Cancer Institute, Tanzania

Participants

Aileen Antolin, Programme Director, Kasuso Foundation, Philippines

Alexandra Nuñez, President, Unidos Contra el Cáncer, Costa Rica

Alexandru Eniu, Senior Medical Oncologist, ABC Global Alliance, European School of Oncology, Portugal

Ana Garces, Country Director, Jhpiego, Guatemala

Anna Cabanes, Senior Advisor, Global Focus on Cancer, USA

Annah Espejo, Coordinator, Capacity, Building, UICC, Switzerland

Bangaly Traore, Programme Coordinator, Association Guinéenne pour la Lutte contre le Cancer, Guinea

Benjamin Anderson, Medical Officer, Cancer Control, WHO, Switzerland

Blaise Nkegoum, Professor of Pathology and Oncology, University Hospital of Yaoundé, Cameroon

Carolyn Taylor, Founder/Executive Director, Global Focus on Cancer, USA

Catherine Kasongo Mwaba, Head Consultant Radiation and Clinical Oncologist, Cancer Diseases Hospital, Zambia

Catia Alas, Programme Coordinator, Ministry of Health Guatemala

Ceisy Nita Wuntu, Lecturer, Cancer Information Support Center Association, Indonesia

Chemtai Mungo, Assistant Professor, University of North Carolina, USA

Clara McKay, CEO, World Ovarian Cancer Coalition, Canada

Clarito Cairo Jr., Programme Manager of the National Integrated Cancer Control Programme, Department of Health, Philippines

Corrine Beaumont, CEO, Know Your Lemons Foundation, USA

Cremelda Parkinson Pratt, CEO/Founder, Thinking Pink Breast Cancer Foundation, Sierra Leone

Eliza Puente, Director, Asociación Mexicana Contra el Cáncer de Mama, Mexico

Emily Kobayashi, Senior Director NCDs, Clinton Health Access Initiative, USA

Fatima Haggar, NCCP Coordinator, Chad

Florence Manjuh, Women's Health Program Supervisor, Cameroon Baptist Convention Health Services, Cameroon

Hadi Abu Rasheed, Scientific Advisor, Qatar Cancer Society, Qatar

Hadiza Arome, Senior Programme Manager, Medicaid Cancer Foundation, Nigeria

Hanaa Serry, Board Secretary, Baheya Foundation for Early Detection and Treatment of Breast Cancer, Egypt

Hauwa Kakudi, Founder, Save a Life Cancer Awareness and Support Network, Nigeria

Hina Hashmi, Director, Atomic Energy Medical Centre, Pakistan Atomic Energy Commission, Pakistan

Huong Tran, Vice Director of the National Institute for Cancer Control, Vietnam

Irene Benson, Director of Development, Know Your Lemons Foundation, USA

Ishak Lawal, Consultant Gynaecologist, End Cervical Cancer Nigeria Initiative, Nigeria

Jacqueline Beuchot, Public Relations Manager, FUCAM, Mexico

Julie Gralow, Chief Medical Officer, ASCO, USA

June Lee, CEO, Breast Specialist of South Florida, USA

Jonas Nsengiyumva, Cancer Focal Point and Supervisor of the Cancer Registry of Bujumbura, Kenyera, Burundi

Khin Thiri, CEO, Pink Rose (Pun Yuang Hninsi) Breast Cancer Patient Support Group, Myanmar

Kirstie Graham, Director, Capacity Building, UICC, Switzerland

Kyle Srinivasan, Global Patient Partnership Director Breast Cancer & Women's Health, F-Hoffmann-La Roche, Switzerland

Leshia Hansen, Cancer Screening and Prevention Specialist, National Cancer Institute, USA

Lisseth Ruiz de Campos, Founder and President, Asociación Salvadoreña para la Prevención del Cáncer, El Salvador

Lucy Ma, Director Global Oncology Public Affairs, Pfizer, USA

Lydia Pace, Assistant Professor, Brigham and Women's Hospital/ Harvard Medical School, USA

Maira Caleffi, Volunteer President, FEMAMA, Brazil

Maria Lourdes Cortez del Rosario, Chairman, Philippine Foundation for Breast Care, Inc. (Kasuso), Philippines

Marina AlBada, Oncology Policy Taskforce Coordinator, Novartis, UAE

Mary Nyangasi, Head, Division of National Cancer Control Programme, Kenya

Mary Wong, Chairman, Global Chinese Breast Cancer Organizations Alliance, Hong Kong

Maura McCarthy, Senior Technical Advisor, Jhpiego, USA

Mélanie Samson, Senior Manager, Capacity Building, UICC, Switzerland

Melissa Lim, Committee Member, Society for Cancer Advocacy and Awareness Kuching, Malaysia

Miriam Mutebi, Vice President, AORTIC, Kenya

Mishka Kohli Cira, Public Health Advisor, National Cancer Institute, USA

Naufel Mohammed, Executive Secretary, Zanzibar Outreach Programme, Tanzania

Nayi Zongo, Surgical Oncologist/President, COBUCAN, Burkina Faso

Nazima Dharsee, Oncologist, Ocean Road Cancer Institute, Tanzania

Neha Goel, Surgical Oncologist, Assistant Professor of Surgery, University of Miami, USA

Ngozi Ejedimu, Patient Navigation/ Community Engagement, The Judah Foundation for Breast Cancer, Nigeria

Noelene Kotschan, CEO and Founder, PinkDrive NPC, South Africa

Partha Basu, Head, Early Detection, Prevention and Infections Branch, IARC, France

Patricia Njiri, Programme Director NCDs, Clinton Health Access Initiative, Kenya

Peter Vuylsteke, Medical Oncologist, University of Botswana/ Botswana Rutgers Partnership for Health, Botswana

Sabrina Zucchello, Senior Manager, Capacity Building, UICC, Switzerland

Sally Donaldson, Fellowships Manager, UICC, Switzerland

Sefonias Getachew, Assistant Professor, Addis Ababa University, Ethiopia

Sinéad Troy, Consultant, Capacity Building, UICC, Switzerland

Sitna Mwanzi, Medical Oncologist, Kenya Society of Haematology and Oncology, Kenya

Yawavi Gloria Gbenonsi, President, African League for the Fight Against Breast Cancer, Belgium

Yin Yin Htun, President, Shwe Yaung Hnin Si Cancer Foundation, Myanmar

Partners and collaborators

This workshop was delivered as part of UICC’s Breast Cancer Programme, kindly supported by the following UICC partners. UICC’s Breast Cancer Programme aims to contribute to the reduction of premature deaths from breast cancer and improve the quality of life of patients, by strengthening the capacity of key breast cancer actors and engaging them in support of the WHO Global Breast Cancer Initiative (GBCI) targets.

In partnership with:

In collaboration with:

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