Guideline implementation for breast healthcare in low- and middle-income countries

Diagnosis resource allocation

Authors

  • Roman Shyyan MD, MSc,

    Corresponding author
    1. Department of Surgery, Lviv Regional Cancer Center, Lviv, Ukraine
    • Department of Oncology, Lviv Regional Cancer Center, Hasheka Street 2a, 79031 Lviv, Ukraine
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    • Fax: (011) 380322953751

  • Stephen F. Sener MD,

    1. Evanston Northwestern Healthcare, Evanston, Illinois
    2. Northwestern University Feinberg School of Medicine, Evanston, Illinois
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  • Benjamin O. Anderson MD,

    1. Department of Surgery, University of Washington, Seattle, Washington
    2. Division of Public Health Services, Fred Hutchinson Cancer Research Center, Seattle Washington
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  • Leticia M. Fernández Garrote MD, PhD,

    1. National Oncology Institute, Havana, Cuba
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  • Gabriel N. Hortobágyi MD,

    1. Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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  • Julio A. Ibarra Jr. MD,

    1. Department of Pathology, Orange Coast Memorial Medical Center, Fountain Valley, California
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  • Britt-Marie Ljung MD,

    1. Department of Pathology, University of California at San Francisco, San Francisco, California
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  • Hélène Sancho-Garnier MD,

    1. International Union Against Cancer, Geneva, Switzerland
    2. Regional Cancer Center, Montpellier, France
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  • Helge Stalsberg MD,

    1. Department of Pathology, University Hospital of North Norway, Tromsø, Norway
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  • on behalf of the Breast Health Global Initiative Diagnosis Panel

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    • The Breast Health Global Initiative Diagnosis Panel members included Gaurav Agarwal; Justus Apffelstaedt; Nuran S. Bese; Maira Caleffi; R. F. Chinoy; Kathleen Errico; Leticia María Fernández Garrote; Gabriel N. Hortobagyi; Julio A. Ibarra, Jr.; Kardinah Britt-Marie Ljung; Mandar Nadkarni; Anthony Nsiah-Asare; Mary Onyango; Hélène Sancho-Garnier; Stephen F. Sener (Co-chair); Roman Shyyan (Co-chair); and László Vass.


  • Complete financial disclosures are presented at the end of this article.

Abstract

A key determinant of breast cancer outcome in any population is the degree to which newly detected cancers can be diagnosed correctly so that therapy can be selected properly and provided in a timely fashion. A multidisciplinary panel of experts reviewed diagnosis guideline tables and discussed core implementation issues and process indicators based on the resource stratification guidelines. Issues were then summarized in the context of 1) clinical assessment, 2) diagnostic breast imaging, 3) tissue sampling, 4) surgical pathology, 5) laboratory tests and metastatic imaging, and 6) the healthcare system. Patient history provides important information for the clinical assessment of breast and comorbid disease that may influence therapy choices. Focused clinical breast examination and complete physical examination provide guidance on the extent of disease, the presence of metastatic disease, and the ability to tolerate aggressive therapeutic regimens. Breast imaging improves preoperative diagnostic assessment and also permits image-guided needle sampling. Diagnostic mammography was not considered mandatory in low- and middle-income countries when resources are lacking. Needle biopsy is preferred to surgical excision for the initial diagnosis of suspicious breast lesions, unless resources are unavailable. Mastectomy should never be used as a method of tissue diagnosis. The availability of predictive tumor markers, especially estrogen receptor testing, is critical when endocrine therapies are available; quality assessment of immunohistochemistry testing is important to avoid false-negative results. Incremental allocation of resources can help address economic disparities and help ensure equity in access to timely diagnosis.Cancer 2008;113(8 suppl):2257–68. ©2008 American Cancer Society.

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