Guideline implementation for breast healthcare in low- and middle-Income countries: Treatment resource allocation


  • Alexandru Eniu MD, PhD,

    Corresponding author
    1. Department of breast tumors, Cancer Institute “Ion Chiricuta” Cluj-Napoca, Romania
    • Cancer Institute “I. Chiricuta”, Department of Breast Tumors, Republicii 34-36, 400015 Cluj-Napoca, Romania
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    • Fax: (011) 40 264-450348

  • Robert W. Carlson MD,

    1. Division of Oncology, Stanford University, Stanford, California
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  • Nagi S. El Saghir MD,

    1. Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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  • Jose Bines MD,

    1. National Cancer Institute-Brasil, Rua, Brazil
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    • Jose Bines receives honoraria from Astra-Zeneca and is a consultant to Astra-Zeneca and Bristol-Meyers-Squibb.

  • Nuran Senel Bese MD,

    1. Cerrahpasa Medical School Department of Radiation Oncology, Cerrahpasa, Istanbul University, Istanbul, Turkey
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  • Daniel Vorobiof MD,

    1. Sandton Oncology Centre, Johannesburg, South Africa
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  • Riccardo Masetti MD,

    1. Department of Surgery, Catholic University of Rome, Rome, Italy
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  • Benjamin O. Anderson MD,

    1. Division of Public Health Sciences, University of Washington, Seattle, Washington and Fred Hutchinson Cancer Research Center, Seattle Washington
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  • on behalf of the Breast Health Global Initiative Treatment Panel

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    • The BHGI Treatment Panel members included Baffour Awuah, Zeba Aziz, Rajendra Badwe, José Bines, Ashwini Budrukkar, Co-chair Robert W. Carlson, Nagi S. El Saghir, Co-chair Alexandru Eniu, Nagi Khouri, Richard R. Love, Riccardo Masetti, A. Nandakumar, Twalib Ngoma, Carlos Perez, Jose Miquel Reyes, Paula Trahan Rieger, Eeva Salminen, Rama Sivaram, Tomoo Tajima, Daniel Vorobiof, Oncology, and Jo Anne Zujewski.

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


A key determinant of breast cancer outcome is the degree to which newly diagnosed cancers are treated correctly in a timely fashion. Available resources must be applied in a rational manner to optimize population-based outcomes. A multidisciplinary international panel of experts addressed the implementation of treatment guidelines and developed process checklists for breast surgery, radiation treatment, and systemic therapy. The needed resources for stage I, stage II, locally advanced, and metastatic breast cancer were outlined, and process metrics were developed. The ability to perform modified radical mastectomy is the mainstay of locoregional treatment at the basic level of breast healthcare. Radiation therapy allows for consideration of breast-conserving therapy, postmastectomy chest wall irradiation, and palliation of painful or symptomatic metastases. Systemic therapy with cytotoxic chemotherapy is effective in the treatment of all biologic subtypes of breast cancer, but its provision is resource intensive. Although endocrine therapy requires few specialized resources, it requires knowledge of hormone receptor status. Targeted therapy against human epidermal growth factor receptor 2 (anti-HER-2) is very effective in tumors that overexpress HER-2/neu receptors, but cost largely prevents its use in resource-limited environments. Incremental allocation of resources can help address economic disparities and ensure equity in access to care. Checklists and allocation tables can support the objective of offering optimal care for all patients. The use of process metrics can facilitate the development of multidisciplinary, integrated, fiscally responsible, continuously improving, and flexible approaches to the global enhancement of breast cancer treatment. Cancer 2008;113(8 suppl):2269–81. © 2008 American Cancer Society.