International Guideline Development for Breast Health Care: Challenge for the New Millennium

The International Problem

Among women around the world, breast cancer is the most common cause of cancer related deaths [1]. Breast cancer mortality is the highest among economically disadvantaged countries (Fig. [1]) [2]. Countries with developed and well-established health care systems have higher breast cancer diagnosis rates, but also have improved breast cancer survival [3]. The reasons for the better survival observed among financially advantaged countries must be multi-factorial. Breast cancer screening combined with comprehensive cancer treatment appears to play synergistic roles in creating better outcomes.

Fig. 1 Breast cancer incidence and 5-year survival in different regions of the world, modified from data provided by Greenlee et al., 2000 [2].

A key step in improving health care is to establish general guidelines for breast health care. Many guidelines have been developed for breast screening, diagnosis and treatment [4] [5] [6]. Such guidelines define evidence-based approaches to breast health care. However, guidelines from the United States or Western Europe might have limited applicability in countries of limited resources. Health care resources vary tremendously in different parts of the world based upon differing socioeconomic factors, health care systems and social factors. It is also possible that the fundamental biology of breast cancer varies in different regions of the world based upon environmental factors. As a result, optimal approaches to breast health care may vary in different parts of the world.

General guidelines for basic screening and cancer care can be established. Such guidelines can be used, particularly in developing countries, as a benchmark for growth and improvement. However, some regions of the world do not have organized programs for breast cancer screening, diagnosis and treatment. Since health care systems cannot be transformed at once, the question becomes where initial efforts be placed to best help women cope with the devastating disease.

References

• 1 Parkin D M, Pisani P, Ferlay J. Global cancer statistics.  CA Cancer J Clin. 1999;  49 33-64
• 2 Greenlee R T, Murray T, Bolden S, Wingo P A. Cancer statistics, 2000.  CA Cancer J Clin. 2000;  50 7-33
• 3 Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002.  CA Cancer J Clin. 2002;  52 23-47
• 4 Carlson R W, Anderson B O, Bensinger W, Cox C E, Davidson N E, Edge S B,. et al . NCCN Practice Guidelines for Breast Cancer.  Oncology (Huntingt). 2000;  14 33-49
• 5 Morrow M, Strom E A, Bassett L W, Dershaw D D, Fowble B, Giuliano A ,. et al . Standard for breast conservation therapy in the management of invasive breast carcinoma.  CA Cancer J Clin. 2002;  52 277-300
• 6 Smith R A, Mettlin C J, Davis K J, Eyre H. American Cancer Society guidelines for the early detection of cancer.  CA Cancer J Clin. 2000;  50 34-49
• 7 Smith R A. Breast cancer screening among women younger than age 50: a current assessment of the issues.  CA Cancer J Clin. 2000;  50 312-36
• 8 Olsen O, Gotzsche P C. Cochrane review on screening for breast cancer with mammography.  Lancet. 2001;  358 1340-2
• 9 Duffy S W, Tabar L, Chen H H, Holmqvist M, Yen M F, Abdsalah S ,. et al . The impact of organized mammography service screening on breast carcinoma mortality in seven Swedish counties.  Cancer. 2002;  95 458-69
• 10 Tabar L, Fagerberg G, Chen H H, Duffy S W, Smart C R, Gad A ,. et al . Efficacy of breast cancer screening by age. New results from the Swedish Two-County Trial.  Cancer. 1995;  75 2507-17
• 11 Screening for breast cancer: recommendations and rationale.  Ann Intern Med. 2002;  137 344-6
• 12 Thomas D B, Gao D L, Ray R M, Wang W W, Allison C J, Chen F L,. et al . Randomized trial of breast self-examination in Shanghai: final results.  J Natl Cancer Inst. 2002;  94 1445-57
• 13 Halsted W S. The results of radical operations for the cure of carcinoma of the breast. Ann.  Surg. 1907;  46 1
• 14 Patey D H, Dyson W H. The prognosis of carcinoma of the breast in relation to the type of operation performed. Br J.  Cancer. 1948;  2 7
• 15 Fisher B, Redmond C, Poisson R, Margolese R, Wolmark N, Wickerham L ,. et al . Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J.  Med. 1989;  320 822-8
• 16 Fisher B, Anderson S, Bryant J, Margolese R G, Deutsch M, Fisher E R,. et’al . Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.  N Engl J Med. 2002;  347 1233-41
• 17 Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A ,. et al . Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.  N Engl J Med. 2002;  347 1227-32