Breast cancer early detection: A phased approach to implementation

Abstract

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered.

Keywords: breast cancer; breast cancer early detection; metrics; phased implementation; resource stratification.

Figure 1

Distinguishing screening from early diagnosis according to symptom onset (WHO Guide to Cancer Early Diagnosis 2017)

Figure 2. Overview of Implementation Phases for Early diagnosis and Detection Pathways

(δ) Pathology services as the basis for breast cancer diagnosis. (*) Regardless of age or domicile. (**) Some middle-income countries introduce clinical breast examination (CBE) combined with mammography to reduce mammography intensity or as stand-alone test for expanded age groups £) Systematic screening offered to women attending health services for any reason, including response to media campaigns promoting breast cancer early detection €) Definition of number of visits in the clinical pathway (one to three): screening, complementary studies, diagnosis. (ϕ) Organized screening as opposed to opportunistic screening. As early detection programs are successfully implemented, early diagnosis services need to be continually supported for all women.

Figure 3a

Common Barriers to Early Diagnosis

Figure 3b

Potential interventions to strengthen early diagnosis (WHO Guide to Cancer Early Diagnosis (2017)

Figure 4

Paradigm of early detection via population-based screening

Figure 5

Universal patient pathway for breast cancer management in three sequential intervals of care (Patient Interval, Diagnostic Interval, and Treatment Interval) highlighting the Patient and Diagnostic Intervals of care. The Patient Interval begins with the onset of clinical symptoms or an abnormal screening exam and extends to the time the patient presents for diagnostic work-up of a recognized or suspected breast abnormality. During the Diagnostic Interval, the identified breast abnormality undergoes a ‘triple test’ work-up based on clinical evaluation, imaging and tissue sampling to achieve a definitive benign or malignant diagnosis. The health system should endeavor to complete the diagnostic work-up within a 60 day (2 month) period, because worsened survival outcomes can result from diagnostic delays extending significantly beyond 3 months.