Health system strengthening: Integration of breast cancer care for improved outcomes

Abstract

The adoption of the goal of universal health coverage and the growing burden of cancer in low- and middle-income countries makes it important to consider how to provide cancer care. Specific interventions can strengthen health systems while providing cancer care within a resource-stratified perspective (similar to the World Health Organization-tiered approach). Four specific topics are discussed: essential medicines/essential diagnostics lists; national cancer plans; provision of affordable essential public services (either at no cost to users or through national health insurance); and finally, how a nascent breast cancer program can build on existing programs. A case study of Zambia (a country with a core level of resources for cancer care, using the Breast Health Global Initiative typology) shows how a breast cancer program was built on a cervical cancer program, which in turn had evolved from the HIV/AIDS program. A case study of Brazil (which has enhanced resources for cancer care) describes how access to breast cancer care evolved as universal health coverage expanded. A case study of Uruguay shows how breast cancer outcomes improved as the country shifted from a largely private system to a single-payer national health insurance system in the transition to becoming a country with maximal resources for cancer care. The final case study describes an exciting initiative, the City Cancer Challenge, and how that may lead to improved cancer services.

Keywords: breast cancer; diagnostic; essential medicines list; national cancer control plans; national health insurance.

Figure 1.

Breast Patient Pathway Overview Universal patient pathway for breast cancer management in three sequential intervals of care including the Patient Interval the Diagnostic Interval, and the Treatment Interval. The Patient Interval spans the time from initial presentation based on onset of clinical symptoms or asymptomatic screening to the point where a breast abnormality warranting further evaluation is detected. During the Diagnostic Interval, the identified breast abnormality undergoes the ‘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. During the Treatment Interval, each patient undergoes individualized evaluation and treatment planning for curative therapy or palliative management, the selection of which depends on the extent of disease and potential for meaningful clinical improvement based on the application of realistically available resources.