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Breast cancer in Sub‐Saharan Africa: Where can we go from here?

The 20th century witnessed amazing progress in breast cancer management. In the early 1900s, Halsted’s radical mastectomy provided hope that better breast cancer outcomes were possible by achieving local control for the majority of women stricken with the disease. By the 1980s, improving breast cancer mortality was observed as sweeping changes in improved early detection evolved in parallel with new endocrine treatment and multidrug systemic chemotherapy regimens for both node-positive and node-negative patients. Between 1990 and 2014, age-adjusted breast cancer death rates dropped by 34% in the U.S. [1], an impressive advance attributable to the combination of improved earlier detection and effective adjuvant therapies [2]. The huge strides seen in economically developed countries have not beenmirrored in Sub-SaharanAfrica. As theworld’smost common cancer amongwomen and the leading cause of female cancermortality around the globe, breast cancer is becoming an increasingly urgent problem in lowand middle-income countries (LMICs). Optimal management strategies from wealthy countries cannot be fully implemented in LMICs due to significant resource constraints. An unacceptably large fraction of women diagnosed with breast cancer in Africa today are no better off than were women at the beginning of the 20th century in Europe or the U.S. Thus we are faced with a painfully difficult question – if the approaches that we use today in the U.S. seem impractical in low-resource settings, should we even begin implementation? The greatest global challenge today is transforming existing knowledge about early detection, diagnosis and treatment into clinical practice. Countries at all economic levels, and particularly LMICs, need stronger health systems to support essential cancer control efforts. In LMICs, adaptations are necessary to span the gap of inadequate healthcare capacity related to limited personal resources, underdeveloped health care infrastructure, lack of pharmaceuticals and cultural barriers. The Breast Health Global Initiative (BHGI) was formed in 2002 to address how evidence-based strategies for breast cancer early detection, diagnosis and treatment could be devised. Using expert consensus review of current and historical research data (most of which comes from high income countries), BHGI devised a set of resource-stratified guidelines (RSGs) to create a comprehensive tool set whereby health care systems can be evaluated for their capacity to deliver breast cancer care with existing resources [3]. BHGI’s RSGs define a prioritization scheme for resource allocation that illustrates a framework for gap analysis to identify when critical resources are missing in a given system. RSGs provide a platform for policymakers to consider how to prepare for breast cancer’s rising tide in their setting. In this issue of the Journal of Surgical Oncology, Ntirenganya and colleagues report on a well-executed, population-based survey of households in two Sub-Saharan African countries – Rwanda and Sierra Leone – to learn about the prevalence of self-appreciated breast masses [4]. Approximate 4% of women reported that they felt a lump in the breast. A very small fraction of these women ever considered seeking medical consultation for evaluation or diagnosis, the primary reason being that the lump was causing no particular disability for them in their daily lives. In addition, financial constraints were a major obstacle for being seen at a medical facility. One-third of women with breast masses sought consultation with a traditional healer in place of being seen at a health center. Many expressed overall distrust of the medical system. The obstacles to evaluation of breast masses observed in this study are widely representative of findings in LMICs throughout the globe, and are not limited to Sub-Saharan Africa. Cancer stigma and fatalistic beliefs commonly prevent women from seeking breast cancer care in a timely fashion. Women often do not know that early breast cancers present as painless masses and that breast cancers found early and treated appropriately are often cured. Without question, awareness education is fundamental to improving breast cancer outcomes in countries at all economic levels. At the same time, medical systems must be prepared to receive patients who come in for evaluation of breast masses or other related complaints. The great majority of palpable masses are benign lesions such as fibroadenomas or cysts, especially in young populations, so healthcare systems must provide access to basic level diagnostic evaluation and tissue sampling. Diagnostic systems for breast masses are not necessarily complex or expensive, but they must be available. The lack of effective diagnostic resources can only reinforce public distrust in their healthcare delivery system. A recent report from Indonesia found that 14% of women screened with CBE had palpable breast masses, but only 1 in 10 of these women actually had a breast cancer [5]. Notably, of the 14 cancers found in study, 13 were appreciated on CBE. Screening mammography added little to cancer detection in this previously unscreened population. Thus, it is sensible as well as evidence-based to forego setting up screening mammography programs in the low resource settings commonly seen in