Covid-19 news could be nudged out of the spotlight this weekend as the American Society of Clinical Oncology’s annual scientific meeting, this year being held virtually, mobilizes 40,000 people around the world across industry, academia, and government. Breakthroughs will almost certainly be announced.
Among the nearly 5,300 scientific abstracts being presented at the ASCO meeting, only about 10 focus on breast cancer in low- and middle-income countries, even though the death rate from breast cancer in those countries is almost double that of the U.S.
My work focuses on this type of cancer. I spent my formative professional years at a leading biotechnology company working at the frenetic pace that breast cancer drug development requires of those who manage clinical trials and portfolios of promising molecules for potential treatments and cures. The objective was to save more lives by being the first to market with the next blockbuster.
For me, the mission of getting a new drug on the market was also personally urgent. My mother survived breast cancer, in large part because she had access to the most advanced treatments at a leading cancer center. I also watched two friends battle breast cancer. One sold her home to be able to afford treatment, despite health insurance and manufacturers’ patient assistance programs, which helped defray the ongoing cost of her medicine. The other had triple negative breast cancer, a particularly virulent type in which the tumor is not fueled by estrogen, progesterone, or the HER2 protein. The illness and treatment cost her a career as a consultant and forced her to move home with her parents.
My mother and friends, who had to access to timely and proper diagnosis through mammography, biopsy and genetic subtyping of their tumors, and cutting-edge treatments, are the lucky ones.
There are very few lucky ones in low- and middle- income countries (LMICs). Even though breast cancer is the leading cause of cancer death in these countries, not even one-third of them offer women the kinds of treatments that we celebrate at big cancer conferences. Routine breast exams aren’t done. Biopsies and other processes to determine diagnoses and effective care are available only to those who have the means to travel to the limited number of top hospitals in the country. Mammography is difficult if not impossible to access.
It might be hard for women in the U.S. to imagine being a woman with breast pain living in a rural community in a low-income country, 150 miles from the closest big-city hospital. She is the mother of three kids and the only way to get to the hospital is a long walk followed by a difficult bus ride. In addition to being far away, the care she needs is intimidating, expensive, and uncoordinated. She might be referred to somewhere even farther away, or she might be told to come back multiple times for tests that sound confusing and frightening.
It’s no wonder that most breast and other cancers in low- and middle-income countries are diagnosed at stage 4, when the cancer has spread to other parts of the body and it’s likely too late for anything but palliative care.
The usual players in the business of global health and development are not adequately addressing breast cancer in low- and middle-income countries. Not wealthy country governments. Not major foundations. Not multilateral organizations. Grant money is sorely lacking to do the work needed to strengthen health systems to save women’s lives from their top cancer killer.
And breast cancer in these countries is not on the agenda of major global health conferences and multilateral meetings, which would be a good way to highlight the fundamental fact that diagnostics are inaccessible and out of reach for so many.
While most cancer researchers are working toward the next blockbuster, that is not the immediate way to save the most lives. Diagnosing cancer earlier, when it is more easily treatable with less expensive measures, would have a huge impact.
One solution is training community health workers to spread awareness about breast health. Another is to make sure nurses in primary health clinics can teach women what’s normal and what’s not, and also conduct clinical breast exams then and there if a woman has symptoms like breast pain or lumps. In some places in India, for example, community health workers now accompany women to make sure they reach the next level of diagnosis at a district hospital.
New approaches to diagnostics must be evaluated so they make sense for the women served, such as methods of self-care and point-of-care diagnostics, including ultrasound for breast tumors, that can be used in primary care clinics.
Once I began looking at breast cancer through a global public health lens, I left biotech and joined Jhpiego, a nongovernmental organization affiliated with Johns Hopkins University, where I work on equity and access in global breast health.
My public health colleagues and I believe that strengthening health systems for cancer care is central to delivering on universal health coverage and achieving the United Nations’ Sustainable Development Goals. Our focus is on improving primary care, with breast health being a vital part of that strategy. We build cadres of providers on the frontlines of primary and community health care who are trained to understand breast disease, perform basic clinical breast exams, and link women to higher levels of diagnosis and treatment.
Making it possible for more women to access proper treatment could be a real boon for global breast health, especially if the global health community takes notice. Tremendous resources have gone toward preventing and treating diseases like HIV and malaria, with real progress being made. Now it’s time to topple breast cancer from being the leading cancer killer of women in many countries. That could be a more challenging problem, because breast cancer is complicated, it isn’t contagious, and treatment is costly and requires a health systems approach.
Even amid the chaos of a pandemic, we need to do more about global breast cancer so women in low- and middle-income countries can be like my mother and friends, living cancer-free after diagnosis and treatment.
Maura McCarthy is the director of partnerships at Jhpiego.