Jo Anne Zujewski, MD Cancer Therapy Evaluation Program Division of Cancer Diagnosis and Treatment...

Jo Anne Zujewski, MDJo Anne Zujewski, MDCancer Therapy Evaluation ProgramCancer Therapy Evaluation Program

Division of Cancer Diagnosis and TreatmentDivision of Cancer Diagnosis and TreatmentNational Cancer InstituteNational Cancer Institute

January 2011January 2011

www.bhgi.info

BREAST HEALTH IN BREAST HEALTH IN

LMCSLMCS

Resource-stratified guidelinesResource-stratified guidelines

Implementation frameworkImplementation framework

Implementation projectsImplementation projects

© 2011 BHGI. All rights reserved.3

WORLD BANK COUNTRY GROUPS WORLD BANK COUNTRY GROUPS WORLD BANK CLASSIFICATION (ATLAS METHOD)WORLD BANK CLASSIFICATION (ATLAS METHOD)

World Bank Country Groups(GNI per capita)

Low Income

($995 or less)

LowerMiddle Income

($996 - $3,945)

UpperMiddle Income($3,946 - $12,195)

High Income

($12,196 or more)

Average female life expectancy at birth 57.8 yrs 69.3 yrs 74.4 yrs 82.4 yrs

Average GNI per capita (2009 US dollars) $403 $1,723 $6,314 $36,953

Total national health expenditure per capita $22 $76 $458 $4,266

Fraction of GDP spent on health care 5.1% 4.3% 6.4% 11.2%

Health expenditure figures 2010 for calendar year 2007; GNI = gross national income http://data.worldbank.org/data-catalog/health-nutrition-and-population-statistics.

© 2011 BHGI. All rights reserved.4

0.19

0.37 0.36

0.30

0.43

0.18

0.37

0.25

0.21

0.20

0.62 0.440.50

0.22

0.51

0.54

0.59

0.33

BREAST CANCER EPIDEMIOLOGYBREAST CANCER EPIDEMIOLOGYGLOBAL DISTRIBUTION OF DISEASEGLOBAL DISTRIBUTION OF DISEASE

2008: 1,380,000 cases; 458,400 deaths2008: 1,380,000 cases; 458,400 deaths50% of cases / 60% of deaths in LMCs50% of cases / 60% of deaths in LMCs

Ratio:MortalityIncidence Globocan 2008 (IARC)Globocan 2008 (IARC)

MISSION STATEMENTMISSION STATEMENT

The The Breast Health Global Initiative (BHGI)Breast Health Global Initiative (BHGI) strives to strives to develop, implement and study evidence-based, develop, implement and study evidence-based,

economically feasible, and culturally appropriate economically feasible, and culturally appropriate guidelines for international breast health and cancer guidelines for international breast health and cancer

control for low and middle income countries to control for low and middle income countries to improve breast health outcomes.improve breast health outcomes.

The The Breast Health Global Initiative (BHGI)Breast Health Global Initiative (BHGI) strives to strives to develop, implement and study evidence-based, develop, implement and study evidence-based,

economically feasible, and culturally appropriate economically feasible, and culturally appropriate guidelines for international breast health and cancer guidelines for international breast health and cancer

control for low and middle income countries to control for low and middle income countries to improve breast health outcomes.improve breast health outcomes.

GLOBAL SUMMIT 2005 – GLOBAL SUMMIT 2005 – BETHESDABETHESDA

RESOURCE STRATIFICATIONRESOURCE STRATIFICATION

Basic level: Basic level: Core resourcesCore resources or fundamental services or fundamental services necessary for any breast health care system to function. necessary for any breast health care system to function.

Limited level: Limited level: Second-tier resourcesSecond-tier resources or services that produce or services that produce major improvements in outcome such as survival.major improvements in outcome such as survival.

Enhanced level: Enhanced level: Third-tier resourcesThird-tier resources or services that are or services that are optional but important, because they increase the number optional but important, because they increase the number and quality of therapeutic options and patient choice. and quality of therapeutic options and patient choice.

Maximal level: Maximal level: Highest-level resourcesHighest-level resources or services used in or services used in some high resource countries that have some high resource countries that have lower priority lower priority on the on the basis of extreme cost and/or impracticality.basis of extreme cost and/or impracticality.

BREAST HEALTH IN BREAST HEALTH IN LMCSLMCS

Resource-stratified guidelinesResource-stratified guidelines

Implementation frameworkImplementation framework

Implementation projectsImplementation projects

BHGI: Health SystemsBHGI: Health Systems

BHGI: Early DetectionBHGI: Early Detection

BHGI: DiagnosisBHGI: Diagnosis

Cancer: 113 (8 suppl), 2008Cancer: 113 (8 suppl), 2008

BHGI: Stage 1BHGI: Stage 1

Cancer: 113 (8 suppl), 2008Cancer: 113 (8 suppl), 2008

BHGI: Stage 2BHGI: Stage 2

Cancer: 113 (8 suppl), 2008Cancer: 113 (8 suppl), 2008

BHGI: Stage 3; Locally BHGI: Stage 3; Locally AdvancedAdvanced

Cancer: 113 (8 suppl), 2008Cancer: 113 (8 suppl), 2008

BHGI: MetastaticBHGI: Metastatic

Executive Summary: Lancet Oncology, 12: in press, 2011Executive Summary: Lancet Oncology, 12: in press, 2011Consensus Supplement: The Breast, in press, 2011Consensus Supplement: The Breast, in press, 2011

GLOBAL SUMMIT 2010 – GLOBAL SUMMIT 2010 – CHICAGOCHICAGO

OPTIMIZING DELIVERYOPTIMIZING DELIVERY

Low-Resource ScenariosLow-Resource Scenarios

Middle-Resource ScenariosMiddle-Resource Scenarios

Problem SolvingProblem Solving

GLOBAL SUMMIT 2010 – GLOBAL SUMMIT 2010 – CHICAGOCHICAGO

OPTIMIZING DELIVERYOPTIMIZING DELIVERY Cancer registries Cancer registries for prevalence , stage, and for prevalence , stage, and

outcomeoutcome National cancer plans define National cancer plans define cancer care networkscancer care networks Multidisciplinary care Multidisciplinary care to avoid fragmentationto avoid fragmentation issuesissues

Lancet Oncology, 12: in press, 2011Lancet Oncology, 12: in press, 2011

OPTIMIZING DELIVERYOPTIMIZING DELIVERY

TrainingTraining linked to equipment linked to equipment acquisition / quality careacquisition / quality care

Public awareness programsPublic awareness programs linked to linked to early detectionearly detection

Clinical breast examination Clinical breast examination (CBE) (CBE) promotionpromotion

CoordinationCoordination of diagnosis and of diagnosis and treatmenttreatment

Address Address pathologypathology, , drug acquisitiondrug acquisition, , workforce issuesworkforce issues

BREAST HEALTH IN BREAST HEALTH IN LMCSLMCS

Resource-stratified guidelinesResource-stratified guidelines

Implementation frameworkImplementation framework

Implementation projectsImplementation projects

AwarenessAwareness

SurvivorshipSurvivorship

Early DetectionEarly Detection

DiagnosisDiagnosis

TreatmentTreatment

AdvocacyAdvocacy

Public ParticipationPublic Participation Health Care DeliveryHealth Care Delivery

BREAST HEALTH IN BREAST HEALTH IN LMCSLMCS

Resource-stratified guidelinesResource-stratified guidelines

Implementation frameworkImplementation framework

Implementation projectsImplementation projects

© 2011 BHGI. All rights reserved.22

LMC IMPLEMENTATION RESEARCH LMC IMPLEMENTATION RESEARCH AFRICAN (WHO AFRO) COUNTRIES – LOW AFRICAN (WHO AFRO) COUNTRIES – LOW

RESOURCERESOURCE

Ratio:MortalityIncidence Globocan 2008 (IARC)Globocan 2008 (IARC)

AFRO REGIONAL ESTIMATES 2008: AFRO REGIONAL ESTIMATES 2008: 68,000 cases; 37,000 deaths68,000 cases; 37,000 deaths

0.62

0.51

0.54

0.59

0.33

© 2011 BHGI. All rights reserved.23

LMC IMPLEMENTATION RESEARCH LMC IMPLEMENTATION RESEARCH LOWER-MIDDLE INCOME COUNTRYLOWER-MIDDLE INCOME COUNTRY

CBE training for nurse CBE training for nurse

midwivesmidwives

IndonesiaIndonesia

© 2011 BHGI. All rights reserved.24

LMC IMPLEMENTATION RESEARCH LMC IMPLEMENTATION RESEARCH UPPER-MIDDLE INCOME COUNTRYUPPER-MIDDLE INCOME COUNTRY

TurkeyTurkeyMammographic Screening in Mammographic Screening in

IstanbulIstanbul

© 2011 BHGI. All rights reserved.25

LMC IMPLEMENTATION RESEARCH LMC IMPLEMENTATION RESEARCH LOWER-MIDDLE INCOME COUNTRYLOWER-MIDDLE INCOME COUNTRY

ColombiaColombiaReadiness Assessment ToolsReadiness Assessment Tools

© 2011 BHGI. All rights reserved.26

LMC IMPLEMENTATION RESEARCH LMC IMPLEMENTATION RESEARCH LOWER-MIDDLE INCOME COUNTRYLOWER-MIDDLE INCOME COUNTRY

PakistanPakistanLocally Advanced Treatment in Locally Advanced Treatment in

LahoreLahore

© 2011 BHGI. All rights reserved.27

LMC IMPLEMENTATION RESEARCH LMC IMPLEMENTATION RESEARCH LATIN AMERICAN COUNTRIES – MIDDLE LATIN AMERICAN COUNTRIES – MIDDLE

RESOURCERESOURCE

Ratio:MortalityIncidence Globocan 2008 (IARC)Globocan 2008 (IARC)

SOUTH + CENTRAL AMERICA ESTIMATES 2008: SOUTH + CENTRAL AMERICA ESTIMATES 2008: 105,900 cases; 33,600 deaths105,900 cases; 33,600 deaths

0.37 0.36

0.30

BHGI GLOBAL ALLIANCEBHGI GLOBAL ALLIANCEBENEFACTOR / FOUNDATIONAL GRANTSBENEFACTOR / FOUNDATIONAL GRANTS• Susan G. Komen for the Cure® Susan G. Komen for the Cure® • European School of Oncology (ESO) European School of Oncology (ESO) • Pan American Health Organization (PAHO)Pan American Health Organization (PAHO)• Sheikh Mohammed Hussein Al-Amoudi Center of Sheikh Mohammed Hussein Al-Amoudi Center of

Excellence in Breast CancerExcellence in Breast Cancer• American Society of Clinical Oncology (ASCO)American Society of Clinical Oncology (ASCO)• LIVESTRONGLIVESTRONG

CORPORATE PARTNERSCORPORATE PARTNERS• GE HealthcareGE Healthcare• Sanofi-AventisSanofi-Aventis