By: Shilpa Murthy MD MPH, Robert Riviello MD MPH
Every time she took that cool bucket bath shower, she anxiously felt the large, irregular bump bulging out of the side of her breast. If she walked the twenty miles to have it examined, who would maintain the house, feed the children, take them to school, and put them to sleep at night? If she went to the hospital she may never see them again—the hospital was a place where people went to die. Or worse she could return home without her breast only to ultimately die from metastasis of her cancer. How would her husband treat her afterwards, how would her children view her—as a disfigured and deformed woman?
These concerns are voiced by millions of poor and disenfranchised women in low- and middle-income countries (LMICs). Once a woman finds a mass she considers it a death sentence since she has never seen anyone cured from breast cancer, all her relatives and neighbors die from late stage cancer or inadequate surgical treatment. For women in high-income countries (HIC), mortality due heart disease far outweighs breast cancer due to strong health care systems where access to high-quality breast cancer services (e.g., early detection through radiologic services; core needle biopsy and pathology services for diagnosis; surgical, chemotherapy, and radiation treatments) are available. In contrast, women in LMICs often present late to hospitals with advanced-stage cancers, where nothing can be done. Even pain control and palliative care is limited due to procurement and funding challenges for pain medications, a small and inadequate medical workforce, and limited resources needed for psychosocial support. If patients do gain access to a surgeon or OB/GYN doctor they may receive inappropriate medical and surgical treatment due to medical educational deficiencies regarding the appropriate management of breast disease. So how do we reduce this inequity for such a curable cancer? While this problem is complex, as LMICs move towards strengthening care around breast cancer, it is critical to determine the appropriate quality metrics that will be integrated into the health care system in order for women to receive the right types of surgical and medical treatments. By monitoring and evaluating health care services that breast disease patients are receiving, nations can ensure patients are receiving improved access to care and that this care employs quality services where the correct surgical and medical treatments are being administered.
Recently, the National Quality Forum (NQF) cancer care consensus endorsed standards of care for breast cancer management in HICs including post breast conserving surgery irradiation, adjuvant chemotherapy, adjuvant hormonal therapy, protocol readings by pathologists according to the College of American Pathologists, needle biopsy diagnosis, and evaluation of the axilla. Many of these quality measures are not feasible metrics in LMICs due to issues with infrastructure, funding, supply chain management, procurement, and training of medical personnel in breast disease management. Therefore, the question arises as to whether NQF measures are appropriate for LMICs at all and if different quality measures should be created for LMICs? We propose that when a nation is starting their breast disease care management program, the NQF quality measurements for breast cancer care in LMICs will need to be different due to the infrastructural infancy of the health system. As LMICs health systems continue to strengthen, these metrics will evolve over time eventually reaching all the current NQF standard measurements.
One of the most-employed metrics, measuring post breast conserving radiation therapy, as a quality metric is inappropriate in many LMICs. Although there are exceptions, breast-conserving therapy is performed for cancers that are detected on mammogram followed by radiation treatment. In many LMICs countries like Rwanda, mammograms and radiation machines do not exist. In order to provide mammogram and radiation services, strong policies around buying, installing, and having technicians readily available for maintaining these machines, and determining what type of hospital (local health center, district, provincial, or tertiary hospital) to install these machines is a large undertaking. Furthermore, increasing the workforce of radiologists and radiation oncology physicians, nurses, and technicians to operate this machinery is a large human resource undertaking. These programs take time to plan and implement and measuring post-conserving radiation therapy is inadequate because no radiation infrastructure exists within many LMICs countries.
Additionally, adjuvant chemotherapy, adjuvant hormonal therapy, needle biopsy and appropriate pathology is challenging. Chemotherapy, hormonal therapies, core needles, and pathology stains are expensive materials and many LMICs cannot afford to keep and distribute a consistent supply of these resources. When supplies do exist, there is an overwhelming number of patients who need these resources for treatment and diagnosis. Physicians have to prioritize which patients receive these resources and face an ethical dilemma as to who receives treatment and who is left to die. Many of these funding and supply chain issues could be potentially resolved if international agencies collaborate to reduce the cost of chemotherapy and medical supplies globally, similar to the way that HIV/AIDS medication costs were reduced. These changes could, in turn, save millions of lives for the poorest patients. Given the inequality in resource distribution to LMICs and patients, it may not be fair to measure all of these NQF metrics in each country. For example if radiation does not exist in a country then it should not be measured, rather that the metric should be if the patient received the correct type of surgery—modified radical mastectomy rather than breast conserving therapy with radiation. On the other hand, NQF may be important measurements as they will inform ministries of health and doctors exactly where the gaps exists within the healthcare system in order for regional policy makers and physicians to address and strengthen the system gaps.
Due to the infancy of breast disease care management systems in LMICs, we propose the following metrics. The key tool in breast disease diagnosis, especially in LMICs, is clinical breast examination (CBE). This examination is not performed at all or performed incorrectly in many LMICs. But it can be readily taught to medical personnel and integrated into medical education. We propose that CBE emphasizing palpation of the clavicular nodes and axilla be one of the global metrics used for breast cancer in LMICs. Additionally, documentation of whether the patient received an ultrasound-guided needle biopsy for diagnosis, whether pathology was performed at all on the biopsy specimen, was subsequent appropriate surgical management performed including axillary dissection, was chemotherapy and radiation therapy provided, and was post-operative training to the patient conducted to prevent postoperative infection, shoulder contracture or frozen shoulder. This documentation will then allow for comparison against NQF standards. These metrics will be starting points that can be used globally and tailored regionally as per the resources available within each country. Over time, as economic development drives improvements in health care development, new measures that strive toward NQF measurements should be used. However, at this moment we believe the above metrics should be a starting point catered to the regional resources available within each country.
Dr. Shilpa S. Murthy MD MPH is currently a second year research fellow at the Center for Surgery and Public Health, Brigham and Women’s Hospital in Boston Massachusetts. She recently completed an MPH at Harvard School of Public Health. She is also a general surgery resident at Indiana University. Dr. Murthy’s interests are in surgical oncology, surgical care delivery and its intersection with health policy in order to improve access and quality surgical care to marginalized populations globally. She also has interests in medical education and simulation based training.
Special thanks to Sarah M. Gray.
Dr. Robert Riviello MD MPH is an Associate Surgeon in the Division of Trauma, Burns, and Surgical Critical Care at Brigham and Women’s Hospital, the Director of Global Surgery Programs at the Center for Surgery and Public Health and Human Resources for Health Rwanda, and an instructor in surgery at Harvard Medical School. His clinical and research interests are in global health, specifically in the reduction of disparities and the expansion of surgical delivery for low-income populations by developing the surgical workforce and surgical infrastructure in sub-Saharan Africa. He currently spends 3-6 months of his time annually in Rwanda engaged in the Human Resources for Health program of Rwanda.