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.
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.
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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.
This article put me up with more attention...Doctors has done great job.... Female Surgeon Dubai for any type of diseases.
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