New global breast cancer initiative highlights renewed commitment to improve survival

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A major new collaborative effort, the Global Breast Cancer Initiative, is being introduced today by the World Health Organization, with the objective of reducing global breast cancer mortality by 2.5% per year until 2040, thereby averting an estimated 2.5 million deaths.  In recognition of International Women’s Day, WHO is hosting an advocacy event “Hearing the call of women with breast cancer” during which the new Initiative will be presented to the global cancer community.

“Although we have seen substantive progress in reducing breast cancer mortality in many high-income countries during the last two decades, little progress has been made in low-and middle-income countries,” said Dr Bente Mikkelsen, Director of the Department of Noncommunicable Diseases at WHO. “The higher mortality in these lower-income countries is a result of late-stage diagnosis and inadequate access to quality care. Together, we can address this unacceptable inequity.”

Survival rates in high-income countries far exceed those in low-income countries

Breast cancer survival five years after diagnosis now exceeds 80% in most high-income countries, compared with 66% in India and just 40% in South Africa. The premature deaths and high out-of-pocket expenditure that arise when breast cancer services are unavailable or unaffordable result in social disruption, impoverishment, family instability and orphaned children and also threaten economic growth.

The importance of addressing this situation has become all the more urgent given that breast cancer has now overtaken lung cancer as the world’s mostly commonly-diagnosed cancer, and is responsible for one in six of all cancer deaths among women, according to statistics released by the International Agency for Research on Cancer (IARC) in December 2020.

The establishment of WHO’s new Global Breast Cancer Initiative follows a steady escalation in the recognition of breast cancer as a public health priority during the last decades. Through the Initiative, WHO, working in unison with other UN agencies and partner organizations, will provide guidance to governments on how to strengthen systems for diagnosing and treating breast cancer, which in turn is expected to lead to improved capacities to manage other types of cancer.

Three pillars: health promotion, timely diagnosis and comprehensive treatment and supportive care

“Global partners, experts and other organizations will be convened through the Initiative to map existing activities, develop roadmaps, and establish multisectoral working groups to address health promotion and early detection, timely breast cancer diagnosis, and comprehensive breast cancer treatment and supportive care,” said Dr Ben Anderson, leading the work on the new Initiative at WHO. “The demand for a global approach, that brings together the best expertise on breast cancer control from around the world, is high, as is the excitement about what can be achieved.”

Health promotion, the first pillar, will include public education about the signs and symptoms of breast cancer, risk reduction strategies (such as avoiding obesity, limiting alcohol intake and encouraging breastfeeding), and reducing the stigma associated with breast health that exists in some parts of the world.

Timely breast cancer diagnosis should reduce delays between the time a patient first interacts with the health system and the initiation of breast cancer treatment. Although breast tumours do not change in days or weeks, cancer survival rates begin to erode when delays to initiate treatment are greater than three months. Current delays in some settings and among certain vulnerable populations can be more than a year. Basic diagnostic services are feasible in all settings, so long as they are well-organized and lead to timely referral for specialist care.

Comprehensive treatment and care for breast cancer treatment should include access to surgery, chemotherapy and/or radiotherapy as well as rehabilitation support for women following treatment and palliative services to reduce pain and discomfort.

A technical package to support implementation

An evidence-based technical package will be provided to countries, linked to online learning platforms and other types of support, and rolled out over the next year. The package will incorporate existing WHO cancer tools and products to promote an integrated approach across cancers and to strengthen health systems more broadly.

For example, the “Technical Specifications of Radiotherapy Equipment for Cancer Treatment,” jointly published by WHO and the International Atomic Energy Agency (IAEA) this month, provides guidance on the procurement and use of radiotherapy equipment. This publication, developed for the Cervical Cancer Elimination Initiative, will at the same time underpin the success of the Global Breast Cancer Initiative. According to a survey conducted by WHO in 2019 [1], radiotherapy is only available in 16% of low-income countries.

Country engagement, including the participation of nongovernmental organizations and input from people who know what it is like to live with breast cancer, will be essential to ensure that efforts made through the new Initiative are integrated into ongoing cancer initiatives, and that approaches are adapted to specific country situations.

“As a breast cancer survivor and advocate, I am excited about the potential of the new WHO Global Breast Cancer Initiative to breathe new life into efforts to prevent and treat breast cancer, and ultimately make a difference to the lives of many thousands of women across the world,” said Bertha Aguilar, of the MILC Foundation in Mexico, and Secretary of the General Assembly of the ABC Global Alliance.

The new Global Breast Cancer Initiative complements other WHO efforts on cancer, the Global Initiative for Childhood Cancer, established in 2018, and the Global Strategy to Accelerate the Elimination of Cervical Cancer, launched in 2020.

New guidance from the World Health Organization (WHO) and the International Atomic Energy Agency (IAEA) on the procurement of radiotherapy equipment could improve access to this life-saving cancer treatment option that is still lacking in many parts of the world.

The new technical guidance aims to ensure that the selection of radiotherapy equipment is appropriate to country and health facility contexts, that treatment is delivered safely, that quality is maintained, and that services are sustainable.

The publication is intended for medical physicists, biomedical and clinical engineers, radiation oncologists, oncologists and anyone else with responsibility for manufacturing, planning, selecting, procuring, regulating, installing or using radiotherapy equipment. It was developed as part of the ongoing collaboration between WHO and the IAEA to foster safety and quality in the medical use of radiation technology.

More than half of cancer patients require radiotherapy

More than 50% of cancer patients require radiotherapy as part of cancer care and it is frequently used to treat the most common types, such as breast, cervical, colorectal, and lung cancer. Yet, access to radiotherapy is inadequate, particularly in low- and middle-income countries.

“IAEA data shows that around one-third of countries still do not have radiotherapy available, out of which 28 are in Africa,” said May Abdel-Wahab, Director of the IAEA’s Division of Human Health. “Many of them would benefit from increased access to radiotherapy services. The key is tailoring radiation oncology solutions to the situation on the ground, underpinned by appropriate safety infrastructure.”  

Types of radiotherapy equipment covered by the guide include external beam radiotherapy machines (both Cobalt-60 and linear accelerators), brachytherapy devices that apply radiation sources directly to tumours and complementary imaging devices such as conventional or computed tomography (CT) simulators, as well as other tools essential for safe operation and quality control. Depending on the type of radiotherapy machine, the need for specialized professionals and infrastructure, as well as quality assurance and maintenance, may vary.

Safety is also covered extensively, with information provided on planning for bunkers to house radiotherapy equipment, shielding for walls, floor and ceilings and emergency buttons for treatment and control rooms. In addition, clear guidance is provided on what is required to ensure functionality of equipment for an optimal equipment lifespan, usually a period of 10-15 years.

Selecting radiotherapy systems appropriate for given settings and matched to the existing workforce help ensure the delivery of safe radiotherapy. It contributes to the improvement of access to life-saving treatment by minimizing service interruptions because of machine downtime and builds a solid foundation for further expansion of services when the health-care system is ready for adoption of more complex radiotherapy systems. 

“While interruptions of radiotherapy equipment predate COVID-19,” said Dr Bente Mikkelsen, Director of the Department of Noncommunicable Diseases at WHO, “they have been exacerbated during the pandemic because of breakdowns in global supply chains and barriers to the free movement of technical service personnel. Any improvement that reduces interruptions can make the difference between life and death for patients whose tumours continue growing while they await treatment.”

Radiotherapy equipment is, however, just one element of cancer management services. Others that need to be in place relate to early detection, diagnostic imaging, laboratory testing, pathology, surgery, systemic treatment and palliative care. The technologies associated with all of these services are listed in the WHO List of Priority Medical Devices for Cancer Management.

Global cancer initiatives

One area where radiotherapy plays an important role is in curing cervical cancer, one of the leading causes of cancer deaths among women, and for which WHO launched a global elimination strategy last year.

 “Cervical cancer is curable if we catch it early,” said Dr Nono Simelela, WHO Assistant Director-General for Strategic Priorities. “We have the tools to save lives. Radiotherapy is one of them. It is also one of the most effective tools to mitigate pain and suffering associated with advanced cancers.” 

Unitaid, a global health agency engaged in finding innovative solutions to prevent, diagnose and treat major infectious diseases in low- and middle-income countries, has recently expanded its portfolio to include HIV co-morbidities, such as cervical cancer. “While Unitaid’s catalytic investments have targeted cervical cancer screening programmes, critical functions such as radiotherapy procurement represent an important component of the continuum of care for any women in need of invasive cancer treatment,” said Robert Matiru, Director of Unitaid’s Programme Division.

Radiotherapy is also an integral part of breast and childhood cancer control, two other major WHO global cancer initiatives. The changes that will be facilitated by the new guidance will also benefit millions of cancer patients globally, including women seeking treatment for breast cancer, now the most commonly-diagnosed form of cancer globally.

The new specifications are an update of a previous version issued by the IAEA, published in 2008.

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