You may ask why do we need another set of guidelines when talking about low and middle income countries. The reality is that although we have different guidelines dealing with breast cancer treatment, and I can name the ESMO guidelines, the recommendation from the NCCN or the St Gallen consensus meeting, the problem with those is that in fact, because of lack of parameters, those guidelines cannot be used in an environment where you lack a lot of information such as, for instance, receptor status or HER2 status. That is why those recommendations, although very well developed, are not directly applicable in a low resource environment. We need to find solutions adapted to the local situation, to give recommendations that are applicable in those settings.
And some countries cannot even afford the minimum standard of care?
The problem of breast cancer is a global problem; it’s the most frequent cancer cause of death in women. Yet, there are countries in which, because of lack of resources, interventions for breast cancer are not really available. In those countries breast cancer treatment, and cancer for that matter, is in competition with other more important causes of mortality. We have to acknowledge that and to understand that in certain settings it is not feasible to talk about breast cancer treatment before addressing other, more important, issues. But once you reach the level at which you have certain basic interventions that are considered the minimum that needs to be done for breast cancer, from there you can start building up a strategy towards optimised breast cancer care.
How is breast cancer currently being treated in low income countries?
As we all know, advanced disease is a feature for many, many patients at presentation in low and middle income countries and that is a huge problem because that’s very resource intensive and the results are obviously poorer than when you have more localised disease. There is no general solution to that. Actually we have realised there is an important heterogeneity in the way the health system is armed to fight against breast cancer. Then there are also different scenarios and the treatment that the woman will receive for her tumour in low and middle income countries will very much vary depending on what is available. You might have certain systems in which you have interventions such as systemic chemotherapy, such as radiation therapy, and some you don’t. Really the challenge is to try to make the optimum of what is available and to build a strategy to improve care.
Where do metronomics fit into this?
There are unique advantages of using metronomic chemotherapy, especially in the setting of low and middle income countries. When you think of it, standard intravenous chemotherapy requires a number of visits to the hospital, requires a number of facilities – you have to have facilities to give chemotherapy, you have to have the proper background in terms of anti-emetics, in terms of supportive systems for blood banks and other things like that. Whereas metronomic chemotherapy, being less toxic, requires less expense in terms of medical equipment, also it requires less expense because medication is cheaper, usually metronomic chemotherapy uses old drugs that are extremely cheap at this time. And it’s particularly appealing in settings where, for instance, distance and travelling to the centre for delivering breast cancer treatment is large. So for a woman that lives far from the hospital it will be very helpful to maybe go once to the hospital, be seen, have a treatment prescribed and then the treatment can be monitored somewhere else in the area, even by a housewife or general practitioner. I’m not saying it is the best way of doing it but I’m saying that we have to find solutions for those women not being able to come to the hospital.
Can you tell us about the Breast Health Global Initiative and whether this includes Ghana?
The Breast Health Global Initiative is an initiative to develop recommendations for breast cancer treatment in countries with limited resources. Although we tried to have a broad approach and to propose a stepwise incremental process to access to care, so that to start from the basic level and once you can achieve the fact that you will be able to offer your patients the alternatives needed at the base level, then you can go up to the limited and then enhance in order to achieve optimal care. But this process is complicated and it has been instrumental for us to develop certain pilot projects such as in Ghana or in Indonesia and other parts of the world, in Latin America, where we really try to see how our guidelines can be implemented into practice. Because a guideline that’s just a published article in a nice journal doesn’t change the life of people so we really wanted, and had this desire, to implement the guidelines. And so far we have been extremely rewarded by what we have seen in practice in Ghana and in other countries in terms of making the difference for the patients.
Where does the funding come from?
The funding for the initiative comes from charity. The pilot projects that we have developed in Ghana and in other countries are locally sponsored or through the means of international organisations that have a desire to help people in those areas. I believe it’s not extremely complicated to get money for these kinds of issues once you have a good idea and once you prove that what you’re trying to do is to improve the outcome of breast cancer patients globally.