At AORTIC I had the pleasure of participating in two things today. The first was a roundtable discussion with Professor Lynette Denny and with Shankar from IARC regarding health equity in cancer. We had a very good turnout, despite it starting at 7:10am, by the time we really got started after a few introductory comments by the three of us there were about 25 people at this roundtable. We were able to bring out a lot of very good ideas from the people who attended. They were mostly women, and I draw attention to that because I have a particular interest in women’s cancers and the role of women leaders in oncology. AORTIC has been very good at encouraging women leaders, the next generation of oncologists, care providers, and also our role in helping to guide policymakers in this regard to reduce inequities in cancer.
So that was a very good discussion and Professor Denny took copious notes and she will be sending around a document, hopefully in a few weeks, which we’ll then share on the AORTIC website. So these were, I think she called them burning issues, or something similar, the things that we all felt very strongly about such as the importance of integration of cancer into health services, the importance of advocacy and leadership, as I mentioned already. So stay tuned for that.
The second session I participated in was the breast cancer workshop in the ministers’ amphitheatre which was also well attended. I shared the podium with a number of excellent speakers who covered a range of topics from genetic epidemiology of breast cancer to the very public health oriented approaches such as what I covered on behalf of the World Health Organisation.
In my talk I spoke about the importance of knowing the difference between early diagnosis and screening. This is something that is often missed, even among people who run programmes. Early diagnosis in the lingo of the World Health Organisation really refers to what happens when a woman presents for care with a breast mass, for example, or other concerning signs suggestive of breast cancer. How then to access care for that woman from diagnostic evaluation, referral if needed, and follow-up if she has cancer for surgery and care; I call that closing the loop. If you can’t close the loop there’s certainly no point in starting any kind of screening programme which really refers to an organised programmatic, usually by invitation, approach to detecting people in the community who don’t have any symptoms but who can come for a test such as a mammogram etc. I feel fairly strongly about this and the World Health Organisation’s position paper on mammography from 2014, which I described, is quite clear about what the health system requirements are for an organised mammogram based screening programme for breast cancer really needs to be effective. In limited resource settings even in countries where they have a reasonable GDP per capita in most settings in many countries it’s just not there. It’s not just a matter of sending machines, it’s a matter of knowing what your population will accept, it’s about knowing what services are available if you do detect something. We’re aware of the problems of over-diagnosis and overtreatment in high income countries and the WHO’s position for regions with fragmented or fragile health systems are to not start mammogram screening but to consider building in services for case finding or early diagnosis, as I mentioned previously, at the same time mobilising advocacy and resources and to trial, and continue to do in the context of clinical trials, good quality clinical breast examination. There is emerging evidence that this is a promising approach that will probably make an impact in many places in the world where widespread screening mammograms just aren’t feasible.
How can training be improved?
What we need to improve in terms of training is going to be teaching healthcare providers, nurses and also community health workers in rural areas and in regions that don’t have access to a cancer centre or a good quality tertiary care facility how to do a breast exam. We need to improve training and capacity for pathology, for basic and essential surgical care. These are the things we need to do more than bringing in equipment that may make very little difference and cost an astronomical amount of money, given the false positive rate etc. The only thing I didn’t mention, though, is the importance of radiotherapy. There again you have the capital costs but these can be offset as covered very recently by the UICC-led Global Task Force on Radiotherapy and I’m sure there are videos by our colleagues, such as Dr Mary Gospodarowicz who is here today, for ecancer that will go into more detail about the importance of radiotherapy in cancer control. I must admit it’s not something I mentioned today because I was focussing on areas where they don’t have access and they need to improve basic services first.