The Breast Health Global Initiative is an organisation that was started back in 2002 with the goal of developing breast care guidelines for limited resource environments, including low and middle income countries. What we recognised at that time was that the guidelines that were being used, such as NCCN, St Gallen, these guidelines were focussed on high income countries and assumed that all of the resources were available. That’s a problem when you’re in an environment where you don’t have all of the resources and you need to decide how am I going to manage to improve outcome in these limited resource settings.

What BHGI developed was this concept of resource stratification, the idea that if we take all of the resources that are needed – surgical resources, radiation, drug therapy, supportive and palliative care – they go in an order. There are some resources, basic level, without which you cannot improve outcome and if those pieces are missing this is important for the healthcare system to know so that they don’t try to use resources that will be wasted. Limited level, enhanced level, maximal level, this provides a framework for doing gap analysis and early detection, diagnosis and treatment of breast cancer.

We developed this approach, we published it and a concept of resource stratification, and its actual application, has now been adopted by multiple organisations. The National Comprehensive Cancer Network, NCCN, has used this framework, this resource stratification, and now has guidelines that represent cancers for more than 75% of the world. So this is very useful.

Now where BHGI is going is to say, well, we have guidelines, we have these frameworks, how do we implement them? What is it that we’re going to do that will actually bring them from something that’s theoretical into something that’s applied? The concept that BHGI is developing is this idea of phased implementation. I can identify where I am with the situation analysis; I can see where I need to go next, what I need are steps to get me there. So it might be that in a low income environment where women are presenting with very advanced tumours, ones that you can see because the breast is distorted or ulcerated, that they need to be able to manage those palpable masses before there would be any discussion of image detection like mammographic screening where not only do you have to manage it but you have to be able to find it even though you can’t feel it. The same is true of drug therapy, the same is true of supportive and palliative care. So we’re developing approaches, working with ministries of health around the world to help identify where are those next key steps. We’re working with partners, including academic partners, governmental partners, industry, to develop practical approaches that can be applied and tested.

A really key concept is this idea of implementation science, that it’s great if you know what to do and it’s great if you do it. But if you do not measure your outcome you will actually not know if you’ve made any improvement. So with these metrics and appropriate metrics that can help you assess whether your system is working or not and with what level of quality, that’s how we intend to improve breast cancer outcomes globally.