Increasing access to breast cancer detection services

Breast cancer is the leading cause of cancer among women worldwide, with over 2 million new cases occurring in 2018. More than 625,000 women die every year from breast cancer. In low- and middle-income countries (LMICs), where late-stage presentation is common, detection and diagnosis are largely inaccessible. For instance, mammography—the gold standard for breast cancer detection—is not available in many LMIC health systems due to lack of resources.

These barriers to detection, diagnosis, and treatment lead to higher rates of morbidity and mortality. Despite a lower incidence of cancer in LMICs compared with high-income countries, total cancer-related mortality is significantly higher in LMICs.

In Peru, breast cancer is the most common cancer in women, representing nearly 20 percent of all new cancer cases (Figure 1). Breast cancer claims approximately 1,900 women’s lives annually.

Drawing on decades of experience advancing breast cancer policies and practices, PATH partnered with volunteers, midwives, and doctors in Peru to develop a holistic approach for breast cancer detection and treatment.

In 2011, with support from the Susan G. Komen foundation and Norwegian Cancer Society, PATH piloted an alternative approach for early detection of breast cancer in Pacasmayo, La Libertad, Peru. The approach is based on community outreach, and it includes clinical breast exams (CBEs) by local midwives, ultrasound triage (UT), and fine-needle aspiration (FNA) biopsies by local doctors—effective methods of detecting breast cancer in the absence of mammography equipment.

In 2016, with support from the Pfizer Foundation, we expanded to more than 50 health facilities, reaching 120,000 patients with this early detection approach. Over this period, more than 22,000 women between 40 and 69 years old received CBEs, more than 200 received UT, more than 150 received FNA biopsies, and more than 35 cases of breast cancer were detected.

This model is eminently scalable in other countries, offering significant potential to save more women’s lives.

In Trujillo, Peru—one of the cities where we’ve been implementing this model since 2016—PATH also introduced a digital tracking system to replace paper forms. This digital innovation came at the request of the Peruvian Ministerio de Salud (MINSA, or Ministry of Health) in 2020 and was successfully piloted in 14 health centers. The streamlined digital tracking system, built with the DHIS2 platform, helped increase the number of breast cancer patients who received follow-up, shortened time between each visit in the detection pathway, and reduced the time spent manually filling out paper forms— strengthening the health care system for 2,110 patients in Trujillo.

It also serves as a feedback loop for providers who are following patients throughout the screening, diagnosis, and treatment pathway. PATH collaborated with consultants from Spain’s Fundación Enlace Hispano Americano de Salud (EHAS, or Hispanic American Health Link Foundation) and the Regional Health Management of La Libertad cancer coordinators. It has been a supportive, iterative, and participatory process, resulting in a functional and easy-to-use system.

To continue scaling the approach, PATH has conducted outreach and training with 250 community health workers (CHWs) in Peru, sharing knowledge on how to use materials to help educate their communities about breast cancer. The CHWs use both print flip charts and short WhatsApp videos to share information about breast cancer risk, as well as signs and symptoms that indicate a woman should seek an annual CBE.

Midwives use a printed manual and a laminated CBE protocol sheet. Fifteen doctors were trained in CBE, UT, and FNA biopsy, including extensive training on follow-up as well as slide preparation following the FNA biopsy. Training sessions included theory, practice with anatomical breast models, and supervised practice with patients.

With PATH’s coordination, Peruvian professionals worked to share knowledge to other countries, presenting the model to colleagues in El Salvador, Guatemala, and Honduras. For example, one Peruvian breast oncologist and expert trainer for breast cancer detection in Trujillo traveled to Guatemala in 2019 to present to a conference of Central American MINSA cancer directors.

PATH believes strongly that south-south cooperation is an appropriate and effective avenue for regional training. It’s cost-effective, too, sometimes just requiring the funding for travel, materials, and coordination of trainings in the new countries.

PATH is at the forefront of the fight against noncommunicable diseases (NCDs). PATH has supported national governments and local institutions in efforts to reach their commitments to the Global NCD Action Plan and the Sustainable Development Goals. PATH focuses on access to primary health care–based NCD prevention and care, including community-based programming, integration of mental health care, and access to affordable medicines and products.

PATH’s work in this area began with women's cancers in 1996 and has since expanded to diabetes and cardiovascular disease. Today, our NCD program works in more than ten countries across sub-Saharan Africa, Asia, and Latin America.

Over the past 20 years, PATH has worked in LMICs—including Ghana, Peru, Rwanda, and Ukraine—to evaluate and strengthen breast cancer early detection and diagnosis. Using our technical capacity, country presence, and extensive global and in-country networks, we pursue culturally appropriate programmatic and technological innovations. We focus on identifying approaches and technologies that are feasible, effective, and affordable in low-resource contexts.

With this extensive, specialized experience, PATH was well positioned to strengthen access to breast cancer detection services in Peru.

PARTNERS LIST

University of Washington, Seattle Cancer Care Alliance, University of California San Francisco, Peruvian National Cancer Institute (INEN), Trujillo’s Regional Cancer Institute (IREN-Norte), Trujillo’s regional ministry of health (GERESA-La Libertad), and Trujillo’s public health network (Red de Salud Trujillo)

Editor's note: If you’re a policymaker or public health practitioner who is interested in accessing and using our breast cancer detection training materials, you can access them all here.