Many With Breast Cancer ‘Systematically Left Behind,’ Report Says

Inequities in breast cancer prevention, detection, treatment, and supportive care worldwide are leaving many patients with breast cancer “systematically left behind and forgotten,” according to a report from the Lancet Breast Cancer Commission.

Commission members noted that despite progress in research and cancer management that has substantially decreased breast cancer mortality in high-income countries, the World Health Organization still recorded 685,000 deaths from breast cancer worldwide in 2020, and treatment inequities remain an urgent challenge.

The multidisciplinary, international commission convened in 2021 with the goal of identifying key areas for change to influence global policy and to improve the lives of those affected by breast cancer.

“Recent improvements in breast cancer survival represent a great success of modern medicine. However, we can’t ignore how many patients are being systematically left behind,” said Charlotte Coles, PhD, of the University of Cambridge in England and the report’s lead author, in a statement accompanying the report’s publication. “Our commission builds on previous evidence, presents new data, and integrates patient voices to shed light on a large unseen burden. We hope that, by highlighting these inequities and hidden costs and suffering in breast cancer, they can be better recognized and addressed by healthcare professionals and policymakers in partnership with patients and the public around the world.”

The commission’s report published in The Lancet had several key takeaways:

Metastatic Breast Cancer

The commission found that inequities in breast cancer care particularly affect patients with metastatic disease. Many of these cases are not recorded by national cancer registries, with the result that the number of patients with metastatic breast cancer is actually unknown and that these patients may not receive appropriate care.

The commission advocated the following:

• A minimum of 70% of registries worldwide (with an ultimate goal of 90%) record cancer stage and relapse
• A minimum of 50% (aiming at 95%) of people with newly diagnosed metastatic breast cancer are discussed at multidisciplinary team meetings
• The number of people with metastatic breast cancer is accurately recorded with the objective of doubling median overall survival in a decade
• Less than 5% of patients are unable to access morphine at the end of their life
• All people with metastatic breast cancer have access to life-saving cancer medicines

The Costs of Breast Cancer

Commission members also observed that the physical, psychological, social, and financial costs of breast cancer are often unrecognized.

These costs can be substantial. According to a commission survey of 606 persons living with breast cancer and their caregivers, 20% of participants with early breast cancer and 25% of those with metastatic breast cancer reported difficulty in covering the costs of travel for treatment. A further 27% with early breast cancer and 35% with metastatic breast cancer said they had financial problems.

The commission recommended that universal health coverage of breast cancer should be expanded “across the continuum of care” in order to eliminate the potential of financial catastrophe for families that experience breast cancer and that at least 20% (with an ultimate goal of 100%) of patients and families with the lowest incomes receive public financing and an essential package of supportive and palliative care across the breast cancer pathway.

The panel also recommended that patients be screened for serious health-related suffering, both at diagnosis and at key milestones throughout the breast cancer pathway.

Communication, Prevention, Detection, and Personalization

The commission called for 100% of healthcare professionals in every country to receive communication skills training and for patient involvement in cancer clinical research from concept to reporting and translation into practice.

The commission also lobbied for policy changes to improve prevention and the early detection of breast cancer.

For example, given the link between breastfeeding and breast cancer prevention, the report suggested laws should allow for at least 18 weeks of parental leave at 100% pay, as well as providing paid breaks and nursing facilities upon return to work.

It also recommended that sugar-sweetened beverages should be taxed at a level increasing its retail price by at least 20%.

Furthermore, the commission argued for improving early detection by promoting efforts at stage-shifting in diagnosis, with a target of diagnosing at least 60% of all invasive cancers at stage I or II.

Finally, the commission also recommended that breast cancer treatment be adequately personalized by giving patients access to accurate subtyping and a full range of treatment modalities. Moreover, the commission suggested that at least 10% of participants in international breast cancer trials should be from low- and middle-income countries, and that at least 10% of those trials should be led or co-led by researchers from those countries.

“In all countries, women with low incomes from minoritized backgrounds often have breast cancer diagnosed at a late stage, with a higher risk of dying,” said commission member Benjamin Anderson, MD, of the University of Washington in Seattle, in a press release. “Our research lays out numerous other inequities in breast cancer that are at risk of widening further, and that can be addressed through global collaboration.”

“Access to evidence-based prevention and care that isn’t dependent on where an individual lives or their ability to pay would reap wide-ranging benefits for patients, families, and healthcare systems striving to achieve universal health coverage,” he added. “We urge decision-makers to implement our recommendations and accelerate progress on closing the breast cancer equity gap.”

In a commentary accompanying the commission’s report, Jennifer Moodley, MBChB, PhD, and Karla Unger-Saldaña, MD, DSc, both of the University of Cape Town in South Africa, noted that while the report identified multiple sources of breast cancer gaps and inequities, “it is also important to recognize and address discrimination as a key determinant of breast cancer disparities.”

Moodley and Unger-Saldaña suggested that multi-level systemic interventions are needed to combat racial and ethnic discrimination in breast cancer care, which should include broad-level anti-racist interventions at the policy and organizational levels, as well as breast-cancer specific interventions within healthcare institutions.

“Research on the mechanisms that underlie reported racial disparities in health outcomes needs to be increased and requires the joint commitment of researchers, journal editors, international health organizations, and funding agencies,” they added. “It is imperative that collectively we uphold a more rigorous standard to avoid perpetuating the status quo.”