Implementation science and breast cancer control: A Breast Health Global Initiative (BHGI) perspective from the 2010 Global Summit

Abstract

Current situation in global breast cancer controlThe world is facing a critical health care problem: in the next few decades cancer will become a leading global public health problem disproportionately increasing in low and middle income countries (LMCs). Breast cancer is a critical component of the global cancer problem. It is the most common cancer among women and the most likely reason that a woman will die from cancer.1Ferlay J. Shin H. Bray F. Forman D. Mathers C. Parkin D. GLOBOCANCancer incidence and mortality worldwide: IARC cancerbase No. 10. Lyon, France: International Agency for Research on Cancer; 2008.2008http://globocan.iarc.frGoogle Scholar New advances in prevention, early detection, diagnosis, treatment and follow-up have improved our understanding of breast cancer care. Unfortunately, limited access to health care means that all of today’s scientific knowledge available about this disease can only be applied to benefit a small portion of the world population.2Salminen E. Izewska J. Andreo P. IAEA’s role in the global management of cancer-focus on upgrading radiotherapy services.Acta Oncol. 2005; 44: 816-824Crossref PubMed Scopus (33) Google ScholarCancer survival is markedly worse in low and lower-middle resource countries than in high resource counties, suggesting that successful treatment is related to available country resources. However, we know that there are large groups of women, even in high income countries, who have poorer outcomes, such as black women in the United States, who currently have poorer outcomes than white women, but who can have similar outcomes if they present with early-stage disease and receive similar treatment.3Bach P.B. Schrag D. Brawley O.W. Galaznik A. Yakren S. Begg C.B. Survival of blacks and whites after a cancer diagnosis.JAMA. 2002 Apr 24; 287: 2106-2113Crossref PubMed Scopus (404) Google Scholar Studies in middle income countries4Yip C. Taib N. Tan G. Mun K. Choo W. Rhodes A. Factors affecting estrogen receptor status in a multiracial Asian country – an analysis of 3062 cases.Breast. 2011; 20 ([TBD])Google Scholar, 5Bright K. Barghash M. Donach M. Gutierrez de Barrera M. Schneider R.F. Formenti S.C. The role of health system factors in delaying final diagnosis and treatment of breast cancer in Mexico City, Mexico.Breast. 2011; 20 ([TBD])Google Scholar and low income countries6Bird P.A. Hill A.G. Houssami N. Poor hormone receptor expression in East African breast cancer: evidence of a biologically different disease?.Ann Surg Oncol. 2008 Jul; 15: 1983-1988Crossref PubMed Scopus (77) Google Scholar, 7Adebamowo C.A. Famooto A. Ogundiran T.O. Aniagwu T. Nkwodimmah C. Akang E.E. Immunohistochemical and molecular subtypes of breast cancer in Nigeria.Breast Cancer Res Treat. 2008 Jul; 110: 183-188Crossref PubMed Scopus (76) Google Scholar have looked at race, age, tumor grade and stage, insurance coverage and other possible contributing risk factors to poorer outcomes, and contribute to the ongoing efforts to inform breast cancer control programs.This publication is the product of the fourth Global Summit held by the Breast Health Global Initiative (BHGI). The BHGI is co-sponsored by Fred Hutchinson Cancer Research Center and Susan G. Komen for the Cure®. The first such meeting was held almost ten years ago. Each Global Summit has brought together breast cancer experts from around the world to discuss breast cancer care in LMCs and identify barriers to optimal breast cancer management. The most recent Summit was designed to address optimal program implementation, education and training, communications and medical technology.One of the goals of the 2010 Summit, convened in association with the SLACOM-Sociedad Latinoamericana y del Caribe de Oncología Médica, and endorsed by the American Society of Clinical Oncology (ASCO), was to publish three consensus statements from the Working Groups on Low Resource Scenarios, Middle Resource Scenarios, and Problem Solving, as well as to publish a collection of articles from specific LMCs to highlight successful and ongoing efforts around the world in breast cancer early detection, diagnosis and treatment, and health systems.The Consensus Findings and Recommendations presented here were derived from the Summit presentations and discussions, and will be no big surprise to experts working in the global breast cancer arena. The core issues for global breast cancer control that were identified at the first Global BHGI Summit in 20028Anderson B.O. Braun S. Carlson R.W. Gralow J.R. Lagios M.D. Lehman C. et al.Overview of breast health care guidelines for countries with limited resources.Breast J. 2003 May–Jun; 9: S42-S50Crossref PubMed Scopus (84) Google Scholar and the resource-stratified guidelines for breast cancer control9Anderson B.O. Shyyan R. Eniu A. Smith R.A. Yip C.H. Bese N.S. et al.Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines.Breast J. 2006 Jan–Feb; 12: S3-S15Crossref PubMed Scopus (256) Google Scholar, 10Anderson B.O. Yip C.H. Smith R.A. Shyyan R. Sener S.F. Eniu A. et al.Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007.Cancer. 2008 Oct 15; 113: 2221-2243Crossref PubMed Scopus (349) Google Scholar remain essentially unchanged. Over the past ten years, research from LMCs has continued to inform the global community but the core issues remain. While each LMC has a unique socio-cultural, political and economic profile, a pattern of common concerns has been well established and is documented in the consensus manuscripts published here.Although this publication presents reports from countries from whom we have not heard before, such as Kashmir11Erwin D.P. Erwin D.O. Ciupak B. Hellenthal N. Sofi M.J. Guru K.A. et al.Challenges and implementation of a Women’s breast health Initiative in rural Kashmir.Breast. 2011; 20 ([TBD])PubMed Google Scholar and the Gaza Strip,12Shaheen R. Slanetz P.J. Raza S. Rosen M.P. Barriers and opportunities for early detection of breast cancer in Gaza women.Breast. 2011; 20 ([TBD])PubMed Google Scholar the core messages are familiar: 1) awareness of breast cancer as a treatable disease and a critical health care issue continues to be a challenge; 2) lack of advanced pathology services, radiotherapy, and drug therapy continues to hamper efforts to improve breast cancer survival; 3) health care financing, infrastructure and quality control continue to limit access to care; and 4) dedicated individuals, working in collaboration, continue to be the driving force behind improvements in breast cancer care.Reports of early detection programs made up the majority of proposed articles and case examples: screening mammography programs in Brazil, Chile, China, and Uruguay13Yip C.H. Cazap E. Anderson B.O. Bright K. Caleffi M. Cardoso F. et al.Breast cancer management in middle-resource countries: consensus statement from the Breast Health Global Initiative.Breast. 2011; 20 ([TBD])Google Scholar; a breast cancer education and CBE program in rural Kashmir11Erwin D.P. Erwin D.O. Ciupak B. Hellenthal N. Sofi M.J. Guru K.A. et al.Challenges and implementation of a Women’s breast health Initiative in rural Kashmir.Breast. 2011; 20 ([TBD])PubMed Google Scholar; and rural early detection programs in Belarus, India and Egypt.14BHGI The Global Summit on International breast health: optimizing healthcare delivery. Seattle, Washington.2010http://portal.bhgi.org/GlobalPortfolio/globalsummit/Pages/Program.aspxGoogle Scholar Some of the programs were developed using qualitative and quantitative research methodologies, while others were developed as grassroots initiatives. All of these efforts add to an increased awareness in their communities that breast cancer is a serious yet treatable disease if diagnosed early.Not all of the breast cancer efforts worldwide make it into the literature, with many important efforts going unpublished. The rigors of the peer review journal publication process can be a barrier to publication, not to mention the time and resources needed to design, implement, measure and report on study programs. At the same time, it is critical that we have evidence-based information about interventions to inform future programs. The BHGI-INCTR Breast Cancer Control Library (www.bhgi.info) was created, and is reported on within these pages,15Lodge M. Corbex M. Establishing an evidence base for breast cancer control in developing countries.Breast. 2011; 20 ([TBD])PubMed Google Scholar to help make research in LMCs more available to those planning breast cancer programs. Open access to research continues to be an issue that needs to be addressed. Many journals now allow authors to post versions of their manuscripts on their institution or personal websites. While the sharing of research information is critical, equally important is developing an understanding of how to apply sound research methodology to real world health care system improvements.Implementation scienceImplementation science and research were core themes of the 2010 Global Summit. Implementation research refers to the scientific study of methods, interventions, strategies and variables that promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, which when sustained will improve the overall quality and effectiveness of health care delivery.16Titler M.G. Everett L.Q. Adams S. Implications for implementation science.Nurs Res. 2007 Jul–Aug; 56: S53-S59Crossref PubMed Scopus (32) Google Scholar, 17Rubenstein L.V. Pugh J. Strategies for promoting organizational and practice change by advancing implementation research.J Gen Intern Med. 2006 Feb; 21: S58-S64Crossref PubMed Google Scholar Implementation research is needed to adapt studies from one region or country to another, or to scale up a successful pilot program to a larger population, or to adopt a program as national policy.When implementation science is integrated into breast cancer control program planning, programs can routinely measure not only outcomes (quantitative research) but also why a program is or is not working (qualitative research). Programs that adopt implementation science as an integral part of their structure are assisted in becoming stable and sustainable. This is particularly crucial for low and lower-middle income countries where economic development is expected to lead to major changes in breast cancer control programs. Changes in breast cancer care are inevitable even in middle and high income countries as new understandings in breast cancer inform best practices. Instead of starting over if a program fails to generate expected outcomes (the trial and error method), implementation science provides the tools needed to modify a program based on quantitative and qualitative data.Implementation science can identify those components of a system that need to be changed rather than the system itself. Because implementation research includes the study of influences on health care professional and organizational behavior and it is inherently an interdisciplinary area of research, it requires a interdisciplinary approach that includes system science, computer science, and behavioral science.18Madon T. Hofman K.J. Kupfer L. Glass R.I. Public health. Implementation science.Science. 2007 Dec 14; 318: 1728-1729Crossref PubMed Scopus (246) Google Scholar The Problem Solving Consensus manuscript discussion on implementation science and the articles in this supplement present and discuss some of the components of systems delivery and implementation issues affecting breast cancer control from a global perspective.Looking to the futureThe BHGI philosophy is to improve breast cancer outcomes in LMCs through the collaboration of an alliance of dedicated organizations and individuals. Our long-term goal is to diminish breast cancer incidence and to improve curability at a global scale. Each Global Summit was a milestone in this process, starting from a consensus guideline development process to more complex implementation discussions.These collaborative actions are currently ongoing through scientific groups and NGOs, but a critical component of success will be the participation of governments. Governments will need to proactively endorse cancer care in their health agendas and provide the financing to implement national cancer plans and a coordinated strategy based on situational analysis and evidence-based research.We are in the midst of an opportunity to change the way cancer is thought of and addressed by our generation. The next United Nations Summit on Non-Communicable Diseases in September 2011 has the potential to be a turning point in cancer history. This is the time for action. We hope the publication of the BHGI Consensus Statements, grounded in the relatively new field of implementation science, together with the individual articles presented in this Supplement, will contribute to establishing the foundation needed to move to the next level of the fight against breast cancer, and the global goal of reducing breast cancer mortality for all women. Current situation in global breast cancer controlThe world is facing a critical health care problem: in the next few decades cancer will become a leading global public health problem disproportionately increasing in low and middle income countries (LMCs). Breast cancer is a critical component of the global cancer problem. It is the most common cancer among women and the most likely reason that a woman will die from cancer.1Ferlay J. Shin H. Bray F. Forman D. Mathers C. Parkin D. GLOBOCANCancer incidence and mortality worldwide: IARC cancerbase No. 10. Lyon, France: International Agency for Research on Cancer; 2008.2008http://globocan.iarc.frGoogle Scholar New advances in prevention, early detection, diagnosis, treatment and follow-up have improved our understanding of breast cancer care. Unfortunately, limited access to health care means that all of today’s scientific knowledge available about this disease can only be applied to benefit a small portion of the world population.2Salminen E. Izewska J. Andreo P. IAEA’s role in the global management of cancer-focus on upgrading radiotherapy services.Acta Oncol. 2005; 44: 816-824Crossref PubMed Scopus (33) Google ScholarCancer survival is markedly worse in low and lower-middle resource countries than in high resource counties, suggesting that successful treatment is related to available country resources. However, we know that there are large groups of women, even in high income countries, who have poorer outcomes, such as black women in the United States, who currently have poorer outcomes than white women, but who can have similar outcomes if they present with early-stage disease and receive similar treatment.3Bach P.B. Schrag D. Brawley O.W. Galaznik A. Yakren S. Begg C.B. Survival of blacks and whites after a cancer diagnosis.JAMA. 2002 Apr 24; 287: 2106-2113Crossref PubMed Scopus (404) Google Scholar Studies in middle income countries4Yip C. Taib N. Tan G. Mun K. Choo W. Rhodes A. Factors affecting estrogen receptor status in a multiracial Asian country – an analysis of 3062 cases.Breast. 2011; 20 ([TBD])Google Scholar, 5Bright K. Barghash M. Donach M. Gutierrez de Barrera M. Schneider R.F. Formenti S.C. The role of health system factors in delaying final diagnosis and treatment of breast cancer in Mexico City, Mexico.Breast. 2011; 20 ([TBD])Google Scholar and low income countries6Bird P.A. Hill A.G. Houssami N. Poor hormone receptor expression in East African breast cancer: evidence of a biologically different disease?.Ann Surg Oncol. 2008 Jul; 15: 1983-1988Crossref PubMed Scopus (77) Google Scholar, 7Adebamowo C.A. Famooto A. Ogundiran T.O. Aniagwu T. Nkwodimmah C. Akang E.E. Immunohistochemical and molecular subtypes of breast cancer in Nigeria.Breast Cancer Res Treat. 2008 Jul; 110: 183-188Crossref PubMed Scopus (76) Google Scholar have looked at race, age, tumor grade and stage, insurance coverage and other possible contributing risk factors to poorer outcomes, and contribute to the ongoing efforts to inform breast cancer control programs.This publication is the product of the fourth Global Summit held by the Breast Health Global Initiative (BHGI). The BHGI is co-sponsored by Fred Hutchinson Cancer Research Center and Susan G. Komen for the Cure®. The first such meeting was held almost ten years ago. Each Global Summit has brought together breast cancer experts from around the world to discuss breast cancer care in LMCs and identify barriers to optimal breast cancer management. The most recent Summit was designed to address optimal program implementation, education and training, communications and medical technology.One of the goals of the 2010 Summit, convened in association with the SLACOM-Sociedad Latinoamericana y del Caribe de Oncología Médica, and endorsed by the American Society of Clinical Oncology (ASCO), was to publish three consensus statements from the Working Groups on Low Resource Scenarios, Middle Resource Scenarios, and Problem Solving, as well as to publish a collection of articles from specific LMCs to highlight successful and ongoing efforts around the world in breast cancer early detection, diagnosis and treatment, and health systems.The Consensus Findings and Recommendations presented here were derived from the Summit presentations and discussions, and will be no big surprise to experts working in the global breast cancer arena. The core issues for global breast cancer control that were identified at the first Global BHGI Summit in 20028Anderson B.O. Braun S. Carlson R.W. Gralow J.R. Lagios M.D. Lehman C. et al.Overview of breast health care guidelines for countries with limited resources.Breast J. 2003 May–Jun; 9: S42-S50Crossref PubMed Scopus (84) Google Scholar and the resource-stratified guidelines for breast cancer control9Anderson B.O. Shyyan R. Eniu A. Smith R.A. Yip C.H. Bese N.S. et al.Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines.Breast J. 2006 Jan–Feb; 12: S3-S15Crossref PubMed Scopus (256) Google Scholar, 10Anderson B.O. Yip C.H. Smith R.A. Shyyan R. Sener S.F. Eniu A. et al.Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007.Cancer. 2008 Oct 15; 113: 2221-2243Crossref PubMed Scopus (349) Google Scholar remain essentially unchanged. Over the past ten years, research from LMCs has continued to inform the global community but the core issues remain. While each LMC has a unique socio-cultural, political and economic profile, a pattern of common concerns has been well established and is documented in the consensus manuscripts published here.Although this publication presents reports from countries from whom we have not heard before, such as Kashmir11Erwin D.P. Erwin D.O. Ciupak B. Hellenthal N. Sofi M.J. Guru K.A. et al.Challenges and implementation of a Women’s breast health Initiative in rural Kashmir.Breast. 2011; 20 ([TBD])PubMed Google Scholar and the Gaza Strip,12Shaheen R. Slanetz P.J. Raza S. Rosen M.P. Barriers and opportunities for early detection of breast cancer in Gaza women.Breast. 2011; 20 ([TBD])PubMed Google Scholar the core messages are familiar: 1) awareness of breast cancer as a treatable disease and a critical health care issue continues to be a challenge; 2) lack of advanced pathology services, radiotherapy, and drug therapy continues to hamper efforts to improve breast cancer survival; 3) health care financing, infrastructure and quality control continue to limit access to care; and 4) dedicated individuals, working in collaboration, continue to be the driving force behind improvements in breast cancer care.Reports of early detection programs made up the majority of proposed articles and case examples: screening mammography programs in Brazil, Chile, China, and Uruguay13Yip C.H. Cazap E. Anderson B.O. Bright K. Caleffi M. Cardoso F. et al.Breast cancer management in middle-resource countries: consensus statement from the Breast Health Global Initiative.Breast. 2011; 20 ([TBD])Google Scholar; a breast cancer education and CBE program in rural Kashmir11Erwin D.P. Erwin D.O. Ciupak B. Hellenthal N. Sofi M.J. Guru K.A. et al.Challenges and implementation of a Women’s breast health Initiative in rural Kashmir.Breast. 2011; 20 ([TBD])PubMed Google Scholar; and rural early detection programs in Belarus, India and Egypt.14BHGI The Global Summit on International breast health: optimizing healthcare delivery. Seattle, Washington.2010http://portal.bhgi.org/GlobalPortfolio/globalsummit/Pages/Program.aspxGoogle Scholar Some of the programs were developed using qualitative and quantitative research methodologies, while others were developed as grassroots initiatives. All of these efforts add to an increased awareness in their communities that breast cancer is a serious yet treatable disease if diagnosed early.Not all of the breast cancer efforts worldwide make it into the literature, with many important efforts going unpublished. The rigors of the peer review journal publication process can be a barrier to publication, not to mention the time and resources needed to design, implement, measure and report on study programs. At the same time, it is critical that we have evidence-based information about interventions to inform future programs. The BHGI-INCTR Breast Cancer Control Library (www.bhgi.info) was created, and is reported on within these pages,15Lodge M. Corbex M. Establishing an evidence base for breast cancer control in developing countries.Breast. 2011; 20 ([TBD])PubMed Google Scholar to help make research in LMCs more available to those planning breast cancer programs. Open access to research continues to be an issue that needs to be addressed. Many journals now allow authors to post versions of their manuscripts on their institution or personal websites. While the sharing of research information is critical, equally important is developing an understanding of how to apply sound research methodology to real world health care system improvements.Implementation scienceImplementation science and research were core themes of the 2010 Global Summit. Implementation research refers to the scientific study of methods, interventions, strategies and variables that promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, which when sustained will improve the overall quality and effectiveness of health care delivery.16Titler M.G. Everett L.Q. Adams S. Implications for implementation science.Nurs Res. 2007 Jul–Aug; 56: S53-S59Crossref PubMed Scopus (32) Google Scholar, 17Rubenstein L.V. Pugh J. Strategies for promoting organizational and practice change by advancing implementation research.J Gen Intern Med. 2006 Feb; 21: S58-S64Crossref PubMed Google Scholar Implementation research is needed to adapt studies from one region or country to another, or to scale up a successful pilot program to a larger population, or to adopt a program as national policy.When implementation science is integrated into breast cancer control program planning, programs can routinely measure not only outcomes (quantitative research) but also why a program is or is not working (qualitative research). Programs that adopt implementation science as an integral part of their structure are assisted in becoming stable and sustainable. This is particularly crucial for low and lower-middle income countries where economic development is expected to lead to major changes in breast cancer control programs. Changes in breast cancer care are inevitable even in middle and high income countries as new understandings in breast cancer inform best practices. Instead of starting over if a program fails to generate expected outcomes (the trial and error method), implementation science provides the tools needed to modify a program based on quantitative and qualitative data.Implementation science can identify those components of a system that need to be changed rather than the system itself. Because implementation research includes the study of influences on health care professional and organizational behavior and it is inherently an interdisciplinary area of research, it requires a interdisciplinary approach that includes system science, computer science, and behavioral science.18Madon T. Hofman K.J. Kupfer L. Glass R.I. Public health. Implementation science.Science. 2007 Dec 14; 318: 1728-1729Crossref PubMed Scopus (246) Google Scholar The Problem Solving Consensus manuscript discussion on implementation science and the articles in this supplement present and discuss some of the components of systems delivery and implementation issues affecting breast cancer control from a global perspective.Looking to the futureThe BHGI philosophy is to improve breast cancer outcomes in LMCs through the collaboration of an alliance of dedicated organizations and individuals. Our long-term goal is to diminish breast cancer incidence and to improve curability at a global scale. Each Global Summit was a milestone in this process, starting from a consensus guideline development process to more complex implementation discussions.These collaborative actions are currently ongoing through scientific groups and NGOs, but a critical component of success will be the participation of governments. Governments will need to proactively endorse cancer care in their health agendas and provide the financing to implement national cancer plans and a coordinated strategy based on situational analysis and evidence-based research.We are in the midst of an opportunity to change the way cancer is thought of and addressed by our generation. The next United Nations Summit on Non-Communicable Diseases in September 2011 has the potential to be a turning point in cancer history. This is the time for action. We hope the publication of the BHGI Consensus Statements, grounded in the relatively new field of implementation science, together with the individual articles presented in this Supplement, will contribute to establishing the foundation needed to move to the next level of the fight against breast cancer, and the global goal of reducing breast cancer mortality for all women. The world is facing a critical health care problem: in the next few decades cancer will become a leading global public health problem disproportionately increasing in low and middle income countries (LMCs). Breast cancer is a critical component of the global cancer problem. It is the most common cancer among women and the most likely reason that a woman will die from cancer.1Ferlay J. Shin H. Bray F. Forman D. Mathers C. Parkin D. GLOBOCANCancer incidence and mortality worldwide: IARC cancerbase No. 10. Lyon, France: International Agency for Research on Cancer; 2008.2008http://globocan.iarc.frGoogle Scholar New advances in prevention, early detection, diagnosis, treatment and follow-up have improved our understanding of breast cancer care. Unfortunately, limited access to health care means that all of today’s scientific knowledge available about this disease can only be applied to benefit a small portion of the world population.2Salminen E. Izewska J. Andreo P. IAEA’s role in the global management of cancer-focus on upgrading radiotherapy services.Acta Oncol. 2005; 44: 816-824Crossref PubMed Scopus (33) Google Scholar Cancer survival is markedly worse in low and lower-middle resource countries than in high resource counties, suggesting that successful treatment is related to available country resources. However, we know that there are large groups of women, even in high income countries, who have poorer outcomes, such as black women in the United States, who currently have poorer outcomes than white women, but who can have similar outcomes if they present with early-stage disease and receive similar treatment.3Bach P.B. Schrag D. Brawley O.W. Galaznik A. Yakren S. Begg C.B. Survival of blacks and whites after a cancer diagnosis.JAMA. 2002 Apr 24; 287: 2106-2113Crossref PubMed Scopus (404) Google Scholar Studies in middle income countries4Yip C. Taib N. Tan G. Mun K. Choo W. Rhodes A. Factors affecting estrogen receptor status in a multiracial Asian country – an analysis of 3062 cases.Breast. 2011; 20 ([TBD])Google Scholar, 5Bright K. Barghash M. Donach M. Gutierrez de Barrera M. Schneider R.F. Formenti S.C. The role of health system factors in delaying final diagnosis and treatment of breast cancer in Mexico City, Mexico.Breast. 2011; 20 ([TBD])Google Scholar and low income countries6Bird P.A. Hill A.G. Houssami N. Poor hormone receptor expression in East African breast cancer: evidence of a biologically different disease?.Ann Surg Oncol. 2008 Jul; 15: 1983-1988Crossref PubMed Scopus (77) Google Scholar, 7Adebamowo C.A. Famooto A. Ogundiran T.O. Aniagwu T. Nkwodimmah C. Akang E.E. Immunohistochemical and molecular subtypes of breast cancer in Nigeria.Breast Cancer Res Treat. 2008 Jul; 110: 183-188Crossref PubMed Scopus (76) Google Scholar have looked at race, age, tumor grade and stage, insurance coverage and other possible contributing risk factors to poorer outcomes, and contribute to the ongoing efforts to inform breast cancer control programs. This publication is the product of the fourth Global Summit held by the Breast Health Global Initiative (BHGI). The BHGI is co-sponsored by Fred Hutchinson Cancer Research Center and Susan G. Komen for the Cure®. The first such meeting was held almost ten years ago. Each Global Summit has brought together breast cancer experts from around the world to discuss breast cancer care in LMCs and identify barriers to optimal breast cancer management. The most recent Summit was designed to address optimal program implementation, education and training, communications and medical technology. One of the goals of the 2010 Summit, convened in association with the SLACOM-Sociedad Latinoamericana y del Caribe de Oncología Médica, and endorsed by the American Society of Clinical Oncology (ASCO), was to publish three consensus statements from the Working Groups on Low Resource Scenarios, Middle Resource Scenarios, and Problem Solving, as well as to publish a collection of articles from specific LMCs to highlight successful and ongoing efforts around the world in breast cancer early detection, diagnosis and treatment, and health systems. The Consensus Findings and Recommendations presented here were derived from the Summit presentations and discussions, and will be no big surprise to experts working in the global breast cancer arena. The core issues for global breast cancer control that were identified at the first Global BHGI Summit in 20028Anderson B.O. Braun S. Carlson R.W. Gralow J.R. Lagios M.D. Lehman C. et al.Overview of breast health care guidelines for countries with limited resources.Breast J. 2003 May–Jun; 9: S42-S50Crossref PubMed Scopus (84) Google Scholar and the resource-stratified guidelines for breast cancer control9Anderson B.O. Shyyan R. Eniu A. Smith R.A. Yip C.H. Bese N.S. et al.Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines.Breast J. 2006 Jan–Feb; 12: S3-S15Crossref PubMed Scopus (256) Google Scholar, 10Anderson B.O. Yip C.H. Smith R.A. Shyyan R. Sener S.F. Eniu A. et al.Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007.Cancer. 2008 Oct 15; 113: 2221-2243Crossref PubMed Scopus (349) Google Scholar remain essentially unchanged. Over the past ten years, research from LMCs has continued to inform the global community but the core issues remain. While each LMC has a unique socio-cultural, political and economic profile, a pattern of common concerns has been well established and is documented in the consensus manuscripts published here. Although this publication presents reports from countries from whom we have not heard before, such as Kashmir11Erwin D.P. Erwin D.O. Ciupak B. Hellenthal N. Sofi M.J. Guru K.A. et al.Challenges and implementation of a Women’s breast health Initiative in rural Kashmir.Breast. 2011; 20 ([TBD])PubMed Google Scholar and the Gaza Strip,12Shaheen R. Slanetz P.J. Raza S. Rosen M.P. Barriers and opportunities for early detection of breast cancer in Gaza women.Breast. 2011; 20 ([TBD])PubMed Google Scholar the core messages are familiar: 1) awareness of breast cancer as a treatable disease and a critical health care issue continues to be a challenge; 2) lack of advanced pathology services, radiotherapy, and drug therapy continues to hamper efforts to improve breast cancer survival; 3) health care financing, infrastructure and quality control continue to limit access to care; and 4) dedicated individuals, working in collaboration, continue to be the driving force behind improvements in breast cancer care. Reports of early detection programs made up the majority of proposed articles and case examples: screening mammography programs in Brazil, Chile, China, and Uruguay13Yip C.H. Cazap E. Anderson B.O. Bright K. Caleffi M. Cardoso F. et al.Breast cancer management in middle-resource countries: consensus statement from the Breast Health Global Initiative.Breast. 2011; 20 ([TBD])Google Scholar; a breast cancer education and CBE program in rural Kashmir11Erwin D.P. Erwin D.O. Ciupak B. Hellenthal N. Sofi M.J. Guru K.A. et al.Challenges and implementation of a Women’s breast health Initiative in rural Kashmir.Breast. 2011; 20 ([TBD])PubMed Google Scholar; and rural early detection programs in Belarus, India and Egypt.14BHGI The Global Summit on International breast health: optimizing healthcare delivery. Seattle, Washington.2010http://portal.bhgi.org/GlobalPortfolio/globalsummit/Pages/Program.aspxGoogle Scholar Some of the programs were developed using qualitative and quantitative research methodologies, while others were developed as grassroots initiatives. All of these efforts add to an increased awareness in their communities that breast cancer is a serious yet treatable disease if diagnosed early. Not all of the breast cancer efforts worldwide make it into the literature, with many important efforts going unpublished. The rigors of the peer review journal publication process can be a barrier to publication, not to mention the time and resources needed to design, implement, measure and report on study programs. At the same time, it is critical that we have evidence-based information about interventions to inform future programs. The BHGI-INCTR Breast Cancer Control Library (www.bhgi.info) was created, and is reported on within these pages,15Lodge M. Corbex M. Establishing an evidence base for breast cancer control in developing countries.Breast. 2011; 20 ([TBD])PubMed Google Scholar to help make research in LMCs more available to those planning breast cancer programs. Open access to research continues to be an issue that needs to be addressed. Many journals now allow authors to post versions of their manuscripts on their institution or personal websites. While the sharing of research information is critical, equally important is developing an understanding of how to apply sound research methodology to real world health care system improvements. Implementation scienceImplementation science and research were core themes of the 2010 Global Summit. Implementation research refers to the scientific study of methods, interventions, strategies and variables that promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, which when sustained will improve the overall quality and effectiveness of health care delivery.16Titler M.G. Everett L.Q. Adams S. Implications for implementation science.Nurs Res. 2007 Jul–Aug; 56: S53-S59Crossref PubMed Scopus (32) Google Scholar, 17Rubenstein L.V. Pugh J. Strategies for promoting organizational and practice change by advancing implementation research.J Gen Intern Med. 2006 Feb; 21: S58-S64Crossref PubMed Google Scholar Implementation research is needed to adapt studies from one region or country to another, or to scale up a successful pilot program to a larger population, or to adopt a program as national policy.When implementation science is integrated into breast cancer control program planning, programs can routinely measure not only outcomes (quantitative research) but also why a program is or is not working (qualitative research). Programs that adopt implementation science as an integral part of their structure are assisted in becoming stable and sustainable. This is particularly crucial for low and lower-middle income countries where economic development is expected to lead to major changes in breast cancer control programs. Changes in breast cancer care are inevitable even in middle and high income countries as new understandings in breast cancer inform best practices. Instead of starting over if a program fails to generate expected outcomes (the trial and error method), implementation science provides the tools needed to modify a program based on quantitative and qualitative data.Implementation science can identify those components of a system that need to be changed rather than the system itself. Because implementation research includes the study of influences on health care professional and organizational behavior and it is inherently an interdisciplinary area of research, it requires a interdisciplinary approach that includes system science, computer science, and behavioral science.18Madon T. Hofman K.J. Kupfer L. Glass R.I. Public health. Implementation science.Science. 2007 Dec 14; 318: 1728-1729Crossref PubMed Scopus (246) Google Scholar The Problem Solving Consensus manuscript discussion on implementation science and the articles in this supplement present and discuss some of the components of systems delivery and implementation issues affecting breast cancer control from a global perspective. Implementation science and research were core themes of the 2010 Global Summit. Implementation research refers to the scientific study of methods, interventions, strategies and variables that promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, which when sustained will improve the overall quality and effectiveness of health care delivery.16Titler M.G. Everett L.Q. Adams S. Implications for implementation science.Nurs Res. 2007 Jul–Aug; 56: S53-S59Crossref PubMed Scopus (32) Google Scholar, 17Rubenstein L.V. Pugh J. Strategies for promoting organizational and practice change by advancing implementation research.J Gen Intern Med. 2006 Feb; 21: S58-S64Crossref PubMed Google Scholar Implementation research is needed to adapt studies from one region or country to another, or to scale up a successful pilot program to a larger population, or to adopt a program as national policy. When implementation science is integrated into breast cancer control program planning, programs can routinely measure not only outcomes (quantitative research) but also why a program is or is not working (qualitative research). Programs that adopt implementation science as an integral part of their structure are assisted in becoming stable and sustainable. This is particularly crucial for low and lower-middle income countries where economic development is expected to lead to major changes in breast cancer control programs. Changes in breast cancer care are inevitable even in middle and high income countries as new understandings in breast cancer inform best practices. Instead of starting over if a program fails to generate expected outcomes (the trial and error method), implementation science provides the tools needed to modify a program based on quantitative and qualitative data. Implementation science can identify those components of a system that need to be changed rather than the system itself. Because implementation research includes the study of influences on health care professional and organizational behavior and it is inherently an interdisciplinary area of research, it requires a interdisciplinary approach that includes system science, computer science, and behavioral science.18Madon T. Hofman K.J. Kupfer L. Glass R.I. Public health. Implementation science.Science. 2007 Dec 14; 318: 1728-1729Crossref PubMed Scopus (246) Google Scholar The Problem Solving Consensus manuscript discussion on implementation science and the articles in this supplement present and discuss some of the components of systems delivery and implementation issues affecting breast cancer control from a global perspective. Looking to the futureThe BHGI philosophy is to improve breast cancer outcomes in LMCs through the collaboration of an alliance of dedicated organizations and individuals. Our long-term goal is to diminish breast cancer incidence and to improve curability at a global scale. Each Global Summit was a milestone in this process, starting from a consensus guideline development process to more complex implementation discussions.These collaborative actions are currently ongoing through scientific groups and NGOs, but a critical component of success will be the participation of governments. Governments will need to proactively endorse cancer care in their health agendas and provide the financing to implement national cancer plans and a coordinated strategy based on situational analysis and evidence-based research.We are in the midst of an opportunity to change the way cancer is thought of and addressed by our generation. The next United Nations Summit on Non-Communicable Diseases in September 2011 has the potential to be a turning point in cancer history. This is the time for action. We hope the publication of the BHGI Consensus Statements, grounded in the relatively new field of implementation science, together with the individual articles presented in this Supplement, will contribute to establishing the foundation needed to move to the next level of the fight against breast cancer, and the global goal of reducing breast cancer mortality for all women. The BHGI philosophy is to improve breast cancer outcomes in LMCs through the collaboration of an alliance of dedicated organizations and individuals. Our long-term goal is to diminish breast cancer incidence and to improve curability at a global scale. Each Global Summit was a milestone in this process, starting from a consensus guideline development process to more complex implementation discussions. These collaborative actions are currently ongoing through scientific groups and NGOs, but a critical component of success will be the participation of governments. Governments will need to proactively endorse cancer care in their health agendas and provide the financing to implement national cancer plans and a coordinated strategy based on situational analysis and evidence-based research. We are in the midst of an opportunity to change the way cancer is thought of and addressed by our generation. The next United Nations Summit on Non-Communicable Diseases in September 2011 has the potential to be a turning point in cancer history. This is the time for action. We hope the publication of the BHGI Consensus Statements, grounded in the relatively new field of implementation science, together with the individual articles presented in this Supplement, will contribute to establishing the foundation needed to move to the next level of the fight against breast cancer, and the global goal of reducing breast cancer mortality for all women.