Abstract
Women in low- and middle-income countries (LMICs) have yet to benefit from recent advances in breast cancer diagnosis and treatment now experienced in high-income countries. Their unique sociocultural and health system circumstances warrant a different approach to breast cancer management than that applied to women in high-income countries. Here, we present experience from the last five years working in rural Bangladesh. Case and consecutive series data, focus group and individual interviews, and clinical care experience provide the basis for this paper. These data illustrate a complex web of sociocultural, economic, and health system conditions which affect womens' choices to seek and accept care and successful treatment. We conclude that health system, human rights, and governance issues underlie high mortality from this relatively rare disease in Bangladesh.
Highlights
The US-based National Comprehensive Cancer Network guidelines for breast cancer management state that even under the best of circumstances “there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement” [1]
Harford [22] has stressed in particular the importance of studying and addressing barriers which delay women from seeking care in low- and middle-income countries, and barriers within the health system which prevent or delay diagnosis of the disease, both of which contribute to advanced stage disease
We believe that the general calls for “breast cancer awareness,” “early detection and mammography” and “access to drugs” are well intentioned but unlikely to result in a significant improvement on morbidity in these contexts
Summary
The US-based National Comprehensive Cancer Network guidelines for breast cancer management state that even under the best of circumstances “there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement” [1]. In lowand middle-income countries with far fewer resources than the US, the circumstances are compounded by multiple factors associated with increased mortality for this disease [2]. Addressing and remedying these inequities requires an exploration into the unique circumstances surrounding the complex barriers women face in receiving information, accurate and timely diagnosis, and effective treatment critical to reducing breast cancer morbidity and mortality [3]. For the past five years, beginning with work to recruit women to a clinical trial of treatment for metastatic breast cancer, we have been increasing our efforts to understand what is happening to women with breast cancer in the Khulna Division of Bangladesh. Our experience calls into question the application of common high-income country models and strategies in such settings
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