Global Task Force Research Articles

Sci-Fri PM: Topics - 03: The Global Task Force on Radiotherapy for Cancer Control: Core Investments

The Union for International Cancer Control (UICC) is a membership-based, non-governmental organization with a mandate to “…to unite the cancer community to reduce the global cancer burden, to promote greater equity, and to integrate cancer control into the world health and development agenda.” COMP is an associate member of the UICC. It is well recognized by the UICC that there are major gaps between high, and low and middle income countries, in terms of access to cancer services including access to radiation therapy. In this context, the UICC has developed a Global Task Force on Radiotherapy for Cancer Control with a charge to answer a single question: “What does it cost to close the gap between what exists today and reasonable access to radiotherapy globally?” The Task Force consists of leaders internationally recognized for their radiation treatment related expertise (radiation oncologists, medical physicists, radiation therapists) as well as those with global health and economics specialization. The Task Force has developed three working groups: (1) to look at the global burden of cancer; (2) to look at the infrastructure requirements (facilities, equipment, personnel); and (3) to consider outcomes in terms of numbers of lives saved and palliated patients. A report is due at the World Cancer Congress in December 2014. This presentation reviews the infrastructure considerations under analysis by the second work group. The infrastructure parameters being addressed include capital costs of buildings and equipment and operating costs, which include human resources, equipment servicing and quality control, and general overhead.

William A. Zoghbi, M.D., lends expertise on special imaging issue of The Methodist Debakey Cardiovascular Journal.

The editors of the Methodist DeBakey Cardiovascular Journal extend a heartfelt thanks to William A. Zoghbi, M.D., for serving as guest editor of this special issue on multimodality cardiac imaging. A leader in cardiology and cardiovascular imaging, Dr. Zoghbi is the William L. Winters Endowed Chair of Cardiovascular Imaging at the Houston Methodist DeBakey Heart & Vascular Center in Houston Methodist Hospital and is director of the hospital’s Cardiovascular Imaging Institute, which he founded in 2005. Dr. Zoghbi completed his internal medicine and cardiology training at Baylor College of Medicine in Houston, where he joined the faculty in 1985 and became the John S. Dunn Professor of Medicine and director of the echocardiography laboratory. Dr. Zoghbi has developed novel techniques to evaluate valvular disorders and cardiac function, improving the noninvasive evaluation and management of heart disease. He is also known for his research on myocardial hibernation and his development of 3-dimensional techniques to evaluate valvular dynamics and measure valvular regurgitation. Dr. Zoghbi has authored more than 250 original publications and has been invited to lecture on his work at every major cardiology conference around the globe. He also has trained more than 100 cardiology fellows in advanced cardiovascular imaging, many of whom now hold positions of leadership in academic medicine. A recipient of the Richard Popp Excellence in Teaching Award from the American Society of Echocardiography (ASE), Dr. Zoghbi chaired the development of national and international guidelines for evaluating native and artificial heart valves with cardiac ultrasound, and he co-chaired the American College of Cardiology (ACC) committee that wrote a monograph on how best to train the new generation of cardiologists in multimodality cardiovascular imaging. Dr. Zoghbi has been actively involved with the ACC, the American Heart Association, and the ASE for more than 25 years, serving as president of both the ASE and ACC and on the ACC’s board of trustees since 2001. He is currently a board member of the World Heart Federation, co-chairing its Global Task Force for Cardiovascular Disease, and recently represented the ACC at the United Nations and World Health Organization. R E C O G N I T I O N S

Multiregional medical device development: regulatory perspective

There are difficulties in conducting worldwide medical device development simultaneously because each country and/or region has their own medical device regulations. However, to aid globalization of the medical device market, and to quickly provide innovative medical devices to patients, attempts have been made to encourage harmonization and convergence of medical device regulations. 'Harmonization by doing' is a bilateral effort from the United States and Japan to develop global clinical trials and address regulatory barriers that may be impediments to timely device approval. The Global Harmonization Task Force (GHTF) was conceived in 1992 in an effort to achieve greater uniformity between national medical device regulatory systems. Since 2012, the GHTF has been replaced by the International Medical Device Regulators Forum.

International Women's Day 2014: women's health equity is progress for all.

International Women's Day 2014: women's health equity is progress for all.

Do point-of-care troponins offer any advantage to the emergency department?

This lecture will begin by providing context and background to the Emergency Department perspective on the assessment of suspected cardiac chest pain. Data will be presented relating to this issue and there will also be discussion in relation to the problem of Emergency Department and hospital overcrowding and how point-of-care troponins may be able to impact upon this. There will be some discussion of the International Federation of Clinical Chemistry (IFCC) Global Task Force educational guidance concerning new high sensitivity troponins. There will be a review of on-market assays and their characteristics. The potential impact of point-of-care assays upon Emergency Department flow will be discussed and illustrated with value stream mapping. Some case examples will be provided. The potential benefits and disadvantages of point-of-care troponins will be illustrated by up to date research information which will represent Emergency Department research that is also possible within primary care.

The ICH, the GHTF, and the Future of Harmonization Initiatives.

Comparison of the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) and the Global Harmonization Task Force (GHTF), the global regulatory harmonization initiatives in the field of drugs and medical devices, respectively, reveals that "harmonization" activities contain several categories. It was also found that the target level of harmonization (ie, that of technical regulatory requirements and that of regulatory processes) greatly affects the implementability of final work products. Those products concerning regulatory processes (most of the GHTF Documents) often require legal changes and are more difficult to implement than those regarding technical requirements (all of the ICH Guidelines), usually implementable by regulatory authorities publishing them as nonbinding suggestions. Globalization of medical product development, manufacture, and distribution increasingly requires regulatory cooperation across borders, which inevitably affects the initiatives. Identifying what "harmonization" each harmonization initiative aims at is indispensable in determining future directions.

Reporting standards for adverse events after medical device use in the peripheral vascular system

New York, NY;Phoenix, Ariz; Houston, Tex; London, Ontario, Canada; Delhi, India; Silver Spring, Md; and Lewiston, MeAdverse event reporting after medical device implanta-tion is essential to understanding the safety and perfor-mance of a device. Standardization of reporting attainsgreat importance when comparing different devices andfor the ongoing surveillance of a marketed device.Although some work has been done to standardize adverseevent reporting for medical devices, a single reference withrecommendations that span investigational and postmarketuse does not exist.Standardization of nomenclature for reporting vascularconditions is one of the objectives of the Society forVascular Surgery (SVS) in its Bylaws.

The State of Cardiac Troponin Assays: Looking Bright and Moving in the Right Direction

Cardiac troponin assays have evolved substantially over 20 years, owing to the efforts of manufacturers to make them more precise and sensitive. These enhancements have led to high-sensitivity cardiac troponin assays, which ideally would give measureable values above the limit of detection (LoD)4 for 100% of healthy individuals and demonstrate an imprecision (CV) of ≤10% at the 99th percentile. Complete integration and proper use of high-sensitivity cardiac troponin assays into clinical practice will be an important step forward for the diagnosis of myocardial infarction and will allow cardiologists to use cardiac troponin as a prognostic indicator for risk-based outcomes assessment. As laboratorians, we wish to comment on the recently published “ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Implementation of Troponin Elevations” (1). Our purpose is to address 8 analytical issues that we believe have the potential to cause confusion and that therefore deserve clarification. Input from the field of laboratory medicine is important for emphasizing our role as analytical-content experts in the process of strengthening our collaborative relationships with various clinical societies. Since the initial publications by the National Academy of Clinical Biochemistry (NACB) in 1999 and by the European Society of Cardiology/American College of Cardiology in 2000, when both organizations endorsed cardiac troponin I (cTnI) or cTnT as the preferred biomarker for the detection of myocardial infaction, numerous other organizations have followed suit and promoted the sole use of cardiac troponin in this clinical application. The American College of Cardiology Foundation (ACCF) 2012 Expert Consensus Document (1) summarizes the recently published 2012 Third Universal Definition of Myocardial Infarction by the Global Task Force (2), thus providing some practical recommendations on the use and interpretation of cardiac troponin in clinical practice. The integration and acceptance of cardiac troponin testing over the past 13 years has …

Application of a High-Sensitivity Cardiac Troponin I Assay to a Health Screen Cohort of Young Asian Women and Association with Cardiovascular Risk Factors

To the Editor: The Global Task Force for the Universal Definition of Myocardial Infarction and the National Academy of Clinical Biochemistry recommend the 99th percentile of cardiac troponin as a diagnostic threshold, provided that assay precision can be demonstrated to have a CV of ≤10% at this concentration (1). To determine the 99th percentile, we applied a high-sensitivity cardiac troponin I (hscTnI) assay (Abbott Diagnostics) to an analysis of a cohort of young, apparently healthy Asian women with low cardiovascular risk, and correlated this result with demographic and clinical characteristics to identify factors associated with higher cTnI concentrations. The cohort was obtained from our hospital staff health-screening program. Fasting serum samples were stored at −70 °C for up to 6 months until analysis. Nonpregnant women 20–65 years of age with no self-reported personal history of heart disease, diabetes, or hypertension were selected for analysis of cTnI concentrations with the Abbott ARCHITECT i 4000 analyzer and a premarket prototype hscTnI assay. Institutional review board approval was obtained for this study (DSRB/2011/01931). SPSS version 19 (SPSS/IBM) was used for statistical analyses. We …

Analysis of safety reporting requirements during medical device clinical trials in Japan

Regulatory convergence in safety reporting requirements for medical device clinical trials has not yet been achieved. The Global Harmonization Task Force (GHTF) issued new guidance, GHTF/SG5/N5, on this topic in August 2012. First, we compared current reporting requirements for drug and medical devices in Japan with the international guidelines International Conference on Harmonization (ICH)-E2A/E2F and GHTF/SG5/N5. As a result, we confirmed that Japan's expedited reporting requirements are nearly the same for drugs and medical devices and that these requirements are similar to those described in ICH-E2A. We also found that GHTF/SG5/N5 differs from the ICH-E2A in several ways. We sorted these differences into three categories: reportable events, reporting time frame, and definitions of terms. Although there are several equivalent terms between the ICH and GHTF guidelines, the terms Serious Health Threat and Device Deficiency are only defined in GHTF/SG5/N5. The reporting time frame for a Serious Adverse Event is either 10 or 30days for medical devices; expedited reporting is not required according to ICH-E2A, but it is covered in the annual Development Safety Update Report in ICH-E2F. GHTF/SG5/N5 recommends substantially stricter requirements than the current requirements in Japan. Therefore, the Ministry of Health, Labour and Welfare (MHLW) seemed to have prioritized the introduction of consistent definitions of terms while maintaining the current reporting time frame, rather than introducing GHTF guidance as it is. This policy is in accordance with the draft proposal on the revision of safety reporting requirements issued by MHLW in October 2012.

Summary of 2012 ESC Guidelines

The new guidelines deal with the management of patients with STEMI and replace the document published in 2008. It covers different aspects such as emergency care and reperfusion therapy but also special subsets such as patient population, logistics, risk assessment and long-term therapies. After the 2000 and 2007 statements the third Global MI Task Force (Joint ESC/ACCF/AHA/WHF) now recognizes in the new definition of acute myocardial infarction (MI) that very small amounts of myocardial injury or necrosis can be detected by biochemical markers and/or imaging, particularly when such necrosis occurs in the setting of the critically ill, after percutaneous coronary procedures or after cardiac surgery.

Statistical Report: Virtual Global Taskforce P2P Online Offender Sample July 2010 – June 2011

This report describes 103 cases of offenders arrested for child pornography possession identified in a Virtual Global Taskforce (VGT) police database designed to explore likely characteristics of offenders accessing, distributing or producing illegal images of children in the online or Internet medium. The production and dissemination of child pornography (CP), child abuse materials (CAM) or child exploitation material (CEM) have been widely criminalized and international efforts to suppress its dissemination endorsed by many nations. The VGT comprises nine collaborating policing agencies combating the dissemination of CEM via the Internet and digital technologies. The data collected for this study focused on the apparent uptake of peer to peer (P2P) sources of CEM (usually pre-teen children and serious sexual abuse) previously noted by practitioners and researchers as well as the significant overlap between such use and offenses against children (Wolak et al. 2011). Policing agencies are concerned that increased accessibility to such CEM may also increase risks of assault on children and whether the online trade in CEM has amplified or escalated the demand for newer and more extreme images of child sexual abuse.

Special CCM Supplement in the American Journal of Tropical Medicine and Hygiene

Although substantial progress has been made over the past two decades in reducing child mortality, the fact remains that far too many children continue to die before their fifth birthday. A large proportion of these deaths—more than one-third—occur as a result of pneumonia, diarrhea, and malaria. Addressing these child killers in the communities where they occur is, therefore, critical for achieving our child survival goals. In June of this year the Governments of Ethiopia, India, and the United States, in collaboration with UNICEF, brought together over 700 government, civil society, and private sector participants from more than 80 countries to renew the global commitment to end preventable child deaths. The evidence presented at the Call to Action summit demonstrated that it is feasible for the world to greatly decrease that most outrageous of inequities—the huge gap in child mortality between the poorest and richest nations—by focusing on reaching the most disadvantaged and hardest to reach children in every country. The program strategy addressed by the papers in this supplement, integrated community case management (iCCM), is one of the novel approaches that will help us do just that. In 2010 UNICEF released “Narrowing the Gaps to Meet the Goals,” a special report on a new study, which showed that an equity-focused approach could move us more quickly and cost-effectively toward MDG 4 & 5, with the potential of averting millions of child deaths by 2015. Training and deploying community health workers to deliver basic health services in hard to reach areas is one of the main equity-focused strategies that must be used. However, we need more evidence on the most effective ways to implement iCCM and information on how to overcome the main barriers that impede the success of this strategy. We need to understand better the best ways to support frontline health workers and the systems they need to effectively deliver iCCM to populations without easy access to facility-based services, and to address demand-side barriers to care. There is a need for well-designed applied research to optimize delivery of these interventions at the community level and to help make these interventions more cost-effective and sustainable. These are exactly the issues and questions that the papers in this important supplement on iCCM address. We hope that the new evidence contained in this supplement will help to inform policymakers, program managers, and all partners who are supporting scale up of community treatment programs aimed at reaching poor and disadvantaged children. It is important to note that, in addition to appropriate treatment, there is recognition that a broad inter-sectoral approach focused on effective prevention—breastfeeding, clean water, good sanitation and hygiene, immunization, insecticide-treated nets, and appropriate behavior change communication—is required for maximum impact on pneumonia, diarrhea, and malaria. We at UNICEF recognize the importance of strong partnerships and will continue to work closely with key partners as part of the global CCM Task Force to put this evidence into action. This includes the World Health Organization (WHO), Special Program for Research and Training in Tropical Diseases (TDR), United States Agency for International Development (USAID), Save the Children, Boston University, Karolinska Institutet, and others, many of whom have made important contributions to this special supplement. UNICEF is committed to working with governments to achieve universal coverage of effective interventions and support iCCM as an essential strategy, which will foster equity and contribute to sustained reduction in child mortality. The evidence presented here will help us do just that.

Can Start-Ups Finish Up?

In this issue of Circulation: Cardiovascular Quality and Outcomes , Xu et al present findings from a search of US patents related to bare-metal coronary stents in an effort to gain insight on how medical device innovation starts and how policies in the United States might help to promote more innovation.1 Of the 245 patents identified by their search strategy for the years 1984 to 1994, the authors report that the most frequently cited stent patents (their measure of patent importance to innovation headlined by the Palmaz and Gianturco patents) were from individual physician inventors working in academic medical centers and their small private companies. They also report a temporal trend that shows, in later years, more patents were granted to public companies. They concluded that policies aimed at supporting these entities might enhance and accelerate innovation because early innovation, in this case, was spurred by individual inventors with their small companies. Article see p 743 It is true that individual practitioners struggling with the challenges of everyday practice are an important source of new-device concepts that can possibly solve an unmet clinical need. However, the journey of successful innovation to maximized impact on public health requires that these early ideas (such as the original stiff, boxcar like tubular stent of Palmaz or the poorly scaffolding clam shell stent of Gianturco) need significant refinement through subsequent innovation (such as the later, industry-based Lau patent of the Multilink stent that …

Review of two decades of cholera diagnostics--how far have we really come?

BackgroundCholera, an ancient scourge, continues to inflict high rates of mortality today. The rising incidence of epidemics in areas of poor sanitation and crowding highlight the need for better epidemic prevention and early response. Such interventions require the availability of rapid and accurate diagnostic techniques to trigger timely response and mitigate the scale of the outbreak. The current gold standard of bacterial culture is inadequate for rapid diagnosis, highlighting the overarching neglect of field diagnostic needs. This paper was written to support the World Health Organisation's Global Task Force on Cholera Control mandated Cholera and diarrhoeal disease laboratory Network (CholdiNet) in devising a protocol for the validation of Rapid Diagnostic Tests (RDTs) for Vibrio cholerae. The status of diagnostic tools for Vibrio cholerae is assessed, describing products that have been commercialised over the last two decades and discussing their peer-reviewed evaluation.MethodReview of post-1990 peer-reviewed and grey literature on rapid diagnostic tests for Vibrio cholerae.ResultsSince 1990, twenty four diagnostic tests have been developed for the detection of Vibrio cholerae in human faecal samples. Fourteen of these have also been described in the literature, with rapid chromatographic-immuno assays (CIA) featuring strongly. Polymerase chain reaction (PCR) assays maintain the ability to detect the lowest amount of bacteria; however CIAs achieve both low detection thresholds and high sensitivity and specificity, making them possible candidates for use in field conditions. Field and laboratory studies were performed in a wide range of settings demonstrating variability in performance, however only a few of these studies were sufficiently stringent, highlighting five RDTs that showed promise in field conditions; COAT, IP cholera dipstick, SMART, IP dipstick and Medicos. In light of non-independent reporting, the authors would like to see these five products undergoing additional studies, with further technical improvements if needed and commercial production. The authors hope that public health use of such a RDT in limited-resource field conditions on stool samples may contribute to effective reduction in cholera epidemic spread.

International Vision and Strategy for Drug Regulatory Authority: The PMDA's International Vision

The past several years saw various countries' drug regulatory authorities (DRAs) internationalizing their activities in response to the rapid globalization of pharmaceutical affairs. This is the second surge of internationalization, coming after the first in the 1990s, when the International Conference on Harmonisation (ICH) and the Global Harmonization Task Force were founded. For maximum effect, a DRA needs to carefully strategize its international activities. The significance of international master plans is discussed in relation to the recently published International Vision of Japan's Pharmaceuticals and Medical Devices Agency (PMDA).

Validation of acute myocardial infarction in the Food and Drug Administration's Mini-Sentinel program.

To validate an algorithm based upon International Classification of Diseases, 9(th) revision, Clinical Modification (ICD-9-CM) codes for acute myocardial infarction (AMI) documented within the Mini-Sentinel Distributed Database (MSDD). Using an ICD-9-CM-based algorithm (hospitalized patients with 410.x0 or 410.x1 in primary position), we identified a random sample of potential cases of AMI in 2009 from four Data Partners participating in the Mini-Sentinel Program. Cardiologist reviewers used information abstracted from hospital records to assess the likelihood of an AMI diagnosis based on criteria from the Joint European Society of Cardiology and American College of Cardiology Global Task Force. Positive predictive values (PPVs) of the ICD-9-based algorithm were calculated. Of the 153 potential cases of AMI identified, hospital records for 143 (93%) were retrieved and abstracted. Overall, the PPV was 86.0% (95% confidence interval; 79.2%, 91.2%). PPVs ranged from 76.3% to 94.3% across the four Data Partners. The overall PPV of potential AMI cases, as identified using an ICD-9-CM-based algorithm, may be acceptable for safety surveillance; however, PPVs do vary across Data Partners. This validation effort provides a contemporary estimate of the reliability of this algorithm for use in future surveillance efforts conducted using the Food and Drug Administration's MSDD.

Troponin elevation in patients with heart failure: on behalf of the third Universal Definition of Myocardial Infarction Global Task Force: Heart Failure Section

Cardiac troponin testing is commonly performed in patients with heart failure (HF). Despite being strongly linked to spontaneous (Type I) acute myocardial infarction (MI)--a common cause of acute HF syndromes--it is well recognized that concentrations of circulating troponins above the 99 th percentile of a normal population in the context of both acute and chronic HF are highly prevalent, and frequently unrelated to Type I MI. Other mechanism(s) leading to troponin elevation in HF syndromes remain elusive in many cases but prominently includes supply-demand inequity (Type II MI), which may be associated with coronary artery obstruction and endothelial dysfunction, or may occur in the absence of coronary obstruction due to increased oxygen demand related to increased wall tension, anaemia, or other factors provoking subendocardial injury. Non-coronary triggers, such as cellular necrosis, apoptosis, or autophagy in the context of wall stress may explain the troponin release in HF, as can toxic effects of circulating neurohormones, toxins, inflammation, and infiltrative processes, among others. Nonetheless, across a wide spectrum of HF syndromes, when troponin elevation occurs, independent of mechanism, it is strongly predictive of an adverse outcome. Clinicians should be aware of the high frequency of troponin elevation when measuring the marker in patients with HF, should keep in mind the possible causes of this phenomenon, and, independent of a diagnosis of 'acute MI', should recognize the considerable ramifications of troponin elevation in this setting.

Regulation of medical devices outside the European Union

The regulation of medical devices across the world is very varied, ranging from comprehensive to none. Over the past two decades, the number, range, and complexity of medical devices has increased. Regulation of these devices has also evolved due to an increasing awareness of the need for a more consistent approach to regulatory documentation. This will aid both manufacturers selling a product in more than one country, and the countries introducing regulation. Current initiatives are working towards manufacturers being able to produce a single set of documents that will fulfil the requirements of all regulatory authorities. In 2001 the World Health Organization (WHO) published ‘A model regulatory programme for medical devices: An international guide’1 which provided a framework to assist member states in establishing regulatory programmes for medical devices. The guide was based on experiences from areas that had already established comprehensive regulatory programmes. The aim was to provide information to nations without medical device regulatory systems that would enable the production of internationally compatible regulations. In 2003 the WHO published ‘Medical device regulations. Global overview and guiding principles’,2 in which it highlighted the complexity of the medical device industry and identified issues related to regulation. This document provided guidance to member states wishing to create or modify their regulatory systems for medical devices. The WHO is continually prompting harmonized medical device regulation through a range of initiatives, the most recent being the First Global Forum on Medical Devices held in Bangkok during September 2010. At the Bangkok meeting it was reported that: approximately 30% of countries have a developed framework for regulation of medical devices; approximately 30% of countries only have partial regulation of medical devices; remaining countries are either developing a framework or do not yet have any regulation.3 The Global Harmonization Task Force (GHTF) was founded in 1992 in response to a growing need for international harmonization of medical device regulation. This is a voluntary group comprised originally of representatives from the medical device regulatory authorities of the five founding members USA, European Union (EU), Japan, Australia and Canada. In 2006, membership was expanded to include the AHWP, International Organization for standardization (ISO), and the International Electrotechnical Commission (IEC). The International Organization for Standardization (ISO) was set-up in 1946 to facilitate the international coordination and unification of industrial standards. ISO is a network of national standards institutes in 163 countries, and is now the world's largest developer and publisher of voluntary international standards. ISO standards are widely adopted at regional and national level, and underpin the procedures and practices of medical device development, manufacture, quality control and conformity assessment requirements. In the global market these standards provide governments with a technical base for health, safety and environmental requirements, and aid the transfer of good practice and knowledge to developing countries. Standards can be obtained from the ISO website (http://www.iso.org/iso/home.html). There are a large number of standards that relate to medical devices and some of the most important include: ISO 13485 Medical devices – Quality management systems – Requirements for regulatory processes (this is a specific medical device standard based on ISO 9001); ISO 10993 Biological evaluation of medical devices; ISO 14155 Clinical investigation of medical devices for human subjects; ISO 14971 Medical devices – Application of risk management to medical devices.

Awareness is the first step in battle against breast cancer

Like many Nigerians, Betty Anyanwu-Akeredolu believed breast cancer was a white woman's something that could never happen to her. So when she felt a lump in her breast in 1997, she reacted as many of her countrywomen might have done: chose to keep all to myself. I was hoping I could wish all away. weeks later, however, she was inspired to seek treatment after seeing a documentary on Carol Baldwin, an American woman who was diagnosed with breast cancer and had a double mastectomy more than 20 years ago, and who has since become a leading campaigner and fundraiser for breast cancer research. realized that I had to confront it says Anyanwu-Akeredolu. had to talk to someone, and I said to myself, 'if what I felt just a few weeks ago turns to be I will recover as this woman did' Anyanwu-Akeredolu tells with pride how she received her full treatment, including a mastectomy and radiation therapy, at the University College Hospital in Ibadan. Several Nigerian survivors tell stories of how travelled to developed countries for treatment. But not many people have the luxury of this choice. The Nigerian health system is all have. We have the health professionals with the skill and willingness to deliver better health care but are constrained by the lack of infrastructure and an enabling environment [ILLUSTRATION OMITTED] The desire to share her story prompted her to found the Breast Cancer Association of Nigeria, an organization that galvanizes action against breast cancer through public education, patient support, advocacy and research. was determined to speak out. Just as I needed to hear from someone who had recovered from breast I wanted to be that person other women could feel reassured by, the one to tell them that if I could recover here in Nigeria, so could they Felicia Knaul, director of the Harvard Global Equity Initiative, Secretariat of the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, also believes women with cancer need more role models, or 'champions' as she calls them. Having seen a champion who continues to live with the disease is very important for women with cancer, she says. Survival rates are improving. With earlier detection and treatment, evidence from around the world demonstrates tremendous hope for survival and for many years of healthy life Just as Anyanwu-Akeredolu did, Knaul decided to help others deal with the disease after being diagnosed with breast cancer in 2007 at the age of 41 in a clinic in Cuernavaca, Mexico and then receiving almost all of her treatment locally. Soon after her diagnosis, she founded Cancer de Mama: Tomatelo a Pecho, a programme that promotes research, advocacy, awareness and early detection in Latin America. Anyanwu-Akeredolu and Knaul's support groups are important for promoting awareness of breast cancer in low- and middle-income countries, where illiteracy, religious beliefs and health, gender and social inequities often prevent women from having access to services and information, particularly on the importance of seeking treatment early if cancer is detected. Further, Knaul says, the advocacy power of breast cancer can be harnessed to promote broader efforts to empower women and to promote women's health in general. Knaul said stigma and discrimination also severely hamper women's decisions and ability to seek medical advice if find a breast lump. Women often struggle to come out publicly about their breast cancer for fear of being abandoned by their partners or of losing their jobs. According to the International Agency for Research on Cancer, breast cancer is the most frequently diagnosed cancer among women, with an estimated 1.38 million cases diagnosed worldwide in 2008. It is also the most frequently reported cause of death from cancer in women in both developed and developing countries. …