Evidence

Why there is a need for a breast cancer program in India? 

Breast cancer is the most common cancer among women in India, with an estimated 178,361 new cases and 90,408 deaths in 2020. The 5-year survival rate is less than 60% and mostly attributed to lack of breast cancer awareness in the community and among health care providers, suboptimal access to services for early detection of breast cancer resulting in late-stage diagnosis, and inequitable access to quality treatment. 

How is the Ministry of Health and Family Welfare of India tackling breast cancer? 

In the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS, 2010) there is guidance for population-based screening of all women aged 30 to 65 years for breast and cervical cancer. However, the gap is in operationalization and implementation of the program which have been observed to be slow and inconsistent. 

What was the objective of The Breast Health Initiative? 

Jhpiego, an international nonprofit health organization affiliated with John’s Hopkins University has been supporting the Departments of Health in the states of Uttar Pradesh and Jharkhand in developing a resource-appropriate, phased implementation strategy for decentralized breast cancer early detection and care. As a result, the Breast Health Initiative was launched in 2018 and implemented in Uttar Pradesh and Jharkhand to demonstrate a scalable model to improve access to early diagnosis and treatment of breast cancer. 

What does this article present? 

In this article, the authors present the key strategies, interventions, and results from the first 18 months of the Breast Health Initiative program implemented in the two states, Uttar Pradesh and Jharkhand. The article claims this is one of the largest efforts to implement and evaluate a breast cancer early detection program in a public health setting in low-to middle-income countries. The strategy included a package of evidence-based interventions which was co-designed and implemented with the stakeholders, as part of the national noncommunicable disease program, through the existing primary health care system. 

Key results from the Breast Health Initiative program

 A total of 108,112 women received breast health education; 48% visited the health facilities for Clinical Breast Examination (CBE), 3% had a positive CBE result, and 41% were referred to a diagnostic facility. The program found that adherence to follow-up care improved considerably, with more women visiting the diagnostic facilities and completing diagnostic evaluation within 1 month from initial screening, and with only 9% lost to follow-up. The program observed a clinically meaningful decrease in time to complete diagnostic evaluation with biopsy, from 37 to 9 days. 

The key programmatic strategies 

1. For spreading awareness/education at community level, the strategies included developing behavior-change communication materials, orienting frontline health care workers on basics of breast health, integration of activities for breast health into community and primary health care programs. 
2. For early detection/screening at primary care level, the strategies included orientation and training of frontline health care workers, development of protocols, systematic integration of breast health care services at all public health systems. 
3. At diagnostic level (secondary or tertiary care), the strategies included setting up ‘single-window breast health care clinics’ with presence of health experts, trained pathologist and laboratory technicians on specimen processing, free diagnostic services for suspected cases and referral tracking, streamlining the diagnostic and treatment pathways to improve efficiency and access for patients, availability of preliminary blood tests and staging investigations including chest x-ray and liver ultrasound. 
4. Cross-cutting strategies involved creating systems for tracking and follow-up of patients across the care pathway and facility-level data compiled monthly for review by district/ state health authorities. 

Key learning from the article: 

1. The results from the 18 months of implementation of the scalable breast health initiative shows it is possible to implement a large-scale, decentralized breast cancer early detection program in India. 
2. Frontline health workers can be trained to deliver the services as part of their routine home and community visits. 
3. It is possible to build the capacity of primary-level health care providers for conducting high-quality Clinical Breast Examinations (CBEs). 
4. Patient-tracking strategy is effective in improving increase and adherence for women with an abnormal Clinical Breast Examination. 

Cancer 2022;0:1-10. © 2022 The Authors: Somesh Kumar, MBBS, MPH, PhD; Gulnoza Usmanova, MD, MPH ; Tapas Sadasivan Nair, MBBS, MD ; Vineet Kumar Srivastava, MD, MPH4; Rakesh Singh, MA, PGDA; Nochiketa Mohanty, MBBS, MPH, MBA; Nadeem Akhtar, MD7 ; Meshach Sunny Kujur, MD; Ashish Kumar Srivastava, MD; Suranjeen Prasad Pallipamula, MD; Gaurav Agarwal, MS, FACS; Amresh Bahadur Singh, MD ; Vivek Kashyap, MD; Maura McCarthy, MPH, MBA; Erica J. Liebermann, PhD; and Ophira Ginsburg, MD, MSc. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society