Championing women’s cancer care: a global challenge

In a recent exchange with Cary Adams, CEO of UICC, Dr Mary Nyangasi, who leads the World Health Organization’s Global Breast Cancer Initiative, discusses the unique challenges women face in cancer care, highlighting the critical role of gender and social norms in health outcomes.

Addressing the stigma around women’s cancers and the socio-economic barriers to effective treatment, Dr Nyangasi outlines the objectives of the Global Breast Cancer Initiative, aiming for early detection, timely diagnosis, comprehensive care,  and proactive global policies.

The conversation also covers advancements in breast cancer treatment, including the potential of artificial intelligence in improving early detection and treatment outcomes.

What are some of the unique challenges that women face when it comes to cancer?

One of the challenges that women face is actually the role of caregiving where they have competing priorities and sometimes they tend to put the care aspect of their family ahead of their own.

Another unique challenge is the stigma surrounding women’s cancers in general. In some societies, the types of women's cancers we see most commonly, cervical and breast cancer concern organs that we don't talk about. This contributes to late stage detection in many settings.

Is that true around the world?

This is true across certain parts of the world, but especially in low- and middle-income countries, and perhaps a bit more in African and Asian regions, where deaths due to women's cancers are particularly high.

What about the socioeconomic factors, such as gender and cultural norms? How do they feed into disparities you see in cancer care and in outcomes, the chances of successful treatment?

Gender plays a significant role in affecting women's access to healthcare. Education level, access to care, and the type of environments where women often find themselves influence their behaviour in seeking screening, diagnostic services, treatment, and continuity of care.

The understanding of disease, family support, and financial capabilities, can further profoundly influence women's access to healthcare.

There can also be the perception that a cancer diagnosis is tantamount to a death sentence, which can discourage early diagnosis and treatment, despite available services. Cancer is even sometimes perceived as contagious.

Addressing these misconceptions is vital. We must advocate and educate to empower individuals with the knowledge that cancer can be cured, especially if caught early.

Beyond the individual, a woman’s cancer diagnosis can affect societal perceptions of her family, which further underscores the need for advocacy and empowerment.

IARC estimates that in 2020, there were 7 million maternal orphans as a result of cancer, with 1 million newly orphaned within that year alone, especially in low- and middle-income countries. What's your perspective on that?

Such statistics highlight the urgent need for governments to support WHO’s initiatives for women's cancer to mitigate the emotional and economic toll. Addressing this issue is also crucial for achieving Sustainable Development Goals.

Women often hold central roles, supporting their families and communities, so their loss has a significant impact. Furthermore, illnesses such as breast and cervical cancer commonly affect women during their most economically productive years. This loss significantly impacts therefore not just a women's immediate family but the wider community as well, undermining social cohesion and economic growth.

Breast cancer is one of the significant causes of death for women worldwide. What is the global status on breast cancer and what are the recent trends and developments been?

In 2022, breast cancer was ranked as the second most common cancer globally and the fourth leading cause of cancer death. It's the most frequently diagnosed cancer among women in 157 out of 185 countries, with about 2.3 million new cases annually and nearly 660,000 deaths, which is significant.

We observe higher incidence rates in Asia, Europe, Latin America, and North America, with the Asian region also leading in mortality, closely followed by Europe.

The good news is that, thanks to the Global Breast Cancer Initiative launched by WHO in 2021, breast cancer is one of the most researched cancers, especially in high-income countries, where there's been substantial progress in educating women about early signs and symptoms, leading to early presentation. However, there’s still a gap in knowledge regarding breast cancer risk factors that needs to be addressed.

What are the primary risk factors for breast cancer?

Breast cancer is often perceived as being tied to specific risk factors. These include alcohol consumption and lack of physical activity, though many women are unaware of the link between alcohol and breast cancer risk, which shows a critical need for education.

It's important to note, however, that the majority of breast cancer cases occur in women who don't have these risk factors. About 15% of women have a genetic predisposition, such as the presence of BRCA genes. The risk increases with age and exposure to oestrogen. This can happen through early onset of menstruation, late menopause, use of combined oral contraceptives, hormone replacement therapies, and lifestyle factors such as lack of breastfeeding. 

In terms of diagnosis and treatment, what progress in detecting breast cancer earlier and treating it more successfully?

We’re seeing notable advances with new immunotherapies and innovative drugs, but radiotherapy, which is a cornerstone of treatment, is becoming less invasive and more patient-friendly. Surgical techniques have also progressed, albeit at a slower pace, to less invasive procedures such as lumpectomies and conservation surgeries. These innovations, along with reconstructive surgeries, help maintain patients’ dignity and address the stigma of organ loss.

They are also fostering confidence in treatment and could encourage more women to seek early detection.

There’s also exciting potential in AI to enhance screening, particularly in radiology and mammographic imaging, making early identification of cancers more efficient.

How does this play out in lower-income settings?

Diagnosing breast cancer, particularly in low and middle-income areas, needs careful consideration. While we’re excited about the latest innovations, it’s critical to evaluate them carefully. We must ensure these advances are ethically sound, cost-effective, and thoroughly validated. Our aim is to assist women effectively without causing any unintended harm.

The goal of WHO’s Global Breast Cancer Initiative is clear and stands on three pillars. First is to increase the rate of early detection, aiming for at least 60% of breast cancers to be identified at stage 1 or 2. Second, we're focusing on timely diagnosis because we know delays can drastically reduce the chances of successful treatment. We're working to ensure that women receive a diagnosis within 60 days of presenting symptoms. Brazil has set a precedent by legally mandating that cancer treatment begin within 60 days of diagnosis.

Finally, our third pillar targets treatment. We want women diagnosed with breast cancer to start and complete their combined treatments promptly, aiming for a 30% completion rate. These are our benchmarks for success, and we're committed to reaching them globally.

And what about the financing? How can countries fund these initiatives, incorporate the data in their universal health coverage packages, have adequate workforce, adequate infrastructure?

It’s essential to have a systemic approach that encompasses not just breast cancer but all types of cancers, including cervical cancer. When talking with health ministers, the conversation centres on integrating breast cancer programs within the broader scope of women’s cancers, to ensure a patient-centred and rights-based approach to healthcare. By addressing cervical and breast cancer in tandem, considering the high prevalence of both among women, we aim for a comprehensive strategy that lays the groundwork to extend these systems to other cancers. This synergy in treatment protocols, surgery, radiotherapy, chemotherapy, and diagnostics is pivotal for managing the wide array of cancers we encounter.

We also need to strengthen policy advocacy and educate leaders, as many lack a fundamental understanding of cancer. Through effective advocacy, we can foster political goodwill, which is essential for addressing cancer. Good governance is key. Without it, we’re quite limited in what we can achieve. When policymakers are informed and on board, we can expect to see increased domestic funding, the creation of supportive policies, and the initiation of new programmes.

Reinforcing the healthcare workforce is crucial. In some countries, the scarcity of oncologists is alarming. In a country with only five oncologists, for instance, where do patients go after they have been diagnosed? It's unethical to promote early diagnosis without the capability to provide subsequent care. We must start by building a system that can deliver.

Drawing from my experience in Kenya, when I led the cancer programme, I saw the need to decentralise care and expand treatment facilities before promoting early diagnosis. There's no benefit to early screening if you can't provide timely treatment – it’s about being empathetic and supportive to the patient's journey.

How do you envision the Global Breast Cancer Initiative growing over the next few years?

I’m thrilled to be part of this fairly new initiative, which shows a real global commitment to women’s rights and health equity.

A crucial part of this initiative is to incorporate integrated practices for comprehensive healthcare, as well as the power of the patient’s voice in our system, which is immensely influential, as it comes from personal experience. I draw a parallel to the HIV movement, where patient advocates played a pivotal role in accessing treatment. While we’ve made strides there, the dream for cancer is still unfolding, and I’m optimistic that global access to cancer care can improve significantly.