benjamin o. anderson, m.d. - harvard...

www.bhgi.infowww.bhgi.infowww.bhgi.info

Benjamin O. Anderson, M.D.Benjamin O. Anderson, M.D.

www.bhgi.infowww.bhgi.info

BHGI resource-stratified guidelines

Low-income: Ghana, West Africa

Middle-income: Latin America


The The Breast Health Global Initiative (BHGI)Breast Health Global Initiative (BHGI) strives to strives to develop, implement and study evidencedevelop, implement and study evidence--based, based, economically feasible, and culturally appropriate economically feasible, and culturally appropriate

guidelines for international breast health and guidelines for international breast health and cancer control for low and middle income cancer control for low and middle income

countries to improve breast health outcomes.countries to improve breast health outcomes.


Comprehensive guidelinesComprehensive guidelines by selected expert panelsby selected expert panels

Consensus opinionsConsensus opinions based on evidence reviewbased on evidence review

PublicationPublication of a) consensus and b) individual manuscriptsof a) consensus and b) individual manuscripts

Global Summit 2002: Global Summit 2002: Health Care DisparitiesHealth Care Disparities

Global Summit 2005: Global Summit 2005: Resource StratificationResource Stratification

Global Summit 2007: Global Summit 2007: Guideline ImplementationGuideline Implementation


Basic level Basic level —— Core resourcesCore resources or fundamental services or fundamental services necessary for any breast health care system to function. necessary for any breast health care system to function.

Limited level Limited level —— SecondSecond--tier resourcestier resources or services that or services that produce major improvements in outcome such as survival.produce major improvements in outcome such as survival.

Enhanced level Enhanced level —— ThirdThird--tier resourcestier resources or services that are or services that are optional but important, because they increase the number optional but important, because they increase the number and quality of therapeutic options and patient choice. and quality of therapeutic options and patient choice.

Maximal level Maximal level —— HighestHighest--level resourceslevel resources or services used in or services used in some high resource countries that have lower priority on some high resource countries that have lower priority on the basis of extreme cost and/or impracticality.the basis of extreme cost and/or impracticality.


Cancer: 113 (8 suppl), 2008 Cancer: 113 (8 suppl), 2008

CONSENSUS STATEMENTSCONSENSUS STATEMENTSEarly DetectionEarly DetectionDiagnosisDiagnosisTreatmentTreatmentHealth Care SystemsHealth Care Systems8 Stratified Tables8 Stratified Tables10 Individual Manuscripts10 Individual Manuscripts

EARLY DETECTION DIAGNOSIS

STAGE I STAGE II LOCALLY ADVANCED METASTATIC

HEALTH CARE SYSTEMS


Dissemination & implementation (D&I) research Dissemination & implementation (D&I) research

Education and training programs Education and training programs

Technology application and developmentTechnology application and development

IMPLEMENTATION STRATEGY: IMPLEMENTATION STRATEGY: Create Create BHGIBHGI Learning LaboratoriesLearning Laboratories in different parts of the in different parts of the world to develop and test educational modules world to develop and test educational modules based on BHGI guidelines and to model program based on BHGI guidelines and to model program expansion to other LMCs.expansion to other LMCs.

www.bhgi.info

RESEARCH RESEARCH SEQUENCE SEQUENCE Early DetectionEarly Detection DiagnosisDiagnosis TreatmentTreatment

Guideline Guideline DevelopmentDevelopment

In print Oct 08In print Oct 08



Readiness Readiness AssessmentAssessment

TurkeyTurkeyBHGI Pilot 5/08BHGI Pilot 5/08

GhanaGhanaPath Lab 4/06Path Lab 4/06

ColombiaColombiaPSPGH Pilot 7/08PSPGH Pilot 7/08

Guideline Guideline AdoptionAdoption

ColombiaColombiaBHGI Pilot 7/07BHGI Pilot 7/07

IndonesiaIndonesiaBHGI Pilot 7/07BHGI Pilot 7/07

Ghana (GBCA)Ghana (GBCA)Open 11/09Open 11/09

SystemSystem--wide wide ScaleScale--upup

Latin AmericaLatin AmericaSummit 4/10Summit 4/10



www.bhgi.info

““Some countries are so poor that breast Some countries are so poor that breast cancer is not a significant problem for them.cancer is not a significant problem for them.””

QUESTION:QUESTION: At what point are resources so At what point are resources so limited, and competing demands so great, limited, and competing demands so great, that breast care programs make no sense to that breast care programs make no sense to create?create?

GHANA BREASTGHANA BREASTCANCER ALLIANCECANCER ALLIANCE

OCTOBER 2008OCTOBER 2008

SITUATION ANALYSIS:SITUATION ANALYSIS:GHANA, WEST AFRICAGHANA, WEST AFRICA

OCTOBER 2004OCTOBER 2004

www.bhgi.info

Public education and advocacyPublic education and advocacy–– DevelopDevelop public education materials (BHGI guidelines)public education materials (BHGI guidelines)

–– CollaborateCollaborate with (NGOs) and advocacy groups to with (NGOs) and advocacy groups to distribute materials and assess impact on breast caredistribute materials and assess impact on breast care

Professional education and trainingProfessional education and training–– DevelopDevelop education curricula (BHGI guidelines)education curricula (BHGI guidelines)

–– CollaborateCollaborate withwith international health organizations international health organizations and medical groups to provide situation appropriate and medical groups to provide situation appropriate education and training and assess impacteducation and training and assess impact

Komen for the Cure TeamOct 16, 2008, Kumasi

Breast Cancer Awareness MarchOct 16, 2008, Kumasi

www.bhgi.info

Ghana College of Physicians and SurgeonsGhana College of Physicians and Surgeons–– Paul Nyame, MDPaul Nyame, MD

KorleKorle--Bu Teaching HospitalBu Teaching Hospital–– JoeJoe--Nat CleggNat Clegg--Lamptey, MDLamptey, MD

Komfo Anokye Teaching Hospital (KATH)Komfo Anokye Teaching Hospital (KATH)–– Anthony NsiahAnthony Nsiah--Asare, MD / Baffour Awuah, MD Asare, MD / Baffour Awuah, MD

Peace and Love HospitalPeace and Love Hospital–– Beatrice Wiafe, MD (Kumasi)Beatrice Wiafe, MD (Kumasi)

Reach for RecoveryReach for Recovery–– Gladys BoatengGladys Boateng

HopeXchange Medical CenterHopeXchange Medical Center–– Riccardo Massetti, MD / Mario CappelloRiccardo Massetti, MD / Mario Cappello

Ghana Breast Cancer Alliance (GBCA) meetingJanuary 30, 2009, Kumasi

www.bhgi.info

HopeXchange: Institute for Professional TrainingHopeXchange: Institute for Professional Training

Training in early detection, diagnosis and treatment Training in early detection, diagnosis and treatment adjusted for lowadjusted for low--income country resourcesincome country resources–– Curriculum based on BHGI GuidelinesCurriculum based on BHGI Guidelines

–– International faculty to teach and learnInternational faculty to teach and learn

D&I methodology applied inD&I methodology applied in--countrycountry

Educational outcomes assessed and reportedEducational outcomes assessed and reported

Groot et al, Breast Journal 12:S81, 2006

Simulation model to estimate costs and health effects of treating stage I, II, III, and IV breast cancer

Data used from 3 regions: North America, Africa and Asia

Effect of extensive early detection (screening) program was assessed

METRICS: Disability adjusted life- years (DALYs) and 2000 dollars

Groot et al, Breast Journal 12:S81, 2006


Target: MiddleTarget: Middle--Income CountriesIncome Countries

BHGI Breast Early Detection Module (BSM):BHGI Breast Early Detection Module (BSM):–– Patient and professional educationPatient and professional education–– Screening and early detection (CBE + mammography)Screening and early detection (CBE + mammography)–– Diagnosis (imaging / tissue sampling / pathology)Diagnosis (imaging / tissue sampling / pathology)–– Triage to linked diagnosis and treatment programsTriage to linked diagnosis and treatment programs

Model program development for middleModel program development for middle--income income regions of Latin America, Eastern Europe and regions of Latin America, Eastern Europe and Asia Pacific.Asia Pacific.


BHGI EARLY DETECTION RESOURCE ALLOCATION Latin America 2009Latin America 2009

????

ColombiaColombiaNational Early Detection ProgramNational Early Detection Program


The Ministry of Social ProtectionThe Ministry of Social Protection

Resolution 1439 issued Resolution 1439 issued November 1, 2002November 1, 2002

Clinical Practice Guidelines by Clinical Practice Guidelines by INSTITUTO NACIONAL DE INSTITUTO NACIONAL DE CANCEROLOGCANCEROLOGÍÍA published A published August 2006August 2006

Presented October 2006Presented October 2006

Colombian National Early Detection ProgramBHGI / NCI Research Team Meeting (2009)


2 year pilot randomized trial for women 50 2 year pilot randomized trial for women 50 --69: 69: –– Intervention: Training + screening mammographyIntervention: Training + screening mammography

–– Control: Control: Current standard of careCurrent standard of care

–– Outcome: Outcome: Tumor size / stage at diagnosisTumor size / stage at diagnosis

Cluster randomized by primary health care centerCluster randomized by primary health care center

7,000 women to be recruited for each arm7,000 women to be recruited for each arm–– 224 physicians trained in 16 health centers224 physicians trained in 16 health centers

–– 24 techs trained from 8 radiology centers24 techs trained from 8 radiology centers

–– > 2,500 women recruited to each arm> 2,500 women recruited to each arm

Proyecto piloto para la implementación de estrategias de detección temprana de cáncer

de mama en Colombia

Instituto Nacional de CancerologíaBogotá - Colombia

Study Design

Health Care Centers RandomizationStratified by Insurance Plan

Intervention GroupEnroll 7,000 women

Control GroupEnroll 7,000 women

Training for primary care MDs, nurses, radiologists, technologists

and breast specialistsNo intervention in health care center

Screening based oncurrent clinical practices

Implement screening programIn health care center

Screening based oncurrent clinical practices

Screening mammogram with diagnosticFollow-up in women > age 50

Follow-up in one yearFollow-up in one year

Statistical Analysis

Clinical stageCancer incidenceEvaluation of participationCost assessmentAdverse effects

Informed consent

Technical skills training Clinical Breast Exam

Screening invitation, documentation,patient follow-up, quality control, etc

Outcome Variables

20 HMOs

Mamografías en el estudio

PruebasMamografias Solicitadas 3627 100.0% 690 23.1%Mamografias Realizadas 2681 73.9% 386 55.9%

Intervenciòn Control

Awareness

Survivorship

Early Detection

Diagnosis

Treatment

Advocacy

Public ParticipationPublic Participation Health Care DeliveryHealth Care Delivery

Awareness

Survivorship

Early Detection

Diagnosis

Treatment

Advocacy

Public ParticipationPublic Participation Health Care DeliveryHealth Care Delivery

LB COLOMBIALB COLOMBIA

LB MEXICOLB MEXICO

LB BRAZILLB BRAZIL


Breast cancer is an international problem Breast cancer is an international problem affecting countries at all economic levelsaffecting countries at all economic levels

BHGI guidelines provide a framework for BHGI guidelines provide a framework for systematic, comprehensive improvementsystematic, comprehensive improvement

Dissemination and implementation Dissemination and implementation through BHGI Learning Laboratories can through BHGI Learning Laboratories can steer guideline application in LMCssteer guideline application in LMCs

BHGI guideline implementation can serve BHGI guideline implementation can serve underserved populations in all countriesunderserved populations in all countries

www.bhgi.info

benjamin o. anderson, m.d. - harvard...

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