Correcting the Course; Better Targeting CME Activities in Breast Cancer care: CME Targeting

Richard Love

doi:10.32768/abc.202294416-420

Richard Love ⁽¹⁾

(1) Amader Gram Cancer Care & Research Center, Rampal, Bagerhat, Bangladesh, United States

https://doi.org/10.32768/abc.202294416-420

Issue
Volume 9, Issue 4, November 2022

Submitted
August 26, 2022

Published
August 28, 2022

Keywords:

Population-affecting; Primary care; Public health; Guidelines; Trust

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U. S. Preventive Services Task Force. Breast Cancer: Screening. Recommendation: Breast Cancer: Screening, Jan 11, 2016. Published January 11, 2016. Accessed August 5, 2022. Available from: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening

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Authors

Richard Love

Amader Gram Cancer Care & Research Center, Rampal, Bagerhat, Bangladesh

richardibcrf@gmail.com (Primary Contact)

Love R. Correcting the Course; Better Targeting CME Activities in Breast Cancer care: CME Targeting. Arch Breast Cancer [Internet]. 2022 Aug. 28 [cited 2024 Jul. 16];9(4):416-20. Available from: https://archbreastcancer.com/index.php/abc/article/view/628

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Richard Love, By the Metrics Surgical Oophorectomy Plus Tamoxifen is the First Adjuvant Treatment Option for Premenopausal Women with Hormone Receptor Positive Breast Cancer , Archives of Breast Cancer: Vol 8, No 1: February 2021

"Imagination at scale is our only recourse." 1 "The right measure for successful health care isn't about the maximum possible for a few, but the average for everyone and the minimum opportunities available to even those with the fewest resources and privileges." 2 The annual global burdens of breast cancer are currently 2.3 million cases and 700,000 deaths, two thirds of all deaths occurring in Asia and Africa, and these burdens are increasing. 3 Where are we addressing these challenges and where not? We are certainly increasing our understanding of the biology of breast cancer and developing more specific effective therapies, but a dominant goal of medical activities in many countries has become financial gain, and the organizational model of services has become grounded in optimal business practices instead of health care as a human right for all. Consequently, we are failing to serve the majority of women in the world who develop breast cancer. We need to dispassionately consider the shortcomings of our interventions for this disease and take to heart lessons from the COVID pandemic about population health in the CME for breast cancer care. 4 The Continuing Education Program Mission Statement of ASCO focuses on objectivity and rigor in increasing the competence and performance of the oncology team as well as continual assessment of practice gaps. 4 This commentary addresses critical gaps.

A brief summary of the population impact of current knowledge and common interventions

Causation and prevention While much is known about the multistage and multifactorial causal biology of breast cancer, practical interventions that change outcomes, here meaning preventing clinical breast cancer, are limited to relatively small populations of high-risk individuals, who are most frequently citizens of highincome countries. Broad preventive interventions that change outcomes for populations are not available. For examples, avoidance of obesity in postmenopausal women and early age at first full-term pregnancy appear to reduce the risk of disease but applying this knowledge to populations is unfeasible and impractical.

Down-staging "Early detection" of breast cancer that results in lower stage disease at the time of diagnosis, generically called "down-staging," has been long promoted as a strategy for improving outcomes from treatment. Intuitively, this concept is compelling, but in practice it has been remarkably difficult to support with rigorous data and even more challenging to apply to populations with convincing proof of benefit.

In clinical practice at present, only two downstaging strategies are applicable: mammography and clinical breast examination. Broadly, true "screening" mammography, that is mammography done in women without any signs or symptoms of clinical breast cancer, appears to be beneficial in populations of women aged 50 and older with higher incidence rates. 5 There are variable, but not insignificant, costs associated with applying this technology to such populations; the most important is diagnosis and treatment of premalignant lesions which would never have progressed to become clinical breast cancer in patients' lifetimes, (overdiagnosis). 5 In individual women of any age and risk level, with no signs or symptoms of clinical breast cancer, the benefits of periodic breast examination are unproven, whether conducted by women themselves or by health professionals. 5 As applied to populations in low-and middleincome countries (LMCs), with broad-based population pyramids and low absolute incidence rates, the practical implications of these state-of-theart assessments have been well summarized by Harford: "Resources in LMCs might be better used to…encourage more women with palpable breast lumps to seek and receive treatment in a timely manner." 6 Diagnosis The potential benefits of prompt diagnosis, which may include less costly treatment, can only be realized in populations with strong primary health care systems and their associated greater public trust. The most remarkable demonstration of this truth occurred in the International Agency for Research on Cancer (IARC) trial of breast self-examination in the Philippines. 7 Women were successfully taught to find their own smaller breast tumors but decided not to seek diagnostic interventions because they did not believe that they could be successfully treated or that they had the financial resources for treatment. 7 The repeated assessment that more women need to be "made aware" of the significance of breast lumps is misplaced. Women of all levels of education and in multiple cultures easily recognize when they have an abnormality in one of their breasts. "Awareness" is not the barrier that prevents women from seeking medical assistance. 7 The strength of their local primary care networks and the prevailing human rights barriers are far more important issues.

Beyond these practical issues concerning if and when women present for diagnosis, the local surgical pathology capacities in many LMCs are so limited that histological diagnosis is often not accomplished when women do present with clinical signs of breast cancer. 8 In high-income countries, molecular characterization of histologically invasive tumors contributes to choosing more effective treatments, but the monetary costs and low availability of genomic testing prevent widespread application in LMICs. 9 Treatment The primary treatment for operable invasive breast cancer is mastectomy which is widely available under the care of qualified surgeons in most LMICs. A second major surgical intervention, adjuvant surgical oophorectomy, is worthy of consideration in premenopausal hormone receptor positive women, a number approaching half of all global new breast cancer cases annually, yet is significantly underapplied. 10 Human rights issues, barriers to care, and financial conflict of interest all play unfortunate roles in this situation. 10 This is particularly tragic because of provocative data strongly suggesting that, once women with prolonged follicular phases are exempted, the average benefit of surgical oophorectomy to women in follicular or luteal phases (easily confirmed by progesterone testing) exceeds the level of benefit from optimally given adjuvant treatments which are not received among high percentages of women in LMICs in any case. 11 The widespread presentation of this treatment option to women in LMICs could save 100,000 lives annually 12 .

A major contributor to improved outcomes with breast cancer in high income countries has been the development of effective systemic therapies. In the decade from 2008-2017 in the United States, breast cancer mortality declined by 16% 14 . However, selection of optimal systemic therapies for individual patients is remarkably complex and ever-evolving. 9 In LMICs, the dearth of well-trained medical oncologists, as well as multiple operational barriers, stand in the way of applying these new treatments widely. Even with remarkably effective and cheap systemic treatments with limited side effects, such as oral tamoxifen for the two-thirds of global cases with hormone receptor positive tumors, the benefits are highly limited by poor long-term adherence. 13 Current evidenced-based treatment guidelines recommend adjuvant radiation therapy to the chest wall and regional lymph nodes in patients with high risk but operable breast cancer. 14 The availability and feasibility of such treatment in the high fraction of women in LMICs who could benefit are painfully limited. 17 Approximately half of all breast cancer patients in LMICs have incurable recurrent disease and need palliative care. Very few women, however, have access to such care, and when available, few receive care of a caliber to make a difference in their quality of life. 15 16 Big picture realities and lessons of the time The dominance of business models in medicine, and lessons from the COVID pandemic in the United States suggest that more public health thinking needs to be applied to this disease if significantly better outcomes for populations are to be achieved (Table 1). 4,20 Table 1. Lessons from COVID pandemic 15 16 Widespread lack of access to medical care Overdependence on doctors Overdependence on clinics and hospitals Inadequate systems for chronic care and prevention Lack of attention to mental health Massive disparities in healthcare Specifically, current educational activities emphasize biology and ignore social determinants of health, explicit values, and important quality-of -care metrics. 17 18 Service models are relatively inattentive to this chronic disease, have limited community accountability, and are dysfunctional and poorly organized. Transformational service models are needed with increased paraprofessional staffing, implemented diagnostic and treatment guidelines, major information technology systems, and disruptive business systems (Table 2). 19 20 21 22 23 Specific targeting activities identified Firstly, the foregoing summary is clear in suggesting unproductive as well as potentially beneficial activities in our educational endeavors (Table 3). Table 2. Medical service models compared modified from 18 Secondly, our system challenges can most practically be met by development of local demonstration/experimentation initiatives. Greater consideration needs to be given to community activities and organizations directed to addressing the social determinants of health. In the clinical setting, it is of significant importance to recognize that while specific breast cancer care components should be targeted (surgical pathology or radiation therapy, for example), improving outcomes for populations is going to require strengthening primary care systems. Trust in the local medical care system is critical to prompt diagnosis, efficient management, and sustained adherence to evidence-based treatment. Such trust is grounded in truly community-oriented primary care.

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This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.

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The author reports no conflicts of interest.

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Correcting the Course; Better Targeting CME Activities in Breast Cancer care CME Targeting

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