The Lancet Breast Cancer Commission
Institution: Department of Oncology, University of Cambridge, Cambridge, UK
Corresponding Researcher: Charlotte E Coles
Data Link(s): NA
Keyword(s): NA
Summary
The Lancet Breast Cancer Commission-a diverse, multidisciplinary international group-are unanimous in our determination to improve the lives of all people who live with or are at risk of breast cancer. We came together in July, 2021, and are committed to raising the standard of breast cancer care to close the equity gap that exists between and within countries. Over a 2-year period, we brainstormed ideas, scoped the literature, obtained funding for dedicated pilot research that provided new data, and produced this Commission report to reduce the effects that breast cancer has on society.
We highlight that, despite tremendous advances in breast cancer research and treatment over the past three decades-leading to a more than 40% reduction in breast cancer mortality in some high-income countries-there remain inequities, with many groups being systematically left behind, ignored, and even forgotten. Our findings suggest that this is a mistake, as people with breast cancer are indispensable to our socioeconomic fabric and culture. We show that the number of people living with metastatic breast cancer is unknown because many cancer registries do not record relapses. Many patients with metastatic breast cancer feel abandoned, isolated, alone, and might not receive appropriate care in both high-income and lower-middle-income countries: this should, and can, be tackled. With adequate evidence-based resources and a shift away from negative societal attitudes towards metastatic breast cancer, it might be possible to cure some patients, treat most, alleviate the suffering of all, and forget or abandon none. We have identified that the hidden costs of breast cancer and associated suffering are considerable, varied, and have far-reaching effects. Costs and suffering can be financial, physical, psychological, emotional, and social, they affect children, families, local communities, and wider society, can occur at all stages of breast cancer, and are evident even within health-care services that are free at the point of delivery. Exposing and reducing costs and suffering provides incentives for policy makers to invest in prevention, early detection, cost-effective therapies, and optimal management of breast cancer. We show that improving patient communication and decision making in breast cancer care improves quality of life, body image, and adherence to therapy, which can affect survival outcomes. Breast cancer is a disease that many patients describe as robbing them of power, but through good communication and facilitating patient autonomy, there could be opportunities for them to regain power and emerge stronger to exercise empowerment in other areas of their lives.
We acknowledge that early detection of breast cancer is fundamentally important and should be available to all individuals, wherever they live. We encourage broadening breast cancer early detection efforts in low-income and middle-income countries (LMICs) from a narrow focus on mammographic screening-which can be unaffordable or unachievable in resource-constrained settings-to include breast cancer early diagnosis as recommended by WHO. Every country that successfully reduced national breast cancer mortality rates between 1990 and 2020 has, as of 2023, the ability to diagnose at least 60% of invasive breast cancers at stages I or II. Evidence from the past 5 years shows that awareness and education focused on finding and treating symptomatic (palpable) breast cancers when they are first discoverable promotes stage-shifting towards reaching-or even surpassing-the stage I or II at diagnosis threshold of 60%. This finding is especially relevant for women younger than the typical screening age of around 50-70 years and older women living in regions where limited access to health care prevents widespread implementation of early detection efforts. We have developed an inclusive evidence-based roadmap of six themes to address these urgent breast cancer challenges.
Prevent: globally, breast cancer is the most common cancer and by 2040, the incidence of new breast cancers is predicted to be more than 3 million per year, rising most rapidly in LMICs. The mindset that this upward trajectory is inevitable and therefore acceptable should be changed; action now can prevent many of these future breast cancers. We emphasise that breast cancer risk factor education is vital, but should be combined with policy change to support sustained behavioural changes and decrease health inequalities. For example, policy makers should reject commercial marketing for products that increase the risk of breast cancer, such as alcohol. We propose that developing coordinated approaches to systematically identify individuals with increased risk of breast cancer and offer them evidence-based prevention interventions relevant to their risk is an aspirational goal to be developed through ongoing research.
Personalise: scientific and clinical research can facilitate equitable and prompt access to the right breast cancer treatment at the right time for individuals, while respecting personal needs and preferences. Better targeting of existing treatments through development of validated biomarkers is needed to identify the people who benefit the most and to reduce treatment burden for those more likely to have higher toxicity than gain. We identify the need to develop and facilitate novel, efficient, patient-centred translational clinical trials and enable a research culture and infrastructure to ensure these can be undertaken globally. Digital health technologies might facilitate personalised breast cancer care and alleviate inequalities through integration of multimodal complex datasets, promoting flexible, coordinated care-particularly for vulnerable patients-democratising access to research, and decentralising trial participation. However, these must be implemented in an equitable way to avoid increasing inequity, as seen with some health technologies.
Include: we urge for the inclusion of patients with metastatic breast cancer in optimal breast cancer care and clinical research. We justify why optimal metastatic breast cancer management is valuable to individuals, families, and society. We show the results of the Commission's international health-care professionals survey, which suggests that there is a growing belief that patients with some subtypes of metastatic breast cancer can be treated for many years as having chronic illnesses, and some patients might even be cured. In addition to collecting data on cancer incidence and stage at presentation, we call for high-quality data on cancer relapses worldwide to include not just those with metastatic breast cancer, but also those with other metastatic cancers. We recommend that stigma around metastatic breast cancer be addressed through raising awareness and educating stakeholders (eg, patients, families, health-care practitioners, and policy makers) and wider society.
Collaboration: we must collaborate (between the previously mentioned stakeholders and wider society) to close the equity gap in breast cancer care and outcomes through global early detection, treatment frameworks, and innovative technologies that are equitably implemented. People with low incomes and those from minoritised populations in all countries often have their breast cancer diagnosed at a late stage with a high risk of dying from their cancer. The early diagnosis inequity gap will widen without intervention. Equitable access to early diagnosis and treatment is a fundamental need for all individuals to improve their breast cancer survival and quality of life. In collaboration with the WHO Global Breast Cancer Initiative, we call for action to deliver stage-shifting, as a sustained decline in breast cancer mortality rates is achieved by diagnosing at least 60% of invasive cancers at stages I-II. Population-based mammographic screening programmes can be established, when feasible, to operate sustainably, but early detection approaches should be adapted to local contexts and resources. We suggest that technological innovations could aid the speed, efficacy, and inclusivity of early breast cancer diagnosis and treatment implementation globally, and these should be combined with an integrated health-care system policy as well as education and advocacy.
Identify: the hidden costs and serious health-related suffering of breast cancer go unmeasured in global health metrics, so its alleviation is not prioritised by policy makers. We call for new, validated tools to record the myriad of costs and suffering sustained by patients, caregivers, and families of those with breast cancer. We also indicate the urgency of developing metrics to measure the full benefits that patients and society place on alleviating suffering related to breast cancer. These novel tools could influence policy makers to set new priorities for breast and other cancers to guarantee that supportive and palliative care is available to all at every stage of the breast cancer pathway, alongside financial protection to prevent catastrophic and impoverishing health expenditure from direct and indirect health-care costs and lost family income.
Communicate: being female is the greatest risk factor for breast cancer and women constitute a group whose fundamental human rights have historically been accorded lesser respect than men in all settings. As such, our final theme focuses on communication and empowerment related to breast cancer. We suggest that prioritising patient autonomy regarding medical treatment is paramount to close the gender equity gap and will have broader impacts for the physical, social, and financial wellbeing of women globally.
We propose a framework to improve communication and aid decision making for those with breast cancer. Placing patients at the centre of clinical communication and empowering them to exercise their voices, become fully informed, and choose their degree of involvement in decisions about their care, is an achievable and necessary global goal. Health communication training should be person-centred and include eliciting patients' core values and preferences for information, explaining goals of care, risk-benefit communication, skills to help estimate and explain prognosis, share serious news, and empathetically and honestly respond to questions, and considerations of local cultural traits and individual differences.
Our inclusive roadmap for change is evidence-based, including new data. It is designed for everyone with a connection to breast cancer but is particularly aimed at policy makers. We suggest detailed measurable indicators of progress with targets and suggested responsible groups. These indicators are designed to be actionable, auditable, and to facilitate lobbying for change. Our work with the Lancet Breast Cancer Commission has catalysed lasting partnerships between co-authors and with other Commissions, key international organisations, and patient groups. As a result, we have ongoing collaborative research and will continue to strive to raise the bar and close the equity gap for breast cancer.
