GE Healthcare
Policy Paper on
Breast Cancer
13-000949
Epidemiology
Early diagnosis of breast cancer: a patient perspective
One in nine women will develop breast cancer at some point in her
life.1 Approximately 1.4 million women were diagnosed with breast
cancer worldwide in 2008, and an estimated 459,000 breast cancerrelated deaths were recorded. Breast cancer represented 23% of all
invasive cancers diagnosed among females that year.2 A comparison
of regional incidences highlights that breast cancer ranks as the
leading cancer among females in most regions, with the exception
of several countries in Eastern and Western Africa, Central/South
America and Southern Asia (where cervical cancer rates prevailed).3
Yet breast cancer incidences are anticipated to increase within lowand middle-income countries, in line with the adoption of western
lifestyle choices.4 As a result of the rising incidence, coupled with
resource and infrastructural limitations, breast cancer has become
a key cause of premature death in less developed regions.5 This
assertion is supported by the projection that two thirds of the 3.2
million breast cancer cases predicted to develop by 2050 will occur
in developing countries.6
From a patient perspective, an important benefit of detecting and
diagnosing breast cancer early is that the use of more complex,
invasive interventions may be averted.20 For example, implementation
of mammography screening programmes can lead to the earlier
detection of smaller breast tumours. As a result, patients can be
treated with minimally invasive interventions;21 averting the need
for more invasive treatments such as radiotherapy, which can be
both physically and emotionally detrimental to a woman’s health.
Additionally earlier detection, followed by timely treatment, can
increase the range of treatment options available to a patient, such
as the opportunity for breast-conserving therapy.22 Subsequently,
detection in the early phases of breast cancer is positively associated
with higher survival rates, which can provide comfort to those who
receive a timely diagnosis early in the disease pathway. An early
diagnosis is important to patients at an emotional level, as well as
clinically improving prognosis, as the psychological state of the patient
has been shown to affect prognosis and a person’s ability to cope with
cancer.23 A meta-analysis conducted by Satin et al. in 2009 estimates
a 26% greater mortality rate among patients experiencing depressive
symptoms, and a 39% higher mortality rate among those diagnosed
with major depression.24
The importance of early diagnosis
Diagnosis of breast cancer in the earlier stages of the disease
pathway has been positively associated with a decrease in breast
cancer mortality, and improved prognosis. Breast cancer control
programmes should ensure diagnosis at the earliest possible stage,
where treatment is more effective.7 The main objective of early
detection or secondary prevention through screening is to detect
early stage cancers. Screening advances the time of diagnosis, and
thus can improve patient prognosis.8 Early detection has been shown
to be important due to the positive association between stage at
diagnosis and survival rates.9 One of the most significant determinants
of survival is stage at diagnosis, which takes into account factors
including tumour size and whether the disease has spread to the
lymph nodes.10 Countries such as Norway have high survival rates
and a high proportion of patients diagnosed with early stage disease
(90% of patients are diagnosed in Stage I or II). Such countries also
typically have high rates of breast cancer screening programme
participation.11 Although mammography screening is the most widely
used tool for diagnosing breast cancer early,12 this screening method
is not a plausible solution in every country, in light of socioeconomic
constraints. However, it is important that there exists a symptomatic
care pathway in every healthcare system—in order to detect breast
cancer early, prevent metastasis and deliver effective treatment
services.13 The goal of earlier detection in low-resource regions is to
downstage symptomatic disease, by reinforcing the importance of
seeking timely examinations and treatment.14
It has been estimated that screening for breast cancer may avert
the number of related deaths by up to 65%.15 Regular breast
screening has been shown to be an effective way of improving patient
prognosis. An analysis of a Swedish randomised screening trial
indicated a 30% reduction in breast cancer mortality, attributable to
breast screening.16 In 2012, an Independent United Kingdom Panel
on Breast Cancer Screening reviewed the benefits of breast cancer
screening in the UK. The Panel suggested there is a 20% reduction in
mortality in women invited to participate in a screening programme
over the course of twenty years.17 It was also estimated that breast
screening programmes prevent approximately 1,300 breast cancerrelated deaths every year, equating to 22,000 life-years saved.18
In the United States, breast cancer mortality fell by 24% between
1990 and 2000. Survival improvements have been attributed to early
detection, by combining timely screening with treatments.19 These
findings highlight the importance of prioritising early detection of
breast cancer within public health policies.
The economic case for prioritising early diagnosis of breast cancer
In 2009, the global cost of new breast cancer incidences was
estimated to amount to almost $29 billion. Productivity losses
accounted for approximately $7 billion of this total, medical costs
contributed to just over $13 billion, and non-medical costs represented
approximately $7 billion of the total cost of new breast cancer cases in
2009.25 Whilst breast cancer is not the leading global cause of death, it
remains one of the costliest diseases to manage.
Direct costs: A University of Oxford report highlights the economic
burden of cancer compared to other non-communicable diseases.
One patient with heart disease costs the UK economy £3,455
(USD$5,508) per year, while a cancer patient represents a cost of
£5,999 (USD$9,564) per year on average.26 More specifically, the
economic cost of breast cancer to the UK is £1.5 billion per year.27
The annual European cost of breast cancer is estimated to be 6 billion
euros (approximately USD$8.1 billion), accounting for 13% of the total
cancer healthcare costs in the European Union.28 A recent report has
identified the average cost per breast cancer case across several
countries. Inpatient costs per case in China amount to approximately
1,000 euros (USD$1,214); direct healthcare costs in Turkey are
approximately 3,000 euros (USD$3,643), and Mexico reported that
direct costs per case in 2003 totalled 4,000 euros (USD$4,858).
The comparison highlights the wide economic disparities across
regions: Germany, for example, reported average costs per patient
of over 30,000 euros (USD$40,366) in 2006.29 In the United States, the
lifetime per patient costs of breast cancer range from USD$20,000 to
$100,000, with higher costs associated with managing patients with
advanced breast cancer.30 These statistics emphasise the extent of the
economic challenge posed by the global prevalence of breast cancer
and non-communicable diseases in general, and the importance of
early diagnosis.
Indirect costs: A Swedish cost of illness study demonstrates that the
indirect costs of breast cancer are more than twice as large as the
direct costs.31 An Oxford University study supports these findings,
highlighting that premature death, absences from work and unpaid
care by friends/family accounts for 64% of all cancer costs.32 An
analysis of the economic impact of non-communicable diseases in
China and India show that non-communicable diseases bear a high,
indirect economic cost; and alongside diabetes and cardiovascular
disease, breast cancer also represents a high indirect cost.33
213-000949
Cost-effectiveness of early diagnosis: Later stage breast cancer has
been shown to be more costly to treat, which may be attributed to
the reality that more intensive and invasive interventions are required
to treat advanced cancer. A study of breast cancer interventions
across Africa, North America and Asia found that treatment of stage I
patients comprised the most cost-effective intervention, whilst stage
IV treatment was the least cost-effective option.34 In Africa and Asia,
treatment of stages I, II and III costs less than USD$390 per DisabilityAdjusted Life Years (DALY) averted; whilst treatment at stage IV costs
more than USD$3,500 per DALY averted.35 Furthermore, a UK NHS
Department of Health report reveals that earlier diagnosis of breast
cancer could provide a population benefit of 319,000 life-years gained,
and an average cost per life saved of £2,329 (USD$3,734).36 Alongside
the positive association between survival rates and stage of diagnosis,
these figures indicate that treating stage I breast cancer is the most
cost-effective intervention, and that early detection of breast cancer
should be prioritised within national cancer programmes.
Educational interventions and basic clinical tools can also prove
economical. Awareness campaigns can encourage women to
understand the importance of early preventative detection measures,
and present at an earlier stage. Subsequently, women will be more
likely to receive earlier referrals for tests, leading to earlier detection
and the administration of basic treatment at an affordable cost.37
Actively publicising the correlation between modifiable risk factors
and non-communicable diseases could incur huge savings: a GE
Healthcare press release dated July 2013 shows that a reduction in
bad habits could save global healthcare systems up to USD$25 billion
annually.
Policy Developments
• World Health Assembly Resolution on Cancer Prevention and
Control in May 2005: Called on Member States to intensify action
against cancer by developing cancer strategies.
• In high-income countries, mammography screening coverage is
now over 70%.38
• Breast Health Global Initiative: Developed resource-specific
and evidence-based guidelines for aspects of breast cancer
management.39
National/regional screening guidelines and developments
• Australia: The national policy, “BreastScreen Australia,” entails the
provision of mammography screening at minimal/no charge to
women over the age of forty. The policy requires the provision of
a comprehensive pathway, including follow-up assessments and
treatment referrals. An evaluation reveals that the programme
achieved the objective of reducing breast cancer mortality, by
approximately 21-28%.40
• Brazil: In March 2011, the Brazilian government committed
USD$2.8 billion to strengthen actions for breast and cervical
cancer prevention, diagnosis and treatment. The strategy includes
strengthening primary healthcare, running public awareness
campaigns, and supporting the public health system network.41
• China: In 2008, a government-funded initiation to screen more than
half a million women, with the aim to provide screening to women
living in rural areas, was launched.42 Additionally GE Healthcare
partnered an outreach programme, launched in 2011 in the Beijing
and Guangdong province. The programme was designed to raise
awareness of (and compliance with) screening procedures, with
the intention of educating women on the importance of early
diagnosis.43
• Europe: In 2003, the European Parliament adopted a Resolution
(A5-0159/2003) to effectively address breast cancer, stating “every
woman should have access to high-quality screening treatment,
and any disparities in access should be minimised.” The European
Parliament sought to reduce the European breast cancer mortality
burden by 25%. A more recent Resolution (2006) calls on Member
States to ensure nationwide provision of specialist breast cancer
units in accordance with EU guidelines by 2016.
• Mexico: In 2005, the Mexico City government initiated the first
voluntary mammography screening programme for women over
the age of forty. The “Instituto de Enfermedades de la Mama”
(FUCAM) conducts over 50,000 screening mammograms annually,
with six mobile units.44 In 2007, the extension of the Popular
Health Insurance to cover all Mexicans diagnosed with breast
cancer means that resources are available to provide a package
of services to women, even if they do not have health insurance. It
was reported in 2010 that data systems and cancer registries are
now being designed and implemented in Mexico.45
• South Africa: The number of mobile mammography units to help
improve the rates of mammography screening for cancer is
increasing.46
• USA: In 2002, the U.S. Preventative Services Task Force
recommended screening mammography, with or without clinical
breast examinations, for women aged 40 and over.47 However
the USPSTF 2009 recommendations advise against routine
screening mammography in women aged 40 to 49 years, instead
recommending biennial screening mammography for women
between the ages of 50 and 74 years.48 These guidelines were
received controversially: it was reported that the mammography
screening rate among women aged 40 to 49 fell by almost 8%
in the period following the publication of the guidelines. In the
two year period after the release of the recommendations, the
mammography screening rate remained approximately 5%
lower than the baseline level.49 In 2011, the Breast Density and
Mammography Reporting Act was introduced, requiring every
mammography summary delivered to a patient to contain
information regarding breast density. Summaries are also required
to communicate that individuals with more dense breasts may
benefit from supplemental screening tests.50
GE Healthcare Best Practice Example – Saudi Arabia Ministry of
Health and GE Healthcare Partnership.
The initiative focuses on improved access and timely diagnosis of
breast cancer. GE Healthcare has worked alongside the Saudi Ministry
of Health to design, plan, and launch the programme (March 31, 2013)
in Riyadh. The total number of patients screened since the programme
launch is over 5,000. The programme entails: a primary assessment
conducted over the phone by Ministry of Health staff; validated by
an initial physical examination; mammography screening at one of
three mobile clinics in Riyadh, linked to a tertiary hub for reading and
diagnosis; and tailored care pathways.51 Key outcomes and messages
from the Phase I launch include: screening was well-received by the
Saudi population; mobile clinics are better received when located
within the community rather than at primary healthcare centers;
and the need to create a talent pool of qualified mammographers to
sustain programme growth.52
313-000949
Policy Challenges
Recommendations
Infrastructural challenges: Although mammography screening is
recognised as the primary evidence-based early detection method,
there can be challenges to adopting nationwide strategies to address
breast cancer using this detection method in light of infrastructure
limitations, and competing demand for resources (particularly in
low- and middle-income countries).53 For example, a mere 5% of the
global resources for cancer research and treatments are invested
in developing countries.54 This creates a barrier to diagnosis: and
it has been estimated that 75% of women with breast cancer in
developing countries are diagnosed in clinical stages III and IV.55 It is
important to note that before an early detection (screening) program
is implemented, facilities for adequate diagnosis and treatment
must already be present. This challenge can be met by: increasing
government investment in infrastructure to accommodate screening
equipment, or using ultrasound technologies as a complementary
strategy.
Developing countries
Socioeconomic challenges: Several studies have demonstrated that
household income and socioeconomic status constitutes a significant
determinant of access to screening.56 This assertion is not limited to
low- and middle-income countries: researchers have concluded that
women who live in deprived areas of London are less likely to attend
their first routine breast cancer screening appointment.57 Individuals
located in low-resource areas such as India lack access to breast
screening programmes, and subsequently the majority of breast
cancers are diagnosed at a later stage.58
Limited information/data: There is limited international data available
on breast cancer statistics, particularly in relation to economic
costs.59 Additionally, there is a limitation as to the availability of data
on incidence rates in low- and middle-income countries, and rural
areas. Incidence figures are typically pooled and extrapolated to
large regions, and so reports tend to reflect only those women who
are easiest to reach. This means that the global figures may not truly
reflect the underlying socioeconomic and cultural diversities driving
incidence and mortality rates.60 This issue is further exacerbated by
the reality that statistics tend to diverge for various ethnic groups: for
example, black, Asian and Hispanic populations have diverse cancer
incidences and survival rates.61 GE Healthcare “#GetFit” consumer
research results highlight that in the majority of regions, lack of
knowledge and information regarding risk factors and lifestyle choices
is a major contributor to the general reluctance to change lifestyle
factors associated with breast cancer. It is thus vital to address the
information gaps.
Cultural barriers: In many countries, there exist cultural barriers to
clinical examinations and breast screening. This may be in relation
to fear, embarrassment, and the stigma associated with being
formally diagnosed with breast cancer.62 In developing countries
with indigenous populations, there often exists the belief that breast
cancer is caused by social misbehaviour and that if a woman develops
breast cancer she will be divorced by her husband and rejected by
the community.63 A study has also found that in the district of Gaza,
misconceptions were frequent, such as the belief that breast cancer is
uncommon, and that the disease can be contagious.64 In light of these
cultural stigmas and barriers, women tend to hide symptoms at early
stages–when treatment is typically most effective.
• Prioritise public health awareness to encourage breast selfexaminations. Although a study conducted by Le Geyte et al.
demonstrates a positive association between tumour stage at
presentation and breast self-examination,65 randomised controlled
studies have not shown that breast self-examination is effective in
down-staging disease. Nonetheless, breast self-examination is a
useful tool for maintaining public awareness of breast cancer.66
• Guidelines for the implementation of community breast health
awareness educational programmes, specific to individual
country needs. Knowledge of the value of early detection is an
important element of early diagnosis: an analysis of the Cairo
Breast Screening Trial indicates that community education to
increase breast cancer awareness may contribute to earlier
presentation of symptomatic breast cancer.67 An example could be
a targeted outreach programme, emphasising the importance of
early stage diagnosis and encouraging clinical breast examinations
for those at high risk of developing breast cancer.68
• Clinical guidelines outlining a symptomatic care pathway, which
provides a clear point of contact for patients, followed by a timely
diagnosis and treatment should be developed. The guidelines
should emphasise the importance of recognising symptoms, and
seeking timely examinations.
• Government investment allocated to the implementation of
sufficient infrastructure and facilities, in order to provide a
foundation for early detection programmes.
• Guidelines for every country to have national cancer registries,
in order to ascertain the magnitude of the disease prevalence, and
gather vital statistical information. This will contribute to ensuring
that the extent of the disease is recognised, so governments are
able to allocate resources according to actual need, rather than
general, anticipated healthcare needs.
• Country-specific economic cost data would provide useful
information to policy makers and non-governmental organisations,
to develop specific strategies to address the disease.69 The extent
of the disease burden would be clearer, providing a foundation for
addressing this global economic issue.
Developed countries
• Guidelines to promote early diagnosis, such as annual
breast screening for the at-risk population, will enable earlier
interventions and improve patient outcomes.
• Prioritise national awareness campaigns, and collaborate with
the national media to ensure maximum impact.
• Clinical guidelines outlining a symptomatic care pathway, which
provides a clear point of contact for patients, followed by a timely
diagnosis and treatment should be developed. The guidelines
should emphasise the importance of recognising symptoms, and
seeking timely examinations.
• Guidelines for every country to have national cancer registries,
in order to ascertain the magnitude of the disease prevalence, and
gather vital statistical information. This will contribute to ensuring
that the extent of the disease is recognised, and so governments
are able to allocate resources according to actual need, rather than
general, anticipated healthcare needs.
• Country-specific economic cost data would provide useful
information to policy makers and NGOS, to develop specific
strategies to address the disease.70 The extent of the disease
burden would be clearer, providing a foundation for addressing this
global economic issue.
413-000949
About GE Healthcare
GE Healthcare provides transformational medical technologies and services to meet the demand for increased access, enhanced quality
and more affordable healthcare around the world. GE (NYSE: GE) works on things that matter – great people and technologies taking on tough
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technologies and performance improved solutions, GE Healthcare helps medical professionals deliver great healthcare to their patients.
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