While breast cancer has long been recognized as a major public health burden in high-income countries, the majority of cases actually occur in low- and middle-income countries (LMCs), and it is expected that incidence rates will rise most rapidly in these locations [1
]. The relative burden of mortality is also higher in less developed countries than in more developed countries, as indicated by higher mortality
incidence ratios (0.44 versus 0.29, resp.) [2
]. Current global initiatives focus on developing and implementing resource-appropriate guidelines and strategies to improve breast health care and breast cancer outcomes in LMCs [3
Common challenges cited for resource-poor countries include limited health care infrastructure [6
], later stages at diagnosis, and competing health care priorities [7
]. The purpose of this paper is to examine the potential for community health worker (CHW) programs to improve access to breast health resources in LMCs. To this end, we briefly review the effectiveness of CHW programs in LMCs and identify key components of a CHW-based breast health program. We focus on South Africa as an example country to assess the feasibility of such a program. South Africa represents a middle-income country, according to its World Bank classification [8
], has a growing cancer control infrastructure including many of the cancer centers in Africa, with well-trained oncologists and radiologists [9
], has historical experience with community-based health worker programs [11
], and has a higher breast cancer mortality
incidence ratio compared to the world standard (), indicating lower survival from breast cancer [2
]. Importantly, it also enjoys advocacy from its First Lady, Her Excellency Madam Tobeka Stacie Madiba-Zuma, who serves as Vice Chairperson of the newly-formed Forum of African First Ladies Against Breast and Cervical Cancer [14
]. Still, barriers to breast care persist. Many women do not have access to the information and screening necessary to prolong survival, as evidenced by the high mortality
incidence ratio in South Africa. These factors illustrate both the need and potential assets for a successful CHW breast health program.
Data from South Africa's National Cancer Registry (NCR) show breast cancer as the leading cancer among women [15
]. South African women have a 1 in 29 lifetime risk of developing breast cancer, with an age-standardized incidence rate of 30.6 per 100,000 population. These rates vary by race group, with Black women having the lowest (16.3) and White women the highest (69.4) rates of breast cancer diagnosis. The NCR is a pathology-based, rather than a population-based “registry” “therefore” these statistics underestimate cancer incidence in South Africa. These statistics belie marked disparities in stages of cancers at diagnosis, survival rates and overall breast cancer in South Africa [16
]. However, the indication of disparities along racial lines adds urgency to the call for expanded access to breast cancer screening, diagnostic services, and treatment, particularly through community-based approaches.
The cancer control continuum is a commonly used public health framework that describes the various stages at which potential programs or interventions can be developed to improve cancer outcomes for population groups () [17
]. For CHWs to intercede with the objective of reducing stage of breast cancer at diagnosis and increasing survival, target areas along the cancer continuum should be early detection, diagnosis, and treatment. Below we present evidence to develop a program model for a successful breast health program focusing on these areas along the continuum.
The Cancer Control Continuum and Suggested Roles of CHWs in LMCs.