Breast cancer outcomes in low-and middle-income countries (LMCs) correlate with the degree to which 1) cancers are detected at early stages, 2) newly detected cancers can be diagnosed correctly, and 3) appropriately selected multimodality treatment can be provided properly in a timely fashion. The Breast Health Global Initiative (BHGI) invited international experts to review and revise previously developed BHGI resource-stratified guideline tables for early detection, diagnosis, treatment, and healthcare systems. Focus groups addressed specific issues in breast pathology, radiation therapy, and management of locally advanced disease. Process metrics were developed based on the priorities established in the guideline stratification. The groups indicated that cancer prevention through health behavior modification could influence breast cancer incidence in LMCs. Diagnosing breast cancer at earlier stages will reduce breast cancer mortality. Programs to promote breast self-awareness and clinical breast examination and resource-adapted mammographic screening are important early detection steps. Breast imaging, initially with ultrasound and, at higher resource levels with diagnostic mammography, improves preoperative diagnostic assessment and permits image-guided needle sampling. Multimodality therapy includes surgery, radiation, and systemic therapies. Government intervention is needed to address drug-delivery problems relating to high cost and poor access. Guideline dissemination and implementation research plays a crucial role in improving care. Adaptation of technology is needed in LMCs, especially for breast imaging, pathology, radiation therapy, and systemic treatment. Curricula for education and trainingThe Breast Health Global Initiative (BHGI) gratefully acknowledges grants and conference support from the following organizations and

Breast cancer is the most common cause of cancer-related death among women worldwide, with case fatality rates highest in low-resource countries. Despite significant scientific advances in its management, most of the world faces resource constraints that limit the capacity to improve early detection, diagnosis, and treatment of the disease. The Breast Health Global Initiative (BHGI) strives to develop evidence-based, economically feasible, and culturally appropriate guidelines that can be used in nations with limited health care resources to improve breast cancer outcomes. Using an evidence-based consensus panel process, four BHGI expert panels addressed the areas of early detection and access to care, diagnosis and pathology, treatment and resource allocation, and health care systems and public policy as they relate to breast health care in limited-resource settings. To update and expand on the BHGI Guidelines published in 2003, the 2005 BHGI panels outlined a stepwise, systematic approach to health care improvement using a tiered system of resource allotment into four levels-basic, limited, enhanced, and maximal-based on the contribution of each resource toward improving clinical outcomes. Early breast cancer detection improves outcome in a cost-effective fashion assuming treatment is available, but requires public education to foster active patient participation in diagnosis and treatment. Clinical breast examination combined with diagnostic breast imaging (ultrasound +/- diagnostic mammography) can facilitate cost-effective tissue sampling techniques for cytologic or histologic diagnosis. Breast-conserving treatment with partial mastectomy and radiation therapy requires more health care resources and infrastructure than mastectomy, but can be provided in a thoughtfully designed limited-resource setting. The availability and administration of systemic therapies are critical to improving breast cancer survival. Estrogen receptor testing allows patient selection for hormonal treatments (tamoxifen, oophorectomy). Chemotherapy, which requires some allocation of resources and infrastructure, is needed to treat node-positive, locally advanced breast cancers, which represent the most common clinical presentation of disease in low-resource countries. When chemotherapy is not available, patients with locally advanced, hormone receptor-negative cancers can only receive palliative therapy. Future research is needed to better determine how these guidelines can best be implemented in limited-resource settings.

High-risk GIST are associated with increased disease recurrence and decreased survival despite complete surgical resection. These patients should receive adjuvant therapy in the form of tyrosine kinase inhibitors.

In 2002 the Breast Health Global Initiative (BHGI) convened a panel of breast cancer experts and patient advocates to develop consensus recommendations for diagnosing breast cancer in countries with limited resources. The panel agreed on the need for a pathologic diagnosis, based on microscopic evaluation of tissue specimens, before initiating breast cancer treatment. The panel discussed options for pathologic diagnosis (fine-needle aspiration biopsy, core needle biopsy, and surgical biopsy) and concluded that the choice among these methods should be based on available tools and expertise. Correlation of pathology, clinical, and imaging findings was emphasized. A 2005 BHGI panel reaffirmed these recommendations and additionally stratified diagnostic and pathology methods into four levels--basic, limited, enhanced, and maximal--from lowest to highest resources. The minimal requirements (basic level) include a history, clinical breast examination, tissue diagnosis, and medical record keeping. Fine-needle aspiration biopsy was recognized as the least expensive reliable method of tissue sampling, and the need for comparing its clinical usefulness with that of core needle biopsy in the limited-resource setting was emphasized. Increasing resources (limited level) may enable diagnostic breast imaging (ultrasound +/- mammography), use of tests to evaluate for metastases, limited image-guided sampling, and hormone receptor testing. With more resources (enhanced level), diagnostic mammography, bone scanning, and an onsite cytologist may be possible. Mass screening mammography is introduced at the maximal-resource level. At all levels, increasing breast cancer awareness, diagnosing breast cancer at an early stage, training individuals to perform and interpret breast biopsies, and collecting statistics about breast cancer, resources, and competing priorities may improve breast cancer outcomes in countries with limited resources. Expertise in pathology was reaffirmed to be a key requirement for ensuring reliable diagnostic findings. Several approaches were again proposed for improving breast pathology, including training pathologists, establishing pathology services in centralized facilities, and organizing international pathology services.

Testosterone (T) facilitates male investment in reproduction in part through its anabolic effects on skeletal muscle. Traits like muscle and strength are energetically costly but are believed to enhance competitive ability in humans and other mammals. However, there are limited data on relationships between T and somatic outcomes in lean, non‐western populations. We evaluate relationships between waking and pre‐bed salivary T and adiposity, fat‐free mass (FFM), arm muscle area (AMA), and grip strength (GS) in a large, population‐based birth cohort of young adult Filipino males (20.8–22.6 years, n = 872). Data were collected as part of the Cebu Longitudinal Health and Nutrition Survey. Neither waking nor evening T predicted FFM, AMA, or GS. However, there were borderline or significant interactions between T and basketball playing (the most common team sport) and weight lifting as predictors of outcomes: higher waking T predicted higher FFM (activity × T interaction P < 0.01), AMA (interaction P < 0.1), and GS (interaction P < 0.02) among frequent basketball players, and GS (interaction P < 0.09) among the smaller sample of weight lifters. In contrast to clinical studies, but consistent with findings in several subsistence‐level populations, T was positively related to adiposity in these lean young males, suggesting that energy status might regulate circulating T. Our findings support a role of the prewaking rise in T as a determinant of energetic allocation to lean mass and strength in the context of repeated muscular use and support the hypothesized role of T as a mediator of investment in costly somatic traits in human males. Am J Phys Anthropol 142:590–599, 2010. © 2010 Wiley‐Liss, Inc.

A key determinant of breast cancer outcome in any population is the degree to which newly detected cancers can be diagnosed correctly so that therapy can be selected properly and provided in a timely fashion. A multidisciplinary panel of experts reviewed diagnosis guideline tables and discussed core implementation issues and process indicators based on the resource stratification guidelines.Issues were then summarized in the context of 1) clinical assessment, 2) diagnostic breast imaging, 3) tissue sampling, 4) surgical pathology, 5) laboratory tests and metastatic imaging, and 6) the healthcare system. Patient history provides important information for the clinical assessment of breast and comorbid disease that may influence therapy choices. Focused clinical breast examination and complete physical examination provide guidance on the extent of disease, the presence of metastatic disease, and the ability to tolerate aggressive therapeutic regimens. Breast imaging improves preoperative diagnostic assessment and also permits image-guided needle sampling. Diagnostic mammography was not considered mandatory in low-and middle-income countries when resources are lacking. Needle biopsy is preferred to surgical excision for the initial diagnosis of suspicious breast lesions, unless resources are unavailable. Mastectomy should never be used as a method of tissue diagnosis. The availability of predictive tumor markers, especially estrogen receptor testing, is critical when endocrine therapies are available; quality assessment of immunohistochemistry testing is important to avoid false-negative results. Incremental allocation of resources can help address economic disparities and help ensure equity in access to timely diagnosis. Cancer 2008;113(8 suppl):2257-68.

The incidence of breast cancer and mortality from this disease remain high in countries with limited resources such as the Ukraine. Because of a lack of mammography equipment and formal screening programs, as well as educational and other factors, breast cancer is usually diagnosed in late stages in such countries. We report the experience of the PATH Breast Cancer Assistance Program in introducing a pilot breast cancer screening program in one territory of the Ukraine, the Chernihiv oblast. The program entailed educating the public, training health care providers in clinical breast examination (CBE) and mammography, opening a dedicated mammography facility, designating a center for breast cancer care, building diagnostic capacity, and fostering the formation of support groups. From 1998 to 2002, 18,000 women underwent screening with CBE and 8778 women underwent screening with mammography. When implementing the program we encountered various cultural, economic, and logistic difficulties, such as reservations about showing bare breasts in educational materials, the lack of an established system for collecting screening data, and barriers to follow-up in women with positive screening results. Screening mammography proved to be more effective in detecting small and nonpalpable lesions; 8.7% of cancers detected in the mammography group were in situ, compared with 0% in the CBE group. However, introduction of CBE as a screening modality required fewer financial resources compared with mammography and was recommended as a transitional method before the introduction of mammography screening programs in countries with limited resources. The introduction of screening was associated with favorable changes in indicators of breast cancer care, including an increase in the percentage of breast-preserving operations and new legislation to provide funding for breast cancer services. We conclude that this successful pilot program of breast cancer screening in a limited-resource setting can serve as an example for other similar programs.

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