Health system strengthening: Integration of breast cancer care for improved outcomes

The adoption of the goal of universal health coverage and the growing burden of cancer in low- and middle-income countries makes it important to consider how to provide cancer care. Specific interventions can strengthen health systems while providing cancer care within a resource-stratified perspective (similar to the World Health Organization-tiered approach). Four specific topics are discussed: essential medicines/essential diagnostics lists; national cancer plans; provision of affordable essential public services (either at no cost to users or through national health insurance); and finally, how a nascent breast cancer program can build on existing programs. A case study of Zambia (a country with a core level of resources for cancer care, using the Breast Health Global Initiative typology) shows how a breast cancer program was built on a cervical cancer program, which in turn had evolved from the HIV/AIDS program. A case study of Brazil (which has enhanced resources for cancer care) describes how access to breast cancer care evolved as universal health coverage expanded. A case study of Uruguay shows how breast cancer outcomes improved as the country shifted from a largely private system to a single-payer national health insurance system in the transition to becoming a country with maximal resources for cancer care. The final case study describes an exciting initiative, the City Cancer Challenge, and how that may lead to improved cancer services.

The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation: Methods and overview

BACKGROUND

The Breast Health Global Initiative (BHGI) established a series of resource-stratified, evidence-based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice.

METHODS

In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation) for guiding the translation of resource-appropriate breast cancer control guidelines into real-world practice. Three expert consensus panels developed stepwise, resource-appropriate recommendations for implementing these guidelines in low-income and middle-income countries as well as underserved communities in high-income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening.

RESULTS

Key findings from the summit and subsequent article preparation included the identification of phased-implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real-world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits.

CONCLUSIONS

Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.

Biochemical characterization of ecuadorian wild Solanum lycopersicum Mill. plants produced from non-cryopreserved and cryopreserved seeds

This paper presents some of the effects of cryopreservation of wild Solanum lycopersicum Mill. seeds on the early stages of germination post liquid nitrogen exposure. Percentage of germination, conversion into plantlets and plant fresh mass were evaluated after cryostorage. Levels of chlorophyll pigments (a, b, total), malondialdehyde, other aldehydes, phenolics (cell wall-linked, free, and total) and proteins were determined. Peroxidase and superoxide dismutase activities were recorded. Liquid nitrogen exposure increased the percentage of seed germination at 5 days but at 7 days, the conversion into plantlets and the plant fresh mass were not statistically different between non-cryopreserved and cryopreserved samples. Several significant effects of cryopreservation were recorded at the biochemical level at 7 days of germination under controlled conditions. Highly significant effects due to liquid nitrogen exposure were observed in leaves: increased levels of peroxidase enzymatic and specific activities and cell wall-linked phenolics. Very remarkable effects were also recorded in roots: decreased contents of chlorophylls and cell wall-linked phenolics.

Maternal milk concentration of zinc, iron, selenium, and iodine and its relationship to dietary intakes

The dietary intake of zinc (Zn), iron (Fe), selenium (Se), and iodine (I) of 31 lactating Mexican-American women attending the Hidalgo County WIC program in Rio Grande Valley (RGV), Texas was estimated from 24-h dietary recall interviews. Milk samples were obtained from lactating mothers who had infants 3 months of age and younger. Milk samples were collected in two visits to assess change in breast milk composition after 1-3 months postpartum: group A--after 30-45 days and group B--75-90 days. Dietary intakes indicated that the study participants had significantly inadequate percent energy intakes than the DRI (Dietary Recommended Intakes) percent recommended kilocalorie values but protein intakes were substantially higher than the percent recommended values. The estimated percent Zn, Fe, Se, and I intakes were also significantly lower than the DRI percent recommended values. The lactating mothers consumed significantly less Zn, Se, and I when compared to the Recommended Dietary Allowances (RDA) even though Fe intake was higher than the RDA value. Breast milk concentration of Zn, Fe, and Se were in agreement within the range of representative values for Constituents of Human Milk but I has significantly less concentration than the representative value. There was no statistically significant correlation observed between dietary intake and milk concentration of Zn, Fe, Se, and I. This study compares the estimated dietary intake of zinc, iron, selenium, and iodine to the concentration of these trace elements in the maternal milk of lactating women of Mexican-American heritage who attend the Rio Grande Valley WIC clinic.

Prophylactic cryoprecipitate in congenital afibrinogenemia

Two siblings with congenital afibrinogenemia received prophylactic infusions of cryoprecipitate in order to prevent serious hemorrhage during early childhood. Three bags (units) of this fibrinogen-containing blood product were administered every 7-10 days for 15 months in one case and 24 months in the other. Hemorrhage was nearly completely prevented during the period of prophylaxis. Side effects from cryoprecipitate were not observed. Prophylactic infusion of cryoprecipitate, made practical by the relatively long half-life of fibrinogen, should be considered in other patients with this disorder.