Intended for healthcare professionals


Breast cancer: from awareness to access

BMJ 2023; 380 doi: (Published 04 February 2023) Cite this as: BMJ 2023;380:p290
  1. Nino Berdzuli, director
  1. Division of Country Health Programmes at the WHO European Regional Office

In 2021, I became one of the “one-in-four” who experience cancer. I had no known risk factors except that I was a woman. Working in the field of oncology, I am used to working with statistics, but it’s frightening to become a cancer statistic overnight.

Every hour in the WHO European Region, 66 women are diagnosed with breast cancer and 18 die from it. If current trends remain unchecked, new breast cancer cases in the region are projected to increase 26.7% and deaths 25.2% between 2020 and 2040.

I will never forget the words that paralyzed me with fear and worry for my 11-year-old son. Fortunately, my breast cancer was caught in time and time matters: there’s a direct correlation between speed of diagnosis and treatment and your chances of survival. It was a challenging time for our family, but I made it through.

The majority of breast cancer cases are self-detected, which highlights how important it is to be “breast aware.” Breast Cancer Awareness Month and “going pink” to raise awareness for breast cancer has been a huge success. At the same time, we need to broaden the conversation beyond awareness and think of self-detection as the very first step in a pathway that must include access to early diagnosis, treatment, and follow-up without creating financial hardship for patients and their families.

Identifying a lump and then what…?

Women are increasingly knowledgeable about the early signs of breast cancer, for example, new lumps, or subtle changes to the skin or shape of the breast. Each new generation and women everywhere, of all abilities and backgrounds, should “know their normal” and recognise and trust when something is not right. Health promotion around breast cancer symptoms should be ongoing and widespread. What is required now is that nobody is left alone with a worrying symptom and without access to care.

The stage at which a cancer is diagnosed (early or late) is a major factor in determining cancer survival. Upon identifying a symptom, every woman should have access to crucial breast health services. Having access to quality, affordable diagnosis and treatment will increase your probability of survival. Primary care is usually the first point of contact with the health care system and family doctors play an important role in guiding patients and navigating complex and often fragmented health systems. Nevertheless, challenges remain, and we must do more to eliminate the barriers that drive disparities at all stages—diagnosis, access to treatment and survival outcomes across the region.

Barriers to accessing early diagnosis and care

Too many women in the European region still face barriers to accessing affordable and quality care. In countries with inadequate universal health coverage and poor financial protection, women may be forced to pay high out of pocket fees for care, putting them at greater risk of being pushed into poverty. This disproportionately affects vulnerable and poor populations leading to negative health and economic consequences and greater inequalities. As the cost-of-living crisis escalates across the region, on the back of financial challenges caused by the covid-19 pandemic for patients and providers, it is vital that people are given easy access to affordable care. There are vast inequities in the region in terms of abilities of health care systems to provide multidisciplinary approach (e.g. medical, radiation and surgical oncologist, and pathologists, nurses) and joint clinical decision-making, standardisation in pathology and imaging reporting, availability and uptake of evidence-based clinical practice guidelines, and cancer care innovations that hinder quality of care and patient outcomes.

In addition to promoting breast awareness, we want to stress the importance of finding cancer early and ensuring that diagnostic services, treatment, and rehabilitation are accessible and affordable to every woman who needs them. This is how we can build trust in our systems and reduce breast cancer mortality. Countries that have succeeded in reducing breast cancer mortality are those with higher levels of universal health coverage and availability of public cancer centres.

Building trust in cancer care

In spite of my medical training and professional experience as a gynaecologic-oncologist treating patients, receiving a breast cancer diagnosis transformed my understanding of the disease and its impact on every single aspect of a person’s life. I was living in a foreign country at the time of my diagnosis. Sitting on the other side of the consultation table, I struggled through the daze of my diagnosis to understand a language I had used every day with my patients.

I had to learn about and navigate a health system I did not know. Initially, not knowing how the system worked or whether the services I required would be available and accessible to me as quickly as I needed them, was hugely concerning. I was extremely fortunate to have people around me who could support me through the care pathway, including a nurse navigator who answered my questions and made information accessible and simple. Most importantly, the system worked as it is supposed to, focusing on my needs as a patient. In this new system, joint decision-making between doctors and patients happens to a greater degree than I was accustomed to. This both empowered me and placed responsibility on me for serious choices concerning my care from treatment to rehabilitation.

Systems must deliver or people lose trust. When the public does not trust the system, they are less inclined to seek care. Women need to be able to have faith that they will be looked after when they seek care. That trust can only be earned by systems that perform well and put the welfare of the patient above all else. This will require further investment in health systems and specifically in the health workforce.

Nurses are the backbone of cancer care and nurse navigators play a vital role in helping patients to navigate often very complex pathways. Even before the covid-19 pandemic, our region faced workforce issues that strained cancer care delivery including shortages in imaging, pathology, nursing, and pharmacy technicians. Covid-19 has made this even more stark with services being delayed, for example during the early stages of the pandemic, in some countries, the diagnosis of invasive tumours fell by 44% and the number of cancers diagnosed in 2020 was 34% lower than expected. We project increases in mortality in coming years due to delays and backlogs.

On World Cancer Day, let’s think beyond awareness and about building trustworthy systems. As a breast cancer survivor, a trustworthy system for me is one that provides easy access to rapid, affordable, and quality diagnosis, followed by evidence-based quality treatment. It is a system that never loses sight of the patient and provides a smooth, supportive journey through the healthcare labyrinth. It is a system that provides financial protection and does not drive families into poverty to cover the costs of care. Early diagnosis, universal health coverage, and access to cancer care are our best bet for increasing cancer survival. The WHO Global Breast Cancer Initiative Implementation Framework provides just this, it gives clear guidance on how countries can reduce breast cancer mortality through a phased approach and investment in strengthening health systems. Together we can turn this Global Framework for regional action, implementing resource-appropriate strategies for tackling system barriers to improve the diagnosis of breast cancer at an early-stage and the timely completion of the treatment pathway.

With commitment from decision-makers and coordination across the health system, countries can make major improvements in breast cancer outcomes. The gains are significant and within reach.

Let's work together to turn awareness into access, and access into trust, so that every woman receives the care and support she needs to live beyond a breast cancer diagnosis.


  • Competing interests: none declared.