Women in low- and middle-income countries (LMICs) have yet to benefit from recent advances in breast cancer diagnosis and treatment now experienced in high-income countries. Their unique sociocultural and health system circumstances warrant a different approach to breast cancer management than that applied to women in high-income countries. Here, we present experience from the last five years working in rural Bangladesh. Case and consecutive series data, focus group and individual interviews, and clinical care experience provide the basis for this paper. These data illustrate a complex web of sociocultural, economic, and health system conditions which affect womens’ choices to seek and accept care and successful treatment. We conclude that health system, human rights, and governance issues underlie high mortality from this relatively rare disease in Bangladesh. 1. Introduction The US-based National Comprehensive Cancer Network guidelines for breast cancer management specifically state that even under the best of circumstances “there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement” . In low- and middle-income countries with far fewer resources than the US, the circumstances are compounded by multiple factors associated with increased mortality for this disease . Addressing and remedying these inequities requires an exploration into the unique circumstances surrounding the complex barriers women face in receiving information, accurate and timely diagnosis, and effective treatment critical to reducing breast cancer morbidity and mortality . For the past five years, beginning with work to recruit women to a clinical trial of treatment for metastatic breast cancer, we have been increasing our efforts to understand what is happening to women with breast cancer in the Khulna Division of Bangladesh. Our experience calls into question the application of common high-income country models and strategies in such settings. 2. Bangladesh Understanding barriers to improving outcomes from breast cancer begins with an appreciation of the broader sociocultural context in which women live. We present our experience in Bangladesh as the backdrop for this exploration. Bangladesh is located in Southern Asia, between India and Myanmar, and borders the Bay of Bengal to the south (Figure 1). It is the seventh most populous country in the world; a country of nearly 160 million people (approximately half the population of the US) in an area half
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