Late-stage breast cancer diagnosis reduced from 36% to 22% among patients who participated in a pilot programme in the Republic of Moldova. Progress was achieved through incremental improvement of the health system, based on WHO recommendations, without any screening programmes or introduction of major additional measures.
For years, the Republic of Moldova has faced a relatively high burden of breast cancer, with 36% of the cases diagnosed late, when the disease is much harder to treat. But this situation is beginning to change.
Before the early diagnosis programme, even as the country was exploring options for nationwide breast cancer screening, women with breast symptoms could experience a complicated journey, with repeated medical visits and long wait times, which could discourage them from timely care-seeking.
“The Republic of Moldova’s experience has shown that evidence-based changes do not always require major additional funding to improve the situation. By applying WHO-recommended restructuring measures, the Republic of Moldova was able to achieve early, visible progress in reducing late-stage diagnosis of breast cancer. This is an important lesson for the whole WHO European Region”, said Alexandru Voloc, WHO/Europe Technical Officer in the Republic of Moldova.
A pragmatic choice
Between 2018 and 2022, the Republic of Moldova piloted a mammography screening programme for women aged 50–70, with nearly 27 000 mammograms performed. The pilot generated valuable data revealing that, despite substantial investment, the programme covered only 2.6% of the target population. It was impossible to scale up the programme to the whole country because the required number of radiologists and radiology technicians exceeded the available workforce.
In 2022, 35.8% of newly diagnosed breast cancers were still diagnosed at stage III or IV. The Republic of Moldova therefore made a pragmatic choice: before searching systematically for cancer among healthy women, make sure that every woman who already has a breast symptom can be diagnosed quickly.
Time is precious
In October 2023, the Republic of Moldova launched a pilot breast cancer early diagnosis programme in 4 regions of the country. Each region had a diagnostic centre able to perform mammography and ultrasound, and the Institute of Oncology in the capital served as the national referral centre where further tests could be done, including biopsy and pathology. The programme was based on the WHO guidelines for early diagnosis.
The idea behind the pilot is simple and powerful. The health system needs to ensure that women with breast symptoms are diagnosed rapidly, without unnecessary wait times and barriers. At the same time, public communication campaigns should encourage women to recognize possible breast cancer symptoms and consult a doctor as soon as they have any concerns.
The programme did not require examining hundreds of thousands of healthy women. Instead, it focused diagnostic resources on women who already had symptoms and needed assessment.
In the Republic of Moldova, a woman who notices something unusual in her breast would usually first visit her family physician (who serves as the main point of contact for primary health care). In the pilot regions, family doctors were reminded of the signs and symptoms of breast cancer and given clear guidance on where to refer women with breast complaints.
Each pilot region identified a diagnostic centre where women could be referred by their family doctor without delay. The specialists at the diagnostic centre could perform a clinical breast exam and determine whether ultrasound or mammography was needed. Imaging could then be done quickly at the same facility. Women with suspicious results were rapidly referred to the Institute of Oncology for further investigation, including biopsy.
Before the programme, a woman with a breast lump could face multiple consultations with back-and-forth referrals and wait more than a month for mammography, then several additional weeks before reaching the Institute of Oncology for the final diagnosis. The new pathway created a fast track from family physician to diagnosis and treatment.
Lessons learned
The Republic of Moldova’s innovation is mainly organizational. The early diagnosis programme connects family doctors, regional diagnostic centres and the Institute of Oncology into one clear pathway, designed around the patient and one goal: helping women with breast symptoms get the right next step quickly.
And it works: In 2024, late-stage diagnosis among patients diagnosed through the programme was reduced from 36% to only 22%.
“The experience shows that early diagnosis needs clear protocols, trained professionals, patient navigation, data and quality assurance. It also gives important insights for potential future screening programmes: if the route from first concern to diagnosis and treatment is slow and complex, screening will not solve that problem”, said Dr Marilys Corbex, WHO Senior Technical Officer.
The pilot revealed a misconception among some family doctors, who had interpreted early diagnosis as a form of screening. An outdated national policy previously recommended annual clinical breast examination for all women, and some family doctors mistakenly believed that this policy was being revived. This resulted in systematic examinations of women without symptoms, unnecessary referrals for imaging, additional workload for already overworked staff and rapid consumption of the limited programme resources.
There were also major differences between regional diagnostic centres. Some centres performed far more imaging but detected fewer cancers, showing that good clinical triage before imaging is essential. WHO therefore recommended exploring financing models linked to programme outcomes, not only to the number of procedures performed.
Another lesson was the need for stronger public health expertise and better data. The programme needs dedicated specialists to monitor coverage, analyse patient pathways and compare performance across centres.
A message for other countries
The Republic of Moldova's experience offers a simple message: Countries do not need to wait for nationwide screening to start reducing late-stage breast cancer diagnosis.
The first step is to ensure that women who already notice a breast problem are recognized, referred, diagnosed and treated without delay.
Early diagnosis starts with existing resources, reorganizes them around women who need care most urgently, and can be improved, measured and scaled over time.