Breast Cancer in Brazil: Past and Future

Gustavo Werutsky

Department of Medical Oncology, Hospital São Lucas PUCRS

Latin American Cooperative Oncology Group

Porto Alegre, Brazil

Disclosures

• Dr Gustavo Werutsky has the following financial relationships to disclose:

• Grants and research support to institution from: AstraZeneca, Roche, MSD, BeiGene, BMS and Novartis.

• Honoraria from: Libbs, Dr Reddys, AstraZeneca and Roche

FACT: Death rates from breast cancer in the United States have dropped 39% between 1989 and 2015

ACS 2017

Changes in Cancer Incidence and Cause of Death in Latin America

Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017. Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.

Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017. Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.

Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.

Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.

Epidemiology and Diagnosis of BC in Brazil

Cancer Registries

Source: http://canceratlas.cancer.org; Goss, Lancet Oncol. 2013 Apr;14(5):391-4; Strasser-Weippl K. Lancet Oncol. 2015 Oct;16(14):1405-38

Epidemiology of Breast Cancer in Brazil

Lee LB. Lancet Oncol 2012; 13, e95-102

Impact of Screening in Breast Cancer Mortality

Welch G. N Engl J Med 2016; 375:1438-1447

Breast cancer treatment are responsible for at least two thirds (68%) of the reduction in mortality over time, while screening is responsible for the remainder.

Screening of Breast Cancer in Brazil

• 50% of all women older than 50 years have had at least one mammogram but few receive regular screening

• Only 24.1% of women aged 50–69 years receive appropriate screening in SUS

• Low mammography quality

Lee BL. Lancet Oncol 2012; 13, e95-102

Interval between symptoms/screening test and start of treatment

Bukowski A. J Glob Oncol. 2016 Nov 30;3(5):433-437.

Diagnosis of Breast Cancer in Brazil

• Median time from symptoms/MMG to diagnosis is 72–185 days.

• High proportion of locally advanced disease – particularly in public health system

• Discordance of ER, PgR and HER2 between local and central lab is a concern – few data

Lee BL. Lancet Oncol 2012; 13, e95-102

Age and Stage at Diagnosis per Health Insurance Type (AMAZONA III)

Rosa DD, Barrios CH, Bines J, et al. SABCS 20185

Mode of detection (AMAZONA III)

Rosa DD, Barrios CH, Bines J, et al. SABCS 2018

Geographic differences in the distribution of molecular subtypes of breast cancer in Brazil

Carvalho F. BMC Women's Health201414:102

Significant molecular heterogeneity in the BRCA1 and BRCA2 genes among Brazilian carriers

Palmero EI. SCIENtIFIC REPoRTS | (2018) 8:9188

Twenty-six novel variants were reported from both genes

BRCA 1 BRCA 2

Breast Cancer Treatment and Prognosis in Brazil

Global Access to Radiotherapy

Atun. Lancet Oncol 2015

AMAZONA I/II – Overall Survival in Stage I-III Breast Cancer Subtypes

Simon S, Bines J, Werutsky G, et al. The Breast 44 (2019) 113-119

Stage II Stage III

Disparities in Breast Cancer Prognosis by Type of Health Insurance – AMAZONA I/II 2001-2005

Liedke PE. Cancer Epidemiol Biomarkers Prev. 2014 Jan;23(1):126-33

N=3142 Sites=28

Real World Data on OS in Metastatic Breast Cancer

Year of Diagnosis

OS (m) 2008 2009 2010 2011 2012 2013

HR+ HER2- (N=9.908)

43.7 (40.2-46.6)

42.0 (38.9-44.6)

40.9 (38.0-43.4)

42.0 (39.2-45.0)

44.5 (41.8-47.3)

40.3 (37.8-ND)

HER2+ (N=2.861)

38.6 (33.6-44.6)

42.3

(38.3-50.8) 40.1

(35.2-45.6) 42.3

(36.5-49.8) 51.1

(46.5-NR) Not

Reached

HR- HER2- (N=2.317)

15.1 (12.7-16.4)

15.1 (13.0-17.4)

14.7 (13.2-17.0)

14.0 (11.4-15.9)

13.9 (11.4-15.9)

14.1 (12.5-15.5)

Delaloge S, et al. ASCO 2017.

OS 24 months

Overall Survival Private: 24 months Public: 21 months P = 0.94

HER2 + HER2 +

MBC Overall Survival by Type of Health Insurance (LACOG 0312)

Werutsky G. SABCS 2017

There was no difference in OS by type of health insurance coverage in any BC subtypes

Median OS: HER2+/HR+ 44 months HER2-/HR+: 36 months HER2+/HR- 34 months HR-/HER2-: 13 months

LACOG 0312 - Brazil SEER - USA

MBC Overall Survival by BC Subtypes (LACOG 0312)

Werutsky G. manuscript in preparation; Gong Y. Scientific Reports 2018; 7:45411

Clinical Trials as an Opportunity

Investment Return in Clinical Research

Asia Pacific 3.1%

Europe 28.7%

Asia 33.7%

Middle East 3.3%

Latin America

7%

Total Recruiting Trials: 933

Map of phase I, II and III Breast Cancer clinical trials in clinicaltrials.gov

Africa 1.2%

North America 65.2%

www.clinicaltrials.gov, accessed Feb 5th, 2018

Clinical Trials as an Opportunity

A STUDY TO OBSERVE PATIENTS CHARACTERISTICS, TREATMENT PATTERNS AND OUTCOMES IN PATIENTS WITH NEWLY DIAGNOSED

BREAST CANCER IN LATIN AMERICA - LATINABREAST (MO39485 - LACOG 0615)

Primary Objectives: describe patients characteristics, breast cancer subtypes at diagnosis, outcomes and build a electronic plataform/database Countries (N=10): Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Guatemala, Mexico, Peru, Uruguay. N=30 sites

Principal Investigators: G. Werutsky, C. Barrios

N=4500 ELIGIBILITY • Newly diagnosed stage I to IV

breast cancer (recurrent or de novo) no more than 3 months prior to data extraction, although they can have received anti-cancer treatment during that time

• Male or Female • >= 18 years

BASELINE • Patient demographics • Medical History • BC diagnosis and

treatment • Disease status and

outcome

FOLLOW-UP (5 years) • Changes / Sequence of

BC treatment Disease status and outcome

• Medical History • Safety

Conclusion

• Need to improve National cancer registry to better understand BC patients characteristics, treatment and outcomes

• Disparities in the access to screening, diagnosis, treatment and outcome is evident in Brazil (specially in public system)

• Implement and Ensure High-Quality Cancer Care Standards

• Cancer research is an opportunity for patients and should be a national priority in Brazil

Obrigado

Gustavo Werutsky

gustavo.werutsky@lacog.org.br