NERRS Breast Imaging. 3 marzo 2012

7/30/2019 NERRS Breast Imaging. 3 marzo 2012

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Breast Cancer in LMICs:

Meeting the Challenge and

Closing the Cancer Divide

Felicia Marie Knaul

NERRS Breast Imaging Course

Massachusetts Medical Society

March 3, 2012


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From anecdote

to evidence


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January, 2008

June, 2007


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From anecdote

to evidence


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Global Task Force on Expanded

Access to Cancer Care and

Control in Developing Countries

= global health + cancer care


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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs

I: Much should be doneII: Much could be done

III: Much can be done

1: Innovative Delivery

2: Access to Affordable Medicines,

Vaccines & Technologies

3: Innovative Financing: Domesticand Global

4: Evidence for Decision-Making

5: Stewardship and Leadership


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Challenge and disprove the

myths about cancer

M1. Unnecessary

M2. Unaffordable

M3. ImpossibleM4: Inappropriate

Should,

Could, andCan..

be done

Expanding access to cancer care and control inlow and middle income countries:

Ch ll d di th


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minimalists:

myths about cancer

M1. Unnecessary NecessaryM2. Unaffordable

M3. Impossible

M4: Inappropriate: either/or


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Breast cancer: myths and realities

It is a disease ofdeveloped countries

It is a disease ofolder women

It is of lower prioritythan cervical cancer

The majority of cases anddeaths occur in the

developing world

A large proportion of casesand deathsperhaps the

majorityhappens in

women


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In developing regions, breast cancer

Most frequent cause of cancer-related death in developingand developed regions

Leading cause if death especially for young women

268,000 of the 458,000 deaths per year are in LIMCs: 58%

Most common cancer in developed and developing regions

4.4 million women alive (diagnosed): how many in

developing regions?

2008: 1.38 million new cases; 50% of which are fromLIMCs

10.9% of all incident cancerssecond to lung

(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).

40% i


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~40% occur in pre-menopausal

women (55

Age of

Diagnosis

Age ofDeath

Source: Author estimates based on IARC, Globocan, 2008 and 2010.

33%

20%54%

66.6%

34.2%65%

Th id i f b


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The epidemic of breast cancer:Unforseen challenge in LDCs

Some 45% of the more than 1 million new cases of breastcancer diagnosed each year, and more than 55% of breast-

cancer-related deaths, occur in low- and middle-income

countries.*

Such countries now face the challenge of effectivelydetecting and treating a disease that previously was

considered too uncommon to merit the allocation of

precious health care dollars.

Source: Porter, P. (2007). "Westernizing Womens Risks? Breast Cancer in

Lower-Income Countries." New England Journal of Medicine 358(3):4

Curado MP, Edwards B, Shin HR, et al., eds. Cancer incidence in five continents. France: International

Agency for Research on Cancer, 2007.


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The divide is the result of concentrating riskfactors, preventable disease, suffering,impoverishment from ill health and deathamong poor populations.

fueled by progress in cutting-edge science andmedicine in high-income countries.

The Cancer Divide:disparities in outcomes

between poor and rich directly related to inequitiesin access and differences in underlying socio-

economic and health conditions.


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Cancer is a disease of both rich and poor;

yet it is increasingly the poor who suffer:

1. Exposure to risk factors2. Preventable cancers (infection)

3. Death and disability fromtreatable cancer

4. Stigma and discrimination

5. Avoidable pain and suffering

The Cancer Divide:

An Equity Imperative

Fac

ets

Whil th M i i h b ti l l


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While the Mexican experience has been particularly

profound, more women are working in the labour

fource throughout LAC and other LDCs

020

60

100

140

180

M

exico

Venezuela

Ecuador

G

uatemala

Brazil

Bolivia

Colombia

Peru

Chile

Nicaragua

DR

Paraguay

Honduras

Uruguay

Argentina

C

ostaRica

E

lSalvador

Panama

Women

Men

Source: FLACSO, Mujeres Latinoamericanas en Cifras, 1995 and CEPAL

(www.cepal.org/mujer/proyectos/perfiles/documentos/t_trabajo2.xls)

Growth of the economically activepopulation, 1970-2002.

Ri k f t t ti


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Risk factor concentration:

Obesity Epidemic, Mexico

10

60

8

32

57

25

10

2

37

25

36 37

29

2

Malnutrition Adequate

Overweight

Obesity

1988

1999

% women 20-49 years

2006

Th i i i LMIC


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Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition in LMICs:

breastand cervicalcancer

53%

20%19%

-31%

0%

LMICs High

income

% Change in # of deaths1980-2010LMICs account for

>90% of cervical

cancer deaths and

>60% of breast

cancer deaths.

Both diseases are

leading killers

especially of young

women.


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The cancer transition within countries:breastand cervicalcancer mortality

Oaxaca

1979-200825

0

8

16 Mexico1955 - 2008

Costa Rica

1995 - 2005

0

0

Nuevo Leon1979-2008

25

0


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Adults

Breast

Cervix Prostate

Testis

HL

N HL

Leukaemia

All cancers

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

Children

LOW

INCOME

HIGH

INCOME

Survival

inequalitygap

LOW

INCOME

HIGH

INCOME

100%

The opportunity to survive (M/I)

should not be defined by income.

Yet it is.


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Stigma:

Juanita

Cancer, and

especially

reproductive

cancers, adds

a layer of

discrimination

onto gender,

ethnicity, andpoverty.

The most insidious example of


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The most insidious example of

injustice is access to pain controlNon-methadone, Morphine

Equivalent opioid consumptionper death from HIV or cancer in

pain by income level

Russia: 937 mg; ALL Developed

countries 57,041


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Mirrors the overall epidemiologicaltransitionprotracted and polarized*:

LMICs increasingly face both cancersassociated with infection, and all other

cancers.

Cancers that were once considered only ofthe poor, now cease to be the only cancers

of the poor. (e.g. cervical & breast cancer)

The Cancer Transition

* Frenk et al

Ch ll d di th


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minimalists:

myths about cancer

M1. Unnecessary NECESSARY

M2. Unaffordable: .for the poorM3. Impossible


Challenging cancer implies taking

resources away from other diseases of

the poor

I ti I CCC


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Investing In CCC:

We Cannot Afford Not ToHealth is an investment, not a cost

Tobacco is a huge economic risk: 3.6% lower GDP

Total economic cost of cancer, 2010: 2-4% of global GDP

Prevention and treatment offers potential world savings of

$ US 131-850 billion mostly due to productivity gains and

reducing suffering

1/3-1/2 of cancer deaths are avoidable:

2.4-3.7 million deaths

Of which 80% are in LIMCs

Investing In CCC:


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Investing In CCC:

The costs to close the cancer divide may

be less than many fear:All but 3 of 29 LMIC priority, candidate cancer chemo

and hormonal agents are off-patent: many < $100 / course

Cost of drug treatment, cervical cancer + HL + ALL(k)in LMICs / year of incident cases: $US 280 m

Pain medication is cheap

Prices drop:HPV 2011 from $US 100 /dose to

GAVI $5

PAHO $14

Challenge and dispro e the


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minimalists:

myths about cancer

M1. Unnecessary

M2. Unaffordable:M3. Impossible POSSIBLE


Challenging cancer implies taking

resources away from other diseases of

the poor

Successes treating other diseases:


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Successes treating other diseases:MDR-TB treatment

Source: Paul Farmer., 2009

cured

83%

abandon

therapy

2%

failed

therapy

8%

died

8%

Mitnick et al, Community-based therapy for multidrug-resistanttuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Outcomes in MDR-TB patients in Lima,

Peru receiving at least 4 months of therapy

WHO 1997, Multidrug-resistant

tuberculosis is too expensive to treat in

poor countries; it detracts attention and

resources from treating drug-susceptible

disease.

Drug % Decline inprice 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Reduced prices of

second-line TB drugs

C


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Campeonas:Drew G. Faust

President of Harvard University22+ year BC survivor

Abish Romeo

Patient, 24 years oldAdvocate, Tmatelo a Pecho

S i t ti l


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Mexico: cervical cancer.

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2006)

0

4

8

12

16

19551965

1975

1985

1995

2005

Success in treating several cancers.



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minimalists:

Myths about cancer& NCD

M1. Unnecessary NECESSARY

M2.Unaffordable AFFORDABLE

M2. Impossible POSSIBLE


Challenging cancer implies taking resources

away from other diseases of the poor

Women and mothers in LMICs


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Women and mothers in LMICs

face many risks through the life cycle

Women 15-59, annual deaths

Diabetes

120,889

Breast

cancer

166,577

Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

Cervical

cancer

142,744

Mortalityin

childbirth

342,900

- 35%in 30

years

= 430, 210 deaths

Th Di l A h t


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The Diagonal Approach to

Health System Strengthening

Rather than focusing on disease-specific vertical

programs or only on horizontal system

constraints, harness synergies that provide

opportunities to tackle disease-specific priorities

while addressing systemic gaps.

Optimize available resources so that the whole ismore than the sum of the parts.

Bridge the divide as patients suffer diseases over a

lifetime, most of it chronic.

Di l S i


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Diagonal Strategies:

Positive Externalities

Promoting prevention and healthy lifestyles:

Reduce risk for cancer and other diseases

Pain control and palliationReducing barriers to access is essential

for cancer, for other diseases, and for

surgery.Reducing stigma for womens cancers:

Contributes to reducing gender

discrimination.


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Delivery: Harness platforms byintegrating cancer prevention,

screening and survivorshipsupport into MCH, SRH,

HIV/AIDS, social welfare andanti-poverty programs.

A Diagonal Strategy:


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Cases:

Mexico

Juanita

M i f f t


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Mexico: summary of facts

Since 2006, breast cancer is the second leading cause ofdeath among women aged 30 to 54 years of age and the

principal cause of death due to tumors.

Seguro Popular: since 2007 all women diagnosed with

breast cancer have very complete access to treatmentwith financial protection

Only 5-10% of cases in Mexico aredetected in Stage 1 or in situ and

70% in stage II-III-IV


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IMSS Mxico: 40-50% of cases are

detected in stages III-IV. 85+ in II+

10%

30%

50%

1992 2002 2006

Stage I Stage II Stage III & IV

Stage at diagnosis by level of municipal


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Stage at diagnosis by level of municipal

marginalization, Mexico, IMSS 2006(Mxico, IMSS 2006)

Source: Authors estimation based on IMSS data, 2006.

N=221(3.8%)

N=1737(30%)

N=2877(49.8%)

N=946(16.4%)

% diagnosedin Stage 4

Late detection by state

0%

10%

20%

30%

40%

50%

Poor (High) Middle Low Very low

Stage 1 Stage 2

Stage 3 Stage 4

< low

> mid

> high


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Why?

Social and health systems

barriers to early detectionand

non-price barriers totreatment

J anita


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br

Juanita


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Barrier 1: myth and machismo

Barrier 2: poor primary careBarrier 3: access to screeningBarrier 4: financing for treatment


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Barrier 2: Poor quality primary care

women diagnosed with bc reported problemswith providers when seeking diagnosis.

In routine, annual repro health/OBGYN visit/

PAP screening, there was no BCE

Physician insisted woman was overreacting and

sent her home with no diagnosis

Health professionals and first-level care

providers report lack of sensitivity of healthpersonnel relating to the requests of women

regarding breast health

Results from a national qualitative studynigenda et al, 2009

Barrier 3: Inequity in addition to


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0%

10%

20%

30%

+ Poorest

Q1 Q2 Q 3 Q 4Least poor

QV

16%

21% 22%24%

28%

Source: ENSANUT, 2006

Barrier 3: Inequity in addition to

lack of overall access and utilization

Only 1 in 5women 40-69

report a

preventivehealth visit

including

mamography2006

Mexico Seguro Popular Insurance


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e co Segu o opu a su a ce

a diagonal strategy that includes financial

protection for catastrophic illness

Accelerated universal vertical coverage by disease

with a specified package of interventions

2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers

2007: Breast cancer

2011: Testicular cancer, prostate and NHL

Seguro Popular and cancer:


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Seguro Popular and cancer:

Evidence of impact

Since the incorporation of childhood cancersinto the Seguro Popular

30-month survival: 30% to almost 70%

adherence to treatment: 70% to 95%.

Access to medicinesan anecdote

Breast cancer

adherence to treatment - NCI Mexico:2005: 200/600 (30%)

2010: 10/900 (1%)

Barrier 4: distance and caregiving

Programs to reduce


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Programs to reduce

barriers

C j t t


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Core project components

1) Expand potential for early detection

Harness anti-poverty and MCH Oportunidades program

Training of health promoters

Improved referral system

Training of primary care-level physicians and nurses

2) Expand potential for care and treatment in secondary levelhospitals

Supervision and capacity building from tertiary to secondary

district hospitals

Centers for chemotherapy and survivorshipsecondary and

primary level

Acreditation of secondary centers so SPSS can finance

3) Increase data-for-decision-making, evaluation and monitoring

Improved or new registries

Evaluation and monitoring

P ti i ti i tit ti


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Participating institutions:

Seguro Popular and MOH Mexico

Ministry of Health of Jalisco, Morelos, Nuevo Leon,

Puebla, Sinaloa.

National Cancer Institute of Mexico

National Institute of Public Health

Cncer de mama: Tmatelo a pecho

Mexican Health Foundation

The Global Task Force on Expanded Cancer Care and

Control in Developing Countries through the Secretariat

based at the Harvard Global Equity Initiative and Seattle

Cancer Care Alliance


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Challenge and disprove theminimalists:

Myths about breast cancer,cancer& NCD

M1. Unnecessary NECESSARYM2. Impossible POSSIBLE

M3.Unaffordable AFFORDABLE

M4. Inappropriate : APPROPRIATE


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Be anoptimist

optimalist

Expanding access to cancer care and control:

Should, Could, and Can be done


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Breast Cancer in LMICs:

Meeting the Challenge and

Closing the Cancer Divide

Felicia Marie Knaul

NERRS Breast Imaging Course

Massachusetts Medical Society

NERRS Breast Imaging. 3 marzo 2012

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Transcript of NERRS Breast Imaging. 3 marzo 2012