Transcript Slide 1

IARC perspectives on the development of a
research agenda for early detection and
control of breast cancer in developing
countries
R. Sankaranarayanan MD
Head, Early Detection and Prevention Section (EDP)
Head, Screening Group (SCR)
International Agency for Research on Cancer
Lyon, France
Age-standardized incidence rates of breast cancer in selected
populations in each continents, 1998-2002
140
SOURCE: Cancer Incidence in Five Continents, Vol. IX.
IARC Scientific Publications No. 160, Lyon, IARC. (2007)
Age-standardized rate (World) per 100,000
120
100
80
60
40
20
0
OCEANIA
EUROPE
ASIA
N. AMERICA
S. AMERICA
AFRICA
IARC perspectives: Current status of health
services infrastructure and investments
•
Poorly developed and invested (most
countries with per capita GNI <1000
USD; no or extremely limited
diagnostic/treatment services)
•
Moderately developed and invested
(Countries with per capita GNI 100010,000 USD, urban rural differences,
intracountry variation)
5-Year Survival from breast cancer (diagnosed during 1993-2001)
21,810 cases
{range: 58-90%}
9,442
{range: 78-84}
China
South
Korea
Turkey
1,329
Singapore
3,204
Cuba
2,169
Costa Rica
2,462
S.Arabia
298
Thailand
2,354
India
Breast Cancer (ICD-10:C50)
• Highest in Hong Kong
SAR
• Lowest in Gambia
{range: 57-65}
{range: 31-54}
11,013
Philippines
1,714
Uganda
162
Zimbabwe
258
Gambia
{range: 40-55}
61
0
20
40
60
80
100
Intra-country variation
• Pronounced in China
(urban  and rural ) &
India & Philippines
• No difference in South
Korea & Thailand
5-year absolute survival for localised and
regional extent of disease among more
and less developed health services –
Breast cancer
Absolute survival for localized and
regional extent of disease among
more and less developed health
services - Breast cancer
100
76.3
80
Localised
Survival%
89.6
47.4
60
40
Regional
Localised-more dev.
75.4
Localised-less dev.
20
0
20
40
60
80
100
Survival%
Regional-more dev.
Regional-less dev.
0
0
2
3
4
5
Year
Less devloped health services-Thailand, India, Costa Rica, etc.
More devloped health services (Singapore & Turkey)
1
Singapore & Turkey: 14 645 cases
Costa Rica, India, Philippines, Saudi Arabia, Thailand: 17 640
cases
Modalities for early detection of breast
cancer
• Awareness!
• Mammography
• Self examination
• Fine needle
aspiration cytology
(FNAC)
• Clinical breast
examination (CBE)
• Ultrasonography
• Core biopsy
• Triple diagnosis
Breast awareness
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Making women aware of normal
breast to facilitate finding
abnormalities at the earliest possibility
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Breast awareness makes each women
to appreciate what is normal for them
Triple diagnosis
•
The use of diagnostic mammography, diagnostic
ultrasonography and fine-needle aspiration biopsy for
diagnosing palpable lumps
•
If any of the three modalities suggests cancer, excisional biopsy
warranted
•
Excellent sensitivity (99%) and specificity (99%)
•
Very good potential for early clinical diagnosis if linked with
awareness programmes
•
Important strategy to improve breast cancer control in low-and
medium-resourced countries.
IARC PERSPECTIVES: FOCUSSED
RESEARCH PRIORITIES
•
Documentation of the pattern and trends in burden of disease,
stage distribution and survival in several resource poor areas
(PBCRs, MRDs, improving staging practice, medical records)
•
Impact of awareness, education and investments/improvement
in health services on stage distribution, 2- and 5-year survival,
mortality
•
Evaluation of the efficacy and cost-effectiveness of CBE in
reducing breast cancer mortality
•
Identifying factors influencing participation of women in early
detection, diagnosis, treatment and follow-up care
IARC PERSPECTIVES:EXIT STRATEGIES
•
Strategic placement of the research activity
•
Contribution to capacity building in health
services
•
Continuity, sustainability of service activities
depending on the outcome of research
•
Roll out and scaling up
IARC PERSPECTIVES: LEARNING FROM
PAST EXPERIENCES
•
WHO-Russia BSE study
•
IARC-Philippines CBE study
•
Shanghai BSE study
•
Recent successes of IARC oral and cervix cancer
screening trials
•
Efficient information systems/collaborating
partners/institutions
Trivandrum Breast Cancer Screening Study (TBCS)
Objective:
To evaluate the extent of stage shift, survival
improvement
and
mortality
reduction
observed following the implementation of a
package of interventions consisting of
improving public and professional awareness
on breast cancer, its early clinical diagnosis
and prompt treatment and offering clinical
breast examination (CBE)
Trivandrum Breast Cancer Screening Study (TBCS)
Aims:
•
Decrease the frequency of advanced (stages IIB, III,
IV) breast cancers from the current 70% of all breast
cancer cases to 45% over a period of 7 years
•
Decrease the incidence rate of advanced (II B plus)
breast cancers by 30% over a 7-year period
•
Increase 5-year survival of breast cancer patients
from the current 55% to 80%
•
Reduce breast cancer mortality by 20% in the
intervention group as compared to the control group
Trivandrum Breast Cancer Screening Study (TBCS)
First round of screening: participation and compliance
(2006-2009)
Control
Number
Total eligible women
59,447
Eligible women interviewed
53,692
Intervention
(%)
Number
(%)
55,844
(90)
52,011
(93)
Received CBE
50,366
(90)
Women positive on CBE
2,880
(6)
Complied to referral for clinical triage by
doctors
1,415
(49)
Negative on CBE and attend referral clinic
394
Not screened and attend referral clinic
57
Referred for diagnostic investigations
986
Complied to diagnostic investigations
872
(88)
In collaboration with RCC, Trivandrum, India
Trivandrum Breast Cancer Screening Study (TBCS)
First round of screening: Investigation rates
Investigation
Number
Rate per 1000
Women screened
Mammography
825
14.8
Ultrasonography of the breast
831
14.9
Fine needle aspiration cytology
335
6.0
Excision biopsy
70
1.3
Nipple discharge for cytology
43
0.8
In collaboration with RCC, Trivandrum, India
Trivandrum Breast Cancer Screening Study (TBCS)
First round of screening: intermediate outcome
(2006-2009)
Control
Intervention
p-value
Number
%
Number
%
Breast cancers cases
62
77
Early clinical stage breast cancers (0-IIA)
20
(32.3)
35
(46.1)
0.095
Size of tumor <=2cm
4
(7.3)
14
(20.6)
0.026
Negative clinical node
30
(48.4)
38
(50.0)
0.815
Early pathological stage breast cancers (0-IIA)
18
(35.3)
39
(60.0)
0.008
Negative pathological node
22
(43.1)
39
(60.0)
0.069
ER positive breast cancers
22
(48.9)
27
(45.8)
0.771
Received conservative surgery
3
(4.8)
14
(18.2)
0.011
Deaths
6
(9.7)
3
(3.9)
0.159
In collaboration with RCC, Trivandrum, India
Trivandrum Breast Cancer Screening Study (TBCS)
Predictability of breast cancer
Criteria for screen
positivity
Breast lump
Others excluding lump
Number
Breast cancers
diagnosed (%)
1,767
31 (1.8)
902
1 (0.1)
In collaboration with RCC, Trivandrum, India
IARC PERSPECTIVES: FOCUSSED
RESEARCH INITIATIVES
•
Organization of a three arm cluster randomised trial
in 2010 for comparative evaluation of routine care,
focussed breast awareness and CBE
•
Will involve around 400, 000 women and follow-up
for a minimum of 9 years!
•
Currently the project proposal is being developed
•
Funding will be sought