World Cancer Leaders’ Summit 2015

Steps towards improving breast cancer treatments in low and middle income countries

Dr Benjamin Anderson - University of Washington, Seattle, USA

Low and middle income countries have breast cancer, the epidemiology is different in many ways from the richer countries, but on the other hand it’s a huge problem and it’s one that’s not being dealt with very well. What are you doing about it?

Our group developed guidelines that are called resource stratifying. That means that you adapt to the existing resources to develop approaches that will improve breast cancer outcomes based upon the biology.

Can you give me an example?

Sure, it’s often said that breast cancer is different in low and middle income countries versus high income countries. Although the biology is essentially the same it’s that they present with later stage disease and they have difficulty achieving access to cancer treatments and then there are problems with following through so that their treatment is complete.

So what are the modalities that lead to success in reducing the burden of breast cancer and improving mortality in that disease in a low income setting?

What we need to do is take a systematic approach to breast cancer. You have to find the disease early, you actually have to prove it’s cancer, which requires systems including pathology, and then you need multidisciplinary treatment which includes surgery, radiation and systemic therapy and it needs to be put together in ways based upon evidence. Many have thought that this is not feasible in low and middle income countries and we respectfully disagree, we think this absolutely is achievable based upon systems approaches and outcomes.

And you say you believe it’s achievable, what are the kind of ways that it’s achieved because you may have a population that’s a rural population, the whole spread of the disease burden might be different.

You’re quite right that you have to adapt to the situation. When one is in low and middle income countries women commonly present with advanced disease, sometimes ulcerating and nearly metastatic. That’s a problem. So sorting out systems for finding the cancers earlier and getting the women to the sites where cancer treatment is available is one of the key strategies. We’ve been working on this in the context of Peru.

Within that, which professionals and which equipment supplies do you need? Presumably you need radiation equipment, you also need good surgeons, don’t you?

There will continue to be a role for surgery in breast cancer for quite some time. Actually it’s an essential resource, you have to be able to remove the tumours using appropriate strategies although that’s not particularly difficult. There are some ways in which we have to adapt resources so we don’t simply use the same tools in low income countries that we do in high income countries. The mammography debate, for example, is largely irrelevant in most of the world because it’s not affordable and because the women are presenting with advanced stage disease that’s detected through clinical means.

So what typically would be the priorities for getting the whole thing to work in a low income setting?

Unlike high income countries where the major debate on early detection is about mammograms - when we start, what age and how we select patients – in low and middle income countries the main question becomes how to find women with the smaller palpable masses, identify what subset of those are likely to be cancer and then develop a triage system to get them to the centre of excellence where that treatment is available. This is a systematic approach that our colleagues have been working in partnership with the National Cancer Institute and Regional Cancer Institute in the north to study and create a system that is functional.

How do doctors get involved with all of that because a doctor may well be good at treating disease but actually organising those systems is not so easy, is it?

Organising the systems is difficult and the clinicians need to be part of the solution. That means they need to understand their national cancer control plan, they need to know what resources are available and they need to take steps to make sure that the patient is correctly referred, that they don’t make mistakes based upon thinking only about their discipline. They need to understand how their work interfaces with other resources and they need to work in collaboration.

In breast cancer can you give me some kind of feel for the amount of benefit you can gain? Because if you treat breast cancer early there is a big gain, isn’t there?

It is certainly correct that we do much better with earlier stage cancer but I think it’s a misconception that early detection saves lives, it’s actually early treatment that saves lives.

Let me say primarily that if you get good treatment, as opposed to not getting good treatment, you do in fact make a big difference, don’t you?

That’s quite right and often what happens is that women are in systems where they don’t get a complete plan, they get pieces and it’s actually predictable based on the biology that that would fail. So while surgery is very important, I’d love to tell you surgery fixes everything since that’s what I do for a living, the fact is that it is only when it is followed by the appropriate adjuvant therapy, and in particular the drug therapy that we see these drops in breast cancer mortality in the high and middle income countries.

You can extend life by many years, can’t you?

Breast cancer is curable, we’ve had great successes and in the upper middle income countries and high income countries we are seeing breast cancer mortality dropping by between 1-2% per year. The question is how do we translate that into systems that have more limited resources.

So how would you sum up the bottom line take home message from this for cancer doctors, cancer clinicians everywhere and planners?

The bottom line is that we need to develop these comprehensive strategies that are appropriately adapted. It’s very important to not take a defeatist view and just say, ‘Oh well, we really just can’t fix this.’ It’s not true, we can. Many of the things that we do are affordable, the surgery could be available, we need to have pathology systems, many of the drugs that we have are very affordable and generic. So it’s by looking at the system as a whole, that’s how we will improve on the outcome of the most common cancer among women around the world.