Kristine M. Conner
University of Pennsylvania Cancer
Last Modified: May 14, 2001
What's the single biggest risk factor for dying of breast cancer, both in the U.S. and worldwide? Poverty, according to a series of presentations given by international researchers at ASCO this morning. Oncologists from the United States, Brazil, India, Australia, South Africa, and Germany came together to take their audience on a "global tour" of breast cancer diagnosis and treatment.
All six presenters responded to a hypothetical case study in which a 44-year-old woman presents with a 7cm painless lump in her right breast. They had been asked in advance to talk about how this woman would likely be dealt with in their respective countries, from diagnosis to treatment and follow-up. They also were asked to discuss any factors, such as culture, region, or socioeconomic status, that would likely affect the procedures which she would undergo.
Notably, all the speakers sketched out roughly the same course of diagnostic procedures and treatments, starting with the use of fine needle aspiration or core needle biopsy for the diagnosis all the way through to the adjuvant use of tamoxifen for cancer that proves to be estrogen-receptor positive. This was rather encouraging evidence that standards of care are being shared effectively at an international level, and Dr. Larry Norton, incoming ASCO president, made this point in his closing remarks. One notable difference in the course of recommended treatment was the emphasis that Monica Morrow, MD, of the U.S., and Klaus Hoeffken, MD, of Germany, placed on the possibility of offering some women breast- conserving surgery (rather than automatic modified radical mastectomy) by first attempting to shrink the tumors with chemotherapy.
However, larger differences emerged when the panelists spoke about how likely women in their countries would be to present with such an advanced breast cancer, and also how likely they would be to have access to what is now considered the standard of care.
In the United States, for example, women are much more likely to present with stage I or stage II cancers than stage III, noted Dr. Morrow of Northwestern University. Data gathered between 1983 and 1996 shows that fewer than ten percent of breast cancers are diagnosed at such a late stage. This percentage has remained constant, even as the incidence of stage I cancer has increased, most likely due to greater awareness about and access to screening. In Australia as well, noted Dr. Russell Basser, access to screening has been good, thanks to a BreastScreen program that offers free mammography screening to women over 40 every two years.
However, the situation is quite different in countries such as Brazil, India, and South Africa, with the respective presenters noting that awareness about and access to screening are limited. And this leads to frequent late-stage diagnosis. According to Dr. Gilberto Schwartsmann of Brazil, data suggests that roughly half of breast cancers in Brazilian women were diagnosed at stage III between 1979 and 1989. Dr. Rakesh Chopra said that "screening is totally out of the question" in India because of cost, so women have to be made aware of breast self-examination.
Furthermore, what treatment these women get is closely tied to socioeconomic status and where they live. Dr. Rakesh Chopra noted that in India, only women who have access to specialized cancer centers would likely receive what is now considered the standard of treatment for stage III breast cancer. Those who go to a government district hospital or medical college would likely be diagnosed with an incisional biopsy, rather than the newer techniques. Furthermore, they would be treated by a general surgeon, who would remove the breast and ovaries, and most likely have no additional care, due to the lack of availability of medical and radiation oncologists. For most of these women, travelling to a special cancer center would be out of the question.
In South Africa, noted Dr. Daniel Vorobiof, black women as a group would be much less likely than white women to have access to a specialized cancer center offering the best standard treatment. And for black rural populations, there are major cultural barriers as well, since cancer is still viewed as a "germ" that must be cast out by a religious healer. White women would be much more likely to have access to the most sophisticated care, and it's known that their lifetime risk is similar to that of women in Westernized nations.
Thus, it became clear that even as industrialized countries such as the U.S., the European nations, and Australia are likely to have much higher rates of breast cancer incidence, women there are more likely to have access to the standard of care outlined by presenters. But certainly there are regional and socioeconomic differences there, too.
American patient advocate Susan Shinagawa, past chair of the Intercultural Cancer Council and present activist with the Asian American Cancer Awareness Network and other groups, cited a litany of statistics that indicated the scope of the problem in the U.S. For example, breast cancer mortality rates are highest for African Americans and Alaska Natives. Among Asian- American and Alaska Native women, breast cancer is now their leading cause of death?not heart disease, as in other groups. Mortality rates are also comparatively higher for white women in Appalachia.
Shinagawa used these and other statistics to make the key point of her presentation: "Racial and ethnic minorities and medically underserved communities have greater suffering and death from cancer."
"If we applied everything we know equally across all populations, we could decrease cancer incidence by 25 percent and mortality by 50 percent," she asserted, although admitted that cigarettes might foil this vision.
So what's the solution, both in the U.S. and worldwide? The panelists as a group talked about educational outreach efforts that are going on or should be going on in their respective countries. They also spoke about efforts to disseminate specialized cancer centers more widely, so that women in more remote regions would also have access to care.
But ASCO president-elect Larry Norton raised a different possibility. It may be impossible to reach women who aren't even receiving the most basic health care with current treatments such as radiation, chemotherapy, and hormonal therapy, since they are expensive and somewhat complex to deliver. The answer may lie in the revolution in genomics, he said, which could lead to treatments that are cheaper and easier to deliver.
"We need to develop therapies that can be safely and cheaply applied worldwide," he said. "We'll have to turn to biology for our answers."