Clinical Breast Cancer April 2004 • 11

editorial

I have previously written on the globalization of breastcancer. A recent visit to Peru, where I was the guest of theInstituto de Enfermedades Neoplasicas in Lima, has led meto consider another aspect of globalization.

Because the vast majority of published work in breast can-cer emanates from North America, Europe, and Japan, wetend to think of breast cancer primarily in First Worldterms. But breast cancer is increasingly a Third World chal-lenge. Recent data from the International Agency for Re-search on Cancer suggest that out of approximately 1.05 mil-lion new cases of breast cancer diagnosed each year, 471,000occur in less developed countries.1

In this world, breast cancer is a very different disease,though a disease that would have been quite familiar toWilliam Halstead. Screening mammography is virtuallynonexistent, and ductal carcinoma in situ and stage I breastcancer are consequently rare. After initial surgical resection,too many women cannot afford adjuvant therapy and, infact, they may not even be able to afford traveling to a dis-tant hospital for follow-up care.

The health care systems are characterized by a profoundlack of resources, aggravated in many countries by civil dis-order, AIDS, and corruption. Social and economic inequali-ties abound; the middle classes form a thin line betweenrich and poor. In such systems, resource allocation is liter-ally a matter of life or death. Should a national healthagency promote screening mammography when the vastmajority of women do not receive Pap smears of the cervix,which are cheaper and arguably more effective? Should ahospital buy the latest taxane or anthracycline derivativewhen children go unvaccinated? Many First World contro-versies (tamoxifen vs. aromatase inhibitor, which aro-matase inhibitor, dose-dense chemotherapy with granulo-cyte colony-stimulating factor support, use of gene chiptechnology in node-negative disease, etc) appear irrelevant

and unimportant in the context of Third World poverty. In-deed, the application of many of the expensive new tech-nologies to such a system might well damage the many inpursuit of benefiting the few.

The oncologists who practice in such systems are wellaware of these issues and wrestle with them daily. They per-form heroically under very trying circumstances. If my ex-perience in Lima was at all characteristic, they are thor-oughly aware of research trends in breast cancer and discussrecent issues of the Journal of Clinical Oncology with a fer-vor unseen in many North American practices.

In addition, they are increasingly a part of the general sci-entific enterprise. The Internet has eliminated many of thetraditional barriers to interaction and integration with thewider world of medicine. Clinical trials of novel agents canbe performed just as well in Peru as in Peoria, given com-mitted clinical researchers. This form of outsourcing has notbeen ignored by drug companies and cooperative groups.The problems of Third World countries—the preponderanceof patients with untreated stage III/IV disease and the lackof alternative agents—are a positive benefit when one is at-tempting to obtain proof of concept in a front-line setting.

Breast cancer is a global problem. As the world growssmaller, it may also have a global solution. Those who,through the good fortune of their place of birth, are blessedwith resources adequate to tackle the problem need to thinkof solutions that benefit the less fortunate.

1. Ferlay J, Bray F, Pisani P, et al. GLOBOCAN 2000: Cancer Incidence,Mortality and Prevalence Worldwide, Version 1.0. IARC CancerBaseNo. 5 Lyon, France: IARC Press; 2001.

George W. Sledge, Jr, MDEditor-in-Chief

Breast Cancer as a World Challenge

George W. Sledge, Jr, MDDivision of Hematology/OncologyIndiana University School of MedicineIndianapolis, IN