International Agency for Research on Cancer

Lyon, France

IARC perspectives on the development of a research agenda for early

detection and control of breast cancer in developing countries

R. Sankaranarayanan MDR. Sankaranarayanan MD Head, Early Detection and Prevention Section

(EDP)Head, Screening Group (SCR)

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Age-standardized incidence rates of breast cancer in selected populations in each continents, 1998-2002

SOURCE: Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160, Lyon, IARC. (2007)

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OCEANIA EUROPE ASIA N. AMERICA S. AMERICA AFRICA

• 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 1000-10,000 USD, urban rural differences, intracountry variation)

IARC perspectives: Current status of health services infrastructure and

investments

0 20 40 60 80 100

Gambia

Zimbabwe

Uganda

Philippines

India

Thailand

S.Arabia

Costa Rica

Cuba

Singapore

Turkey

SouthKorea

China

5-Year Survival from breast cancer (diagnosed during 1993-2001)

Breast Cancer (ICD-10:C50)• Highest in Hong Kong

SAR• Lowest in Gambia

Intra-country variation• Pronounced in China

(urban and rural ) & India & Philippines

• No difference in South Korea & Thailand

{range: 58-90%}

{range: 78-84}

1,329

3,204

2,169

2,462

21,810 cases

9,442

298

2,354 {range: 57-65}

{range: 31-54}11,013

{range: 40-55}1,714

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258

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5-year absolute survival for localised and regional extent of disease among more and less developed health services – Breast cancer

75.4

89.6

47.4

76.3

0 20 40 60 80 100

Regional

Localised

Survival%

Less devloped health services-Thailand, India, Costa Rica, etc.

More devloped health services (Singapore & Turkey)

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0 1 2 3 4 5

Year

Surv

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Localised-more dev.

Localised-less dev.

Regional-more dev.

Regional-less dev.

Absolute survival for localized and regional extent of disease among more and less developed health services - Breast cancer

Singapore & Turkey: 14 645 casesCosta Rica, India, Philippines, Saudi Arabia, Thailand: 17 640

cases

Modalities for early detection of breast cancer

• Awareness!

• Self examination

• Clinical breast examination (CBE)

• Ultrasonography

• Mammography

• Fine needle aspiration cytology (FNAC)

• Core biopsy

• Triple diagnosis

• Making women aware of normal breast to facilitate finding abnormalities at the earliest possibility

• Breast awareness makes each women to appreciate what is normal for them

Breast awareness

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

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)

• 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

Aims:

Trivandrum Breast Cancer Screening Study (TBCS)

Trivandrum Breast Cancer Screening Study (TBCS)

Control Intervention

Number (%) Number (%)

Total eligible women 59,447 55,844

Eligible women interviewed 53,692 (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)

First round of screening: participation and compliance (2006-2009)

In collaboration with RCC, Trivandrum, India

Investigation NumberRate 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

Trivandrum Breast Cancer Screening Study (TBCS)

First round of screening: Investigation rates

In collaboration with RCC, Trivandrum, India

First round of screening: intermediate outcome (2006-2009)

Control Interventionp-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

Trivandrum Breast Cancer Screening Study (TBCS)

In collaboration with RCC, Trivandrum, India

Predictability of breast cancer

Trivandrum Breast Cancer Screening Study (TBCS)

In collaboration with RCC, Trivandrum, India

Criteria for screen positivity

Number Breast cancers diagnosed (%)

Breast lump 1,767 31 (1.8)

Others excluding lump 902 1 (0.1)

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