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Reports Thematic Workshop on Breast Cancer
Control at EMRO
Dr. Robert Burton (Monash University, Australia) provided an overview of breast cancer control, pointing out that survival from breast cancer in women has improved in many countries, especially in North America, Europe and Australia. Much of this is a result of improved awareness resulting in a reduction in tumor size (with most patients presenting in stages 1 and 2) at presentation and improved treatment. The room for improvement of survival in technically advanced countries is now very small. In low- and middle-income countries, however, a much higher fraction of women present in stages 3 and 4. Therefore, the first aim of an early detection program in such countries is to promote diagnosis in stages 1 and 2. This is not the objective of mammography, which is to find impalpable breast cancers in stage 1, and it misses many invasive breast cancers in younger women. Even in high-income countries, the value of mammography in reducing mortality may be small. Reduction in breast cancer mortality in the UK seems almost entirely due to treatment, while in Australia, reduction in breast cancer mortality was greatest in women aged 40-49, a group not targeted for breast screening by mammography! In contrast, improvement in therapy response through the introduction of National Clinical Practice Guidelines was substantial. Dr. R. Bekkali (Association Lalla Salma Against Cancer - ALSAC) provided some insights into screening strategies in Morocco. In the ALSAC study the target group for screening is women aged 45-65, as many cases are identified in women age 45-49, a population subset of more than 2 million women. The mean age of detection of incident cases is 48 years. Morocco has higher reported breast cancer incidence than Tunisia and Algeria, but a much lower incidence than in the West. Because of limited radiological resources, a telemammography pilot project was first conducted using digital mammography, with second reading of images in Brussels. Among the first 1000 women, five cases of breast cancer were found but three had clinically detectable disease. Consequently, the Scientific Board of the Lalla Salma Association recommended that screening be undertaken by clinical breast examination. Following this recommendation, a screening program was initiated through the primary health care system. Women are invited to be screened by clinical breast examination (CBE) conducted by physicians and nurses trained in CBE. Diagnosis is carried out at the secondary health care level where CBE is repeated, and mammography, ultrasound, biopsy and pathology can be performed if necessary. If breast cancer is confirmed, treatment is performed at the tertiary level. Dr. Bekkali also pointed out that in Morocco it is difficult to persuade women without symptoms to be examined. In an attempt to overcome this, a media campaign, using print and television, was initiated in May 2008 to provide the necessary health education. This campaign, which was the first time in Morocco that breast cancer has been talked about in public, was led by women affected by breast cancer. A well-known singer acted as a celebrity advocate. In implementing the screening process in the public health system, 2,300 family physicians were trained, 120,654 CBEs performed, and 1284 women identified as suspected of having breast cancer. Dr. Anthony Miller (University of Toronto, Canada) discussed the pros and cons of different methodologies relating to early detection: education alone, CBE/breast self examination (BSE) and mammography. He pointed out that mammography screening is less effective in women under age 50, and the technical and personnel requirements for population-based mammography screening are very substantial. An IARC working group (2002) determined that the reduction in risk of death from breast cancer by mammography screening was 12% in women aged 40–49 and 25% in women aged 50–69. In a large, more recent, UK trial among women aged 39-41 on entry, the ratio of breast cancer deaths at mean follow-up of 10.7 years in the intervention arm relative to the control was 0.83 (95% CI 0.66-1.04), i.e. a non-significant 17% reduction in breast cancer mortality. He pointed out that there has been only one trial that was specifically designed to evaluate the role of mammography over and above annual breast examinations and the teaching of BSE - the Canadian National Breast Screening Trial among women aged 50-59. In this trial, no breast cancer mortality reduction was found in the mammography-containing arm. A model-based analysis however suggested a benefit from CBE/SBE of 20% compared to no screening, and an extension of this observations suggests that breast examination is far more cost-effective than mammography screening. Although in Western countries breast cancer mortality has been falling, the timing of this recent fall is compatible with improvements in therapy, but is not compatible with an effect of mammography screening. Moreover, the lack of any reduction in mortality prior to 1990 suggests that early detection is not effective in the absence of effective treatment. Dr. Miller also described a trial of breast examination as a means of screening in Cairo. The pilot study included 4000 women, and 10,000 women were subsequently randomized using the cluster method in two other areas. There was a high rate of breast cancer detection with good compliance with diagnosis and preliminary evidence of a stage shift to an earlier stage at diagnosis in the BE group. The experience is now being replicated in Khartoum, Sana'a and Yazd (Iran), with projects designed to be compatible with local resources. Dr. Miller feels that BSE should be taught as part of BE and used as a means of contributing to breast cancer awareness, but should not be used by itself.
It was emphasized that a beneficial population impact requires an organized approach and a high compliance rate, not only with screening, but with diagnosis and recommended treatment. Opportunistic screening has been shown to be ineffective. There are detriments from early detection and screening, and we need to ensure they are not hidden, and that women are not coerced into screening. Dr. Manzoor Ahmed (President, College of Pathologists, Pakistan) discussed the importance of rapid and accurate diagnosis in the control of breast cancer. This requires excellent communication, particularly between the surgeon and pathologist. The latter must distinguish between benign and malignant lesions and provide all information required to facilitate treatment planning. There should be quality assurance and standardization of practices. Minimally invasive needle biopsy is simple and inexpensive and can be done as an outpatient but requires carefully trained staff. Core-needle biopsy provides more information than fine needle aspiration and has the advantage that enough tissue is obtained to determine hormone receptor status. Pathology reports should include, tumor size, information on whether or not the margins are free of tumor, the degree of nodal involvement of the axillae (based on lymph node biopsies), histological subtype and, where possible, hormonal status. Inaccuracies in diagnosis can be reduced by supervision, better training, and academic involvement. Dr. H. Khalid (Vice President, Cairo University) discussed clinical management, pointing out that after a tissue diagnosis has been made, the next step is to assess the extent of disease (stage). Tumor size can be assessed by ultrasound (preferred in women under 30 years) or mammography (preferred with older women in addition to ultrasound if necessary). In Egyptian women with early stage disease, breast conserving surgery is preferred; this usually involves post-surgical radiation therapy, and in a few cases, additional systemic chemotherapy. Systemic treatment is necessary for locally advanced breast cancers, and is most generally given after surgery, although neoadjuvant therapy (prior to surgery) also improves outcome. In technically advanced countries, survival of advanced breast cancers has improved with combination chemotherapy regimens. Multidisciplinary care is essential, as it formalizes discussions and decisions about diagnosis, stage and plans for the right combination and sequence of treatment. Treatment guidelines have been produced by the Breast Global Health Initiative, in addition to other organizations, and recently updated (2008). Local (Egyptian) guidelines have also been produced. A unusual form of breast cancer – inflammatory breast cancer, which progresses rapidly, comprises 8% of breast cancers in Egypt and is particularly difficult to manage. This form of cancer is extremely rare in Western countries. Dr. R. Sankaranarayanan (Head Early Detection and Prevention Section and Head Screening Group, International Agency for Research on Cancer) discussed the evaluation of any breast cancer control program.
Obtaining these indicators requires a program database. The quality of the program can be assessed by linking with an appropriate (population-based) registry. Official death records often need to be supplemented with data from other sources (e.g. church and other registers) in order to obtain as complete information as possible. In CBE studies it is essential to identify the fraction of cancers missed by follow-up of screened women. This may add considerably to cost. Dr. Sankaranarayanan discussed two recent studies. In Trivandrum, a cluster-randomized breast cancer screening study, designed to evaluate the extent of stage shift, survival improvement and mortality reduction in the context of a package of interventions consisting of breast awareness, CBE and improving public and professional awareness on breast cancer, its early clinical diagnosis and prompt treatment was carried out. Over 90,000 women were divided between the two arms. In the control group, education on cervix cancer and cervix cancer detection were offered in clinics. In the intervention arm, education on BSE, early detection of breast cancer, CBE, FNAC, biopsy, staging and treatment were offered. Thirty-four breast cancers have been detected in the intervention arm, and 26 in the control arm, of which 60% and 42% are stage I and IIa, respectively. These findings, that show that education alone can result in down staging, are now being used to inform the regional breast screening program. In Sarawak it has been possible to demonstrate that a simple health awarness program, without screening, can result in patients presenting for treatment with less advanced cancer. Similar observations have been made in South Korea. These findings should be taken into consideration by cancer control committees in determining optimal approaches to breast cancer control in the context of available resources. Dr. N. Elsaghir, from the American University of Beirut Cancer Center, discussed the prevention and early detection of breast cancer in Arab countries. Unfortunately, tertiary prevention – i.e., the treatment of advanced disease, is the primary form of cancer control in Arab countries. Given the cost of treating advanced disease in the majority of patients, there is a need to move to secondary and primary prevention. In Lebanon and other countries, the incidence of breast cancer is increasing, in part from improved detection, and also from changes in lifestyle: increased fat in the diet, limited exercise among women, the increasing age of the mother at first birth and the frequent use of hormone replacement therapy (HRT); there is clearly a role for primary prevention. In Tunisia, approximately 5-7% of newly diagnosed cases are inflammatory breast cancer. The prevalence of mutations in genes that predispose to breast cancer (BRCA1 and 2) is unknown. Misdiagnosis, and/or negligence by primary physicians often leads to delays in diagnosis, but other factors contributing to advanced disease at the time of therapy include:
OBSTACLES AND SOLUTIONS In the afternoon a series of working groups took place. These included:
Adapted from a report by Anthony Miller, University of Toronto, Toronto, Canada |
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Copyright © 2010 The International Network For Cancer Treatment and Research