1. ABC1: Advanced Breast Cancer 1
1st Consensus Conference
November 3-5, 2011, Lisbon, Portugal
Managing Breast Cancer in Low and Middle
Income countries
Nagi S. El Saghir, MD, FACP
Professor & Director,
Breast Center of Excellence
NK Basile Cancer Institute
American University of
Beirut, Beirut, Lebanon

2. Beirut Marathon November 7, 2010
Coming up : Beirut Marathon November 27, 2011

3. Breast Cancer Incidence Rates
Worldwide and in LMC
• Incidence is declining in many parts of
USA and Europe (with variations according to
state, socio-economic status, race)
• Estimated Incidence (& Prevalence) is
rising in most Low- & Middle- Income
Countries (Lack of widespread Regional
and/or National cancer registries)

4. USA: Trends in Breast Cancer Incidence Rates
Drop seen till 2004, stabilization since then
Desantis C, Siegel R, Bandi P, Jemal A. CA Cancer J Clin 2011 Oct 3, Epub

5. Estimated age-standardized incidence
rates: ASR /100,000 women /year
for breast cancer: GLOBOCAN 2008
Ferlay J, Shin JR, Bray F, et al. Int. J. Cancer: 127, 2893–2917 (2010)

6. Breast Cancer in LMCs
• Global number of new breast cancer cases in
2008: ~ 1.38 Million
• LMCs account for 45% of new breast cancer
cases worldwide; expected to make 70% of
cases by 2020
• 54% of annual breast cancer deaths occur in
LMC
• Nearly 50% increase in breast cancer global
incidence and mortality is expected 2002-2020
Lingwood RJ, Boyle P, Milburn A, et al. Nat Rev Cancer 2008; 8: 398–403.
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

7. Increased incidence & worse survivals in LMCs
Factors associated with increased incidence:
• Change in reproductive patterns
• increased life expectancy
• Changing lifestyle characteristics
Factors associated with worsened cancer survival:
• largely attributable to late stage presentation:
- In India, 50-70% of cases have locally advanced
disease at diagnosis
- In Arab countries, 60-80% had LABC and MBC
Chopra R. The Indian scene. J Clin Oncol 2001; 19 (suppl 18): 106S–11S
El Saghir N, Khalil M, Eid T et al, Intl J Surg. 2007 Aug;5(4):225-33

8. WHO Definitions:
Income-status & effects on health care



• The lower the income status:
 Lesser average life expectancy
 Lower public funding of health
 Higher out-of-pocket health expenditure
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

9. Survival by stage vs status of health services
of countries
Sankaranarayanan R, Swaminathan R, Brenner H, et al. Lancet Oncol 2010; 11: 165–73
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

10. Breast Cancer Survival vs Race/Ethnicity (USA)
Race/Ethnicity Breast Cancer-specific survival
2001-2007
Non-Hispanic White 88.8%
African American 77.5%
Asian American/Pacific Islander 90.3%
American Indian/Alska Native 85.6%
Hispanic/Latina 83.8%
• Survival Rates are lowest in African American
• Decline of Mortality rates is slower in poorer areas
DeSantis C, Siegel R, Bandi P, Jemal A. CA Cancer J Clin 2011 Oct 3, Epub

11. Breast Health Global Initiative BHGI
a Guideline and Project-Development group
BHGI Resource Stratification
(Anderson BO, Carlson R, Eniu A. 2006)
 Basic level: Core resources or fundamental services
necessary for any breast health care system to function.
 Limited level: Second-tier resources or services that
produce major improvements in outcome such as survival.
 Enhanced level: Third-tier resources or services that are
optional but important, because they increase the number
and quality of therapeutic options and patient choice.
 Maximal level: Highest-level resources or services used in
some high resource countries that have lower priority on
the basis of extreme cost and/or impracticality.

12. BHGI GUIDLINES for management of breast
cancer according to levels of resources
Anderson BO, Carlson R, Eniu A, et al. Cancer 2008;113:2221-2243
•HEALTH CARE SYSTEMS •EARLY DETECTION •DIAGNOSIS
•STAGE I •STAGE II •LOCALLY ADVANCED •METASTATIC

13. BHGI: Guidelines  Implementation
 Optimization of management & care delivery
Lancet Oncology 2011; The Breast (suppl) 2011
• Anderson BO, Cazap E, El Saghir NS, Yip CH, Khaled HM, Otero IV,
Adebamowo CA, Badwe RA, Harford JB. Optimisation of breast cancer
management in low-resource and middle-resource countries: executive summary of
the Breast Health Global Initiative consensus, 2010. Lancet Oncol. 2011
Apr;12(4):387-98
• El Saghir NS, Adebamowo, CA, Anderson, BO, Carlson RW, Bird PA, Corbex M,
Badwe RA, Bushnaq MA, Eniu A, Gralow JR, Harness JK, Masetti R, Perry F,
Samiei M, Thomas DB, Wiafe-Addai B, Cazap E. Breast cancer management in
low resource countries (LRCs): Consensus statement from the Breast Health Global
Initiative. The Breast 20 (2011) S3 - S11
• Yip CH, Cazap E, Anderson BO, Bright KL, Caleffi M, Cardoso F, Elzawawy AM,
Harford JB, Krygier GD, Masood S, Murillo R, Muse IM, Otero IV, Passman LJ,
Santini LA, da Silva RC, Thomas DB, Torres S, Zheng Y, Khaled HM. Breast
cancer management in middle-resource countries (MRCs): consensus statement
from the Breast Health Global Initiative. Breast. 2011 Apr;20 Suppl 2:S12-9.

14. LMCs: Resources & Treatment Limitations
• Mastectomy remains the most common surgical
procedure
• Radiation therapy, where available, is more often
used only for palliative care than treatment
• Systemic chemotherapy is not always
administered by trained medical oncologists
whose numbers are few anyway
• Proper choices of therapy require good quality
pathology laboratories and reliable determination
of ER, PR and HER2 that are not always available
• Palliative care remains very fragmented
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

15. LMCs: Recommendations by the BHGI 2010
• Public awareness and Early Detection programs: Reduces
taboos and excessive fears
• Clinical breast examination should be promoted as a
necessary method for clinical diagnosis of breast
abnormalities
• Need to optimize tissue sampling and pathology services
• More early detection, and more Radiation Therapy centers
reduce mastectomy rates
• Need for Integration of services within multidisciplinary
settings
• Reduce barriers to access of cancer treatment and drugs
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

16. BHGI, Guidelines for stage IV
Anderson, BO, Carlson R, Eniu A. et al. Cancer 2008;113:2221-2243

17. Treatment of patients with
Metastatic Breast Cancer in LMCs
• Cytotoxic chemotherapy: CMF, anthracyclines provide
good short-term palliation
• Training of health care professionals (Oncologists and
others) to deliver chemotherapy & monitor side effects
• Targeted therapy, ex. trastuzumab, along with chemo, is
highly active against HER2-overexpressive breast
cancer but remains too expensive to be available for
patients in LMCs
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

18. New Therapies: Access and costs in LMCs
• High costs, usually given for long terms
• Anti-HER2 therapy
Anti-HER2 therapy beyond progression
Anti-HER2 therapy beyond response
Other targeted therapies
Anti-angiogenic therapy, …
• The issue of “Statistically significant “ results
vs “clinically meaningful “ results is very relevant
in LMCs!
• Costs and accessibilty: Major problems

19. New Therapies: access and costs in LMCs
• Generics are Good options:
• However, Many physicians in LMCs remain
uncomfortable prescribing generics, either
- because of poor quality control on
manufacturing of generics
- because of strong “big pharmaceuticals”’
lobbying
- “Copies” (Illegal) of drugs are promoted as
“Generics” and authorized in many countries!

20. Training & “Brain drain”
from Low-resource to high resource countries
• Health care workers providing anticancer therapy need
good education and proper training
• Training in countries with enhanced resources is a very
common and beneficial practice, but carries risk of
having trained people stay in high-income countries
• Most LMC have graduates and trainees pursue higher
education and training in countries with enhanced
resources  suffer from the Brain Drain phenomenon
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

21. Suggested solutions for “Brain drain”:
Onsite training / Improve local conditions
• On-site training by International Experts (of physicians, medical
oncologists, radiologists, pathologists, nurses, nurse practitioners, pharmacists and
all health care providers)
• Short-term stays overseas reduce chances of staying
there
• Encourage commitment of traveling trainees to returning
back home
• Improve local facilities and working environments
• Increase local supporting staff
• Better compensation in their homeland
• And, of course: Socio-economic and political reforms!
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

22. BHGI LEARNING LABORATORY:
On-Site Training at Ghana Breast Cancer
“Specialty Training Course series 2010”

23. Promoting multidisciplinary management
of patients with breast cancer in LMCs
• Care for patients with breast cancer is best
delivered through multidisciplinary teams.
- “Breast Units”
- “Breast Centers of Excellence”
• Improves standards of care
• Sets up models for the rest of the country or region
where they are created
• Communications with physicians in rural areas
help to improve care in the whole country
Anderson BO, Cazap E, El Saghir NS, et al. Lancet Oncol. 2011 Apr;12(4):387-98

24. Multi-Disciplinary Management in LMCs
338 Physicians in Arab countries survey: 72% hold TUMOR BOARDS
Only 52% hold it weekly
57% attend Tumor Boards at Neighboring Hospitals
93% agree it should become mandatory
100% agree to have at least a MINI-TUMOR BOARD
meeting with whoever is available!
(Ex: Surgeon +Radiologist +/- Oncologist +/- Pathologist, …, )
El Saghir NS, El-Asmar N, Hajj C. et al. The Breast 20 (2011) S70 - S74

25. Down-staging of breast cancer in
LMCs
• A priority goal of Cancer Control Programs that
countries with low and middle income:
• Community awareness
• Early detection
 Downstaging and Prevention of LABC and MBC
 Improvement of outcome and quality of life

26. Awareness campaigns help downstage
breast cancer at presentation
Early detection saves breasts, saves lives, and saves families!

27. Awareness Campaigns help downstage breast
cancer: Ex.: in Lebanon and other Arab countries
• Young age at presentation: 50% are below the age of 50y
(not changed)
• Patient advocates: Sporadic, still not organized
• High proportion of Locally advanced and metastatic
diseases at presentation: 60-80%: presently decreasing
• High rates of Mastectomy: 88-60%: presently
decreasing, down to 50% or less in many centers
• Low percentages of in-situ disease: <5% (presently
increasing in some areas, due to use screening
mammography!)
Adapted from El Saghir N, Khalil M, Eid T et al, Intl J Surg. 2007 Aug;5(4):225-33

28. Regulatory Agencies & Guidelines in LMCs
• Absence of reliable Local Regulatory Agencies in most countries
• Reliance on International regulatory agencies: FDA & EMEA, NICE,
others
• International Guidelines remain essential; however, Guidelines
often assume unlimited resources!
• Adaptation of guidelines to local areas: ex.: NCCN-MENA
(Abulkhair O, Saghir N, Sedky L, et al. JNCCN 2010 Jul;8 Suppl 3:S8-S15):
have had limited success & utilization
• BHGI Guidelines
• ABC1 has adopted a great initiative of addressing the issue of
resources
• Prices are hoped to go down to make drugs accessible for women
worldwide: … Imaginable ?!!!!!!!! … Why not ?!!!!!!!

29. Thank you for your attention!
Raouche Twin Rocks, Beirut, Lebanon