Breast Cancer in the Americas:

Closing Divides
UMIA-SONHS-Sylvester Global Oncology Symposium:
BREAST CANCER IN THE AMERICAS:
CARE TO CLOSE DIVIDES
October 16, 2018

Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho
January, 2008
June, 2007
PRESIDENCIA 2016-18
 Outline
1. Growing equity and
health priority
2. Mexico: Systemic innovations
across the cancer continuum
 Demographic and epidemiologic transitions
have been rapid and profound: LATAM
In just over 40
years, LAC will
achieve the aging
rates that most
European countries 66% 69%
took over two Communicable
centuries to reach.
Non-
Life expectancy has
Communicable
increased from
approx 30 in 1920, Injuries
to over 75 today 25%
16% 15%
In only a few
decades, causes of 9%
death changed 1980 2016
dramatically.
Source: IHME. GBD 2016.
Mortality is increasingly concentrated
in Chronic and NCDs: Breast Cancer

-43% 22% doubled

Mortality Cervical
in Breast cancer
cancer
childbirth

12,946 - 10,771 - 8,942 -

7,386 13,140 17,918

Annual deaths, Women 15-59, 1990 and 2016

Source: Estimates based on data from IHME 2016
 Leading causes of death among women
15 to 49 years, select LAC countries, 2016
Chile Costa Rica México Brasil

Bolivia Perú Jamaica Colombia

Source: IHME. GBD 2016

 Leading causes of death among women
15 to 49 years, select LAC countries, 2016

Country Breast cancer

Chile 2
Costa Rica 1
Mexico 4
Brazil 5
Colombia 2
Jamaica 1

Source: IHME. GBD 2016

Peru 6
Bolivia 7
 The Opportunity to Survive is,
but should not be, defined by income.
Inequality gap in survival:
Lethality (mort/incidence) Avoidable breast
60 cancer deaths
Haiti
Latin America
and the 55%
40 Caribbean
Jamaica
Low and
middle
Peru
Trinidad & income 64%
20
Tobago countries

0
Low income Lower middle Upper middle High income
countries income income countries
Source: Own estimates based on Globocan 2012
Trends in breast cancer mortality rates: USA,
Canada, Brazil, Costa Rica, Mexico, Colombia

USA, Canada --35%:

25 Awareness, Earlier detection
Age-adjusted mortality rate

and Better treatment

20
Canada
15
USA
Costa Rica Brazil
10
Mexico
5 Colombia

0
1955 1970 1985 2000 2013
1955196019651970197519801985199019952000200520102013 ¿2030?
Source: Data extracted from CI5plus.
 Stage at diagnosis and survival,
Breast cancer, Women, USA
% patients diagnosed at each 5 – year relative survival rate for
stage each stage at diagnosis

61% Localized
Confined to the organ
of origin

Regional
Spread to nearby
tissues or lymph
5% nodes

Distant
32% metastatic
99% 84% 24%
Spread to other
parts of the body

Source: American Cancer Society

 Breast Cancer Stage at Diagnosis:
Latin America and USA

Stage at
diagnosis
Lat Am USA

I 21% 80%
II-III 71% 19%
IV 7% 1%

Sources: Justo, Wilking, Johnsson, Luciani, Cazab, 2014, The Oncologist; and ACS. Facts & figures, 2015-2016.
 In LMICs a very large % of Breast Cancer
cases and deaths are in women <55
Low income LAC High Income
Diagnosis

33%
Age at

66% 61%
15-39

40-54

>55
Age at
Death

34%
67% 61%
Source: Estimaciones de los autores basadas en IARC, Globocan 2012
 Outline
1. Growing health priority for LAC

2. Innovations from
Mexico: harness
platforms and
integrate
Breast cancer: care continuum
Primary
Prevention

Early
Detection

Diagnosis

Treatment

Survivorship

Palliative
Care
 Breast cancer: care continuum

Primary Early Palliative

Diagnosis Treatment Survivorship
Prevention Detection Care

Mexico: Exemplary programs for

prevention of risk factors
and financing treatment but….
late detection, long lag time between
diagnosis and treatment, and little access
to survivorship or palliative care.
Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities
Seguro Popular now covers more
than 56 million Mexicans and
includes cancers in the
national catastrophic illness fund
Universal coverage by disease with an
effective package of interventions
2004/6: HIV/AIDS, cervical, ALL in kids
2007: Pediatric cancers; Breast cancer
2011+ : Testicular, Prostate, NHL,
Ovarian and Colorectal
 Seguro Popular and breast cancer:
Evidence of impact
Adherence to treatment:
2005: 200/600
2010: 10/900

Human faces of impact:

Guillermina
Abish
 Breast Cancer early detection:
Delivery failure
• 10-15% of cases detected in Stage I
• Poor municipalities: 50% Stage 4; 5x rate for rich
Municipalities
I II
States 50% III IV

High %
Stage IV

High Access to
Marginalized
Source: Authors’ estimates with database from IMSS, 2014 basic Services
 Inclusion of early detection of breast cancer in
the cash transfer, anti-poverty program Prospera

• Training materials for beneficiaries includes information about

early detection of breast as well as cervical cancer
• 3 million copies for promoters and trainers
• Reaches more than 90% of poor households in rural areas
Engage and Train primary care promoters, nurses and
doctors in early detection and post-treatment
management of breast cancer: Tómatelo a Pecho

> 16,000
Health Promoters
8 Risk Score (0-10) Significant increase in knowledge,
7 *
among health promoters,
6
especially
5
in clinical breast examination
4
(Keating, Knaul et al 2014, The Oncologist)
3
Pre Post 3-6 month
 CHW Education Project
Engaging CHWs in South Florida to promote early detection
of breast cancer among the farmworker population
– Adaption of the Mexico “train-the-trainer” models and
materials to local South Florida context
– Project aim: harness the role of CHWs and train on breast
cancer early detection and access to breast health and
breast cancer treatment and survivorship services
 Closing breast cancer divides
is an achievable
health, equity & economic imperative.

Synergistic strategies combining

advocacy and empowerment of women,
with universal health coverage platforms
need to be
developed, implemented and evaluated.
 Breast Cancer in the Americas:
Closing Divides
UMIA-SONHS-Sylvester Global Oncology Symposium:
BREAST CANCER IN THE AMERICAS:
CARE TO CLOSE DIVIDES
October 16, 2018

Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho