International Disparity in Breast Cancer Outcomes: The Time to Close the Gap Is Now

cancernetwork.com

By ROISIN M. CONNOLLY, MB, BCh
Medical Oncology Fellow
Breast Cancer Program
The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center
Baltimore, Maryland
ANTONIO C. WOLFF, MD, FACP
Associate Professor of Oncology
Breast Cancer Program
The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center
Baltimore, Maryland | December 16, 2010

Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

Breast cancer is a significant global health issue: An updated analysis by the International Agency for Research on Cancer estimated that there were 1.38 million new breast cancer cases diagnosed in 2008 and confirmed that it remains the most frequent cause of cancer death in women worldwide.[1] Despite significant improvements in cancer incidence rates and outcomes in recent decades in high-income countries,[2] breast cancer case-fatality rates are unacceptably high in low- and middle-income countries [LMCs].[3] With an ever-ageing and increasing population worldwide, the number of new cancer cases will continue to grow in decades to come.

As well described by Dr. Anderson in this issue of ONCOLOGY, the Breast Health Global Initiative [BHGI] developed a number of evidence-based breast cancer guidelines aimed at resource-limited regions in an effort to improve breast cancer outcomes in LMCs. These guidelines include strategies believed to be acceptable and feasible to implement in LMCs, and relate to breast cancer early detection, diagnosis, and treatment. The BHGI gives specific recommendations reflective of the varying levels of resources available in each country.

The estimated global cost of treating breast cancer in 2009 was 24 billion US dollars.[3] However, the costs of many of the interventions for breast cancer early detection and treatment are unaffordable for many. The BHGI guideline, which outlines treatment resource allocation, acknowledges this potential barrier. For instance, it recommends tamoxifen as a low-cost drug that should be considered the most basic level of adjuvant hormonal therapy for women with hormone receptor [HR]-positive disease, based on a clear survival advantage over mere observation. The lack of an overall survival advantage from the upfront use of aromatase inhibitors over tamoxifen in large randomized trials of postmenopausal women is noted, and it states that this class of agents should be considered only if resources allow.[4] Oophorectomy is cited as a reasonable adjuvant endocrine strategy alone or in combination with tamoxifen in premenopausal women. In fact, the feasibility of this strategy was reported in Vietnamese patients with early breast cancer who were randomized to oophorectomy plus tamoxifen versus observation,[5] and Love et al reported a significant five-year overall survival benefit favoring the intervention [78% vs 70%, respectively, P = .041]. Equally important, a cost-effectiveness analysis of this intervention showed a cost of $350 per year of life saved.

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Author: Leslie Carol Botha

Author, publisher, radio talk show host and internationally recognized expert on women's hormone cycles. Social/political activist on Gardasil the HPV vaccine for adolescent girls. Co-author of "Understanding Your Mood, Mind and Hormone Cycle." Honorary advisory board member for the Foundation for the Study of Cycles and member of the Society for Menstrual Cycle Research.