Breast Cancer Strategy Group of INCTR

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Breast Cancer Strategy Groupof INCTR

• Goals Objectives
• A Progress Report

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INCTR

• Non-profit organization.
• Goals
• Development of infrastructure in collaboration
  with physicians scientists of host countries
  for cancer treatment and control.
• To improve understanding of genetic and
  environmental factors that predispose people to
  various types of cancers and thus develop
  prevention strategies.
• Collaboration between the developed and
  developing countries.

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Cancer Care in Developing Countries

• It is estimated that by 2020, 80-90 of all
  cancers will be in developing countries which
  have only 5 of the world resources.
• By 2020 nine million (75) of the worlds cancer
  deaths will be in developing countries.
• Cancers which can often preventable with access
  to screening, immunizations and information e.g.
  liver, cervical cancers etc are on the rise.
• Over 80 of cancers are incurable due to lack of
  screening, late diagnosis and poor public
  awareness.
• Financial constraints, illiteracy and co-morbid
  conditions also contribute to this dismal
  picture.

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Epidemiology of Research in Low and Middle Income
Countries (LAMI)

• Over 85 of the worlds population lives in the
  153 countries (World Bank Criteria).
• Research is needed to meet the enormous and unmet
  health needs of LAMI countries.
• Scientific journals play an important role in
  production and dissemination of research.
• The gap between these and high income countries
  is widening in terms of publications.
• At present only a fraction of research published
  in widely accessible oncology journals is from or
  about these countries.

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Objectives of Disease Specific Strategy Groups

• Strategy groups comprises of investigators from
  developing countries who are interested in
  developing projects relevant to the study of
  disease of interest.
• Projects undertaken may include
• Translational research.
• Epidemiological studies.
• Clinical studies.
• Educational programs for public and
  professionals.

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Breast Cancer Strategy Group Meeting First

• Brussels, May 29th,2002.
• Participants 24.
• Purpose To identify potential collaborative
  projects relating to early detection and
  treatment of breast cancer in developing
  countries.

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Issues/Needs for Early Detection of Breast Cancer
in DC-First

• The following points were highlighted during
  ensuing discussions
• Need to assess the incidence and demographic data
  in countries where cancer registries are not
  available.
• Role of mammography as a population based
  screening tool in developing countries?
• Need for alternative detection programs e.g.
  mammography in high risk groups only.
• Need to assess efficacy of breast self
  examination and clinical breast examination by a
  physician.
• Need of professional education.
• Need for public education.

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Ideas/Proposals for Collaborative Activities
Related to Early Detection of Breast Cancer in
DC-First

• Training courses on cancer registration Dr. Joe
  Harford (NCI) proposed to serve as contact
  person.
• Development of public awareness
  program-demonstration project.
• Validation of physical examination as screening
  procedure.

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Ideas/Proposals for Collaborative Activities
Related to Treatment of Breast Cancer in
Developing Countries-First

• Inflammatory breast cancer is more prevalent in
  developing countries but is ill defined. More
  information is needed.
• Protocol for locally advanced breast
  cancer/inflammatory breast cancer needs to be
  developed.
• Study biological differences of breast cancer in
  developing and developed countries however
  logistics are a problem.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003) Second

• Objectives
• To make some progress on the projects of interest
  identified in the May 2002 meeting.
• Develop a study to identify characteristics and
  risk factors for breast cancer relevant to
  developing countries.
• Project related funding should also be a
  component of various projects.
• Presentations were made by various members of the
  sub-committee on epidemiological and clinical
  data.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)India

• Incidence of BC is increasing.
• Accounts for 10 of cancers.
• Higher incidence in urban areas.
• Crude incidence rate higher in high SES and
  literate women.
• Muslims and Parsis have a higher incidence.
• Early stage disease in lt25 patients.
• ER positive tumors occurred with same frequency
  in pre and post menopausal women.
• Women belonging to high SES and literate
  presented with early disease.
• In 2 distinct time periods(1960-1989 vs.
  1990-1998) public education programs did not
  affect disease stage significantly.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)Peru

• Incidence of BC is increasing and has now
  surpassed cervical cancer.
• Patients generally belong to lower SES.
• Most frequently occurs between 35-60 years.
• 36 present with Stage I and IIA BC, II B in
  (14), III (33) and IV in (16).
• Risk factors include family history of BC or any
  cancer and obesity (needs to be better defined).
• Poor follow up.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)Eygpt

• Cases analyzed were between 1986-1993.
• 27 of all cases were breast cancers.
• 85 received both chemotherapy and radiation.
• 45 patients were lt45 years.
• 54 had T2 disease and 33 had T3-4.
• 83 had MRM and 16 BCS.
• Women with smaller tumors, lower grade and LN
  negative fared better.
• Inflammatory breast cancer accounted for 15 of
  all BC cases.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)Pakistan

• Breast cancer incidence the highest reported from
  Asia other than Israel.
• Median age 45 years.
• No identifiable risk factors known in 70 cases.
• MRM is performed in more than 95 cases.
• Advanced disease present in gt60 cases.
• Poor outcome noted in patients belonging to low
  SES and illiteracy.
• RR of developing BC is 1.44 in women born of
  first cousin marriages.
• Incidence of BRAC12 is 8.4 in breast cancer
  patients.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)

• Dr. Guy Leclerq was interested in working on a
  collaborative project on genetic profile of
  breast cancer in developing countries.
• His work suggests that that the ER receptor in
  our countries has a protein truncation which
  affects the binding of estradiol /tam.
• He is also working on the types of BRCA12
  mutations in developing countries.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)Conclusions

• Incidence of BC rising.
• Risk factors for rising incidence need to be
  identified.
• Lack of public awareness.
• Advanced disease common especially related to
  lower SES and literacy.
• Treatment strategies for developing countries
  need to be identified.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)Conclusions

• On professional knowledge
• Lack of knowledge of referring physicians results
  in inadequate staging and diagnosis.
• Patients mismanaged prior to referral.
• Professional education of surgeons especially at
  district level hospitals essential.
• Post fellowship training and up to date standards
  of care must be maintained.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Jan 2003)Decisions

• Due two paucity of information o breast cancer
  and lack of published data on outcomes etc. it
  was necessary that a formal collaborative
  retrospective study of BC cases should be
  undertaken at participating institutes.
• Data collection will include risk factors,
  clinico-pathologic features, treatments,
  outcomes.
• Period 1993-1997.

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Breast Cancer Strategy Group Meeting (May 2003)
Third

• Objectives
• To obtain further information from participants
  about their perspectives on breast cancer in
  their countries.
• Further development of breast cancer survey.
• Development of treatment protocol for locally
  advanced breast cancer.
• Possibility of conducting molecular studies.

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Breast Cancer Strategy Group Meeting (May 2003)
Third

• The designed retrospective survey was circulated
  and discussed.
• Modifications were made to improve the quality of
  information.
• A pilot of 250 surveys will be done in order to
  determine problems of missing data and problems
  related to completion of survey.

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Breast Cancer Strategy Group Meeting (May 2003)
Third

• Two other important decisions were taken
• Development of treatment protocol for locally
  advanced breast cancer.
• To examine the role of neo-adjuvant chemotherapy
  in LABC.
• Interest was expressed in comparison of CMF to
  anthracycline based chemotherapy.
• To study estrogen receptor molecular
  heterogeneity and genomic profile of BC patients
  in developing countries.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Early Detection) (Oct 2003,
Fourth) Egypt

• This meeting was attended by also Dr. Richard
  Chamberlain and Dr Amr Soliman from MD Anderson.
• Efforts were needed to make early diagnosis and
  appropriate referrals as majority (60) patients
  presented late and had inadequate treatment.
• Mammography as a screening modality is not
  feasible and emphasis on clinical breast exam and
  self examination had to made.
• Major discussion was focused on knowledge,
  attitudes and practices (KAP) of primary care
  physicians about BC in developing countries.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Oct 2003) Egypt-follow up

• A pilot study was undertaken in Egypt,Pakistan
  and Tunisia.
• To identify strengths and weakness in medical
  education and primary health care practices.
• Develop an educational programs to improve
  referrals and early detection.
• A questionnaire was designed to assess KAP of
  physicians about BC , diagnosis, management and
  risk factors.
• Development of questionnaires, lectures, and pre-
  and post-testing (March-August 2004) to
• 260 physicians in Pakistan
• 150 physicians in Egypt
• 75 physicians in Tunisia.
• Data analysis is in progress.
• ? We anticipate the increase in the overall score
  of the questionnaire after the delivery of
  presentations underlying the basics of IBC.

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Breast Cancer Strategy Group Meeting
Sub-Committee (Oct 2003) Egypt-Result

• The module in Pakistan was conducted in one urban
  and 2 semi-urban areas
• It was very well received.
• Younger doctors more receptive.
• Doctors in urban areas understood the concepts
  better.
• Urban and young doctors working in academic
  institutes were more receptive to change in
  thinking.

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Breast Cancer Strategy Group Meeting
Sub-Committee (May 2004)

• Objectives
• Finalize the retrospective breast cancer survey
  and agree upon plans for initiation.
• Treatment protocol for LABC.
• Specific biologic studies that can be undertaken
  for patients with BC.

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Breast Cancer Strategy Group Meeting
Sub-Committee (May 2004)

• The retrospective survey was sent to Susan Komen
  Foundation for funding.
• We were unsuccessful in getting the grant due to
  
• Quality of retrospective nature of study and
  associated pitfalls.
• What impact it will have on the reduction or
  early diagnosis in women from developing
  countries?
• The accuracy of data and subsequent comparison.
• I think there is an unconscious perceived bias
  against research from developing countries as
  reviewers do not understand the difficulties of
  carrying out research and also question the
  validity of data .

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Editors/Reviewers/Researchers for Low Middle
Income (LAMI) Countries

• Editors and reviewers should be familiar with
  research needs and research infrastructure in
  LAMI countries.
• Encourage publications from LAMI countries.
• Include editors and reviewers with a special
  interest and expertise in LAMI countries in
  editorial boards.

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Breast Cancer Strategy Group Meeting
Sub-Committee (May 2004)

• The group considered that despite setback
  retrospective study should be considered.
• It was important to demonstrate that high quality
  data can be collected from the developing world.
• It was also hoped that by gathering data the
  proposal could be resubmitted either as
  prospective or retrospective study in future.
• Alternative sources for funding should be
  explored.
• The target date for completion will be 18 months
  from the start of study.

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Breast Cancer Strategy Group Meeting
Sub-Committee (May 2004)

• Protocol for LABC was discussed and in principle
  agreed upon.
• A randomized 3 arm study will be conducted
  comparing standard treatment arm with FAC and
  CMF with concurrent RT in experimental arms.
• A draft protocol will be discussed in this
  strategy group meeting.

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Breast Cancer Strategy Group Meeting
Sub-Committee (May 2004)

• Dr Leclerq and Dr. Lacroix again attended the
  meeting.
• They described their work on ER and their
  variants.
• They are also studying patterns of gene
  expression in breast cancer.
• Various collaborative projects were discussed.
• Issues discussed were Shipping of samples
  outside the country of origin costs involved.
• He was willing to train doctors if they could get
  funding through ICRETT etc.

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Breast Cancer Strategy Group Meeting
Sub-Committee (May 2004) Future directions

• Role in professional educational activities.
• Development of guidelines for the management of
  breast cancer.
• Early detection programs and public awareness
  campaigns.
• INCTR has been invited to participate in two
  meetings in which it might be an opportunity for
  strategy group members to develop a program
  tailored to needs of professionals in developing
  countries.
• Participants agreed that more time was needed to
  formulate their ideas about the content for a
  professional education program.