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Breast Cancer in Brazil: Past and Future
Gustavo Werutsky
Department of Medical Oncology, Hospital São Lucas PUCRS
Latin American Cooperative Oncology Group
Porto Alegre, Brazil
Disclosures
• Dr Gustavo Werutsky has the following financial relationships to disclose:
• Grants and research support to institution from: AstraZeneca, Roche, MSD, BeiGene, BMS and Novartis.
• Honoraria from: Libbs, Dr Reddys, AstraZeneca and Roche
FACT: Death rates from breast cancer in the United States have dropped 39% between 1989 and 2015
ACS 2017
Changes in Cancer Incidence and Cause of Death in Latin America
Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017. Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.
Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017. Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.
Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.
Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), 2017.
Epidemiology and Diagnosis of BC in Brazil
Cancer Registries
Source: http://canceratlas.cancer.org; Goss, Lancet Oncol. 2013 Apr;14(5):391-4; Strasser-Weippl K. Lancet Oncol. 2015 Oct;16(14):1405-38
Epidemiology of Breast Cancer in Brazil
Lee LB. Lancet Oncol 2012; 13, e95-102
Impact of Screening in Breast Cancer Mortality
Welch G. N Engl J Med 2016; 375:1438-1447
Breast cancer treatment are responsible for at least two thirds (68%) of the reduction in mortality over time, while screening is responsible for the remainder.
Screening of Breast Cancer in Brazil
• 50% of all women older than 50 years have had at least one mammogram but few receive regular screening
• Only 24.1% of women aged 50–69 years receive appropriate screening in SUS
• Low mammography quality
Lee BL. Lancet Oncol 2012; 13, e95-102
Interval between symptoms/screening test and start of treatment
Bukowski A. J Glob Oncol. 2016 Nov 30;3(5):433-437.
Diagnosis of Breast Cancer in Brazil
• Median time from symptoms/MMG to diagnosis is 72–185 days.
• High proportion of locally advanced disease – particularly in public health system
• Discordance of ER, PgR and HER2 between local and central lab is a concern – few data
Lee BL. Lancet Oncol 2012; 13, e95-102
Age and Stage at Diagnosis per Health Insurance Type (AMAZONA III)
Rosa DD, Barrios CH, Bines J, et al. SABCS 20185
Mode of detection (AMAZONA III)
Rosa DD, Barrios CH, Bines J, et al. SABCS 2018
Geographic differences in the distribution of molecular subtypes of breast cancer in Brazil
Carvalho F. BMC Women's Health201414:102
Significant molecular heterogeneity in the BRCA1 and BRCA2 genes among Brazilian carriers
Palmero EI. SCIENtIFIC REPoRTS | (2018) 8:9188
Twenty-six novel variants were reported from both genes
BRCA 1 BRCA 2
Breast Cancer Treatment and Prognosis in Brazil
Global Access to Radiotherapy
Atun. Lancet Oncol 2015
AMAZONA I/II – Overall Survival in Stage I-III Breast Cancer Subtypes
Simon S, Bines J, Werutsky G, et al. The Breast 44 (2019) 113-119
Stage II Stage III
Disparities in Breast Cancer Prognosis by Type of Health Insurance – AMAZONA I/II 2001-2005
Liedke PE. Cancer Epidemiol Biomarkers Prev. 2014 Jan;23(1):126-33
N=3142 Sites=28
Real World Data on OS in Metastatic Breast Cancer
Year of Diagnosis
OS (m) 2008 2009 2010 2011 2012 2013
HR+ HER2- (N=9.908)
43.7 (40.2-46.6)
42.0 (38.9-44.6)
40.9 (38.0-43.4)
42.0 (39.2-45.0)
44.5 (41.8-47.3)
40.3 (37.8-ND)
HER2+ (N=2.861)
38.6 (33.6-44.6)
42.3
(38.3-50.8) 40.1
(35.2-45.6) 42.3
(36.5-49.8) 51.1
(46.5-NR) Not
Reached
HR- HER2- (N=2.317)
15.1 (12.7-16.4)
15.1 (13.0-17.4)
14.7 (13.2-17.0)
14.0 (11.4-15.9)
13.9 (11.4-15.9)
14.1 (12.5-15.5)
Delaloge S, et al. ASCO 2017.
OS 24 months
Overall Survival Private: 24 months Public: 21 months P = 0.94
HER2 + HER2 +
MBC Overall Survival by Type of Health Insurance (LACOG 0312)
Werutsky G. SABCS 2017
There was no difference in OS by type of health insurance coverage in any BC subtypes
Median OS: HER2+/HR+ 44 months HER2-/HR+: 36 months HER2+/HR- 34 months HR-/HER2-: 13 months
LACOG 0312 - Brazil SEER - USA
MBC Overall Survival by BC Subtypes (LACOG 0312)
Werutsky G. manuscript in preparation; Gong Y. Scientific Reports 2018; 7:45411
Clinical Trials as an Opportunity
Investment Return in Clinical Research
Asia Pacific 3.1%
Europe 28.7%
Asia 33.7%
Middle East 3.3%
Latin America
7%
Total Recruiting Trials: 933
Map of phase I, II and III Breast Cancer clinical trials in clinicaltrials.gov
Africa 1.2%
North America 65.2%
www.clinicaltrials.gov, accessed Feb 5th, 2018
Clinical Trials as an Opportunity
A STUDY TO OBSERVE PATIENTS CHARACTERISTICS, TREATMENT PATTERNS AND OUTCOMES IN PATIENTS WITH NEWLY DIAGNOSED
BREAST CANCER IN LATIN AMERICA - LATINABREAST (MO39485 - LACOG 0615)
Primary Objectives: describe patients characteristics, breast cancer subtypes at diagnosis, outcomes and build a electronic plataform/database Countries (N=10): Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Guatemala, Mexico, Peru, Uruguay. N=30 sites
Principal Investigators: G. Werutsky, C. Barrios
N=4500 ELIGIBILITY • Newly diagnosed stage I to IV
breast cancer (recurrent or de novo) no more than 3 months prior to data extraction, although they can have received anti-cancer treatment during that time
• Male or Female • >= 18 years
BASELINE • Patient demographics • Medical History • BC diagnosis and
treatment • Disease status and
outcome
FOLLOW-UP (5 years) • Changes / Sequence of
BC treatment Disease status and outcome
• Medical History • Safety
Conclusion
• Need to improve National cancer registry to better understand BC patients characteristics, treatment and outcomes
• Disparities in the access to screening, diagnosis, treatment and outcome is evident in Brazil (specially in public system)
• Implement and Ensure High-Quality Cancer Care Standards
• Cancer research is an opportunity for patients and should be a national priority in Brazil
