Dr. Felicia Marie KnaulMiami Institute for Advanced Study of the Americas and Miller School of Medicine,

University of Miami; Fundación Mexicana para la Salud; Tómatelo a Pecho

Breast Cancer in the Americas: Closing Divides

through Systemic Innovation & Advocacy

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.

Estrategias para reducir el cáncer de mama en las Américas:

Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS),

la Unión Latinoamericana Contra el Cáncer de la Mujer(ULACCAM)

y Tómatelo a Pecho, A.C.

October 29, 2018

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.

Enero, 2008Junio, 2007

PRESIDENCIA 2016-18

Outline

1. Growing health

priority for LAC 2. Meeting the challenge: Integrating breast

cancer into Universal Health Coverage

3. UHC: Examples from Mexico

4. Monitoring progress to close divides

Breast Cancer:

Incidence and mortalityLAC and Global, Globocan, 2018

Annual Daily Hourly How often

IncidenceLAC 199,734 547 23 3 min.

Global 2,088,849 5,722 238 15 sec.

MortalityLAC 52,558 106 4 15 min.

Global 626,679 1453 61 1 min.

Fuente: Globocan 2018.

Fuente: Estimaciones propias con base en Globocan 2018.

In Latin America, Breast cancer is….

The most common cancer of women

The 5th most common cancer overall

186,000 new cases each year

14% of all new cancer cases

47,000 deaths per year

The 3rd most common cause of death in

women aged 15-69

Source: Own estimates based on Globocan 2018 & Knaul, F. M.,

Arreola-Ornelas, H., Rodriguez, N. M., et al., (2018).

Avoidable Mortality: The Core of the Global Cancer

Divide. JGO, 4, 1-12.

The Opportunity to Survive is,

but should not be, defined by income.

Avoidable breast

cancer deaths, 2106

Latin America

and the

Caribbean

55%

27,000

Low and

middle

income

countries

64%

220,000

Inequality gap in survival:

Lethality (mort/incidence)

Low income

countries

Lower middle

income

Upper middle

income

High income

countries

0

20

40

60

Haiti

Jamaica

Peru

Trinidad &

Tobago

Trends in breast cancer mortality rates: USA,

Canada, Brazil, Costa Rica, Mexico, ColombiaA

ge

-ad

jus

ted

mo

rta

lity

ra

te

Source: Data extracted from CI5plus.

0

5

10

15

20

25

1955196019651970197519801985199019952000200520102013

Canada

USA

Costa Rica Brazil

MexicoColombia

¿2030?

USA, Canada --35%:

Awareness, Earlier detection

and Better treatment

1955 1970 1985 2000 2013

México 2030?:

• <19,000 muertes

• O

• +5,200 muertes

Stage at diagnosis and survival,

Breast cancer, Women, USA% patients diagnosed at each

stage

5 – year relative survival rate for

each stage at diagnosis

61%

32%

5%

99% 84% 24%

LocalizedConfined to the organ

of origin

RegionalSpread to nearby

tissues or lymph

nodes

Distant

metastaticSpread to other

parts of the body

Source: American Cancer Society

Breast Cancer Stage at Diagnosis:

Latin America and USA

Sources: Justo, Wilking, Johnsson, Luciani, Cazab, 2014, The Oncologist; and ACS. Facts & figures, 2015-2016.

Stage at

diagnosisLat Am USA

I 21% 80%

II-III 71% 19%

IV 7% 1%

Source: Estimaciones de los autores basadas en IARC, Globocan 2012

In LMICs a very large % of Breast Cancer

cases and deaths are in women <55

High Income

15-39

40-54

>55

Ag

e a

t

Dia

gn

os

is

Ag

e a

t

De

ath

33%

34%

61%

61%

LAC

Outline1. Growing health priority for LAC

2. Meeting the challenge:

Integrating breast

cancer into Universal

Health Coverage 3. UHC: Examples from Mexico

4. Monitoring progress to close divides

Universal Health Coverage

(UHC)

All people must obtain the health services they

require - prevention, promotion, treatment,

rehabilitation and palliative care - without the risk

of impoverishment (WHO)

LAC: a wave of global reforms in the difficult context of complex

epidemiological transition, and with highly fragmented health systems

An effective UHC response to chronic illness

must integrate interventions along the

Continuum of disease:1. Primary prevention

2. Early detection

3. Diagnosis

4. Treatment

5. Survivorship

6. Palliative care

….As well through each

Health system function

1. Stewardship

2. Financing

3. Delivery

4. Resource generation

Breast cancer: care continuum

Primary

Prevention

Early

Detection

Diagnosis

Treatment

Survivorship

Palliative

Care

Stage of Chronic Disease Life Cycle /components CCC

Primary

Prevention

Secondary

preventionDiagnosis Treatment

Survivorship/

Rehabilitation

Palliation/

End-of-life

care

Costa Rica

México Partially PartiallyPartially

Colombia Partially Partially

PeruPartially

X

Coverage (?) of breast cancer in select LAC

countries by care-control continuum:

complex analysis

Outline1. Growing health priority for LAC

2. Meeting the challenge: Integrating breast

cancer into Universal Health Coverage

3. UHC: Examples

from Mexico4. Monitoring progress to close divides

Breast cancer: care continuum

Primary

Prevention

Early

DetectionDiagnosis Treatment Survivorship

Palliative

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.

The Economist, 2018

• “UHC is sensible, affordable and

practical even in poor countries.

Without it the potential of modern

medicine will be squandered.”

• “…cover as many as

possible…

more people but start with a

limited range of benefits….

as under

Mexico´s Seguro Popular.”

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 now covers more

than 56 million Mexicans and

includes cancers in the

national catastrophic illness fund

Seguro Popular and breast cancer:

Evidence of impactAdherence to

treatment:

2005: 200/600

2010: 10/900

Human

faces of

impact:• Guillermina

• Abish

¡Cancer registry

– finally a reality!

Stay tuned.

Breast Cancer early detection:

Delivery failure • 10-15% of cases detected in Stage I

• Poor municipalities: 50% Stage 4; 5x rate for rich

Source: Authors’ estimates with database from IMSS, 2014

50%

I II

III IV

High %

Stage IV

MarginalizedHigh Access to

basic Services

Municipalities

States

Engage and Train primary care promoters, nurses and doctors in early detection and post-treatment

management of breast cancer: Tómatelo a Pecho

Significant increase in knowledge,

among health promoters,

especially

in clinical breast examination (Keating, Knaul et al 2014, The Oncologist)

8

7

6

5

4

3Pre Post 3-6 month

Health Promoters

Risk Score (0-10)

*

> 16,000

Engaging CHWs in South Florida to promote early detection of

breast cancer and access to treatment for the farmworker population

– Adaption of the Mexico “train-the-trainer” models and materials

– Aim: harness the role of CHWs in promoting breast health, and

breast cancer early detection, treatment and survivorship services

South Florida: Univ. Miami

CHW Education Project

Outline1. Growing health priority for LAC

2. Meeting the challenge: Integrating breast

cancer into Universal Health Coverage

3. UHC: Examples from Mexico

4. Monitoring progress

to close divides

Annual monitoring of regional and country-specific

progress: comparative country performance makes it a

powerful tool for national advocacy.

Designed to provide policy-oriented data, in an instrument

that can be effectively utilized by civil society for

advocacy to promote change.

Can be readily transformed into National Observatories by

and for local advocacy groups and civil society.

Core, basic indicators from secondary data sources.

Possible addition of more complex indicators.

Evidence-based advocacy :ULACCAM Women´s Cancer Observatory –

in construction for launch in 2019

1a) National cancer plan

...1b) updated in past 5 years

...1c) National women´s cancer specific plan

2) Integration of women´s cancer into

women´s health plans

3) A national cancer registry that includes

women´s cancer

4) An office for women´s cancer in the

Ministry of Health

5a) Offical MOH women´s cancer regulations

….5b) Updated every 5 years

6) One or more registered NGOs working on

women´s cancer

ULACCAM Regional Observatory

scorecard: examples of indicators

Does the country have….

Yes

Yes, not updated

No

No information

Has a national

cancer plan

Preliminary data

A more complex indicator: Access to morphine for all palliative care and pain relief

Lancet Commission indicator and INCB data

% of Palliative care

need potentially met

with registered

morphine

% of All medical need

(W. Europe

benchmark)

potentially met with

registered morphine

Colombia 71 % 8 %Guatemala 26 % 3 %Mexico 36 % 4 %Panama 70 % 8 %Peru 30 % 4 %Uruguay 33 % 4 %

Latin America 33 % 4 %

Source: Lancet Commission on Palliative Care and Pain Relief and INCB data author calculations

A more complex indicator:Trends(?) in incidence and mortality from breast cancer

in selected countries, LAC:

1 Datos basados en IHME, 2012. Representan los años mencionados.

2. Datos basados en GLOBOCAN, 2008. Representan los valores de 2005.

3. Datos basados en GLOBOCAN, 2012. Representan los valores de 2010.

4. Datos basados en GLOBOCAN, 2018. Representan los valores de 2016

Colombia Mexico Argentina Chile Trinidad and

Tobago

19801

(IHME)

Mortality 749 1499 3757 792 81

Incidence 1761 3862 9931 1,910 167

M/I 0.43 0.39 0.38 0.41 0.49

20052

(Globocan)

Mortatlity 2120 5217 5873 1248 135

Incidence 6655 13,939 18,712 4199 285

M/I 0.32 0.37 0.31 0.30 0.47

20101,3

(IHME)

Mortality 2649 5680 6163 1455 2014

Incidence 8686 20,444 19,386 4081 487

M/I 0.30 0.28 0.32 0.36 0.42

20164

(Globocan)

Mortality 3702 6884 6,380 1688 259

Incidence 13,380 27,28321,558

5,393 657

M/I 0.28 0.25 0.30 0.31 0.39

Challenge: from survival to

survivorship

Dr. Felicia Marie KnaulMiami Institute for Advanced Study of the Americas and Miller School of Medicine,

University of Miami; Fundación Mexicana para la Salud; Tómatelo a Pecho

Breast Cancer in the Americas: Closing Divides

through Systemic Innovation & Advocacy”

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.

Estrategias para reducir el cáncer de mama en las Américas:

Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS),

la Unión Latinoamericana Contra el Cáncer de la Mujer(ULACCAM)

y Tómatelo a Pecho, A.C.

October 29, 2018