Status of breast cancer in Latin American: Results of the breast cancer revealed initiative

ElsevierVolume 181, January 2023, 103890Critical Reviews in Oncology/Hematology

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Abstract

The Breast Cancer Revealed initiative was designed and conducted to know the status of breast cancer at each point of breast cancer care, through i) prevention, ii) detection, iii) diagnosis, iv) treatment, and iv) the capacity of our health systems. The expert panel from 11 Latin American countries identified several strategies and proposed high impact priorities, including implementation of prevention policies, improve primary healthcare capacity for breast cancer screening, have adequate infrastructure to make effective and timely diagnoses, have a multidisciplinary team in the treatment process, access to a variety of treatments for all types of patients, have a coordinated and articulated system from primary care to specialized hospital. In a region with limited resources, prioritization in high-impact strategies for breast cancer control could lead to improved clinical outcomes and quality of life for our patients.

Introduction

Breast cancer (BC) is the leading malignancy in women around the world with ≈ 2.3 million new cases per year. Breast cancer is an important public health problem in Latin America and the Caribbean with > 210 thousands new cases per year and ≈ 60 thousand deaths per year (Sung et al., 2021). Other important epidemiologic characteristic of BC patients in Latin America is the high frequency of triple negative breast tumors representing an important challenge for the treatment of these patients (Vallejos et al., 2010, Zevallos et al., 2020). With the growing and aging population and changes in lifestyle, the burden of breast cancer in our region will increase to ≈ 314 thousands new cases and per year and 94.6 thousand deaths by 2040 (Sung et al., 2021, Bray and Møller, 2005).

The situation of breast cancer in Latin America is particular with some barriers to adequate management of this disease, including high burden of advanced disease, inadequate access to medical resources, inadequate access to specialized cancer care and insufficient breast cancer research (Justo et al., 2013, Cazap, 2018). In addition to these barriers, there are large disparities in access to cancer care where resource availability is concentrated in few urban areas (Cazap, 2018).

Despite advances in breast cancer management that result in a dramatic improvement in overall survival, particularly in metastatic disease, this outcome does not necessarily translate into reality in Latin America, particularly in low-resource settings (Cazap, 2018, Barrios et al., 2018). Technological disparities are also evident in the region. There is limited access to genomic platforms due to test costs, lack of inclusion of molecular tests in insurance coverage, and few local laboratories providing genomic profiling services. It is difficult to set the setting for precision medicine in breast and other cancers (Pinto et al., 2019a, Alvarado-Cabrero et al., 2021).

Few studies evaluate the current scenario of breast cancer care in Latin American countries, which focuses mainly on aspects of the disease. To address the main problems of breast cancer in Latin America, we conducted the Breast Cancer Revealed initiative with the aim of knowing the status of breast cancer at each point of breast cancer care, through i) prevention, ii) detection, iii) diagnosis, iv) treatment and iv) the capacity of our health systems. Experts from 11 Latin American countries (Mexico, Cuba, Santo Domingo, Colombia, Ecuador, Peru, Bolivia, Chile, Paraguay, Argentina, and Uruguay) participated in multidisciplinary focus groups to identify patient-centered strategies to overcome barriers and propose priority focus areas.

Section snippetsBreast cancer prevention

The approach to breast cancer prevention must be multidisciplinary. It should involve physicians, nurses, midwives, and other healthcare professionals and decision makers. Many countries have implemented public policies, created with good intentions, but only on paper and they are not implemented. Breast cancer awareness is heavily based on private actors, and it is limited to the month of October, where it must be maintained over time throughout the year. It should be maintained throughout the

Early detection of breast cancer

Something very important is the heterogeneity in strategies of BC screening in the different Latin American countries. Some countries conduct screening programs appropriately and other countries have low performances of its screening programs. The capacity of BC detection in Latin America is low. There is a lack of mammogram machines (they are concentrated in urban zones), scarce trained personnel, Oncologists want to detect the breast tumors as early as possible; however, not only highly

Diagnosis of breast cancer

The region is very heterogeneous, and it is difficult to provide a number representing all regions. In some patients, 10–20% have advanced disease at diagnosis, while in other, this percentage is 50%. The first line of diagnosis is the general practitioner or gynecologist. There is no good articulation between specialties, and unfortunately, after histological and imaging evaluation, the patient returns to the first line instead of the oncologist. It represents a loss of time and delays in the

Treatment for breast cancer

Most BC patients are treated in a multidisciplinary environment; however, the multidisciplinary team mainly works in specialized centers and not in other centers. Despite the scientific evidence, there is no preference for conservative surgery in the region. Research is needed to understand it. The main sources of financing for treatment are public insurances and, to a lesser degree, social security, semi-private, or private insurances. In metastatic breast cancer, patients have three lines of

Capacity of health systems and patient monitoring

There is poor articulation between the levels of primary and specialized care due to deficient medical formation in competences such as elaborating a clinical record for breast cancer, a correct breast and axilla examination, when to request a mammography for screening or diagnosis and also to derive patients to the oncologists. There is a delay in the diagnosis of breast cancer. Once the patient is diagnosed in primary care, there is a long bureaucratic path until the cancer specialist is

Discussion

Breast cancer is a relevant health problem in Latin America, and cervical cancer is the most important malignancy among women in the region. In contrast to cervical cancer, where the etiology is primarily an infectious agent, breast cancer has several etiological factors, representing a challenge to primary prevention (Abubakar et al., 2018, John et al., 2018). The natural history of breast cancer, although complex, offers opportunities for early detection and early intervention, resulting in

Conclusions

The knowledge of breast cancer has great advances since Perou et al. (2000) unveiled the biology of this disease and changed (Perou et al., 2000). Although it produced a revolution in the development of new drugs and improved the outcomes of breast cancer, in some regions, patients have been poorly benefited from these advances. Management of breast cancer in Latin America represent a challenge, particularly in the public system. The Breast Cancer Revealed initiative conduct to identify

Funding

Roche Pharma LATAM provided logistic support for the working meetings. The sponsor did not participate in the conception, writing, or approval of this manuscript.

Conflict of Interest Statement

JMC received grants from Roche and Genomic Health and payment for lectures from BRP Oncology Updates and Roche Bolivia. The other authors declare they have not potential conflict of interests with this research.

Acknowledgment

None.

Natalia Carolina Ayala, MD. Specialist in Clinical Oncology; Head of the Clinical Oncology Service of the J.R. Vidal Hospital; Professor of the Faculty of Medicine of the National University of the Northeast (UNNE) of Oncology and the Final Practice; Member of the Argentine Association of Clinical Oncology and the Oncology Society of Corrientes. UNNE Doctoral Thesis.

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