Women-specific cancersChallenges and opportunities

Vivien Tsu, PhD, MPHAssociate Director for Reproductive HealthPATH

CORE Group, Spring Meeting

Baltimore, May 12, 2011

Cancer: not just a disease of the rich

• More than 3.3 million deaths among women globally

• Despite younger populations, 63% are in poorer countries

• Women-specific cancers are substantial portion everywhere

Breast

Cervix

Uterus

OvaryAll

other

Cancer deaths in more developed countries, 2008

Breast

Cervix

Uterus

Ovary

All other

Cancer deaths in less de-veloped countries, 2008

Trends are worrying

1990 2010 20300

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

Estimated number of breast cancer deaths

More developedLess developed

1990 2010 20300

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Estimated number of cervical cancer deaths

More developedLess developed

• Numbers are going up, especially in developing countries

• Differences between rich and poor are growing

Survival difference is dramatic

Breast cancer Cervical cancer0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

Mortality ratio, 2008

USAfrica

Rat

io o

f d

eath

s to

cas

es

Why is the burden of cervical cancer so high in poorer countries?

• Overall, nearly ½ million cases; more than ¼ million deaths each year

• >80% in developing countries

• Expected to increase to >775,000 new cases per year by 2030, with 99% of deaths in developing countries

• No sustainable, organized screening programs, despite many efforts

• “Competing” health problems

• Prevalence of high-risk HPV infection higher

• Limited awareness of cost-effective approaches to prevention

• Until recently, no vaccine available to prevent infection

Breast cancer rates rising in low- and middle-income countries

Reasons similar to those for many other chronic diseases:

• Increasing life expectancy – women are living longer

• Changing lifestyles – urbanization, less physical activity, higher calorie and fat diets

• Plus Changing reproductive behaviors – fewer children, starting later, less breastfeeding

Impact on women, families, communities

Women

• Painful illness, premature death, stigma, and isolation

Families

• Cost of medical care

• Loss of economic contribution and non-income generating work

• Loss of caregiver for children, elderly, sick, and disabled

• Loss of family advisor

Community

• Loss of social and political leaders at prime of life

• Loss of experienced teachers and health workers

• Loss of managers of food security – women produce 75% of food in poor countries

Exciting new opportunities

• New prevention options for cervical cancer – screening and vaccine

• New ideas for adapting breast cancer detection and treatment to low-resource settings

Cervical cancer screening

• New technologies

– Visual inspection with acetic acid (VIA)

– HPV DNA testing

• New strategies

– Screen and treat, without intervening diagnostic step before precancer treatment

– Services provided by non-physicians with appropriate training

– Samples for HPV testing collected by women themselves

– Once or twice in a lifetime screening for women 30–49 years old

HPV vaccination

• Human papillomavirus is primary cause of cervical cancer; current vaccines protect against types that cause ~70% of cases (and a portion of other female cancers)

• Will also prevent about half the precancers and reduce costs for future screening programs

• Experience with vaccine is growing – shows vaccination is feasible and acceptable

• Cost of the vaccine is dropping rapidly; current PAHO price is <$14/dose

$0

$25

$

60

$120

2006 07 08 09 2010

Breast cancer: early detection is key

• Can’t prevent disease but can improve survival

• Health education can raise awareness of symptoms, overcome stigma, and improve early care-seeking

• Feasible methods like clinical breast exam (CBE) can be done by trained health workers and detect many early tumors

• Early results from study in Mumbai* showed that 71% of cancers in women screened by CBE were early stage, as compared with only 51% among women receiving only health education

* Mittra I, et al. Int J Ca 2010.

Diagnostic and treatment opportunities for breast cancer

• General physicians and nurses can be trained to take needle biopsies and use ultrasound

• Generic tamoxifen is low-cost, taken orally, and generally well tolerated

• Planned study in Africa will assess use of 2–3 month course of tamoxifen where lab testing not available; tumor response will determine whether to continue or not

• Treatment recommendations can be tailored to available resource levels (e.g., use older drugs that still give good benefit at lower cost)

Cervical cancer and maternal mortality

Information resources

Breast cancer

• BHGI Library

http://portal.bhgi.org/docs/default.aspx

• National Cancer institute

www.cancer.gov/cancertopics/types/breast

• BreastCancer.org

www.breastcancer.org

Cervical cancer

• RHO cervical cancer library www.rho.org

• WHO/ICO (Institut Català d'Oncologia) Information Centre www.who.int/hpvcentre/en

• WHO Cervical Cancer www.who.int/reproductivehealth/topics/cancers

Next steps

To get recognition of magnitude of burden and commitment to feasible and effective solutions

To reduce stigma and raise awareness in communities that cancer is treatable and, in the case of cervical cancer, preventable

To identify cost-effective approaches for breast cancer, as has already been done for cervical cancer

The primary health care system and train health workers in basic skills for community education, screening, and primary treatment of women’s cancers

ADVOCATE

EDUCATE

EVALUATE

STRENGTHEN

Conclusions

• Cancer burden on women is real and growing – especially among the most disadvantaged.

• Practical solutions already exist – both for prevention and for relieving suffering.

• Investments in obstetric care and HIV are lost if women then succumb needlessly to cancer a few years later.

Vivien Tsu, PhD, MPH

Associate Director for Reproductive Health

PATH

Email: vtsu@path.org

Thank you