IARC perspectives on the development of a research agenda for early detection and control of breast cancer in developing

2. IARC perspectives on the development of a research agenda for early detection and control of breast cancer in developing countries R. Sankaranarayanan MDHead, Early Detection and Prevention Section (EDP)Head, Screening Group (SCR)

3. Age-standardized incidence rates of breast cancer in selected populations in each continents, 1998-2002 SOURCE: Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160, Lyon, IARC. (2007) Age-standardized rate (World) per 100,000 OCEANIA EUROPE ASIA N. AMERICA S. AMERICA AFRICA

4. IARC perspectives: Current status of health services infrastructure and investments • Poorly developed and invested (most countries with per capita GNI <1000 USD; no or extremely limited diagnostic/treatment services) • Moderately developed and invested (Countries with per capita GNI 1000-10,000 USD, urban rural differences, intracountry variation)

5. 5-Year Survival from breast cancer (diagnosed during 1993-2001) 21,810 cases {range: 58-90%} 9,442 {range: 78-84} 1,329 • Breast Cancer (ICD-10:C50) • Highest in Hong Kong SAR • Lowest in Gambia • Intra-country variation • Pronounced in China (urban  and rural ) & India & Philippines • No difference in South Korea & Thailand 3,204 2,169 2,462 298 {range: 57-65} 2,354 {range: 31-54} 11,013 1,714 {range: 40-55} 162 258 61

6. 5-year absolute survival for localised and regional extent of disease among more and less developed health services – Breast cancer Absolute survival for localized and regional extent of disease among more and less developed health services - Breast cancer Singapore & Turkey: 14 645 cases Costa Rica, India, Philippines, Saudi Arabia, Thailand: 17 640 cases

7. Awareness! Self examination Clinical breast examination (CBE) Ultrasonography Mammography Fine needle aspiration cytology (FNAC) Core biopsy Triple diagnosis Modalities for early detection of breast cancer

8. Breast awareness • Making women aware of normal breast to facilitate finding abnormalities at the earliest possibility • Breast awareness makes each women to appreciate what is normal for them

9. Triple diagnosis • The use of diagnostic mammography, diagnostic ultrasonography and fine-needle aspiration biopsy for diagnosing palpable lumps • If any of the three modalities suggests cancer, excisional biopsy warranted • Excellent sensitivity (99%) and specificity (99%) • Very good potential for early clinical diagnosis if linked with awareness programmes • Important strategy to improve breast cancer control in low-and medium-resourced countries.

10. IARC PERSPECTIVES: FOCUSSED RESEARCH PRIORITIES • Documentation of the pattern and trends in burden of disease, stage distribution and survival in several resource poor areas (PBCRs, MRDs, improving staging practice, medical records) • Impact of awareness, education and investments/improvement in health services on stage distribution, 2- and 5-year survival, mortality • Evaluation of the efficacy and cost-effectiveness of CBE in reducing breast cancer mortality • Identifying factors influencing participation of women in early detection, diagnosis, treatment and follow-up care

11. IARC PERSPECTIVES:EXIT STRATEGIES • Strategic placement of the research activity • Contribution to capacity building in health services • Continuity, sustainability of service activities depending on the outcome of research • Roll out and scaling up

12. IARC PERSPECTIVES: LEARNING FROM PAST EXPERIENCES • WHO-Russia BSE study • IARC-Philippines CBE study • Shanghai BSE study • Recent successes of IARC oral and cervix cancer screening trials • Efficient information systems/collaborating partners/institutions

13. Trivandrum Breast Cancer Screening Study (TBCS) Objective: To evaluate the extent of stage shift, survival improvement and mortality reduction observed following the implementation of a package of interventions consisting of improving public and professional awareness on breast cancer, its early clinical diagnosis and prompt treatment and offering clinical breast examination (CBE)

14. Trivandrum Breast Cancer Screening Study (TBCS) Aims: • Decrease the frequency of advanced (stages IIB, III, IV) breast cancers from the current 70% of all breast cancer cases to 45% over a period of 7 years • Decrease the incidence rate of advanced (II B plus) breast cancers by 30% over a 7-year period • Increase 5-year survival of breast cancer patients from the current 55% to 80% • Reduce breast cancer mortality by 20% in the intervention group as compared to the control group

15. Trivandrum Breast Cancer Screening Study (TBCS) First round of screening: participation and compliance (2006-2009) In collaboration with RCC, Trivandrum, India

16. Trivandrum Breast Cancer Screening Study (TBCS) First round of screening: Investigation rates In collaboration with RCC, Trivandrum, India

17. Trivandrum Breast Cancer Screening Study (TBCS) First round of screening: intermediate outcome (2006-2009) In collaboration with RCC, Trivandrum, India

18. Trivandrum Breast Cancer Screening Study (TBCS) Predictability of breast cancer In collaboration with RCC, Trivandrum, India

19. IARC PERSPECTIVES: FOCUSSED RESEARCH INITIATIVES • Organization of a three arm cluster randomised trial in 2010 for comparative evaluation of routine care, focussed breast awareness and CBE • Will involve around 400, 000 women and follow-up for a minimum of 9 years! • Currently the project proposal is being developed • Funding will be sought