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Closing divides to meet the

challenge of womens cancer


Medical Humanities Summer Institute
Womens Intimate Health and Sexual Citizenship in the Caribbean
University of Miami Coral Gables, FL
May 19, 2017

Dr. Felicia Marie Knaul


Miami Institute for the Americas and Miller School of Medicine, University of Miami
Fundacin Mexicana para la Salud and Tmatelo a Pecho
women an NTD.
Breast cancer is becoming a
cause of death of poor
women, although it is a
disease of poor and rich.
Layers of social isolation and
discrimination around both
diseases constitute obstables
that transcend (lack of)
access to health care.
Integrate, rather than
January, 2008
Breast cancer in LMICs: myths
and realities

disease of older A large proportion of cases and


deaths perhaps the majority
women
happens in women <54

disease of The majority of cases and


developed countries deaths occur in low and middel
income countries
More deaths and DALYs lost
lower priority than due to breast cancer in all
crevical cancer developing regions except the
poorest
Womens cancer deaths
Globally Caribbean
Cervical Breast

#1 cancer of women #1 cancer of women


#2 overall # 3 overall

#2 cancer of women #2 cancer of women


#5 overall #4 overall cause

Source: Estimates based on data from Globocan 2012 & IHME, 2015
Mortality rank: breast and cervical cancer
Women 15 to 49, countries by income level
1 Breast cancer
HIV / AIDS other
Jamaica
12 3 Cervical cancer
Diabetes
Breast
10 5 Hemorrhagic
stroke Cervical
Number of cause of death

8
in the age group

Low
Upper-middle income High income
income
The cancer transition: by income, region:
breast and cervical cancer 1980-2010

200
% Change in incidence

179 BC cases (I)


and mortality

113 BC deaths (M)


96
100
43 CC cases (I)
37 35
CC deaths (M)
0

-14 -14
Caribbean High income

Source: Knaul, Arreola, Mendez. estimates based on IHME, 2012.


The Opportunity to Survive
is, but should not be, defined by income.

5
0
inequality gap

4
Haiti
0
Survival

USA+Cda

Guyana
Jamaica

2
0 Bahamas
Cervical
Breast

0
Low Lower Upper High
Income Middle Middle Income

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.


In LMICs a very large % of Breast Cancer
cases and deaths are in women <55
Low income Lat Am & Carib High Income
Diagnosis

33%
Age at

66% 62%
15-39

40-54

>55
Age at
Death

34%
67% 61%
Fuente: Estimaciones de los autores basadas en IARC, Globocan 2012
Global trends:
breast cancer mortality
30

USA
Age-adjusted mortality rate

Canad
Australi
a

Mexico

0
1975 1980 1985 1990 1995 2000 2005 2010 2014 2025
?
Source: Data extracted from CI5plus.
Detection + Treatment = survivorship
(Source: American Cancer Society)

Stage at Detection Survivorship, USA

0-1 98%
2-3 84%
4 27%

WITH TIMELY AND


PROPER TREATMENT
Fuente: American Cancer Society. Breast Cancer Facts & Figures, 2007-2008. Atlanta, GA. : American Cancer Society, Inc.,
y Secretara de Salud. Programa de Accin: Cncer de mama. Mxico, D.F.
Mexico: with Seguro Popular

Every Mexican

woman has the


right to financial
protection for
breast cancer
treatment
Globally-
recognized
health systems
Breast Cancer early detection:
Failure
10-15% of cases detected in Stage I
Poor municipalities: 50% Stage 4; 5x rate for rich

I II
50% III IV

High %
Stage IV

Po
o r 0%
Marginalized High Access
Juanita:
Advanced metastatic breast cancer
as a result of stigma, misinformation
and a series of missed opportunities
and barriers to access
Low quality primary care services
One in every two women diagnosed with breast
cancer reported problems with medical attention in
the diagnostic process
Did not receive breast clinical examination or
information in their routine annual exam & pap test
Doctor did not value the importance of signs and
symptoms manifested by the woman, and sent her
home without a diagnosis
Both primary care providers and specialists
recognized the lack of sensitivity of health care
providers to the needs and voice of womens
RESULTS FROM A NATIONAL QUALITATIVE STUDY
Nigenda et al.
Engage and Train primary care promoters, nurses
and doctors in early detection of breast cancer

> 16,000
Health Promoters
8 Risk Score (0-10) Significant increase in knowledge,
7 *
among health promoters,
6
especially
5
in clinical breast examination
4
(Keating, Knaul et al 2014, The Oncologist)
3 3-6 month
Pre Post
Why dont young women with breast
cancer seek treatment earlier in Mexico?
(Hubbling, Knaul, forthcoming)

CHILDREN WORK:
no tena alguien con : No
quien dejar a mis es cualquier trabajo que le da uno perm
hijos.

Primero estn mis hijos porque no INDEPENDENCE/RES


tengo dinero para irme a checar.
PONSIBILITY:
Creo que s yo tengo ese error de ver
ABANDON que falta de lo dems pero no

MENT:
When I got cancer, I had my partner,
MISINFORMATIO
atenderlo de que me falta a mi.

but he left. [Because of cancer?] Mmhmm. N/DENIAL:


Seeing my body without breasts, Pues es que yo vea en la tele que
that kind of woke me up to a lot of decan que cncer de mama les da a
things, right? Sometimes here is this las cuarenta y cinco para adelante.
Uno se pone de necio y de terco y
person with you, but its like they
dice, no, no, este.. no me pasa nada.
really arent here with you.
No me pasa nada.
Sometimes the person next to you
makes you feel like you are alone.
Fragmentation of
women, health and cancer
What is maternal mortality?
Why are there so few NGO advocates and
groups working on behalf of women with
cervical cancer. and so many on breast?
Why is breast cancer - advocacy, detection and
treatment - so separated from womens
health, sexual and reproductive health, gender
empowerment, and education?
Why do we focus on only one part of a woman
s body?
Why do we focus on only one aspect of a
womans Global
life and health
neglect tends to fragment
the social
determinants ofand silo survivorship
disease, by disease or by
and
overall well-being? population group
Diagonal Strategies and
Positive Externalities,
A novel approach to global health

All of Me, All of We


Example:
Reducing stigma around womens cancers:
Contributes to reducing
gender discrimination.
Closing divides:
Health System Responses to the
challenge of breast and cervical cancer
February 23, 2017
Miami Institute of Americas, University of Miami

Dr. Felicia Marie Knaul


Miami Institute for the Americas and Miller School of Medicine, University of Miami
Fundacin Mexicana para la Salud and Tmatelo a Pecho
DE LA MUJER
PAISES SOCIOS

ARGENTINA 3
BRASIL 3
COSTA RICA 3

COLOMBIA 2

10 ECUADOR
EL SALVADOR
1
1
countrie MXICO 4

s PER
URUGUAY
2
1
VENEZUELA 2
TOTAL 22

PRESIDENCIA