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Breast Cancer Disparities:

Closing Global Divides


NCoBC 2019 29th Annual Interdisciplinary
Breast Center Conference, Las Vegas. March 18, 2019

Felicia Marie Knaul y Héctor Arreola Ornelas*


University of Miami: Sylvester Comprehensive Cancer Center, Institute for Advanced Study
of the Americas and Miller School of Medicine, University of Miami;
*Mexico: Tómatelo a Pecho and FUNSALUD
59: Disparities in Breast Cancer Care

Felicia Marie Knaul, PhD

Disclosures:
Consultant: Merck/EMD Serono
Grant/Research through University of Miami,
Tomatelo a Pecho and FUNSALUD: Merck/EMD
Serono, Roche, Novartis, Chinoin, NADRO
January, 2008
June, 2007
Outline
1. Growing equity and
health priority
2. Meeting the challenge: Integrating breast cancer
into Universal Health Coverage
3. UHC and Cancer: the Mexico case
Rank of breast cancer as a cause of death
Women, 15-49, by income and geographic regions, 2017

Global 4
North America 1
Europe & Central Asia 1
Latin America &
Caribbean 1
By
Geographic East Asia & Pacific 2
region Middle East & North
4

Source: IHME. GBD 2017


Africa
South Asia 5
Sub-Saharan Africa 10
Mortality is increasingly concentrated in
Chronic and NCDs: Breast Cancer

-41% +30% +62%

Mortality in Cervical
Breast cancer
childbirth cancer

323,227 to 101,090 to 159,141 to


191,981 130,917 258,302

Annual deaths, Women 15-59, 1990 and 2017


Source: Estimates based on data from IHME 2017
Change in the concentration of
incidence & mortality of cervical and breast cancer
1990 to 2017, by country income group

42 44 Low Income
41
40
Change in the concentration
between 1990 and 2017

24 Low Middle Income


16
20 10 13
4
5 10 7 Upper Middle Income
4
0
High Income

20

-31 -30 -33


40 -36

Incidence Mortality Incidence Mortality

Cervical cancer Breast cancer

Source: Own estimates based on IHME, 2017


Breast and Cervical cancer mortality rates
Mexico, select states, 1979-2016
20 20
CDMX Nuevo León
18 18
16 16
14 14
12 12
High GDP 10 10
8 8
6 6
4 4
2 2
0 0
1979

1985

1990

1995

2000

2005

2010

2015
2016

1979

1985

1990

1995

2000

2005

2010

2015
2016
20 Puebla 20 Oaxaca
18 18
Low GDP 16 16
14 14
12 12
10 10
8 8
6 6
Source: Own 4 4
estimations based on
data by DGIS. Base de
datos de defunciones
2 2
1979-2016. SINAIS.
Secretaría de Salud.
0 0
1979

1985

1990

1995

2000

2005

2010

2015
2016

1979

1985

1990

1995

2000

2005

2010

2015
2016
The Opportunity to Survive is, but should not
be, defined by income… Breast Cancer
Breast cancer Inequality gap in survival:
Mortality / Incidence Avoidable mortality:
0.7
Total Min Max
Lethality (mortality/incidence)

0.6
India 43 61
0.5
0.59 Low 53 Zimbabw
Afghanistan
e

0.4 Lower 40 57
0.48
Mexico
Chile middle 50 Ukraine Yemen
0.3
0.28 Upper
China 35 25 44
0.2
0.23 Middle Argentina Turkmenistan

0.1
High 22 57
income 33 Germany UAE
0
Lower Upper
Low
income middle middle
High
income 75% in LMICs
income income
Source: Own estimations based on Globocan 2018 y Knaul FM, et al., 2018
Women <55: large % of Breast Cancer
cases and deaths are in LMICs
Low income LAC High Income
Diagnosis

33%
Age at

66% 61%
15-39
40-54

>55
Age at

61% 34%
Death

67%

35,433 52,558 178,554


Trends in breast cancer mortality rates:
USA, Canada, Brazil, Costa Rica, Mexico, Colombia

USA, Canada --35%:


25 Awareness, Earlier detection
Age-adjusted mortality rate

and More & better treatment


20 USA
Canada
15
Brazil
Costa Rica
10
Mexico
5 Colombia

0
1955 1970 1985 2000 2013
1955196019651970197519801985199019952000200520102013 ¿2030?
Source: Data extracted from CI5plus.
Outline
1. Growing equity and health priority

2. Meeting the challenge:


Integrating breast cancer into
Universal Health Coverage
3. UHC and Cancer: the Mexico case
Universal Health Coverage
All people must obtain the health services they require - prevention,
promotion, treatment, rehabilitation and palliative care - without the
risk of impoverishment (WHO)

A wave of global reforms in the difficult context of


complex epidemiological transition, and with
highly fragmented health systems

• Mexico • Peru • China


• Colombia • South
• Chile Africa
An effective UHC response to chronic illness
must integrate interventions

Continuum of disease:
1. Primary prevention
2. Early detection
3. Diagnosis
4. Treatment ….As well as each
5. Survivorship
6. Palliative care 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
Coverage of breast cancer, select LAC countries by
control-care continuum: very complex to analyze
Stage of Chronic Disease Life Cycle
/components CCC
Palliation/
Primary Secondary Survivorship/
Diagnosis Treatment End-of-life
Prevention prevention Rehabilitation
care

Costa Rica

Mexico Partial Partial

Colombia Partial Partial

Country X Partial

Country Y Partial
The Diagonal Approach to
Health System Strengthening
Rather than focusing on either disease-specific vertical or
horizontal-systemic programs, harness synergies that
provide opportunities to tackle disease-specific priorities
while addressing systemic gaps and optimize available
resources
Diagonal strategies add value:
Exploit existing platforms – e.g. anti-poverty programs
Generate positive externalities, increase effectiveness at a given
cost
Bridge disease divides using a life cycle response to avoid disease
silos
`Diagonalizing` Cancer Care:

1. Financing: Integrate cancer care into national social insurance


and social security programs and reforms
2. Delivery: Integrate cancer prevention, survivorship and
palliative care into existing primary care platforms, anti-poverty
programs and HIV/AIDs.
3. Pain control and palliative care: reducing barriers to access
for cancer care improves access for all, and strengthens surgical
platforms
4. Advocacy: integrate advocacy around women´s cancer to
catalyze women´s health and empowerment, health system
reform, & SDGs
Outline
1. Growing equity and health priority
2. Meeting the challenge: Integrating breast cancer
into Universal Health Coverage

3.UHC and Breast Cancer:


the Mexico case
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.”
Mexico: Seguro Popular

Almost half of Mexican households lacked


health insurance, which limited access to
care, reduced opportunities to pool risks,
and generated catastrophic expenses.
2004: Legislative reform produced Seguro
Popular & the System for Social Protection
in Health
Seguro Popular now covers more than 53
million Mexicans and includes cancers in
the national catastrophic illness fund

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,
Colorectal

Example: Trastuzumab included since 2008 for all Her2Neu+ Mexican


Seguro Popular and breast cancer:
Evidence of impact

Human faces of impact:


Guillermina, Abish

Adherence to
treatment,
INCAN :
2005: 200/600
2010: 10/900
Achievements: Overall survival in patients with breast cancer
in Mexico attended by Seguro Popular according to clinical and
demographic characteristics. (Reynaldo, Bargallo et al)
By clinical stage at diagnosis
By Age
Overall Survival (proportion)

Sorce: Reynoso-Noverón, N., Villarreal-Garza, C., Mohar A; Bargalló-Rocha, E. (2017). Journal of global oncology,
Analysis Time (months) Analysis Time (months)

By histologic grade By breast cancer subtype


Overall Survival (proportion)

Analysis Time (months) Analysis Time (months)


Breast cancer: care continuum

Primary Early Palliative


Diagnosis Treatment Survivorship
Prevention Detection 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.
5-year Survival and (cases by stage):
breast cancer: USA and Mexico

Mexican
USA - ACS
Nat Cancer
Stage data
Institute
(2014)
(2017)
0-I 98% (>60%) 97% (14%)
II-III 85% (30%) 82% (73%)
IV 27% (5%) 36% (13%)
Sources: ACS. Facts & figures, 2017-2018; & Reynoso-Noveron, Mohar et al, Journal of Global Oncology, 2017.
Breast Cancer early detection: Delivery failure

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

Municipalities
I II
States 50% III IV

High %
Stage IV

High Access to
Marginalized
Source: Authors’ estimates with database from IMSS, 2014
basic Services
Juanita:
Advanced metastatic breast cancer is the
result of a series of missed opportunities
Barrier: Low quality primary care services

½ of women diagnosed with breast cancer reported


problems in the diagnostic process

Did not receive BCE or information in their


routine annual exam & pap test
Doctors understated the importance of signs
and symptoms manifested by the women, and
sent them home without a diagnosis

NATIONAL QUALITATIVE STUDY Nigenda et al.


Engage and Train primary care promoters, nurses and
doctors in early detection and post-treatment
management of breast cancer: Tómatelo a Pecho

> 16,000
Health Promoters
8 Risk Score (0-10) Significant increase in knowledge,
7 * among health promoters,
6
especially
5
in clinical breast examination
(Keating, Knaul et al 2014, The Oncologist)
4

3
Pre Post 3-6 month
New initiatives and updates:
Mexico Primary Care training project

• Training medical
students
• Incorporating
survivorship, pain
control & palliative care
• Expansion of the train-
the-trainer model
beyond Mexico…
Engaging CHWs in South Florida to reduce the impact of
breast cancer among the migrant farmworker population:
University of Miami and local NGOs

• Qualitative research to guide adaption of


the Mexico “train-the-trainer” models and
materials
• Harness the role of CHWs on breast
cancer early detection, breast health and
breast cancer treatment and survivorship
services
Closing breast cancer divides
is an achievable
health, equity & economic imperative.
Synergistic strategies combining
interdisciplinary teams and
layered human resources
with universal health coverage platforms
need to be
developed, implemented and evaluated.
Be an
optimist Ju

and an
optimalist

We can close global cancer divides


Breast Cancer Disparities:
Closing Global Divides
NCoBC 2019 29th Annual Interdisciplinary
Breast Center Conference, Las Vegas. March 18, 2019

Felicia Marie Knaul


University of Miami: Sylvester Comprehensive Cancer Center, Institute for Advanced Study
of the Americas and Miller School of Medicine, University of Miami;
Mexico: Tómatelo a Pecho and FUNSALUD