Breast cancer: prevention and control

Introduction

Breast cancer is the top cancer in women both in the developed and the developing world. The incidence of breast cancer is increasing in the developing world due to increase life expectancy, increase urbanization and adoption of western lifestyles. Although some risk reduction might be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries where breast cancer is diagnosed in very late stages. Therefore, early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control. The recommended early detection strategies for low- and middle-income countries are awareness of early signs and symptoms and screening by clinical breast examination in demonstration areas. Mammography screening is very costly and is recommended for countries with good health infrastructure that can afford a long-term programme. Many low- and middle-income countries that face the double burden of cervical and breast cancer need to implement combined cost-effective and affordable interventions to tackle these highly preventable diseases. WHO promotes breast cancer control within the context of national cancer control programmes and integrated to noncommunicable disease prevention and control. WHO, with the support of Komen Foundation, is at present conducting a 5-year breast cancer cost-effectiveness study in 10 low- and middle-income countries. The project includes a programme costing tool to assess affordability. It is expected that the results of this project will contribute to provide evidence for shaping adequate breast cancer policies in less developed countries.
Breast cancer burden

Breast cancer is the most common cancer in women worldwide, comprising 16% of all female cancers. It is estimated that 519 000 women died in 2004 due to breast cancer, and although breast cancer is thought to be a disease of the developed world, a majority (69%) of all breast cancer deaths occurs in developing countries (WHO Global Burden of Disease, 2004). Incidence rates vary greatly worldwide, with age standardized rates as high as 99.4 per 100 000 in North America. Eastern Europe, South America, Southern Africa, and western Asia have moderate incidence rates, but these are increasing. The lowest incidence rates are found in most African countries but here breast cancer incidence rates are also increasing. Breast cancer survival rates vary greatly worldwide, ranging from 80% or over in North America, Sweden and Japan to around 60% in middle-income countries and below 40% in lowincome countries (Coleman et al., 2008). The low survival rates in less developed countries can be explained mainly by the lack of early detection programmes, resulting in a high proportion of

women presenting with late-stage disease, as well as by the lack of adequate diagnosis and treatment facilities.
Breast cancer risk factors

Several risk factors for breast cancer have been well documented. However, for the majority of women presenting with breast cancer it is not possible to identify specific risk factors (IARC, 2008; Lacey et al., 2009). A familial history of breast cancer increases the risk by a factor of two or three. Some mutations, particularly in BRCA1, BRCA2 and p53 result in a very high risk for breast cancer. However, these mutations are rare and account for a small portion of the total breast cancer burden. Reproductive factors associated with prolonged exposure to endogenous estrogens, such as early menarche, late menopause, late age at first childbirth are among the most important risk factors for breast cancer. Exogenous hormones also exert a higher risk for breast cancer. Oral contraceptive and hormone replacement therapy users are at higher risk than non-users. Breastfeeding has a protective effect (IARC, 2008, Lacey et al., 2009). The contribution of various modifiable risk factors, excluding reproductive factors, to the overall breast cancer burden has been calculated by Danaei et al. (Danaei et al., 2005). They conclude that 21% of all breast cancer deaths worldwide are attributable to alcohol use, overweight and obesity, and physical inactivity. This proportion was higher in high-income countries (27%), and the most important contributor was overweight and obesity. In low- and middle-income countries, the proportion of breast cancers attributable to these risk factors was 18%, and physical inactivity was the most important determinant (10%). The differences in breast cancer incidence between developed and developing countries can partly be explained by dietary effects combined with later first childbirth, lower parity, and shorter breastfeeding (Peto, 2001). The increasing adoption of western life-style in low- and middle-income countries is an important determinant in the increase of breast cancer incidence in these countries.
Breast cancer control

WHO promotes breast cancer control within the context of comprehensive national cancer control programmes that are integrated to noncommunicable diseases and other related problems. Comprehensive cancer control involves prevention, early detection, diagnosis and treatment, rehabilitation and palliative care. Raising general public awareness on the breast cancer problem and the mechanisms to control as well as advocating for appropriate policies and programmes are key strategies of populationbased breast cancer control. Many low- and middle-income countries face now a double burden of breast and cervical cancer which represent top cancer killers in women over 30 years old. These countries need to implement combined strategies that address both public health problems in an effective and efficient way.

Prevention

Control of specific modifiable breast cancer risk factors as well as effective integrated prevention of non-communicable diseases which promotes healthy diet, physical activity and control of alcohol intake, overweight and obesity, could eventually have an impact in reducing the incidence of breast cancer in the long term.
Early detection

Although some risk reduction might be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries. Therefore, early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control (Anderson et al., 2008). There are two early detection methods:

early diagnosis or awareness of early signs and symptoms in symptomatic populations in order to facilitate diagnosis and early treatment, and screening that is the systematic application of a screening test in a presumably asymptomatic population. It aims to identify individuals with an abnormality suggestive of cancer.

A screening programme is a far more complex undertaking that an early diagnosis programme. (WHO, 2007). Irrespective of the early detection method used, central to the success of population based early detection are careful planning and a well organized and sustainable programme that targets the right population group and ensures coordination, continuity and quality of actions across the whole continuum of care. Targeting the wrong age group, such as, younger women with low risk of breast cancer, could cause a lower number of breast cancers found per woman screened and therefore reduce its cost-effectiveness. In addition, targeting younger women would lead to more evaluation of benign tumours, which causes unnecessary overload of health care facilities due to the use of addition diagnostic resources (Yip et al., 2008).
Early diagnosis

Early diagnosis remains an important early detection strategy, particularly in low- and middleincome countries where the diseases is diagnosed in late stages and resources are very limited. There is some evidence that this strategy can produce "down staging" (increasing in proportion of breast cancers detected at an early stage) of the disease to stages that are more amenable to curative treatment (Yip et al., 2008).
Mammography screening

Mammography screening is the only screening method that has proven to be effective. It can reduce breast cancer mortality by 20 to 30% in women over 50 yrs old in high-income countries

when the screening coverage is over 70% (IARC, 2008). Mammography screening is very complex and resource intensive and no research of its effectiveness has been conducted in low resource settings.
Breast self examination (BSE)

There is no evidence on the effect of screening through breast self-examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommend for raising awareness among women at risk rather than as a screening method.
References

Anderson BO et al. (2008). Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer, 113, 222143. Coleman MP et al. (2008). Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol, 9, 73056. Danaei G et al. (2005). Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet, 366, 178493. IARC (2002). Breast cancer screening, IARC handbooks for cancer prevention, volume 7, Lyon, International Agency for Research on Cancer, IARCpress. IARC (2008). World cancer report 2008. Lyon, International Agency for Research on Cancer. Lacey JV Jr. et al. (2009). Breast cancer epidemiology according to recognized breast cancer risk factors in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial Cohort. BMC Cancer, 9, 84. Peto J. (2001). Cancer epidemiology in the last century and the next decade. Nature, 411, 3905. Yip CH et al. (2008). Guideline implementation for breast healthcare in low- and middle-income countries: early detection resource allocation. Cancer, 113, 224456. WHO (2007). Cancer control: knowledge into action: WHO guide for effective programmes: early detection. WHO (2008). The global burden of disease: 2004 update.