Alexandra Bukowski

Progress and remaining challenges for cancer control in Latin America and the Caribbean

Cancer is one of the leading causes of mortality worldwide, and an increasing threat in low-income and middle-income countries. Our findings in the 2013 Commission in The Lancet Oncology showed several discrepancies between the cancer landscape in Latin America and more developed countries. We reported that funding for health care was a small percentage of national gross domestic product and the percentage of health-care funds diverted to cancer care was even lower. Funds, insurance coverage, doctors, health-care workers, resources, and equipment were also very inequitably distributed between and within countries. We reported that a scarcity of cancer registries hampered the design of credible cancer plans, including initiatives for primary prevention. When we were commissioned by The Lancet Oncology to write an update to our report, we were sceptical that we would uncover much change. To our surprise and gratification much progress has been made in this short time. We are pleased to highlight structural reforms in health-care systems, new programmes for disenfranchised populations, expansion of cancer registries and cancer plans, and implementation of policies to improve primary cancer prevention.

Epidemiology and pathophysiology of pregnancy-associated breast cancer: A review

The interactions between pregnancy and breast cancer (BC) are complex. Overall, parity is associated with long-term protective effects against BC, however in a small group of susceptible patients, pregnancy can lead to the development of a form of BC with a particularly poor prognosis. Pregnancy-associated breast cancer (PABC) remains an under-studied but important and growing clinical problem worldwide. Several aspects of PABC, including risk factors and mechanisms involved in its occurrence and aggressiveness, are incompletely understood. This review aims to summarize the epidemiology, biology, patho-physiology and clinical characteristics of PABC. We emphasize that age at first pregnancy, absence of breastfeeding and family history stand out as possible risk factors for developing PABC that ought to be incorporated into clinical tools for assessing a womans risk of developing PABC. Also, improved methods for identifying women at risk of developing PABC in the general population are needed.

Improving access to high-cost cancer drugs in Latin America: Much to be done

Lack of access to high‐cost medications is a complex issue at the intersection of economics, medicine, politics, and ethics, and it poses a significant threat to global health care. The problem is even more significant in low‐ and middle‐income countries, such as those in Latin America, where governments and individuals struggle to pay for products that are priced at several times the level of their per capita gross domestic product. In this review, we examine the determinants for increasing drug costs and how Latin American countries face this burgeoning crisis. We emphasize that a number of opportunities and strategies to reduce costs and improve access exist and should be identified and implemented, ideally within a regional approach with multiple stakeholders involved and based on systematic and transparent cost‐effectiveness analyses. Cancer 2017;123:1313–1323.

End-of-Life Care in Latin America

Cancer has become a global pandemic with disproportionately higher mortality rates in low- and middle- income countries, where a large fraction of patients present in advanced stages and in need of end-of-life care. Globally, the number of adults needing end-of-life care is greater than 19 million, and up to 78% of these patients are living in low- and middle- income countries. In the Americas alone, more than one million people are in need of end-of-life care, placing an enormous burden on local health systems, which are often unprepared to meet the challenge presented by this complex patient population. In Latin America, cancer care is characterized by the presence of vast inequalities between and within countries, and the provision of end-of-life care is no exception. Disparities in access to advanced care planning, with a lack of provision of adequate palliative care and pain medication, are common in the region. These shortcomings are related in large part to inadequate or inappropriate legislation, lack of comprehensive national palliative care plans, insufficient infrastructure, lack of opportunities for clinical training, unreliable reporting of data, and cultural barriers. This report reviews the current status of end-of-life care in Latin America, focusing on identifying existing deficiencies and providing a framework for improvement.

An alert to Latin America: Current human papillomavirus vaccination trends highlight key barriers to successful implementation

&NA; Human papillomavirus vaccine programs run the risk of repeating the problems associated with Papanicolaou testing programs in low‐income and middle‐income countries: an efficient, life‐saving tool that unfortunately is underused for cancer prevention. There is a great need for vigilance in the ongoing implementation of the human papillomavirus vaccine in Latin America.

Disparities in Breast, Lung, and Cervical Cancer Trials Worldwide

Purpose As cancer burden has risen worldwide, physicians, patients, and their advocates have become aware that the clinical cancer trial research paradigm is not ubiquitous. Furthermore, the number and characteristics of trials that are registered in low- and middle-income countries (LMICs) compared with that in high-income countries (HICs) are unknown. Methods We collected retrospective data on trials for breast, lung, and cervical cancer registered in ClinicalTrials.gov or with the WHO International Clinical Trial Registry Platform between 2010 and 2017. The data were then classified as trials within LMICs or HICs using definitions from the World Bank. Results Included in these analyses were 6,710 trials, of which 3,164 (47%) were breast cancer trials, 3,283 (49%) were lung cancer trials, and 263 (4%) were cervical cancer trials. There were 1,951 (29%) trials from LMICs and 4,759 (71%) trials from HICs (P < .001). Although the proportion of phase III trials in HICs versus LMICs was similar (18% v 17%; P = .66), the number of phase I trials in LMICs was significantly lower than that of HICs (20% v 2%; P < .001). For several LMICs with the highest mortality-to-incidence ratios for breast, lung, or cervical cancer, there were no cancer trials registered in the registration data bases searched for this work. Conclusion There are differences in access to cancer clinical trials in LMICs compared with HICs. Several factors, such as excessive cost and a lack of infrastructure and expertise, may explain these differences.

A Rare Presentation of Primary Breast Carcinoma in the Vulva: A Case Report and Literature Review.

Mammary gland carcinoma arising from ectopic mammary tissue in the vulva is an extremely rare occurrence with only 28 cases reported in the literature and carrying an uncertain prognosis.

Endometrial Cancer in Brazil: Preparing for the Rising Incidence

Brazil has a population of over 206 million people.1 It is estimated that there will be 6.22 new cases of endometrial cancer (EC) for every 100,000 Brazilianwomen in 2018.2 From the estimated 6,000 cases in 2016, GLOBOCAN predicts an increase to 9,372 new cases in 2025 and to 11,963 in 2035.3 Obesity and overweight are well recognized, important risk factors for EC.4–7 Data from the Brazilian Institute of Geography and Statistics (IBGE, in the Portuguese acronym) show that, in the past 5 decades, the percentage of women > 20 years old who are overweight or obese increased from 29 to 48% and from 8 to 17%, respectively.8–10 These trends will only worsen over time, as the IBGE predicts that 38.2% of Brazilian women will be obese by 2022. Older age is another important risk factor,with 75%of the patients with type I EC (mainly endometrioid histology) being postmenopausal.11 According to the IBGE, the estimated life expectancy in Brazil increased by almost 5 years in the past 15 years, from 73.9 in 2000 to 78.8 years in 2014,12 with an estimated life expectancy of more than 80 years by 2023.13,14 Surgery for EC should be performed by dedicated gynecologic oncologists15 because oncological outcomes improve when EC surgical procedures are performed by high-volume surgeons and inhigh-volume centers.16However, other than in the USA, in the UK or in Germany, where gynecologic oncology is a subspecialty of its own that requires 3 þ years of formal training, there is no society of gynecologic oncology in Brazil, and subspecialty training of 1 to 2 years is offered in only a few institutions. In addition, > 70% of the Brazilian population are covered by the public health system17 and have difficulty accessing specialized institutions. Therefore, typically, general gynecologists or surgeons perform gyneco-oncologic surgery. Twomajor randomized trialscomparingminimally invasive surgery (MIS) through laparoscopy to traditional open hysterectomy18,19 for the treatment of EC showed thebenefits ofMIS in terms of morbidity without compromising the oncologic outcomes. Despite a lackof formal data, based on other studies in lowandmiddle-incomecountries (LMICs),20 it is reasonable to deduct that Brazilian public hospitals lack laparoscopic devices and the capacity to treat all eligible EC patients in the public healthcare systemwith MIS. Apart from the lack of infrastructure, the availability of MIS also depends on the medical training of the surgeon, which is often insufficient, as discussed above. Another minimally invasive procedure is robotic surgery. The US Food and Drug Administration (FDA) approved robotassisted management for gynecologic cancer in 2005 and, in 2009, a survey among the members of the US Society of Gynecologic Oncologists (SGO) revealed that 27% of the responders had performed robotic-assisted surgery, and 66% planned to increase their use of it.21 The first Brazilian public robotic platform, thedaVinciXi Surgical System(Strattner, Rio de Janeiro, RJ, Brazil). was implemented in the Brazilian National Cancer Institute (INCA, in the Portuguese acronym) in 2012. As of June 2018, 39 robotic systems had been installed in Brazil. It is worth emphasizing that only 4 of these 39 robotic platforms were operating in public hospitals.22 Most EC cases are diagnosed at an early stage, and international guidelines recommend adjuvant pelvic radiation or brachytherapy, depending on the risk of recurrence.23,24 In 2013, the INCA and the Brazilian Society of Radiotherapy (SBR, in the Portuguese acronym) estimated a shortage of 135 machines and 90,000 patients per year not receiving radiation therapydespite its indication.25Overall, thepublichealthcare sector covers only 69.5% of the need for radiotherapy in Brazil, and there are some states with coverage of less than 50%.25 Based on recommendations of the Brazilian government in 2014 (1 teletherapy machine per 500,000 inhabitants),26 412 machines would be needed to cover the entire

Abstract P4-10-09: Delay in diagnosis of breast cancer in Mexican young women: Report of the “Joven y Fuerte” prospective cohort pilot phase

Background : Delay in diagnosis and treatment initiation of breast cancer (BC) has been associated with advanced stages and poor outcome. In developed countries, age has not been solely reported as an independent predictor of diagnosis delay. In Mexico, median time since tumor detection to treatment initiation is about 7 months, but young women are underrepresented in these studies. We aim to describe time intervals related to diagnosis in Mexican young women with BC (YWBC). Methods: Newly diagnosed YWBC were invited to participate as part of this prospective cohort. Patient accrual began in November 2014 at two public cancer centers in Mexico. Patients completed self-report surveys including questions regarding mode of detection, time from first symptom to medical appointment (patient interval) and time from first symptom to diagnosis (total interval). Pearson chi-square tests were used to examine the effects of patient and clinical characteristics on patient interval and clinical stage. Results: 96 YWBC with median age at diagnosis of 35 y (range 21-40) were enrolled in our pilot phase. 82.3% had tumor detected by self or partner. 62.5% of YWBC were diagnosed as locally advanced disease (IIB-IIIC). Median tumor size was 3.5 cm (0.5-12.0), with node involvement in 66.7%. 53.1% of YWBC had a patient interval of 12 months, 39.6% reached a total interval >12 months. Patient interval and clinical stage were not significantly associated with occupation, education, marital status, current partner or method of detection. Conclusions: In this cohort, most patients had a greater total delay than previously reported in Mexico, possibly attributed to long health-system intervals, which could contribute to worse outcomes in YWBC. The prospective nature of this study allows the recollection of biologic characteristics, treatment scheme and adherence to treatment, to determine their impact on clinical outcome besides diagnosis delay. “Joven & Fuerte”, the first dedicated program for the care of young breast cancer patients in Latin America, aims to develop YWBC-tailored interventions to early diagnose or “downstage” BC among young women by endorsing patient navigation, increasing general population awareness and improving providers9 knowledge in low-middle income countries, such as Mexico. Citation Format: Castro-Sanchez A, Barragan-Carrillo R, Miaja M, Platas A, Martinez Cannon BA, Fonseca A, Vega Y, Bukowski A, Chapman J-A, Goss P, St. Louis J, Bargallo-Rocha JE, Mohar A, Pena-Curiel O, Villarreal-Garza CM. Delay in diagnosis of breast cancer in Mexican young women: Report of the “Joven y Fuerte” prospective cohort pilot phase [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-09.

Patient Navigation to Improve Access to Breast Cancer Care in Brazil

Noncommunicable diseases, such as cancer, are surpassing infectious diseases as the most pressing health care threat in lowand middle-income countries (LMICs). By 2025, 59% of new cancer cases and 68% of all cancer deaths will occur in LMICs, and health care systems in these countries are struggling to respond to this changing landscape. InBrazil, breast cancer is themost commoncancer and the leading cause of cancer death among women, with 14,206 deaths in 2013 and 57,960 newcancerdiagnosesestimated for theyear2016.