ESMO SUMMIT LATIN AMERICA 2019 · cancer incidence in latin america and the caribbean. females....

ESMO SUMMIT LATIN AMERICA 2019

Breast Cancer in Latin America

Yanin Chavarri Guerra, MDInstituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán

March 2019

CONFLICT OF INTEREST DISCLOSURE

Roche (research funds)

BREAST CANCER INCIDENCE

Breast cancer is the most common cancer in Latin American women.

Rates:

113/ 100 000 inhabitants (Martinique)

37.4 / 100 000 inhabitants (Guatemala)

199, 734 cases (2018)

Goss, Chavarri-Guerra et al. Lancet Oncology 2013; 14:391 Globocan 2018

CANCER INCIDENCE IN LATINAMERICA AND THE CARIBBEANFemales

192,703

54,377

ASR per 10,000

BREAST CANCER INCIDENCE BY AGE

Central America South America

Di Sibio, et al. Cancer Epidemiology 2016: S110

Villarreal-Garza C, Chavarri Guerra Y et al. The Oncologist 2013;18:26-34

Country Mean age at diagnosis

Ecuador 55.9Colombia 56.7Mexico 52.7Costa Rica 57.8Chile 58Panama 56.7Venezuela 54.5Peru 54Brazil 56.1Argentina 60.2Uruguay 61

Breast cancer trends(1998-2007)Incidence increased: Brazil, Chile and Costa Rica.Incidence declined: Argentina

Di Sibio, et al. Cancer Epidemiology2016: S110

RISK FACTORSEpidemiological transition in the region

• Education and Wealth

• Obesity and overweigth

• Reproductive factors (fertiility rate, age at childbearing)• Population aging

• Population > 65 years: 10% Argentina, 14% Uruguay, 7% Mexico and Brazil

Nahila J, et al. The Oncologist 2013

POPULATION AGING

World Bank 2019

CANCER INCIDENCE BY AGELatin America

Soto Perez de Celis… Chavarri Guerra Y, et al. Clin Trans Oncol 2018; 20: 1117

CANCER INCIDENCE BY AGELatin America

Soto Perez de Celis… Chavarri Guerra Y, et al. Clin Trans Oncol 2018; 20: 1117

CANCER INCIDENCE IN WOMEN > 65

Latin America and the Caribbean United States

Pilleron S, et al. JAGS 2019

CANCER MORTALITYFemales

ASR per 10,000

47,777

BREAST CANCER MORTALITY BY AGE

Central America South America

Di Sibio, et al. Cancer Epidemiology 2016: S110

Breast cancer trends(1998-2007)

Mortality has been stable

Di Sibio, et al. Cancer Epidemiology2016: S110

Villarreal-Garza C, Chavarri Guerra Y et al. The Oncologist 2013;18:26-34

Country Mean age at death

Ecuador 60.2Colombia 58.5Mexico 57.1Costa Rica 62.7Chile 64.1Panama 62.8Venezuela 58.2Peru 58.4Brazil 59.5Argentina 66.4Uruguay 63.2

INCIDENCE TO MORTALITY RATIOS

Possible explanations:

Tumor biology

Disease Stage at diagnosis

Access to cancer care

Goss, Chavarri-Guerra et al. Lancet Oncology 2013; 14:391

BC MOLECULAR SUBTYPELatin America

64%17%

19%

ER+HER2+TN

Romieu I, et al. NPJ 2018

BC MOLECULAR SUBTYPES BY AGE AT DIAGNOSIS

23%

25%

52%TNHER2HR pos

15%

23%62%

TNHER2HR pos

< 45 years > 45 years

Villarreal-Garza C, et al. Clinical Breast Cancer 2016

BRCA1/2 FREQUENCY

Argentina 19-28.3%

Bahamas 2.8-23%

Brazil 2.3-35.5%

Chile 7.1-20.4%

Colombia 1.2-24.6%

Costa Rica 4.5%

Cuba 2.6%

Mexico 4.3-28%

Peru 5%

Puerto Rico 47.8%

Uruguay 17%

Venezuela 17.2%

Chavarri Guerra Y et al. Rev Inv Clin 2018

BRCA1/2 MUTATIONS

BRCA 1/2 frequency 1.2 – 4.9% / ∼ 20 – 30%

BRCA 1: most frequent Founder mutations (ex9-12del, A17082, 3450del4, 5382insC) Large rearrangements OR 4-6 (del exon 1-2, 9-12, 14, 16-17)

• BRCA 2: Costa Rica, Cuba, Puerto Rico, Uruguay 3034del4, c.156_157insAlu

Chavarri Guerra Y et al. Rev Inv Clin 2018

BRCA 1

Dutili, et al. Breast Cancer Research Treat 2015

BRCA 2

Dutili, et al. Breast Cancer Research Treat 2015

ADMIXTURE IN LATIN AMERICA

Adhikari, et al. Curr Opin Genet Dev 2016; 41: 106

STAGE AT DIAGNOSIS

Nahila J, et al. The Oncologist 2013

0

20

40

60

80

100

120

MinasGerais, BR

Porto Alegre,BR

Rio Grande,BR

Rio deJaneiro, BR

Sta Catarina,BR

Sao Paulo,BR

Chile Colombia Mexico Peru Uruguay

Stage 1 Stage II Stage III Stage IV

Mammogram coverageDelays in cancer care

MAMMOGRAM COVERAGE

Reyes Ortiz CA et al. Preventive Medicine 2006; 42:375

DELAYS

Bukowski A, Goia A, Chavarri Guerra Y JGO 2017:3

DISPARITIES IN ACCESS TO CAREBrazil (public vs private hospitals)

Liedke P… Chavarri Guerra Y ,et al. CEBP 2014: 23

ACCESS TO CAREImprovement in the region during the lastdecade

Reforms towards more universal health care access

Argentina: All patients with BC have free access to oncology treatment by law.

Brazil: In 2009, new oncological drugs were incorporated, 60 days law

Colombia: Public and private sectors are integrated

Peru: Public health insurance covers BC diagnosis

Nahila J, et al. The Oncologist 2013

PATIENT NAVIGATION PROGRAMSLatin America

Rio de Janeiro, Brazil60% of cases started treatmentwithin the law 60 days period

GuatemalaEnsure tratment plan350 patients

Mexico CityReferral within the health public systemReferral time 7 days

Goia S SABCS 2018Flood D JGO 2018Chavarri Guerra Y The Oncologist 2018

Patient navigators work within hospitals to help patients find physicians, deal with insurance, treatment adherence, to get supportive care and follow-up with patients to make sure theyget to appointments.

ACCESS TO CARESeguro PopularMexico

Reynoso Noveron N, et al. J Glob Oncol 2017:3

OUTCOMESMexico (Seguro Popular)

Reynoso Noveron N, et al. J Glob Oncol 2017:3

MORTALITY/INCIDENCE RATIO2002/2008

Nahila J, et al. The Oncologist 2013

CONCLUSIONS• Breast cancer is the leading cause of cancer deaths in Latin America.

New cases 192,000 / Deaths 77,000

• Incidence is increasing.

• Epidemiological transition/ Aging of the population.

• Higher proportion of younger women/ TNBC/ BRCA carriers

• Reduced survival compared to other countries (due to late diagnosis).

• Outcomes has improve during the last years.

• Reforms /Iniciatives to imporve access to care should continue and be tailored according to the region needs.

Thank you

Thank you!!!