Breast Cancer in Asia

CH YipProfessor

Department of SurgeryUniversity Malaya Medical Centre

Current Issues in Breast Cancer

3rd July 2010

Incidence of breast cancer in Asia

• Generally incidence rates are lower than in the Western countries

• However the incidence is rising at a more rapid rate than in Western countries

BREAST CANCER (Female) 1.15 million cases in 2002 (10.6% total)

BREAST CANCER EPIDEMIOLOGY:Breast cancer mortality / incidence ratios

More developed countries0.30 (190K deaths / 636K cases)

Less developed countries0.43 (221K deaths / 514K cases)

Globocan 2002 (IARC)B Anderson

Breast cancer – Incidence in AsiaGlobocan 2002

46.6

34.7

33 31.7

30.8

26.2

24.7

21.5

20.6

20.4

20.2

19.6

18.7

16.6

16.6

50.1

48.6

83.2

101.

1

0

20

40

60

80

100

120

USA

Aust

ralia

Pak

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Sing

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Phili

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Japa

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Jord

an Iraq

Mal

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Indo

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S A

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Cam

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Bru

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Kore

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Mya

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Chi

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Ban

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Thai

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The incidence of breast cancer is lower in Asia compared to the

western countries

WHY?

Australia 1 in 10

Malaysia 1 in 20

#1 The rate of increase in breast cancer in developing countries is more

than in the developed countries

#2 When a woman from a low incidence country migrates to a high-incidence

country, her risk of breast cancer increase

Risk factors for breast cancer are different in different parts of the world

Lifestyle and diet are important risk factors

In Asia , lifestyles are rapidly changing

•Less children

•Later age at first childbirth

•Less breast feeding

•More urbanisation

•More obesity

•More westernised diet

What are these risk factors

NCR (Malaysia) Report 2003‐2005

• Ten top cancers in Malaysian womenBreast 31.3%Cervix Uteri 10.6%Large Bowel 9.9%Ovary 4.3%Leukemia 3.7%Lung 3.6%Lymphoma 3.4%Corpus Uteri 3.3%Thyroid 3.1%Stomach 2.7%

Female Breast Cancer – NCR report 2003-2005

• 11 952 new cases over 3 years• Commonest cancer in Malaysia overall• Commonest cancer in Malaysian women • Crude rate 41.3 per 100,000• Age standardised rate (ASR) 46.4 per 100,000• Cumulative risk 5.0 ie a woman in Malaysia

have a 1 in 20 chance of developing breast cancer in her lifetime

Female Breast Cancer– NCR report 2003-5Race Incidence

Ethnic Group No % CR ASR CumR

Malay 4969 33.6 27.7 34.9 3.6Chinese 5051 30.3 66 59.8 6.3Indian 1265 31.2 47 54.1 6

Malay women 1 in 28 lifetime riskChinese women 1 in 16 lifetime riskIndian women 1 in 17 lifetime risk

Female Breast Cancer– NCR report 2002

Race Mean Age Median Age (range)

Malay 48.1 (10.8) 47 (15-86)Chinese 51.4 (11.4) 50 (23-96)Indian 52.3 (11.4) 51 (28-87)

Female Breast Cancer– NCR report 2003-2005Age Incidence

Age No % CR0-9 5 0 0.110-19 10 0 0.220-29 181 1.5 3.730-39 1512 12.6 37.340-49 4050 33.9 117.450-59 3479 29.1 154.060-69 1822 15.2 141.570+ 901 7.5 105.1

Prevalent age group 40-49Highest age-specific incidence 50-5948.1% below the age of 50

Population pyramid

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74

75+

12 10 8 6 4 4 6 8 10 12Population in Percentage

Males Females

2002World standard Male and Female Population by Age

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74

75+

12 10 8 6 4 4 6 8 10 12Population in Percentage

Males Females

2002Male and Female Population of Developing Country by Age

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74

75+

12 10 8 6 4 4 6 8 10 12Population in Percentage

Males Females

2002Male and Female Population of Developed Country by Age

World Std population:

Average between Developing and Developed countries

Developing country:

For most cancers with rising age incidence, crude rate therefore always HIGHER after age standardization

Developed country:

For most cancers with rising age incidence, crude rate therefore always LOWER after age standardization

Ethnic population pyramid

Malay

Broad base pyramid, hence rate generally

increase after age standardization

Chinese

Narrower base pyramid, hence rate generally decrease after age

standardization, espfemales

Indian

Intermediate base and rate increase after age

standardization

Female Breast Cancer– NCR report 2003-2005Age Incidence

Age

spec

ific C

ance

r Inc

iden

t per

100

000

popu

latio

n

A ge group

Malay Chinese Indian

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70+0.0

240.4

Age specific incidence – breast cancer

Age

spec

ific C

ance

r Inc

iden

ce p

er 1

0000

0 po

pula

tion

Age group

Female:Peninsular Malaysia Female:Singapore Female:South Australia

0- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+

0

317.3

USA

UK

Sweden

Philippines

Singapore

Japan

Korea

India

China, Thailand

Figure 1: Age‐specific incidence rate for breast cancer 

Different patterns of Western countries and Asian countries

Geographical differences in age incidence

• The difference in age at presentation between Asia and Western countries could be explained by the birth cohort effect ie women of successive generations are more exposed to risk factors

• Women born after the Second World War are at higher risk than those born before

• This could be related to the rapid change in lifestyle in most Asian countries after the war as dietary factors in childhood and adolescence play an important role in the aetiology

• With time, the age incidence of breast cancer may be similar to Western countries

Age incidence in Japan

• The mean age at presentation has increased over the years from 48 years in 1946-1959, to 53.9 years in 2000-2001.

• Postmenopausal breast cancer has increased from 40.6% in 1946-1959 to 55.4% in 2000-2001

Histopathology of breast cancer in Asia

• More infiltrating ductal compared with infiltrating lobular

• More Grade 2/3 cancers compared to Caucasians

• Possibility of more HER2 over-expressing cancers

• Less ER and PR positivity

Grade of tumour by ethnic groups UMMC 2001-2006

A recent update by Elston etal reported an 18% Grade 1, 27% grade 2 and 45% Grade 3.

Chinese Malays Indians

Grade 1 91 (10%) 25 (9.3%) 12 (7.1%)

Grade 2 479 128 81

Grade 3 338(37.2%) 115(42.9%) 75 (44.6%)

Total 908 268 168

Hormone receptor status at presentation

13239 cases.    

Gapstur etal Cancer 1996

White(%)

Hispanic (%)

Black(%)

Malaysia(%)

ER+PR+ 58 58 49 42.9ER+PR- 15 12 14 11.1ER-PR+ 6 8 7 8.8ER-PR- 20 22 35 37.2

15 year review of ER status in UMMC

Year ER positive ER negative Total

1994‐1998 150 (54.3%) 126 276

1999‐2003 588 (56.6%) 451 1039

2004‐2008 1019 (58.3%) 728 1747

Total 1757 (57.4%) 1305 3062

P=0.406

15 year review of ER status in UMMC

Race ER positive ER negative Total

Malay 318 (52%) 293 611

Chinese 1218 (59.4%) 832 2050

Indian 221(55.1%) 180 401

Total 1757 1305 3062

P=0.003

15 year review of ER status in UMMC

Age ER positive ER negative Total

Less than 40 192 (51.1%) 185 377

40 and above 1565 (58.3%) 1120 2685

Total 1757 1305 3062

P=0.007

Stage at presentation

• Generally presents at later stages compared with Western countries

• Late stage of disease due to the absence of a mammogram screening programme

• Socio-cultural factors are also barriers to early detection

Late presentation in Asian countries are very common

Ignorance and poor education

Geographical isolation and inadequate access to medical care

Absence of screening programme

Social and cultural barriers

Financial problems Traditional Treatment

Advanced cancers

India – 76% of breast cancers are in Stage 3 and 4

Korea – 50% present with Stage 0-1 Sabah, Malaysia – 52.2% present with Stage 3-4

Japan – 10% present with Stage 3-4

Why do women present late?

Taboos

Myths

Stigma

Silence

“Put aside”

No pain, cannot be cancer

Cancer only in old people

Mastectomy means death

Breast Cancer in UMMCStage at presentation 1993-2008 (3689 cases)

Early Stage –Stage 1 and 2Late Stage – Stage 3 and 4

0%10%20%30%40%50%60%70%80%90%

100%

1993

1995

1997

1999

2001

2003

2005

2007

Stage 4

Stage 3

Stage 2

Stage 1

Breast Cancer in HKL and UMMCMalaysia

CH Yip, NA Mohd Taib, I Mohamed, "Epidemiology of breast cancer in Malaysia", 2006, Asian Pac J Cancer Prev, Vol. 7, no. 3, pg. 369-374

Hisham AN and Yip CH. Spectrum of breast cancer in Malaysian women: an overview. World J Surg 2003;27:921-23.

Hospital Kuala Lumpur

University Malaya Medical Centre

Stage 3‐4 50‐60% 30‐40%

Malays 48% 23%

Chinese 35% 59%

Indians 17% 16%

Size 5.4 cm 4.2 cm

Age 50 years 50 years

Sabah – Queen Elizabeth Hospital

186 patients presenting in 2005‐2006

• Stage 1            12.9%

• Stage 2 30.1%

• Stage 3             36.6%

• Stage 4 15.6%

4 factors  significantly related to late presentation were:

• Non‐Chinese, Poor (earning < RM1000 per month, Rural, and Not educated

Leong BC, Chuah JA, Kumar VM and Yip CH. Breast cancer in Sabah, Malaysia: a two year prospective study. Asian Pac J Cancer Prev 2007;8(4):525-9.

Penang Cancer Registry 1994-1998

• Launched on 15th Dec 2003• ASR 34.6 per 100,000• Higher incidence in Chinese (43.1)

followed by Indians (35.2) and Malays (19.4)

• Estimated 1 in 28 women will develop breast cancer in Malaysia

Penang Cancer Registry 1994‐1998

• Stage 1 – 15.4 %

• Stage 2 – 46.9 %

• Stage 3 – 22.2%

• Stage 4 – 15.5%

Breast Cancer in UMMCStage at presentation and race 2008 (442 cases)

Early Stage –Stage 1 and 2Late Stage – Stage 3 and 4

0%10%20%30%40%50%60%70%80%90%

100%

Malays Chinese Indians

Stage 4

Stage 3

Stage 2

Stage 1

Stage 0

Malays 72

Chinese 313

Indians 57

Why do women present late?

• Small pilot study in UMMC on 25 women presenting with late disease

• 60% had tried alternative therapy as the first choice of treatment; the rest ignored the symptoms or prayed, hoping that it would go away

• One had spent over USD10 000 of alternative therapy

• Main reasons was fear of surgery and belief in traditional treatment, others were financial, family problems, did not know that cancer could spread….

• Most had been diagnosed early but did not agree to conventional treatment

Taib NA, Yip CH etal APJCP 2007

Barriers to early detection

• 34 year old lecturer from a local university

• Married with 4 children aged 2 to 7 years old

• Right breast lump for 4 years on traditional medicine

• Poor education and poverty are not the only barriers 

to early detection of breast cancer

Traditional Medicine

• 33 yr old diagnosed with breast cancer when 36 weeks 

pregnant

• After delivery defaulted surgery

• Presented 5 months later with a large right breast mass

• Alternative therapy with joss sticks

Why do women present late?

• Mixed method (qualitative quantitative) study based on the grounded theory

• Three recurring themes– Fatalism– Belief in traditional treatment– Decision making not in the hands of the

woman

SURVIVAL FROM BREAST CANCER

A woman in the developing world is more likely to die from breast cancer compared to the

developed world

WHY?

Global Differences in Breast Cancer Diagnosis and Outcomes: Survival

• Estimated mortality-to-incidence ratios are generally lower in developed regions1

USA (83–88%)2*

Europe (60–83%)2*

Developing countries(45–72%)3**

Women diagnosed: *1990–1994; **1982–1992

ASR 5

-yea

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al

1Shibuya, et al. BMC Cancer 2002;2:37; 2Coleman, et al. Ann Oncol 2003;14(Suppl 5):V128–V149; 3Sankaranarayanan, et al. IARC Sci Publ 1998;145:135–73

Five year survival rates around the world

USA 86%

Korea 85%

Australia 84%

United Kingdom 75%

Singapore 70%

Malaysia 59%

Philippines 52.4%

India 46.7%

Uganda 44%

Oman 64%

Survival from breast cancer depends on:

EarlyDetection

Treatment

AND

Breast Cancer Survival by Stage (U.S. Data):

Localized

Regional

Unstaged

Distant

The best chance of cure is from EARLY DETECTION

Breast Cancer Survival in Malaysia

• Mortality statistics inaccurate

• Only 40% of deaths are medically certified

• Hospital data – UMMC database on breast cancer 1993‐2002.  Exclude DCIS and patients who absconded.  Total of over 800 patients

• Patient’s IC checked with the Registry Dept (JPN) to see if they are alive or dead

Yip etal APJCP 2006

0 20 40 60 80 100

Survival times

0.0

0.2

0.4

0.6

0.8

1.0

Estim

ated

sur

viva

l pro

babi

litie

sOverall survival plot

0.584

Median follow-up : 55 months(1 month to 107 months)

Overall Survival Breast Cancer Patients in UMMC- 1993-1997 (n=423)

0 20 40 60 80 100

Survival times

0.0

0.2

0.4

0.6

0.8

1.0

Estim

ated

sur

viva

l pro

babi

litie

s

Stage 1Stage 2Stage 3Stage 4

Survival Plot by Stage

Stage 1

Stage 2

Stage 3

Stage 4p < 0.05

Survival by Stage in UMMC

1993-1997 (n=423)

Mohd Taib NA, Yip CH, Mohamed I. Survival analysis of Malaysian women with breast cancer: results from the University Malaya Medical Centre. Asian Pac J Cancer Prev 2008 Apr-Jun;9(2):197-202

0 20 40 60 80 100

Survival times

0.0

0.2

0.4

0.6

0.8

1.0

Estim

ated

sur

viva

l pro

babi

litie

s

ChineseIndianMalay

Survival Plot by Race

p = 0.0025

Survival by Race in UMMC-1993-1997 (n=423)

5‐year Overall Survival 

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

Months

Surv

ival

Pro

babi

lity

patients 93 - 97patients 98 - 02

93-97 Median follow-up : 56 months98-02 Median follow-up : 53 months

76.2%

59.1%

Ethnic Group

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

OthersMalayIndianChinese

Months

Surv

ival

Pro

babi

lity

p= 2.85e-010

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

ChineseIndianMalay

Months

Surv

ival

p-value0.00631

5-year survival probability

1993-1997 1998-2002

Chinese 63.5% 81.6%

Indian 57.4% 80.4%

Malay 47.5% 58.9%

Other NA 92.9%

p=0

1993-97 1998-2002

Stage

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

stg IVstg IIIstg IIstg Istg 0

p= 0

Surv

ival

Pro

babi

lity

Months

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

Months

Surv

ival

IIIIIIIV

p-value=0 1993‐1997 1998‐2002

Stage 0 NA 100%

Stage 1 82.6% 95%

Stage II 72.8% 87.1%

Stage III 39.8% 56.3%

Stage IV 13.2% 20.7%

p=0.

1993-97

1998-2002

History of Breast ServicesBreast Clinic database - non-dedicated service-General Surgeons performing surgery and chemotherapy

1993-1996

Dedicated Breast Unit with surgical chemotherapy service

In-house radiotherapy services

Daycare Oncology chemotherapy service

1996

1998

1999

History of Breast Services

1993 to present

2000 Reconstruction

2003 Combined pathology meeting

1993 Radiologist services

Support Services

2003- Breast Care Nurse sanctioned

2005-Breast Cancer Resource Centre

1993- Survivor Support-BCWA

2007-Psychooncology services

2007- Free basic prosthesis kit

2007- Palliative care consultancy

Besides Early Detection,

TREATMENT

makes a big

difference to

SURVIVAL

TREATMENT

SURVIVAL

ARE THERE ADEQUATE TREATMENT FACILITIES IN DEVELOPING COUNTRIES

Manpower –doctors, nurses, paramedical staff

Radiotherapy machines

Medical facilities – hospitals, clinics, labs, operating theatres

15 African nations have no radiotherapy machines!!

Spending Per Capita for Health

Source: World Bank, World Development Report 2004

(from Worldmapper, www.worldmapper.org

Territory size shows the proportion of worldwide spending on public health services that is spent there. This spending is measured in purchasing power parity.

Geographic Map

Minimal amount spent on health care in Africa

Equity of access – world-wide

Treatment is inadequate in developing countries

Lack of manpower

Lack of facilities

Competing priorities – the major health problems may be

infectious diseases rather than breast cancer

Lack of drugs

Lack of psychosocial support

If breast cancer survival rates were uniformly as high as the best in the world, 100,000 fewer women would die of

breast cancer each year in the developing world.

CLOSING THE GLOBAL GAP IN BREAST CANCER CARE

What can we do?

The Breast Health Global Initiative (BHGI) strives to develop, disseminate and foster the implementation of evidence-based, economically feasible, and culturally

appropriate “Guidelines for International Breast Health and Cancer Control” to improve breast health outcomes for

middle and low income countries with limited health care resources.

MISSION STATEMENT

AWARENESS

EDUCATION

ADVOCACY

SHARING

EMPOWERMENT

SUPPORT

CONCLUSION

• Breast cancer is the commonest cancer in women in Malaysia

• One third of breast cancers occur in the 40‐49 age group

• Breast cancer continues to be diagnosed in late stages especially in the Malay women

• Survival of breast cancer is lower than in the developed countries

• Research into barriers to early detection are required

• Health education programmes need to emphase that breast cancer can be cured if diagnosed and treated early and that alternative therapy is ineffective

There are global differences in incidence, mortality, age at presentation and stage at

presentation

Women in Asia developing countries present at a younger age, and with late stages, and they are

more likely to die from the disease

CONCLUSIONS

Treatment is inadequate in most parts of the developing world

Thank You