Women in developing nations, once thought to have a small chance of contracting breast cancer, are increasingly getting the disease as lifestyles incorporate risk factors common in industrialized nations, panelists at the Harvard School of Public Health (HSPH) said Tuesday (April 14).
While their risk is rising, the prognosis for women in developing countries is poor because those nations often lack a strong health care infrastructure. Compounding the problem is the fact that cultural issues often cause delays in seeking care, so physicians see more cases in later stages when treatment options are limited.
The discussion, moderated by HSPH Dean Julio Frenk, was the inaugural event in a new series of “participatory panels” bringing together Harvard faculty to discuss public health issues.
“My hope is [that] we can begin to address some of the most pressing public health problems of our times,” Frenk said.
Frenk called breast cancer in developing nations “an unforeseen health priority” and said that the experience of his wife, Felicia Knaul, who has recently undergone treatment for breast cancer, gave him a new understanding of the challenges Mexican women face. Knaul, a senior economist at the Mexican Health Foundation, was a member of the panel.
“The days when we thought that communicable diseases were a problem of poor people and noncommunicable diseases were a problem of the [wealthy] are over. Now the poor are also subject to noncommunicable diseases,” Frenk said. “The health systems in developing countries are under enormous strain because they have to balance these complex priorities.”
Though cultural issues may be less concrete than medical ones, Frenk said they are considerable, with stigma, discrimination, machismo, and a tendency to reduce women to body parts all factors in the sometimes deadly delay in breast cancer screening and treatment.
Knaul, who had her last infusion to treat her breast cancer a week earlier, said there was no better way to celebrate than a panel discussion on the topic. She painted a picture of breast cancer in Mexico that not only showed that the disease is on the rise, but also that it’s striking younger women and causing a greater percentage of deaths than in the United States.
While roughly 60 percent of breast cancer cases in the United States are detected at Stage 1, just between 5 percent and 10 percent of cases in Mexico are. More than half of Mexican breast cancer cases are detected in Stage 3 or 4, when the disease is much more difficult to treat. Since 2006, Knaul said, breast cancer has been the number one cause of tumor-related death among women aged 30 to 54 and the number two cause of death from all causes.
Globally, though 45 percent of cases occur in the developing world, 55 percent of deaths from breast cancer occur there.
“The evidence is showing us that this is a disease striking all women of all ages of all socioeconomic backgrounds in developing and developed countries,” Knaul said.
The result, Knaul said, is that these nations’ health infrastructures are being forced to play catch-up with the disease, facing the challenge of detecting and treating an ailment they had previously thought they didn’t need to be concerned about.
Mexico has already proven it can act to improve cancer outcomes for women, as Knaul presented evidence of cervical cancer rates on the decline. Still, she said, cultural and financial barriers must be overcome. Government health care, for example, covers a woman’s treatment — but not screening — for breast cancer.
Lawrence Shulman, chief medical officer and senior vice president for medical affairs at the Dana-Farber Cancer Institute and associate professor at Harvard Medical School, said that screening and early detection remain the only effective ways to increase survivability for breast cancer patients.
Even in the United States, he said, the survival rate of women whose cancer is not detected until late stages is very poor. The improvements in breast cancer survival are related to advances that detect and treat the disease at its earliest stages. Mammography is a far more useful tool than breast self-exams, Shulman said, citing a United Kingdom study that showed mammography as the only technology that improved outcomes.
New digital technology may allow mammography to spread to parts of the world where medical expertise is scarce, because the digital images could be sent to experts elsewhere to be read, he said. Even in that case, however, a robust health care infrastructure is still needed to perform the medical follow-up, including biopsy and treatment.
Walter Willett, Fredrick Stare Professor of Epidemiology and Nutrition and chair of the HSPH Nutrition Department, reviewed research into breast cancer risk factors that show that the problem will likely continue to increase in the coming years.
Women around the world are having fewer children, a trend that increases breast cancer risk. In addition, the risk of breast cancer increases with weight gain as a woman ages; with reduced activity; with the use of hormone therapy; and with increased alcohol consumption — all factors on the increase as Western lifestyles spread around the world.
Jennifer Leaning, professor of the practice of global health at HSPH, said that though it is known that screening and early detection can dramatically improve outcomes, they may be difficult to implement in some places around the world. In traditional, male-dominated societies, the most important roles for women are those of bearing children, providing men sexual pleasure, and working to support the family. In some societies, women need the permission of men — and even have to be accompanied by them — to travel to hospitals and clinics.
Leaning said there are some occasions — childbirth and the illness of a child —where it is commonly accepted that women need to attend a medical facility. Interventions and screenings designed to take advantage of those occasions may provide some success, she said.
Another area of opportunity lies with the expansion of health care services in the fight against HIV, which requires that people regularly visit health clinics to get antiretroviral drugs, Leaning said.