GLOBAL HEALTH

Burden of Breast Cancer in Poorer Women Featured in First of Participatory Panels on Public Health Priorities

The recent recognition of breast cancer as an “unforeseen public health priority” in Mexico and many parts of the less-­developed world formed the basis of an April 14 event hosted by HSPH dean Julio Frenk, the first in a planned series of “participatory panels” on public health issues.

Photo by Suzanne Camarata

In the first of an HSPH series of participatory panels addressing public health issues, (from left) Felicia Marie Knaul, Julio Frenk, Walter Willett, Lawrence Shulman and Jennifer Leaning discussed the socioeconomic barriers preventing women from getting breast cancer diagnosis and treatment in less-developed countries.

The policy forum served as a personal introduction of the dean and his family—his wife, ­Felicia Marie Knaul, a Harvard-trained economist, and their daughters, Hannah and Maha, ages 12 and 4.

The occasion also marked the end of chemotherapy treatments for Knaul, who was diagnosed with breast cancer in 2007 in Mexico. One way in which she coped, she said, was by plunging into research and advocacy on breast cancer, with the active support of her husband, the former Minister of Health in Mexico. Together, they have helped open a new window on the previously unrecognized toll of breast cancer among the poor in Mexico and other less-developed countries. They have also drawn attention to the social and cultural barriers that aggravate problems of access to early diagnosis and care for many women.

The pervasive code of machismo means that women are reluctant to seek early detection for a disease that could require breast surgery, said Frenk. “A lot of women say, ‘I wouldn’t get a mammogram because if it turns out there is a problem, my husband would abandon me.’ This has led me to understand that the fight against breast cancer is also a fight for the dignity of women.”

Other panelists were Lawrence Shulman, a breast oncologist and HMS associate professor of medicine at Dana-Farber Cancer Institute and Brigham and Women’s Hospital; Jennifer Leaning, HSPH professor of the practice of global health; and Walter Willett, chair of the HSPH Department of Nutrition.

Knaul, born in Canada, said that she and Frenk shared the common public health “myth” that breast cancer is primarily a disease of wealthy women and developed countries. In the developing world, cervical cancer has garnered much more attention because of a long history of causing death and disability, particularly among the poor.

But this assumption was shattered when Knaul and others dug into the statistics and found that cervical cancer mortality had peaked in 1990, declining rapidly thereafter due in large part to improved screening and treatment, while deaths from breast cancer have risen steadily.

“In fact, breast cancer is striking women at all socioeconomic levels in all developing and, especially, middle-income countries,” said Knaul, senior economist at the Mexican Health Foundation and director of the Carso Health Institute program, Breast Cancer: Take It to Heart (Tomatelo a pecho).

In 2008, she, Frenk, and four other researchers published a paper—“Breast Cancer in Mexico: A Pressing Priority”—whose striking findings have served as a wake-up call. Among their revelations:

• Breast cancer in 2006 overtook cervical cancer as the leading cause of cancer deaths in women.

• Rather than being mainly a disease of older women, breast cancer is the second leading cause of death for women ages 30 to 54.

• Forty-five percent of all breast cancer cases and 55 percent of deaths occur in developing countries.

• In almost all cases, the woman finds the tumor herself. In Mexico, about five to 10 percent of breast cancers are discovered while in Stage 1 or 2 when they are highly treatable, compared to about 60 percent in the United States. Although Mexico’s health system now covers breast cancer treatment for most women, mammography and other early detection services are scarce. As of 2006, only one in five women age 40 to 69 reported having a mammogram or breast clinical exam in the past year.

Although mammography resources are in short supply in Mexico and other less-developed countries, Shulman said that the technology is crucial to saving lives. “The key to reducing mortality is the mammogram. You can’t get away from this.” Breast cancer that is not found early and spreads to other organs has a poor prognosis even with the latest therapies, he said.

One potential strategy for expanding mammography services is “task-shifting”—training non-MD technicians to interpret the breast X-rays. Another is to exploit telemedicine by having images taken in remote areas beamed to specialists elsewhere to be read.

The panelists agreed that more data on specific risk factors among women in developing countries is vital to combating the breast cancer epidemic in developing countries. Willett summarized findings from the Nurses’ Health Study showing that variables of diet—including red meat and milk consumption, body weight, height, alcohol consumption, physical activity, and use of hormone replacement therapy—all play a role in determining breast cancer risk.

Women who have their first child at an early age and who have a large number of pregnancies are less likely to develop breast cancer. Willett suggested that drugs that mimic the effects of pregnancy may offer a potential method of reducing breast cancer risk when women adopt more “Westernized” behaviors, such as delaying pregnancy and having fewer children.

Leaning predicted that expanding early detection of breast cancer in the developing world would be extremely difficult given the “desperate state of women” in many regions.

Women in these cultures may be valued only as “vessels” for sexual satisfaction or reproduction, and their access to healthcare is often entirely controlled by men, she noted. In fact, healthcare access is provided typically on two main occasions: during childbirth or when a child is seriously ill. “We should think about rolling out breast cancer screening at these times,” Leaning said. Similarly, healthcare professionals should capitalize on the need for HIV/AIDS care as an avenue to provide breast cancer screening.

Frenk referred to the HIV/AIDS epidemic on a hopeful note in his closing remarks.
“A lot of what we’re saying now about breast cancer was said in the past about how difficult it would be to get HIV/AIDS treatment to people in less-developed countries,” he said. “We’re at a similar beginning with breast cancer, another stigmatizing disease with barriers to treatment for disenfranchised people.”
A webcast of the panel is available at www.hsph.harvard.edu/administrative-offices/deans-office/panels-on-public-health-priorities/.

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