2. Breast Cancer Research in the Developing World Dr. Steven Narod Canada Research Chair in Breast Cancer Boston – November 2009

3. Annual numbers of breast cancers Top 10 countries China224,000 USA195,000 India 113,000 Germany 53,000 Russia 52,000 Italy 38,000 Brazil 38,000 France 38,000 United Kingdom 36,000 Indonesia 28,000

4. Breast Cancer Cases by Continent Asia 508 South America 82 Africa 69 Central America 18 (677) North America 213 Europe 324 Australia 11 (548)

5. By Stage of Development Developing 739 Developed 486 (IMF)

6. Why do research in developing world? Major cause of death in those countries Most breast cancers occur in developing world Rates may be increasing Populations aging Better understanding of variation in patterns, etiology Might lead to understanding in North America Different stage at presentation Might be specific etiology for other ethnic groups Planning of services Milestones

7. Examples Advanced cancers: Different than North America From stage 4 to death Metastastic oophorectomy/tamoxifen New drugs (Raises ethical issues)

8. Recessive genes Different diets Different environmental exposures Questions about Etiology

9. Towards a Standard Set of Descriptors Population or hospital-based Private or Public Prevalent or incident cases One year of diagnosis, several year of diagnosis

10. Variables to Collect Age of diagnosis Means of detection patient, physician, mammography Size Nodes examined Nodes positive Locally advanced Clinical Stage Grouping (early, locally advanced, metastatic) ER PR HER2 Grade

11. Variables to Collect, cont…. o Treatment o Radiotherapy (y/n) o Chemotherapy o Regimen o Surgery o Mastectomy o Lumpectomy o Bilateral mastectomy o Hormonal therapy o Oophorectomy o Age of oophorectomy o Tamoxifen o Aromatase inhibitors o Menopausal status at diagnosis o Age of menopause o Date of last follow-up o Date of Death o Cause of Death

12. Questions to address Are people getting appropriate treatment? Is stage at presentation improving? Is treatment effective?

13. Western model applied to developing countries Promotes two-tiered system May not be best approach for population Access and affordability All populations may not respond the same

14. Possible recessive basis for breast cancer Test of recessive disease, parents related Test in children of consanguinous parents Homozygosity mapping Countries with high rates of consanguinity: Pakistan Bangladesh Yemen Saudi Arabia

15. Risk Factors May Differ Vietnam: 300 cases and 300 hospital controls No effect of family history No effect of parity Very low frequency of BRCA1 and BRCA2 Different risk factors?

16. Hypothesis There are no common risk factors for breast cancer.