Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Multidisciplinary Coordination for Curative TreatmentKarla Unger-Saldaña, MDInstituto Nacional de Cancerología, México (México)

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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MULTIDISCIPLINARY COORDINATION FOR CURATIVE TREATMENT

Alejandro Mohar, MD10 / 16 / 2018Seattle, WA

Presented by: Karla Unger‐Saldaña

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Cancer in LMICMexican Health System in contextMultidisciplinary coordination

Cancer in LMICMexican Health System in contextMultidisciplinary coordination

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Copyright 2018©, BHGI. All rights reserved. With the exception of a copy for personal use, no part of this publication may be reproduced or transmitted in any other form or by any means, electronic or mechanical, without first obtaining written permission from Breast Health Global Initiative.

Cancer in LMICMexican Health System in contextMultidisciplinary coordination

Cancer in LMICMexican Health System in contextMultidisciplinary coordination

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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1. Projected growth of new cases: 18.1 m (2018) 21 m (2030)2. 75% of future cancer burden will occur in low and middle income countries

CA J Cliniicians, GLOBOCAN 2018

Ca

201818,100,000

203021,000,000

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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BREAST CANCER MORTALITY:INCIDENCE RATIO

0 0.1 0.2 0.3 0.4 0.5

Puerto Rico

Uruguay

Chile

Brazil

Peru

Venezuela

Paraguay

Mexico

Nicaragua

Honduras

French Guiana

Jamaica

Guyana

Trinidad and Tobago

Usa

Latin AmericaW Europe

BRAY & PIÑEROS, SALUD PUB MEX, 2016.

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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CLINICAL STAGES AT DIAGNOSIS%

HIGH INCOME MIDDLE INCOME

Unger‐Saldaña K. World J Clinical Oncology, 2014.

0

10

20

30

40

50

60

70

Sweden Norway UK Canada Denmark Mexico Brazil Peru Egypt India Nigeria

I

II

III

IV

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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BC HEALTH SYSTEM INTERVALS

0 2 4 6 8

BrazilNigeria

RwandaMexico

ColombiaFrance

CanadaGermany

1st medical consultation

Treatmentstart

Arndt, 2003. (n=380)Mayo, 2001. (n= 29,000)Molinie, 2013. (n=1494)

Piñeros, 2011. (n=1105)

Unger‐Saldaña, 2015. (n=886)Pace, 2015. (n=144)

Pruitt, 2015. (n=31)Rezende, 2008. (n=105)

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Clinical stage

Less developed health systems:‐ Saudi Arabia‐ Costa Rica‐ Philipines‐ India‐ Thailand

More developed health systems:‐ Hong Kong‐ Singapore‐ Turkey

Survival (%)0.0 50.0 100.0

Metastásica

Regional

Localizada

Sankaranarayan, et al. Lancet, 2010.

BC 5-YEAR SURVIVAL RATES

Localized

Locally advanced

Metastasic

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Cancer in LMICMexican Health System in contextMultidisciplinary coordination

Cancer in LMICMexican Health System in contextMultidisciplinary coordination

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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• 1,964,375 km2

• 131,000,000 inhabitants• LE: 76.9 years

• Inequities- 6th Richest man in the World

(70 billion USD)- 9 million: < 50 USD/month- 53 million: < 150 USD/month

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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* Total health spending is 4 times lower than the OCDE countries average.

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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SOCIAL SECURITY INSTITUTIONS (for the formally employed) 

MINISTRY OF HEALTH FACILITIES

UNINSURED

Ministryof Health

Regulation

PRIVATE SERVICESOut‐of‐pocket

expenses

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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TUMOR YEAR OF INCLUSIONUterine cervix 2003

Breast 2007Children /adolescents 2008

Non‐Hodgkin’s lymhoma 2011Testicular 2011

BMT 2011Prostate 2011

Colo‐rectal 2015Ovary 2016

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Cancer in LMICMexican Health System in contextMultidisciplinary tumor boards

Cancer in LMICMexican Health System in contextMultidisciplinary tumor boards

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Kesson et al. BMJ 2012;344:bmj.e2718

• Scotland• n = 13,722• Non-random interv.• 1995: inclusion of

multidisc. care• Retrospective cohort• Time series analysis

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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• Global Cancer Institute• 500 participants• 25 LMIC• 37 USA experts

St. Louis et al. ASCO, 2017. Abstract 6556.

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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RADIOTHERAPYHORMONE-TX

SURGERY

CHT NEO / ADY TARGET TX-MAB

SBRHRs / HER-2

*** Seguro Popular - NCCN & St. Gallen adapted guidelines

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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n = 10,433

3 institutions (SP):- INCAN - FUCAM- COE

BC dx 2008 -2013

Mexico: Pop. 130 millions

Mexico City & Metropolitan Area:Pop. 22 million

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Variable Num (%)Age (Mean, DE) 52.5±12.2Presentation:

- Screening- Symptoms

n=4651883 (8.5)3,768 (91.5)

Tumor size (mm) (Median, range)

n=7,07635 (20-50)

TYPE OF SURGERYRadical Conservative

n=8,2305,481 (66.6)2,749 (33.4)

SYSTEMIC TXAdjuvantNeoadjuvantPalliative

N=6,8783,422 (49.8)2,941 (42.8)515 (7.5)

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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4

13

21

1815

13

3

10

4

0

5

10

15

20

25

0 I IIA IIB IIIA IIIB IIIC IV NC

Percen

t (%)

49 % LABC

n = 10,433

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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CLINICALSTAGE

OVERALL 5-YEAR

SURVIVALEARLY D. 94.86LOC. ADV. 78.31METAST. 27.78

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Breast CancerNATIONAL PUBLIC HEALTH PROBLEM LATE DX

An epidemic within an epidemic…THE COSTS WILL BECOME UNSUSTAINABLE ($ 20,000 USD/ patient)

Proposal: collaborative effortPRIMARY & SECONDARY PREVENTIONMULTIDISCIPLINARY TREATMENTPILOT IMPLEMENTATION PROJECTSLONG RUN National Cancer Control Plan

Breast CancerNATIONAL PUBLIC HEALTH PROBLEM LATE DX

An epidemic within an epidemic…THE COSTS WILL BECOME UNSUSTAINABLE ($ 20,000 USD/ patient)

Proposal: collaborative effortPRIMARY & SECONDARY PREVENTIONMULTIDISCIPLINARY TREATMENTPILOT IMPLEMENTATION PROJECTSLONG RUN National Cancer Control Plan

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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Thank you

www. incan.sa lud.gob.mx

Thank you

www. incan.sa lud.gob.mx

Dr. Mohar: • Elected member of the UICC 

Board of Directors 2018‐2021

Breast Health Global Initiative – 2018 Global SummitSeattle, Washington

October 15 – 17, 2018

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