Abstract SS1-2: Guidelines and management of advanced breast in limited resource settings
Authors: El Saghir N 
Published: May 2016

Abstract
Advanced Breast Cancer Burden and Guidelines: GLOBOCAN 2012 data estimated a total of 1.67 million breast cancer cases worldwide. Advanced Breast Cancer (ABC) represents only 5-10% of cases in High Income Countries (HIC) but still represents about 60% of cases in Low and Middle Income Countries (LMIC). Improvements in breast cancer outcomes seen in HIC have not yet been seen in low-resource settings. We will discuss Breast Health Global Initiative (BHGI)1 and ABC Consensus Guidelines2.
Locally Advanced Breast Cancer: Diagnosis: Clinical evaluation, biopsy, staging, then systemic therapy followed by surgery and radiation therapy.2,3 Pathology and receptor evaluations are important in order to choose the type and duration of systemic therapy. Pathology: Pathology services remain scarce in many LMIC. BHGI considers ER should be made available in LMIC. Systemic Therapy: pre-operative chemotherapy, with anthracyclines, or sequential anthracyclines & taxanes, with or without trastuzumab. 2,3,4 Anthracyclines are widely available. Generic taxanes have become recently available. Chemotherapy administration requires training and setup. For patients with ER positive tumors hormonal therapy can be considered. Tamoxifen is widely available. Aromatase inhibitors have become generic, but at a higher cost. Surgery: Surgery remains essential for LABC, usually after initial Neoadjuvant therapy. Infrastructure and human resource capabilities need further development in most LMIC5. Radiation Therapy: it is either not available or not accessible for millions of cancer patients worldwide. Investment in RT not only enables treatment of cancer cases to save lives and provide palliative care, but also brings positive economic benefits.6 Targeted Therapy: Trastuzumab was recently added to the “Essential Medications List” of the WHO for early breast cancer.7 It is essential for LABC. It requires determination of HER2 receptors. Shorter durations of trastuzumab therapy, or reducing its price are discussed.
Metastatic Breast Cancer: Hormonal Therapy: is the mainstay of management for hormone receptor-positive MBC, unless patients have so-called visceral crisis requiring chemotherapy for rapid response2. Tamoxifen, with OFS by LHRHa, radiation, or oophorectomies. In post-menopausal women, aromatase inhibitors (AI) have a slight advantage, but more expensive. Fulvestrant, everolimus, and palbociclib are prohibitively expensive. Chemotherapy: it is generally palliative. Options of hormonal therapy or less toxic chemotherapy should be offered where appropriate. Targeted therapy: Trastuzumab, pertuzumab and t-DM1 prohibitive costs do not allow use in most LMIC.
Supportive Care and Survivorship: Support, palliative care and access to pain medication is variable and limited in many LMIC8.
Conclusions: Resource-stratified guidelines, multidisciplinary management, more access to modern therapy, improved resources are all needed to improve access to care and to reduce disparities in patients' outcome.
References: 1. Anderson BO (BHGI) Lancet Oncol 2011; 2. Cardoso F (ABC2) Breast. 2014; 3. El Saghir (BHGI) The Breast 2011; 4. El Saghir (BHGI). Cancer 2008; 5. Sullivan R Lancet Oncol 2015; 6. Atun, et al. Lancet Oncol 2015; 7. Shulman & Torode: UICC-WHO EML 2015; 8. Distelhorst S (BHGI) Lancet Oncol. 2015
Citation Format: El Saghir N. Guidelines and management of advanced breast in limited resource settings. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr SS1-2.