While breast cancer mortality has reduced by as much as 40% over the past three decades, and five-year breast cancer survival rates exceed 90% in some countries, these figures mask global inequalities. Dr Carlos Barrios, director of the Latin American Clinical Oncology Research Group in Porto Alegre, Brazil, tells Katherine Price how The Lancet Breast Cancer Commission’s latest report provides a roadmap for change and how clinicians around the world can support it.
Breast cancer cases are increasing globally, and by 2040, it is predicted that there will be three million new diagnoses per year, with people living in low- and middle-income countries (LMICs) disproportionately affected.
‘We need to recognise that there has been unequal progress, and if we keep on doing what we have done so far, that’s not going to change,’ says Dr Carlos Barrios, director of the Latin American Clinical Oncology Research Group in Porto Alegre, Brazil.
To help to achieve this aim, Dr Barrios was invited to participate in The Lancet Breast Cancer Commission, an interdisciplinary group of commissioners and patient advocates from high-, middle- and low-income countries across the world seeking to address inequalities in healthcare access and education and counter the perception that this predicted upward trajectory in breast cancer cases is inevitable.
The Commission published a report in April 2024, which Dr Barrios co-authored while also coordinating the working group looking at metastatic breast cancer (MBC). He says the report offers a roadmap for achieving more equal progress on breast cancer care worldwide.
‘The task that was given to us was to try to identify the discrepancies and be transformative – what do we need to do to change this situation?’ he says.
Breast cancer prevention and early diagnosis
As well as improving representation of participants and research leads from LMICs in trials, many of The Lancet Breast Cancer Commission’s recommendations are for policy change, and Dr Barrios was keen that those responsible for making such changes were explicitly named.
‘Most of the recommendations require a very active and proactive position of policymakers and administrators,’ he explains.
For example, researchers estimate that up to a quarter of breast cancer cases in high-income countries (HICs) could be prevented by modifying risk factors such as alcohol, physical activity and obesity. In addition, identifying those at increased risk is essential for equitable access to personalised prevention strategies, including cheap and effective medications, and early detection programmes. The authors call for stage-shifting as a sustained decline in breast cancer mortality rates can be achieved by diagnosing at least 60% of invasive cancers at less than 2cm in size.
‘More than 50% of that improvement that we see in the mortality is actually driven by early diagnosis and adjuvant therapy,’ says Dr Barrios.
More information needed
The findings highlight a lack of information in some areas, particularly MBC rates. Relapse is not typically recorded by most national cancer registries, even though 20-30% of patients with early breast cancer relapse.
‘If you don’t have a specific number, it’s very difficult to know the size of the problem and how to devote strategies to these patients,’ says Dr Barrios.
‘We need registry data that tells us actually how many patients we have with metastatic breast cancer, what treatment these patients received, and what the outcomes are of these patients in different places in the world.’
Within the past five years, median survival has reached five years for two of the three main MBC subtypes, which account for approximately 85% of patients with breast cancer, and some subgroups are starting to be considered as having a chronic disease. Dr Barrios and the report authors argue for eradicating social stigma around MBC as a rapidly fatal disease, and for patients to not be excluded from potentially life-extending treatments.
They make the case for at least 70% of registries worldwide to record MBC rates, and for initiatives to promote societal inclusion of people living with MBC, such as, changes to labour laws that empower more flexible working arrangements.
There is also a lack of information around the associated and hidden consequences of breast cancer – the physical, psychological, social and financial costs that are not routinely captured by global health metrics.
The Commission’s UK-based CASCARA pilot study found that a fifth of participants with early breast cancer and a quarter of those with MBC reported difficulty in covering the costs of travel for treatment, for example, and tools are needed to measure these costs and the benefits of addressing them to guide policymakers on interventions.
Multidisciplinary working
The report also argues that at least half of patients with MBC should be discussed at multidisciplinary meetings, as well as 80% of patients with a new breast cancer diagnosis. However, while a multidisciplinary approach from diagnosis onwards is essential, as is applying approaches that have worked well in HICs to settings with fewer resources. And this must be tailored to local contexts.
‘Most patients with breast cancer in the world are not going to be treated in institutions where you have the ability for multidisciplinary discussion,’ says Dr Barrios. ‘Most will be managed by physicians [who] work alone, that are outside the capitals, that are not in the tertiary centres.’
As such, telementoring and virtual multidisciplinary meetings are suggested by the Commission to help enable resource sharing between cancer centres and local community hospitals, even between HICs and LMICs, with a vision for technology-enabled data exchange between all stakeholders of the oncology healthcare system and always with a focus centred in the patients’ best interests.
What clinicians can do
Although many of the recommendations are actions and targets for policymakers, Dr Barrios stresses that clinicians can make a difference by identifying discrepancies around them. ‘See what you can do as a clinician in your everyday clinic to identify patients that may have problems with information or access to healthcare procedures or medications,’ he says.
Better patient communication, for example, is key in improving quality of life, decision-making, body image, and even adherence to therapy – with subsequent positive impacts on survival. The Commission’s report calls for all healthcare professionals to receive communication training and for patient involvement in all stages of breast cancer clinical research, and even provides a framework for patient-centred consultations.
It stresses that healthcare professionals are there to help patients make the decisions that are best for them, which requires the patient to understand the goals, logistics and side effects of treatment, and the clinician to understand the patient’s preferences, values and life goals.
Revolutions in breast cancer treatment
While action from clinicians is crucial, enduring change sits firmly within the power of policymakers. It is hoped that widely sharing the The Lancet Breast Cancer Commission’s report, its findings and recommendations, for example at global oncology conferences, will pave the way to global government and policymaker attention and engagement.
‘The idea here is that we need to have a more significant impact on the national cancer care plans, because that’s where the action will reach the patients,’ says Dr Barrios.
He is optimistic about further improvements in breast cancer care on the horizon, particularly the development of new drugs in the treatment of hormone-receptor-positive disease and antibody-drug conjugates. He says these are ‘revolutionising’ MBC management and will eventually improve cure rates and help patients with early disease as well. He is also keeping a keen eye on research being led by fellow Commission participant Felicia Knaul at the University of Miami into measuring hidden costs and suffering, which he says would be ‘extremely significant’ and transformative for patients and for clinical practice.
Dr Barrios and his co-authors hope that application of the recommendations set out in The Lancet Breast Cancer Commission’s report will not only lead to improvements in breast cancer rates, treatment and outcomes in a more equal way, but have a positive impact across the cancer field, healthcare and society as a whole.
‘[These] solutions and strategies could be applicable to other diseases, and also empowering women in general,’ says Dr Barrios. ‘If we make women more participatory in the process, this will have much broader implications for women in society overall.’
