1. Women-specific cancers Challenges and opportunities Vivien Tsu, PhD, MPH Associate Director for Reproductive Health PATH CORE Group, Spring Meeting Baltimore, May 12, 2011

3. Despite younger populations, 63% are in poorer countries

6. Why is the burden of cervical cancer so high in poorer countries? Overall, nearly ½ million cases; more than ¼ million deaths each year >80% in developing countries Expected to increase to >775,000 new cases per year by 2030, with 99% of deaths in developing countries No sustainable, organized screening programs, despite many efforts “Competing” health problems Prevalence of high-risk HPV infection higher Limited awareness of cost-effective approaches to prevention Until recently, no vaccine available to prevent infection

7. Breast cancer rates rising in low- and middle-income countries Reasons similar to those for many other chronic diseases: Increasing life expectancy – women are living longer Changing lifestyles – urbanization, less physical activity, higher calorie and fat diets Plus Changing reproductive behaviors – fewer children, starting later, less breastfeeding

8. Impact on women, families, communities Women Painful illness, premature death, stigma, and isolation Families Cost of medical care Loss of economic contribution and non-income generating work Loss of caregiver for children, elderly, sick, and disabled Loss of family advisor Community Loss of social and political leaders at prime of life Loss of experienced teachers and health workers Loss of managers of food security – women produce 75% of food in poor countries

9. Exciting new opportunities New prevention options for cervical cancer – screening and vaccine New ideas for adapting breast cancer detection and treatment to low-resource settings

10. Cervical cancer screening New technologies Visual inspection with acetic acid (VIA) HPV DNA testing New strategies Screen and treat, without intervening diagnostic step before precancer treatment Services provided by non-physicians with appropriate training Samples for HPV testing collected by women themselves Once or twice in a lifetime screening for women 30–49 years old

11. $0 $25 $60 $120 2006 07 08 09 2010 HPV vaccination Human papillomavirus is primary cause of cervical cancer; current vaccines protect against types that cause ~70% of cases (and a portion of other female cancers) Will also prevent about half the precancers and reduce costs for future screening programs Experience with vaccine is growing – shows vaccination is feasible and acceptable Cost of the vaccine is dropping rapidly; current PAHO price is <$14/dose

12. Breast cancer: early detection is key Can’t prevent disease but can improve survival Health education can raise awareness of symptoms, overcome stigma, and improve early care-seeking Feasible methods like clinical breast exam (CBE) can be done by trained health workers and detect many early tumors Early results from study in Mumbai* showed that 71% of cancers in women screened by CBE were early stage, as compared with only 51% among women receiving only health education * Mittra I, et al. Int J Ca 2010.

13. Diagnostic and treatment opportunities for breast cancer General physicians and nurses can be trained to take needle biopsies and use ultrasound Generic tamoxifen is low-cost, taken orally, and generally well tolerated Planned study in Africa will assess use of 2–3 month course of tamoxifen where lab testing not available; tumor response will determine whether to continue or not Treatment recommendations can be tailored to available resource levels (e.g., use older drugs that still give good benefit at lower cost)

14. Cervical cancer and maternal mortality

15. Information resources Breast cancer BHGI Library http://portal.bhgi.org/docs/default.aspx National Cancer institute www.cancer.gov/cancertopics/types/breast BreastCancer.org www.breastcancer.org Cervical cancer RHO cervical cancer library www.rho.org WHO/ICO (Institut Català d'Oncologia) Information Centre www.who.int/hpvcentre/en WHO Cervical Cancer www.who.int/reproductivehealth/topics/cancers

16. Next steps

17. Conclusions Cancer burden on women is real and growing – especially among the most disadvantaged. Practical solutions already exist – both for prevention and for relieving suffering. Investments in obstetric care and HIV are lost if women then succumb needlessly to cancer a few years later.

18. Thank you Vivien Tsu, PhD, MPHAssociate Director for Reproductive HealthPATHEmail: vtsu@path.org