Despite advances in healthcare, breast cancer incidences in Asia are rising rapidly.

The risk of developing the disease increases with age, but Asian women are being diagnosed at a younger age compared to their Western counterparts.

“The peak age of breast cancer is about 10 years younger in Asia. There is also a suggestion that there may be a difference in the tumor biology of women diagnosed with breast cancer in Asian nations as compared to Western nations.

“This will have a consequence in the treatment recommended for these patients, with the aim of trying to improve survival rates. The main difference that impacts survival is the stage at which patients are presented,” says Professor Arlene Chan, a medical oncologist at Curtin University’s School of Medicine in Australia.

Chan was part of a team involved in the Lancet Oncology Commission to identify countries with a high population density and socio-cultural ethnic attitudes that would impact the disease in terms of patient presentation and acceptance of treatment.

She was presenting the findings at the inaugural Specialists Conference organized by Ramsay Sime Darby Health Care in Kuala Lumpur last week.

Approximately 10 percent to 25 percent of breast cancer patients in Asian countries present with de novo metastatic disease, compared to only 3 percent to 5 percent in Europe and United States. This means they are diagnosed as stage IV or advanced, from the start.

The disease profile in these patients is more severe, whereby higher proportions of local advanced tumors are seen and distant metastases detected, and multiple metastatic sites are more likely.

Chan says, “The proportion of patients presenting with stage III, which although considered potentially curable, has a much higher relapse rate than stages I and II. In Australia, about 10 percent to 12 percent of patients might present with stage III, whereas in certain parts of Asia, such as China and India, the rates are up to 35 percent to 40 percent.”

A number of factors were identified for this spike, and these include the lack of screening programs, population density, scarcity of resources, and cultural restrictions and limitations.

“In India, for example, women do not present themselves even when they feel a lump, for fear of bringing shame to the family; a lack of understanding on whether treatment can be delivered; fear of surgery; and unavailability of drugs. The same applies with metastatic and locally-advanced cases. These are large, potentially fungating, ulcerating tumors that also tends to be in a younger age group,” she says.

A fungating wound is a result of cancer that is growing under the skin, breaking through it to create a wound. As the cancer grows, it blocks and damages tiny blood vessels, which can starve the area of oxygen. This causes the skin and underlying tissue to die.

Chan adds, “There is data to show that breast cancer occurring in those under the age of 30 or 35 may have worse biological behavior.

“In terms of oestrogen-positive breast cancer, the standard of care is anti-oestrogen treatment to reduce the risk of relapse, yet in the study, it was found that there is a high likelihood that a Chinese would decline treatment. For patients who decline conventional treatment, their outcome and data never get collected.”

Locally, our cancer data is poor [the last National Cancer Registry report was updated in 2007], so most analyses rely on estimates by Globocan, an international agency for research on cancer.

According to a 2016 report Breast Cancer in Asia: The Challenge and Response, written by The Economic Intelligence Unit and commissioned by Pfizer, the Malaysian age standardized rate (ASR) of incidence is 38.7 per 100,000 a year, which is below the global mean, but mortality is at 18.9, 47 percent higher than the world figure!

Consultant breast surgeon and president of Breast Surgery International, Dr Yip Cheng Har, says: “That might translate to one in 20 Malaysian women getting breast cancer in their lives, with the incidence highest among the Chinese and lowest among the Malays.

 “Malaysian women present at an earlier age; the median age is about 50, with 50 percent below 50 [years of age], whereas in Western countries, only 20 percent are below the age of 50. The age group at risk right now is 40 to 49, but the mean age is increasing,” said Har.

“The reason is not necessarily that younger women have higher incidences. It’s because looking at the age-specific incidence rate, Malaysia has a younger demographic, with a median age of 26. In the United Kingdom, the median age is 40. Only 15 percent of our population is above 60, so that’s why the ASR goes up,” Har explained further.

Breast cancer is the most well-researched form of cancer, and if caught early, it is largely treatable. In well-off countries in the region (South Korea, Hong Kong, Australia, Japan, Taiwan, Singapore), the five-year survival rate is typically between 80 percent and 92 percent, with five countries having figures roughly comparable to that of the US.

But, data indicates that progress against the disease is highly uneven in the region, with five-year survival rates in developing countries such as Thailand, India and Malaysia, far behind their developed country counterparts.

Of the 10 countries studied, Malaysia ranked the lowest for five-year survival rate at 49 percent.

“This figure is embarrassing because we are an upper middle income country, and yet, we’re on par with lower income countries like Cambodia.

“It’s not because we don’t have a good universal healthcare system but our women are resistant to treatment. Despite the free screening programs widely available, women throw away these vouchers!” laments Har, who has published many papers on the subject.

“This delayed presentation is common. They are scared of mastectomy and decision-making.

“A lot of them depend on their significant other to take them to hospital. It’s almost as if women here need sanctioning to go to hospital!

“Even the highly-educated, irrespective of race, come in late because of their belief in traditional medicine. If they find a lump, they wait for some time before going to the hospital.

“So, from the time of diagnosis to starting treatment, there is a big delay. If you delay long enough, the breast will start to ulcerate.”

The triple negative is the most aggressive form of breast cancer, and tough to treat and beat. This diagnosis means that the offending tumor is oestrogen receptor-negative, progesterone receptor-negative and HER2-negative, thus giving rise to the name “triple negative breast cancer.”

Although we have no central population screening, Har says small studies have shown that our indigenous population are more prone to this type of cancer.

Chan says, “Aside from the high cost of drugs and technology, if healthcare providers can tailor for the socio-cultural-ethnic attitudes of that nation, we feel that it would make a big difference in terms of survival.”

Har concludes, “If you’re diagnosed early, you need not lose your breast or have chemotherapy. Even if they find something abnormal in the mammogram, you have to be counselled and educated first before acting on it.

“Self-examination is important.”

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