By Nagi S. El Saghir, MD, FACPChair, ASCO International Affairs Committee
Professor and Director, Breast Center of Excellence, Naef K. Basile Cancer Institute, American University of Beirut Medical Center
Detecting cancer before it causes symptoms and signs is a basic principle of early detection. This has to be coupled with evidence that diagnosing disease at that early time will result in improved outcomes and no increased harm. Clinical trials are conducted to show that. This has been the case in breast cancer and some other malignant diseases.
Breasts are an external organ that is amenable to a self-exam and clinical examination by a physician or health care professional, and further earlier detection can be obtained by mammographic imaging for women with average risk. Women at a higher risk are offered breast MRIs. New research focuses on developing ultrasound machinery that is less operator-dependent than currently available. Although more promising research utilizing molecular biology is under way, the whole world still relies on the above methodologies.
In the midst of all the controversies surrounding the above methods, especially timing and frequency of screening mammography, it remains hard to argue against success. Clinical trials have shown positive results of using screening mammography. Published clinical observations and practicing oncologists and surgeons have seen favorable changes in countries that adopted screening strategies. This has resulted in earlier stages at diagnosis, better survivals, and more breast-conserving therapy.
As much as it is tempting to extrapolate medical strategies from high-income countries to low- and middle-income countries, it cannot and should not be automatically done in one package. Also, people should take advantage of good achievements, avoid mishaps, and search for better ways of implementing advances in prevention and early detection.
Successful awareness campaigns
Like many places around the world, in Lebanon, we make lots of noise about breast cancer. Campaigns have run yearly for the past 12 years. Although people do emphasize mammography, we keep insisting that this is more of an awareness campaign. The media has been very helpful in spreading the word. Radio, TV stations, newspapers, and magazines help spread the word. These campaigns have helped defuse the taboo surrounding the word “cancer.” Women are afraid of the word “cancer” because it is historically associated with death. However, with early detection, these campaigns allow us to tell people that if they ever have breast cancer, we can detect it at an early stage and they can then be cured of it.
People listen when we tell them that with early detection, breast cancer isn’t a death sentence, and they may not even have to lose their breasts or have all their armpit nodes removed. It’s also exciting to be able to tell patients that if their tumor is sensitive to hormones and is of a slow-growing nature, they may avoid chemotherapy and depend only on hormonal therapy. Those ideas can be easily translated into lay language by journalists, and as a result, these messages have been very effective.
Those campaigns have a measurable impact, and we are now seeing fewer advanced cases and relatively more early-stage breast cancer diagnoses. We’re performing more breast-conserving surgery and fewer mastectomies. We also emphasize cure and celebration of survivorship, and for that, after lighting up the famous Raouche Rocks in the middle of the Mediterranean Sea in 2012, this year we organized the formation of a human pink ribbon at the American University of Beirut Soccer Green Field with volunteers, survivors, medical students, high school pupils, and supporters who were all happy performing such community service for a good cause like raising awareness against breast cancer.
More challenging prevention and screening campaigns
Although breast issues usually attract more attention, we should not forget to keep going forward with our campaigns on other diseases, particularly lung, colon, and cervical cancers where prevention and screening have been shown to be effective.
Anti-smoking campaigns require more efforts and vigilance. Smoking remains very prevalent among young people, especially in Europe and elsewhere around the world. We should be more vigilant after the recent introduction and promotion of e-cigarettes (which risk to return “smoking” back to its old status of a “socially acceptable habit” in the U.S.) at a time when cigarette smoking remains widespread.
Worldwide campaigns to promote colonoscopy in people over 50 years of age remain weak and need to be intensified. Campaigns to prevent cancer of the cervix are still hampered by the high cost of vaccines in South America and other continents. More education and promotion of the results of the recent study from India presented at the ASCO 2013 Annual Meeting in Chicago, regarding the use of visual inspection of the cervix with acetic acid should boost early detection and survival benefits for women in low- and middle-income countries.
Tactics to reduce disparities
ASCO, through its ASCO International portfolio, aims to reduce disparities in the outcome of patients. ASCO depends on its members to spread and disseminate oncology knowledge and skills worldwide through conferences, courses, grants, research, and volunteering. ASCO not only emphasizes multidisciplinary management modalities (for which we will be holding a special international session at ASCO 2014) but also promotes a multidisciplinary approach to prevention and early detection.
The ASCO International Affairs Committee is adding the themes of cancer prevention and early detection to its International portfolio and is working with ASCO’s Cancer Prevention Committee to disseminate knowledge about smoking, obesity, awareness, and early detection. The International Committee is working in collaboration with the National Cancer Institute’s Center for Global Health, European Society for Medical Oncology, World Health Organization (WHO), Union for International Cancer Control, and national, regional, and local medical societies, organizations, and governments, in order to enhance cancer prevention and early detection across continents.
These efforts will help us achieve the United Nations and WHO’s goal of reducing the cancer burden by 25% by the year 2015, which ASCO has participated in drafting and is committed to pursuing.