Breast Cancer in
Eastern Europe and
Central Asia
Julie R. Gralow, M.D.
Professor and Director, Breast Medical Oncology
University of Washington School of Medicine
Fred Hutchinson Cancer Research Center
Seattle Cancer Care Alliance
Top 10 Cancers in Women:
Central/Eastern Europe vs USA
Breast Cancer Incidence and
Mortality Worldwide
Incidence
Globocan 2008 data
Mortality
Factors Associated with Global
Differences in Breast Cancer Survival
• Low awareness and education of the
public as well as health care providers
• Limited screening
• Reduced health care access
• Later stage at diagnosis
• Limited treatments available
• Cultural barriers to care
Many of these factors are addressable
without major monetary investments
The Development of the Eastern
Europe/Central Asia Breast
Cancer Advocacy Project
Engaging Patient Advocates in Cancer
Education, Outreach and Policy-making
Ukraine Breast Cancer
Assistance Project
1997-2000
• Program for Appropriate
Technology in Health
(PATH)
• Ukrainian Ministry of
Health
• US Agency for
International
Development (USAID)
• University of Washington
Why Was the US Government
Interested in Funding a Ukraine Breast
Cancer Project?
Cancer Risk and
Ionizing Radiation
Exposure
Most strongly linked
to thyroid cancer,
leukemia and breast
cancer
Chernobyl Museum
Kiev, Ukraine
Contaminated Areas Following
1986 Chernobyl Nuclear Power
Plant Accident
• Country Size of contaminated area (km2)
37–185 kBq/m2
>185 kBq/m2
• Russia
49,800
8,100
• Belarus 29,900
16,600
• Ukraine 37,200
5,700
• Sweden 12,000
• Finland
11,500
• Austria
8,600
• Norway 5,200
• Bulgaria 4,800
Hatch M et al, Epidem Reviews 2005
What Has Happened with Breast
Cancer Risk Post-Chernobyl?
• Increase in premenopausal breast cancer in
women from contaminated areas of Ukraine close
to Chernobyl compared with Ukraine female
population rates
– Standardized incidence ratio = 1.50, 95 percent
confidence interval: 1.27, 1.73
Prysyazhnyuk AY et al. Cancer incidence in Ukraine after the Chernobyl
accident. In: Chernobyl: message for the 21st century. Proceedings of the
Sixth Chernobyl Sasakawa Medical Cooperation Symposium 2002.
Ukraine Breast Cancer Assistance
Project Goals
• Primary aim: to strengthen breast cancer early
detection, diagnosis, treatment in 3 cities in
Ukraine
• Additional key objective: to improve the quality
of life of breast cancer patients
Assessment of Treatment
Practice in Ukraine
Kiev City Oncology
Hospital
Fighting the Crab –
Kiev, Ukraine
Assessment of Treatment
Practice in Ukraine
• Limited discussion of disease + treatment – “Don’t
say the Word”
• Treatment decisions based on drug cost/availability,
not science
• Number of cases treated and exact regimens difficult
to determine
• Very low doses of
chemotherapy used –
“Ukrainian women cannot
tolerate Western doses”
Ukraine Breast Cancer Assistance
Project: Odessa Chemotherapy Trial
• “Western” doses of
chemotherapy safe and
effective
• Education + experience
with clinical trials
• Presentation of results by
Ukrainians at national +
international conferences
• Consent process created
dialogue between
physician and patient
Chernihiv Pilot Breast Cancer
Screening Program
PATH Psychosocial Support
Project for Breast Cancer
Survivors
Breast Cancer in Ukraine:
PATH Psychosocial Support Project
• Limited discussion of disease and
treatment – “Don’t say the word”
• Interventions: Improving patient
understanding, public awareness
– Development of educational
materials for patients, families,
public
– Development of a survivor
support and outreach network
through training
– Exchange visits
– Psychosocial support by health
care providers and survivors
Lives Renewed: The Emergence of a Breast
Cancer Survivor Movement in Ukraine
Bishop A, et al. Reprod Health Matters 9:126-134, 2001
• In 1997:
– No breast support groups (or even the concept of
patient support systems or services) existed in Ukraine
• 1997-2000:
– PATH project educated breast cancer patients,
encouraged establishment of patient survivor groups
• By 2001:
– Advocates from 15 Ukrainian cities had begun
providing mutual support in an organized way
– Annual breast cancer walk (“March for Life and Hope”)
organized by breast cancer advocates in Kiev
From “Don’t Say the Word” in 1997
to the 1st “March for Life and Hope” in 2001
Kiev, Ukraine
Contiuation of the
Ukraine Breast Cancer
Survivorship Movement
• 1999: no breast cancer survivor groups
• 2001: survivor groups in 15 cities, 12 oblasts
• Early 2005: national association of survivor groups
formed
• 2011: breast cancer survivor groups in 22 cities,
representing nearly all of the country’s 25 oblasts
• Breast cancer support groups throughout Ukraine
now provide regular opportunities for women to
receive the emotional support that contributes to
their healing
Successor to PATH Project
Eastern European/Central Asia Breast Cancer
Advocacy Forums
Vilnius, Lithuania 2003
Kiev, Ukraine 2005
Minsk, Belarus 2007
Bishkek, Kyrgyzstan 2009
Vilnius, Lithuania 2011
?Tbilisi, Georgia 2013
Breast cancer patients, advocates, health care professionals,
policy makers, pharmaceutical representatives
Goals of Eastern Europe/Central Asia
Breast Cancer Advocacy Conferences
• To combat breast cancer by building advocacy
groups with skills to address inadequacy in
information, inequity in treatment and care,
and injustice in breast cancer early detection,
screening, and prevention
Goals of Eastern Europe/Central Asia
Breast Cancer Advocacy Conferences
• Raise awareness of the impact of breast cancer on society
• Provide information on critical breast cancer issues to
promote community activism
• Establish health care standards for women with breast
cancer
• Understand what women with breast cancer want and need,
and how to address those needs
• Bring together doctors, patients and activists as equals
around a common cause
• Connect isolated women to international communities for
collaboration
• Establish patient-doctor dialog and focus health care to the
patient
1st Eastern European Breast Cancer
Advocacy Conference
Vilnius, Lithuania 2003
2nd Eastern European Breast Cancer
Advocacy Conference
Kiev, Ukraine 2005
3rd Eastern European Breast Cancer
Advocacy Conference
Minsk, Belarus 2007
Democracy Building through Breast
Cancer Advocacy
Fulfullment Report of In Rays of Hope (Belarus NGO) to
US Embassy
• Throughout US history, great social
advancements such as abolition of
slavery, women’s suffrage, and civil
rights evolved not from government
initiative, but from voluntary
grassroots movements. Each began
with a group of passionate people
coming together around a common
cause.
•The Breast Cancer Advocacy Conference in Minsk was a
momentous occasion in grassroots activism. By coming
together with a passion to combat the impact of breast cancer
in Belarus, conference participants set a course to change how
the issue will be recognized at all levels.
Democracy Building through Breast
Cancer Advocacy
Fulfillment Report of In Rays of Hope (Belarus NGO) to US
Embassy
• As a result, breast cancer early detection, screening and
prevention will become a national priority in Belarus.
• By inviting international participants, the conference planted
seeds for similar grassroots mobilization efforts throughout
the former Soviet Union.
4th Eastern European Breast Cancer
Advocacy Conference
Bishkek, Kyrgyzstan 2009
Eastern Europe/Central Asia Breast Cancer
Advocacy Conferences
Communicating, Sharing Ideas, Collaborating
Vilnius, Lithuania 2003
Bishkek, Kyrgyzstan 2009
(Kazakhstan van!)
Kyrgyzstan Conference 2009
5th Eastern European Breast Cancer
Advocacy Conference
Vilnius, Lithuania 2011
2007 Institute of Medicine Report on
Cancer Control Opportunities in Lowand Middle-Income Countries
Sloan FA, et al, National Academies Press, 2007
• Advocacy has a key role to play in bringing the public’s
concerns about cancer to decision makers
• Summary recommendations: Advocacy
– Active support and assistance of cancer advocacy in
low- and middle-resource countries
– Suggested activities:
» Set up advocacy networks within countries,
regions, and internationally
» Identify successful approaches to cancer
advocacy and replicate/adapt for use in other
settings
» Provide hands-on training and technical
assistance
A global call to action for cancer in
low-and middle-income countries is
beginning to emerge….
New Initiatives
Evidence for the Feasibility and
Effectiveness of Cancer Care and Control
in Countries of Low or Middle Income
• Much can be done without the latest and most expensive
technologies
• Task and infrastructure shifting could benefit the health
systems of even wealthy countries
• Expansion of treatments for MDR-TB and AIDS in poor
countries shows that new initiatives for care of complex
diseases can be effective and strengthen health systems
• Coordinated financing and procurement can secure
reduced prices and increased access to interventions
• Demonstration programs show that effective cancer
diagnosis and treatment can be introduced even in rural
areas of low-income countries in which specialized
services are absent
Farmer P, et al. Expansion of cancer care and control in countries of low and
middle income: a call to action. Lancet 376, 2010
Closing the Cancer Divide:
A Blueprint To Expand
Access In Low And Middle
Income Countries
A Report Of The Global Task
Force On Expanded Access
To Cancer Care And Control
Released October 28, 2011
http://ghsm.hms.harvard.edu/uploads
/pdf/ccd_report_111027.pdf
New Initiatives
UN High-level Meeting on the Prevention
and Control of Non-communicable
Diseases
September 19-20, 2011
New Initiatives
Pink Ribbon Red Ribbon Campaign
Launched September 13, 2011
• Partnership to leverage public and private investments
in global health to combat cervical and breast cancer in
Sub-Saharan Africa and Latin America, particularly in
HIV+ women
– George W. Bush Institute
– U.S. President’s Emergency Plan for AIDS Relief
(PEPFAR)
– Susan G. Komen for the Cure
– Joint United Nations Program on HIV/AIDS (UNAIDS)
• initial commitments of $75 million over five years
http://www.state.gov/r/pa/prs/ps/2011/09/172244.htm
Breast Cancer Advocacy: What Next?
Collaboration between Fred Hutchinson
Cancer Research Center and Uganda
Cancer Institute
• Medical Oncology fellowship
training agreement since 2004
• Seattle and Ugandan researchers
collaborate to study and treat
infection-related cancers
• FHCRC-Uganda joint Cancer
Center under construction in
Kampala (groundbreaking October
4, 2011)