Overview of Breast Cancer Conditions in South America

 
 

Overview of Breast Cancer Conditions in South America

Anushka Pramanik, Suhitha Kopparthi, and Dr Lopamudra Das Roy

Published: October/2023

@BreastCancerHub, All Rights Reserved

Abstract

               Breast cancer is the most commonly diagnosed cancer in South America. The landmass consists of twelve countries and despite innovative medicinal research and technological advancements, breast cancer incidence and mortality rates have been increasing steadily in the region throughout the past 25–30 years. This research paper presents an overview of breast cancer in South America and includes information relating to the demographic, lifestyle, socioeconomic, environmental, and cultural factors that may have led to the development of breast cancer. Early screening and properly regulated treatment protocols are crucial to combat the increasing cases of breast cancer, which are all covered as well. Research and statistics were obtained from a multitude of reliable sources such as PubMed, the Pan American Health Organization, the National Library of Medicine, and the Lancet. There is a lower incidence rate of breast cancer in the northern countries of South America (Panama, Ecuador, and Columbia) while there is a high incidence rate in the southern countries (Uruguay, Argentina, Chile). The high mortality-to-incidence ratios in Latin America indicate poor survival, as they are connected to late-stage diagnosis and decreased access to treatment. The difference in incidence and survival rates appears to be because of factors related to diet, exercise, socioeconomic issues, screening availability, and the environment. It has been revealed that age is the main risk factor as the demographic changes in the region will cause epidemiological shifts and increase breast cancer incidence.

Incidence of Breast Cancer in South America

There has not been much research conducted specifically on South American mortality and incidence rates in recent years however, as of 2013, breast cancer annual incidence (114,900 cases) and mortality (37,000 deaths) were the highest of all women's cancers in Latin America [1]. It is noted that scientists used research from previous years about breast cancer in South America to predict that the number of deaths from breast cancer is expected to double by 2030, to 74,000 every year [2]. The same study also concluded that Argentina, Uruguay, and Venezuela would continue to have the highest mortality rates. Additionally, a total of ten countries displayed increases in mortality rates. These nations include Brazil, Columbia, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, and Venezuela [3].

Risk Factors

               The majority of breast cancer cases in South America are diagnosed at late stages, treatment resources are limited, and the mammogram screening rate is very low. Although there have been numerous studies conducted, the majority of breast cancer causes remain unclear. However, there have been several risk factors that remain consistently constant, and it is a combination of these that leads to an increased risk of breast cancer.

There are numerous factors that individuals cannot change. Women with inherited genetic mutations in genes such as BRCA1/2 (BRCA) pathogenic variants (PVs) are at an increased risk of breast cancer. In a study among 1,627 participants (95.2% with cancer) enrolled Latin American Clinical Cancer Genomics Community Research Network, 236 (14.5%) participants were detected with BRCA PVs [4].  Women with these PVs in either of these genes, have up to 80% lifetime risk of breast cancer [5]

If family history is present within a first-degree relative such as a mother, sister, or daughter or multiple diagnosed family members on either the mother’s or father’s side of the family, there is a higher chance of breast cancer. Limited available data suggest that up to 15% of all breast cancer cases in the Latin American region are hereditary.

Early menarche (the first occurrence of menstruation) and late menopause (the end of menstruation) can also raise the risk of getting breast cancer since women are exposed to hormones longer. Adolescent girls aged 15-19 who have early menarche bear the burden of negative sexual, reproductive, and other health outcomes in low- and middle-income countries [5]. In South America, these countries include Argentina, Bolivia, Brazil, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, and Venezuela [6].

Additionally, hormone replacement therapy (HRT) is used in some cases of menopause to replace the estrogen that the body stops making. Some studies have shown that HRT slightly increases the risk of breast cancer but the risk is small [6]. Nevertheless, the use of hormone therapy among Latin American women is low and instead, they use alternative therapies, including massage, dietary changes, and herbal medicines [7].

Moreover, there are multiple factors that an individual can alter relating to diet and lifestyle habits that can affect one’s risk of breast cancer. A lack of physical activity is associated with increased breast cancer risk via multiple interrelated biological pathways that may involve adiposity, sex hormones, insulin resistance, and chronic inflammation [8]. This lack of activity may also lead to being overweight or obese, as having more fat tissue can increase your chance of getting breast cancer by raising estrogen and insulin levels [9]. It is recommended to engage in moderate to vigorous intensity physical activity for 4 to 7 hours per week. Data from Latin American countries (including Chile, Peru, Argentina, and Brazil) showed a high prevalence of adult physical inactivity, 50-91% [10]. However, Latin American women spend more time on household physical activity, which falls under moderate intensity. Every 3 hours per week of moderate-intensity physical activity can result in a decrease in the risk of breast cancer [11]

Individuals who smoke for many years carry an increased risk of breast cancer as well. Women who are current smokers and have been smoking for more than 10 years appear to have about a 10 percent higher risk of breast cancer than women who’ve never smoked [12]. Although variable by country, adult smoking prevalence in Latin America has been reported to be approximately 40% for men and 24% for women, with a 32% prevalence overall [13]. Toxins in tobacco and cigarette smoke can weaken the immune system, making it harder to kill cancer cells. When this occurs, cancer cells can continue to grow and spread to other parts of the body. Smoking is highly injurious to health and can also lead to cancers of the lung, pancreas, bladder, stomach, colon, and rectum [14].

Numerous studies provide evidence that alcohol is also a risk factor for the incidence of breast cancer. Scientists estimate that the risk of breast cancer goes up another 10% for each additional drink women regularly have each day [15]. Although alcohol consumption in South America is low compared to Europe and the US and averages 5.5 liters of pure alcohol per year per capita, it is wise to limit alcohol consumption as any reduction in the amount you drink will lower breast cancer risk [16, 17, 18].

Role of Environment

Today, increasing evidence points to the role of environmental factors in contributing to breast cancer.

Essentially, ionizing radiation is the only environmental factor confirmed to increase breast cancer risk [19]. Applications of ionizing radiation can produce various types of health-related consequences. Female breast tissue is greatly sensitive to the carcinogenic effects of radiation, especially when the exposure occurs at an early age.

Ionizing radiation carries enough energy to break off electrons from atoms, which can usually break chemical bonds in DNA molecules. Simultaneous genome damage can overwhelm the DNA repair mechanism which can lead to cancer.

In South America, there are significant differences present in the radiological protection programs due to the lack of qualified human resources and little funding. This increases the possibility of radiological accidents and reduces the effectiveness of initiatives in the region to cope with the consequences of radiological emergencies. A high percentage of Latin American countries lack optimal infrastructure and trained personnel for medical response in radiological emergencies. These emergencies can occur in any nuclear or radioactive facility relating to the industrial, medical, or research sector [20]

Moreover, patients who have undergone radiotherapy are at the highest risk of radiation-induced breast cancer but South America faces a shortage in radiation therapy (RT) units due to delays in investment.

Information was obtained concerning the 11 most populous countries in Latin America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, Paraguay, Peru, Uruguay, and Venezuela). As of 2020, a population of 557, 213, 447 individuals was recorded and this accounted for 85% of Latin American inhabitants. Overall external beam radiotherapy use rate was estimated for 663, 236 annual new cases in 2020, versus 916 592 annual new cases by 2030 [21]

Additionally, some scientists believe environmental pollutants and hazardous chemicals are possible risk factors for breast cancer. These include pesticides such as DDE and DDT and polychlorinated biphenyls (PCBs), which are all widespread in the environment today. DDT is banned in the United States but is still widely suspected of high usage across Latin America [22]

These substances are of special interest due to their estrogen-like properties, which some breast cancers can grow in response to. Currently, more research is required in this area of study as no clear link has been established between breast cancer risk and exposure to certain pollutants and chemicals.

Socioeconomic Factors

The reduction in poverty levels across South America has led to improvements in health-related indicators such as increased life expectancy and reduced infant mortality. Unfortunately, the measures needed to maintain these achievements have needed to be improved as people currently face an increased burden of chronic diseases accompanied by an aging population. A large percentage of the elderly population is experiencing poorer conditions due to the lack of access to basic healthcare services.

Countries that are attaining improved socioeconomic conditions are reporting an increase in cancer types that are associated with so-called “Westernized lifestyles.” This often shows up as an increase in breast cancer, but it is not always the case in South American countries, where different patterns are observed based on HDI (Human Development Index) levels. HDI is a composite measure of a country's average achievements in three basic aspects of human development: health, knowledge, and standard of living [23]. Countries with the highest inequality-adjusted HDI have decreasing rates of breast cancer mortality, while countries with the lowest inequality-adjusted HDI in the region have increased breast cancer mortality rates.

In addition, studies in Brazil reported an inverse correlation between breast cancer mortality and social exclusion index (a common indicator of poverty) as well as a positive association between breast cancer mortality and a rural residence [24, 25, 26]

In the United States, 60% of breast cancer occurrences are diagnosed in the earliest stages; conversely, in Brazil and Mexico, only 20% and 10%, respectively, are diagnosed at an early stage [27]. The incidence rate of breast cancer in Latin America is lower than that in more developed countries, whereas the mortality rate is higher. This is due to differences in screening strategies and access to treatment.

Studies have shown that access to breast cancer care primarily depends on the type of insurance one has and the geographical location they reside in. Even so, within a particular insurance company or country, there are vast differences in treatment access depending on the wealth of the region and the willingness to invest in breast cancer care [28].

More research is to be conducted on cancer screening and treatment regarding the relationship between socioeconomic inequalities and cancer in South American countries. Currently, information from Argentina, Brazil, Colombia, Costa Rica, Mexico, and Peru consistently shows an independent association between health insurance status and cancer screening coverage for breast cancer [29, 30, 31].

Diet

               A key part of an individual’s lifestyle is their diet. Each location has a different diet correlating with its environment and culture. South American nations are no exception. Some prime foods consumed by South Americans are beans, rice, corn, plantains, squash, peppers, and tomatoes. Starchy vegetables, creams, cheeses, and carbohydrates such as tortillas and empanadas are also a dominant part of South American diets. Additionally, many South Americans consume chicken, fish, or beef daily [32]. Diets not only feed individuals but are also a major factor in breast cancer cases. For instance, over the years scientists have distinguished the good foods from the bad concerning breast cancer. Foods such as fruits and vegetables without starch are said to be great for health and do not have any negative outcomes on breast cancer [33]. On the other hand, foods with higher starch contents are not ideal for consumption as they are said to increase the risk of breast cancer. When analyzing the diets of South Americans as stated above, it is seen that there are many risky foods intertwined into their diets. For instance, starchy vegetables, beef, and cheeses are present in the diets of South Americans but are not recommended to be eaten by scientists. This demonstrates that there is a risk present because of South Americans’ diets.

Ethnicity

South America is a very ethnically diverse continent making the genetic makeup of its people vastly different. This has resulted in insufficient data on breast cancer in South America. The main ethnic groups residing in South America are white (individuals from Europe), black (individuals from Africa), indigenous people, and mestizo (half European and half American Indian) [34]. Due to the huge difference in ethnicities, it is hard for individuals to conduct studies about ethnicities as a whole in South America. For that reason, there is an insufficient amount of research out there about how ethnicity in South America plays a role in breast cancer. Breast cancer can occur in a person because of a multitude of reasons. One key factor is genetics along with gender and ethnicity. All of these three mentioned reasons cannot be controlled.

Some ethnicities are more prone to getting breast cancer than others. According to studies, women with Black or White ethnic backgrounds are more likely to get breast cancer. For instance, Black women have a higher probability than other ethnicities to be diagnosed with triple-negative breast cancer which is usually harder to find and thus diagnosed at a more advanced stage making it more complicated to treat [35]. Additionally, women are much more likely to develop breast cancer than men. As of the last day of 2022, December 31st, there were about 224 million females as compared to 218 million males [36]. Having more females than males is one reason for the many breast cancer cases in South America.

Moreover, the ethnicities that make up a majority of South America are those that are the most likely to be diagnosed with breast cancer. Every single country in South America has about 50% or more individuals originating from Europe [37]. This statistic is then followed by individuals of Black ethnicity. Both of these ethnicities are at high risk for breast cancer. While white women are the most common group of people who get diagnosed with breast cancer, black women are most group of people who get diagnosed with the most severe breast cancer [35]. Due to these ethnicities being accountable for a major chunk of South America’s population, the continent has an overwhelming amount of breast cancer cases.

Age

Like other countries, a majority of the cases of breast cancer in South America are derived from individuals with ages older than 50. But unlike other continents, South America has many cases coming from individuals who are younger than 45. One main reason for breast cancer to be found in young South American individuals is simply because of the makeup of the continent. The countries in South America have a younger age population structure resulting in one out of five cases to be found in women younger than 45 which is twice the frequency compared to developed countries [38].

Compared to the older population in the South American countries, the younger population has a higher incidence rate meaning that they are more prone to getting a disease [38]. The main reason for the higher incidence rate is the constantly increasing adolescent pregnancies [39]. To this day South America remains the only continent in which pregnancies in young women are not decreasing [40]. Pregnancies can be dangerous and account for multiple side effects in young South American women thus leading to the high incidence rates. One way to ease the high incidence rates is to advocate for safe sex education for the masses.

COVID

Breast cancer screening programs are set in place to detect cancer at early stages or precursor lesions, leading to decreased mortality [41]. Detection of a disease at an early stage can make treatment more effective than it would be later on as the signs and symptoms may get worse. In addition, regular screenings can identify risk factors that increase the likelihood of developing the disease and this knowledge could be used to prevent further development of the disease [41]. Within developing countries, medical screenings and prevention protocols have had a profound effect on public health, however, due to major events, such as the COVID-19 pandemic, screening rates and access to healthcare infrastructures have been negatively affected, increasing the burden of cancer mortality [42].

Healthcare services had to take measures to maximize COVID-19 patients and reduce non-COVID-19 patients’ circulation. This resulted in reduced outpatient visits and postponed exams, procedures, and elective surgeries. These measures negatively impacted cancer patients as the timing of diagnosis and treatment is critical when regarding recovery. National screening programs were temporarily suspended to decrease the health system demand and national health agencies recommended the postponement of visits, exams, and procedures that were not urgent during quarantine [43, 44]

Breast cancer patients in Brazil had more advanced-stage diseases upon their first visit to a cancer treatment center during the COVID-19 pandemic due to the health service adjustments. The safety compromises made resulted in long-term negative impacts on oncologic patients.

In Brazil, women aged 50 - 74 years are recommended for breast cancer screening exams which are provided by the Brazilian public health system. If abnormal results are detected, individuals are encouraged to get a biopsy and then directed toward a cancer center in case of a positive result for malignancy. Breast cancer patients had more advanced tumor stages during the pandemic (September/20–January/21) at the first visit compared to the same period before the pandemic (September/19–January/20) [42-Figure 1]

This could be associated with an increase in avoidable cancer death and proper interventions are required to restore the quality and quantity of screening services before the pandemic.

Screening

Screening is a powerful tool utilized to find cancer before its harmful symptoms appear. There are many types of screening tests when it comes to breast cancer. Some of these tests include taking a breast ultrasound, a diagnostic mammogram, breast magnetic resonance imaging, and a biopsy [45]. The most commonly heard screening test is the diagnostic mammogram. This test makes use of X-rays which examine breasts and identify if there are any lumps or other abnormalities. However, not every continent is taking advantage of such a device. In South America, a continent bringing in about 200,000 breast cancer cases annually in women, mammograms are unfortunately not used as commonly as they should be [46]. In Northern Peru for instance, mammogram screening is unavailable. Additionally even in countries where screening with a mammogram is free, mammography coverage is not where it should be. According to the World Health Organization, to be significant, mammography should be utilized by at least 70% of the population. Nonetheless, coverage is low. Mexico has a 22% reach while Argentina, Chile, and Costa Rica have a reach between 32% and 46% [46].

Studies have indicated that in countries such as Mexico, Brazil, Columbia, and Chile, less than 22% of women are diagnosed with stage one breast cancer. On the other hand, Uruguay takes a unique approach with mammography accounting for their 75% reach in population. Instead of just recommending screening with a mammogram, Uruguay takes it a step further by requiring mammogram screenings for women who want to work. This approach has proven to be very successful and is the reason for 40% of breast cancer cases in Uruguay are caught at stage one.

There are numerous reasons as to why many South American countries do not have an adequate screening execution. Some of those reasons include having poor education on the matter of breast cancer as well as having a lack of availability of facilities that provide cancer screenings [46].  The unavailability of access to medical facilities is a huge issue. Though advocates are trying to make things better, South American countries are not able to reach the standard of care that the developing countries are at. One of the reasons is because of their geography. There are a vast majority of people who are too far to receive treatments such as chemotherapy and radiotherapy making it blatantly clear to oncologists that the medical care in South America is not where it should be. Moreover, some nations are not able to meet their demand. For instance, in South America only two countries, Chile and Brazil, have sufficient facilities and machines to perform adequate radiotherapy services to whoever needs it [46].

Additionally, one serious factor in acquiring breast cancer is genetics. Countries, namely Argentina, Brazil, Columbia, and Mexico have national guidelines set in place recommending genetic testing and counseling. However, many factors are stopping South Americans from receiving these tests and counseling. Mainly the economic barrier has severely halted genetic cases from being spotted. For individuals in South America who are a part of the public health system, costs are exorbitant and not covered by public health insurance making it problematic for them to take part in genetic testing and counseling [46].

Treatment Scenario in South America

For the most beneficial breast cancer treatment and recovery, a multidisciplinary team is formed to create a patient’s overall treatment plan that consists of multiple specializations such as surgery, radiation oncology, and medical oncology. Various other healthcare professionals such as social workers, pharmacists, genetic counselors, nutritionists, and therapists are also involved. If the patient is over the age of 65, a geriatric oncologist or geriatrician may be included as well.

The organization of this breast cancer care delivery team is varied across regions and, in general, is not up to the standard observed in more developed countries. In an attempt to maximize results with limited resources, a challenge arises when trying to balance the level of investment in prevention, early detection, detailed diagnosing, and biological therapies, as well as the patient’s quality of life and this is the foundation of an ongoing debate between scientists.

To a great degree, treatment in South America is similar to options offered worldwide but breast cancer mortality rates are still high due to the limiting factors of improper access and affordability of diagnostic procedures. National Cancer Control Plans (NCCP) are critical for the organized administration, financing, and delivery of cancer care but the NCCP presence is absent in Latin America. Most Latin American countries have published guidelines and medical care standards (MCS) from governmental authorities, cancer institutes, and scientific associations that detail treatment processes. Still, the challenge arises when the implementation of policies is tracked, as we want to ensure consistent compliance with the guidelines across the whole population [26]. Many authors and experts believe that there is no need for new MCS and that efforts should be concentrated on further coordination and use of valid scientific evidence in the diffusion of medical care [47, 48]. A study was conducted concentrating on the evolution of the 42 cancer registries in Latin America during the period 1950-1995 and it concluded that around 43% of them failed due to lack of technical support and scarce financial support [49].

The BHGI (Breast Health Global Initiative) has published treatment guidelines for low and medium-income countries, which consider prevention and treatment options according to available resources [50-54]. Frequently, internationally referenced treatment guidelines assume unlimited resources, so such an adjustment is necessary.

A lack of continuity and long waiting times are especially evident for cancer patients as the care process can be lengthy and involve different disciplines. Waiting for diagnostic results or treatment can put a large psychological strain on patients as well so medical professionals are currently working to develop a so-called seamless care process. Nevertheless, overall in Latin America, around 30% (range of 0%-64%) of patients waited for more than 3 months for a diagnosis at the country level [26]

Involvement and education is the key to recovery as well-informed patients are a prerequisite for increased participation in treatment decisions even when an imbalance of information occurs between the patient and physician. It was found that the gap between public and private settings also impacts patients’ involvement because in some regions, patients are not offered a second option if they can’t pay for it, they do not choose the treatment center, and they do not receive a clear treatment plan. Emotional-support initiatives such as wigs, prosthetics, and additional information are not always provided but some of these gaps are filled by non-governmental organizations (NGOs).

It was found that Latin American NGOs lack leadership in the Department of Cancer Care and that faulty patient information services and governmental failure to include them in policy decision-making need further improvements [55]. These findings reflect the highlighted strengths and weaknesses of NDOs. Strengths include a highly committed staff base, expertise in pediatric services, and pushing the emergency of innovative programs. In contrast, NDOs weaknesses are their small size and restricted community outreach, inadequate funding, lack of collaboration among groups, and the inability to develop advocacy programs and media relations approaches. It is important to note though, that these weaknesses do not apply to all the countries included in the study.  In Brazil, Costa Rica, Mexico, and Peru, active and consistent organizations produce information, advocate for the general public, and provide patients with emotional support [5].

Conclusion

Currently released research on breast cancer indicates that there needs to be more data provided on recent incidence and mortality rates in countries of South America. Epidemiological data is of varying quality and quantity across South America, which highlights the need for investments in Latin American health systems for breast cancer research and treatment. The available studies, however, highlight that the main reasons for the high breast cancer burden in South America is because of diet, exercise, environment, socioeconomic factors, and screening availability. Many of these factors are influenced by the culture or geographical location of the area. Some specific demographic factors of high influence include the aging population and low socioeconomic development. While there has been some progress in select countries, early diagnosis and access to proper treatment remain inaccessible to a large portion of the population.  Most Latin American countries have published guidelines and medical care standards (MCS) from governmental authorities, cancer institutes, and scientific associations that detail treatment processes. Still, the challenge arises when the implementation of policies is tracked, as we want to ensure consistent compliance with the guidelines across the whole population

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