Population Health, Global Bioethics, and Breast Cancer Treatment

The 20th anniversary feature article on "Twenty Years of Systemic Therapy for Breast Cancer" and its reviews in the January 2006 issue of ONCOLOGY are incomplete from a global perspective. I must gently protest the suggestion that the "end of breast cancer as a serious cause of human mortality is now in sight."[1] Some numbers: Of 1.5 million new cases of breast cancer annually, over half now occur in Asian women, and two-thirds (1 million cases) occur in women living on a few dollars a day at best (projections from reference 2). Bangladesh, with less than half the population of the United States—and half the incidence of breast cancer—has the same number of annual deaths as the United States.

Further, consider issues of cost-effectiveness. While I don't doubt that "the agent with the single greatest public health impact in all of oncology (at least to date) has been tamoxifen," the cost-effectiveness of this adjuvant treatment is about $3,000/year of life saved. This figure is above the per capita annual gross domestic product in many countries—a measure that the WHO Commission on Macro-economics and Health suggests should define appropriate cutoffs for cost-effective interventions.[3] In fact, the only systemic adjuvant intervention in breast cancer that is cost-effective worldwide is surgical oophorectomy. In contrast, adjuvant trastuzumab (Herceptin) costs $100,000 per year of life saved (based on a 10-year -horizon).[4]

In summary, for the majority of the women in the world diagnosed with breast cancer, the much trumpeted adjuvant therapies of the last 3 decades are financially out of reach, and barring some enormous changes in funding such therapies, breast cancer is likely to remain as much a cause of human mortality in the forseeable future as it is today.

We live in a world with enormous disparities in health care. A relatively large proportion of public resources for health benefit the well-off rather than the poor in most societies. Population health and global bioethics should be part of every discussion of treatments for cancer.

—Richard R. Love, MD
Professor of Medicine,
Hematology/Oncology
Professor of Public Health,
Epidemiology/Biometrics
Director of International Oncology
Comprehensive Cancer Center
The Ohio State University
Columbus, Ohio

References:

1. Mina L, Sledge GW: Twenty years of systemic therapy for breast cancer. Oncology (Williston Park) 20:25-32, 2006.

2. Parkin DM, Pisani P, Ferlay J: Estimates of world wide incidence of 25 major cancers in 1990. Int J Cancer 80:827-841, 1999.

3. Macroeconomics and Health: Investing in Health for Economic Development: Report of the Commission on Macroeconomics and Health. Geneva, World Health Organization, 2001.

4. Hillner BE: Clinical and cost-effectiveness implications of the adjuvant trastuzumab in Her 2+ breast cancer trials (abstract 5040). Breast Cancer Res Treat 94(suppl 1):S219, 2005.