October is Breast Cancer Awareness Month!

October is Breast Cancer Awareness Month!

A STUDY OF CHARACTERISTICS AND MANAGEMENT OF BREAST CANCER IN TAIWAN Eric Kam-Chuan Lau, OMS II a, Jim Yu, OMSII a, Christabel Moy, OMSII a, Jian Ming Chen, MD b, Shoei Loong Lin, MD b, Athena Lin, PhD a,c

Background 1. Basics: Receptor Subtypes of Breast Cancer 2. Breast Cancer in Taiwan 3. Comparisons of Breast Cancer in Taiwan vs. USA

Breast Cancer: Basic Information Subtype Prevalence in the US Common target therapy Estrogen or Progesterone Receptor (ER/PR +) 65-75% Endocrine therapy HER2 + (includes ER/PR+ AND ER/PR- ) Triple Negative (ER/PR-, HER2-) 20-25% Herceptin or tykerb +/- adjuvant therapy 10-17% NA

Prevalence of Breast Cancer Subtypes Differ by Race (%) Race ER/PR+ HER2- ER/PR- HER2+ Triple Positive Triple Negative Unknown White 62 4 9 9 16 Hispanic 52 7 11 13 17 Black 47 6 11 20 16 Asian 55 8 12 9 16 http://www.tnbcfoundation.org

Breast Cancer: Basic Information The presence of receptor positivity 1) Influences aggressiveness, likelihood of recurrence, and prognosis of the cancer 2) Opens up the option of treating the patient with targeted therapy

Stage of Breast Cancer upon Diagnosis in United States Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2002-2008, All Races, Females Stage at Diagnosis Localized (confined to primary site) Regional (spread to regional lymphnodes) Distant (cancer has metastasized) Stage Distribution (%) 5-year Relative Survival (%) 60 98.4 33 83.9 5 23.8 Unknown (unstaged) 2 50.7 Source: Surveillance Epidemiology and End Results. 2012. National Cancer Institute. 30 June 2012

Top 10 Cancer Mortality Rates in Taiwan Per 100,000 in 2008 1. Liver and Intrahepatic Bile Ducts: 27.12 2. Trachea, Bronchus, and Lung: 27.04 3. Colon, Rectum, Rectosigmoid Junction and Anus: 15.56 4. Female Breast: 11.33 5. Oral Cavity, Oropharynx and Hypopharynx: 8.39 6. Stomach: 8.04 7. Prostate Gland: 6.67 8. Cervix Uteri: 5.34 9. Esophagus: 5.27 10. Pancreas: 4.78

Incidence of Common Cancers in Taiwanese Women, 1979 2002. Breast Cancer currently has the highest incidence rate of any cancer in Taiwan! 2

TW vs. USA: Breast Cancer Statistics Taiwan Median Age at Diagnosis: 45 yo United States Median Age at Diagnosis: 61yo Age-Adjusted Incidence Rate: 56.07/100,000 women Age-Adjusted Incidence Rate: 124.3/100,000 women (all races)

TW vs. USA: 5-Year Overall Survival Rate Taiwan United States 81% 89% Why?

Taiwanese Healthcare System National Health Insurance (NHI) Single Payer System Health expenditures constitute 6.9% of GDP in 2011 Compare to the USA: 15.2% Overall Life Expectancy in 2012: 78.48 Years. Comparable to the USA: 78.49 Years.

Hypothesis Different 1. Prevalence of ER/PR/HER-2 receptor (+) 2. Stages of breast cancer upon diagnosis 3. Approaches to management of breast cancer May contribute to Taiwan s lower survival rate for breast cancer patients.

Methods Data from 18 ongoing breast cancer patients were collected at Taipei Hospital in Taipei, Taiwan. Data Collected Includes: Age Family history of breast cancer Age at diagnosis Subtype of breast cancer (Luminal, etc) ER/PR/HER-2 status Stage of cancer (TMN System) Lymph node involvement at diagnosis History of surgery performed on the breast Chemotherapy and targeted therapy regimen Therapy side effects. Comparative data on breast cancer in the United States was collected using the Surveillance, Epidemiology, and End Results database.

Results

ER/PR and HER2 Status in Patients HER2- /ER/PR+ (39%) HER2- /ER/PR- (6%) HER2+/ER /PR+ (33%) HER2+/ER /PR- (22%) N = 18

Number of Patients Patient Population Age at Diagnosis 7 6 5 4 3 2 1 0 <20 35-44 45-54 55-64 65-74 75-84 85+ Median Age of Patients at Diagnosis: 49

Number of Patients Age of Patients with ER/PR/HER Status 7 6 HER2-/ER/PR+ HER2+/ER/PR+ HER2-/ER/PR- HER2+/ER/PR- 5 4 3 2 1 0 <20 35-44 45-54 55-64 65-74 75-84 85+

Number of Patients Status of Breast Cancer Upon Diagnosis 12 10 10/17 (59%) 8 6 5/17 (29%) 4 2 1/17 (6%) 1/17 (6%) 0 Axillary Lymph Node Involvement Only No Lymph Node Involvement Perineural Involvement Only Distant Metastasis

Number of Patients Breast Cancer Diagnosis Status with ER/PR and HER2 Status 11 Breast Cancer Diagnosis Status compared with ER/PR and HER2 Status HER2-/ER/PR+ HER2-/ER/PR- HER2+/ER/PR+ HER2+/ER/PR- 10 9 8 7 6 5 4 3 2 1 0 Axillary Lymph Node involvement (10/17, 59%) No Lymph Node Involvement (5/17, 29%) Perineural involvement only (1/17, 6%) Distant Metastasis (1/17, 6%)

Number of Patients Breast Cancer Target Subtype and Use of Targeted Therapy 14 Received Targeted Therapy Given Traditional Chemotherapy Only 12 10 8 6 4 2 0 50% Received Herceptin HER2+ Breast Cancers 25% Received Hormone Therapy ER/PR+ Breast Cancers

Conclusions: Three Factors that Might Have Contributed to a Lower 5 Year Overall Survival Rate in Taiwan Compared to the United States

Conclusions #1: HER-2 overexpression was high in our patient population, at 55%. 20-25% is normally seen in the USA.

ER/PR and HER2 Status in Patients HER2- /ER/PR+ (39%) HER2- /ER/PR- (6%) HER2+/ER /PR+ (33%) HER2+/ER /PR- (22%) N = 18

Conclusions #2: Lymph node involvement upon diagnosis was high, at 59%. 33% b is normally seen in the USA.

Number of Patients Breast Cancer Diagnosis Status with ER/PR and HER2 Status 11 Breast Cancer Diagnosis Status compared with ER/PR and HER2 Status HER2-/ER/PR+ HER2-/ER/PR- HER2+/ER/PR+ HER2+/ER/PR- 10 9 8 7 6 5 4 3 2 1 0 Axillary Lymph Node involvement (10/17, 59%) No Lymph Node Involvement (5/17, 29%) Perineural involvement only (1/17, 6%) Distant Metastasis (1/17, 6%)

Conclusions #3: An unexpectedly low percentage of ER+/PR+ and HER-2+ patients were given first line targeted therapy (25% and 50% respectively) in lieu of traditional chemotherapy.

Number of Patients Breast Cancer Target Subtype and Use of Targeted Therapy 14 Received Targeted Therapy Given Traditional Chemotherapy Only 12 10 8 6 4 2 0 50% Received Herceptin HER2+ Breast Cancers 25% Received Hormone Therapy ER/PR+ Breast Cancers

Conclusions These three factors may play a role in lowering the survival rate of breast cancer patients in Taiwan. Larger studies are warranted to explore this complex issue.

Sources 1 Leong, Stanely P.L., et al.. Is Breast Cancer the Same Disease in Asian and Western Coutnries?" World Journal of Surgery, Volume 34, Article 10 (2010): 2308-2324. Online. 2 Incidence and mortality rates for the top 10 cancer in Taiwan 2008. Taiwan Cancer Registry, 2008. Online, 30 June 2012 3 : Cheng, Skye Hongjun, et al. Unique features of breast cancer in Taiwan. Breast cancer Research and Treatment, Volume 63, Number 3 (2010), Pages 213-233. 4 : Surveillance Epidemiology and End Results. 2012. National Cancer Institute. 30 June 2012 <http://seer.cancer.gov/statfacts/html/breast.html#survival> 5 : Susan G. Komen for the Cure. 2011. 30 June 2012 <http://ww5.komen.org/breastcancer/subtypesofbreastcancer.ht ml>

Acknowledgements We would like to thank the following for making this research possible: a Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA b Taipei Hospital, Department of Health, New Taipei City, Taiwan (R.O.C.) c Global Health Program, Touro University California, Vallejo, CA, USA