There has been progress with breast cancer,
but thereís room for improvement in the region
Dr Mothaffar Fahed Rimawi: I donít know what the number is. I donít think it exists for the region. It was actually one of the things we were talking about with several leading physicians and officials in Doha and the UAE - the need to have such national or even regional efforts to try and describe the prevalence and incidence of breast cancer. There are numbers of how many cases per health care sector and I think there are some national numbers, but in trying to characterise the actual prevalence, the lifetime risk that people have, what we do is extrapolate from Western numbers, use one in eight, one in ten women. The population here is different, thereís a large expatriate population and that population by definition is younger, you may not see the older age cancers. People told me about the large number of younger women with breast cancer - and again is this because of the average age of the population or is it really more common? We donít know, but what we do know is the lifestyle is changing in the region. Thereís a lot of Western-style eating Ė for example, a diet richer in saturated fat, less fruit and vegetables Ė and also changes in reproductive decisions, delaying pregnancy increases risk and having multiple children reduces the risk. Lactation helps. If thereís a message to women in the region it is to basically consider those decisions.
Middle East Health: Is the incidence increasing?
Dr Mothaffar Fahed Rimawi: In general, we know the incidence of breast cancer is increasing in the world and that again has to do with lifestyle, but an important factor is a lot of women used to die young, for example in childbirth, but as health care has improved in other aspects women are living longer to develop breast cancer.
Middle East Health: Do you have any idea what the mortality rate from breast cancer Ė in the region and the world for comparison?
Dr Mothaffar Fahed Rimawi: I donít think those numbers exist. What I can tell you is that from what Iíve seen at the medical centres Iíve been at, patients are receiving really top-notch care in terms of the drugs, multi-disciplinary care, and the expertise of physicians is very comparable to the West.
Middle East Health: What are the most common types of breast cancer in the Middle East? Is this the same around the world or does this region have some unique features regarding breast cancer?
Dr Mothaffar Fahed Rimawi: The majority is the hormone receptor-positive breast cancer, thatís generally no different in the Middle East than it is in Western countries, however it varies by age. The things we check in breast cancer are the oestrogen receptors (ERs) and the progesterone receptors (PRs), these together are known as hormone receptors. The third receptor we check is HER2- positive breast cancer, this accounts for about 20- 25% of breast cancer. Itís unique because it has this protein called HER2 and the cancer needs it to grow and survive and so what weíve been able to do very successfully is develop drugs that target this protein and turn it off and therefore turn the [cancer] cell machinery off. Iíve done a lot of research starting from the laboratory and then taking it to patients, to a point where weíre combining different treatments. Thereís a proportion of patients you can probably treat successfully with these drugs alone, without chemotherapy Ė for a type of breast cancer thatís considered aggressive, this is fantastic. Weíve done a lot of work towards achieving this and I think weíve made significant progress and probably in the next five to ten years thereíll be a good proportion of women with this type of breast cancer who are treated without chemotherapy. One of my research interests is a strategy called de-escalation, essentially to identify patients with whom we can omit parts of treatment or replace them with less toxic ones without compromising outcomes, weíre working very actively on this and have made good progress.
Middle East Health: Talking about your research I understand you have recentlycompleted some research to do with breast cancer screening. Obviously, this is an important preventative measure. How advanced is this in the region? And what can be done to improve it?
Dr Mothaffar Fahed Rimawi: Every country in the region has national campaigns, I know these things exist in Jordan and Lebanon and the GCC area and there is a very strong national push towards that. What I hear from colleagues is the frequency is not high enough yet. For it to be effective it needs to happen in two-thirds of the population to make a difference, so weíre not there yet but I think itís important for women to understand their own risk and discuss it with their doctor and come up with a screening programme that works for them. Some women may be at higher risk and require more careful screening.
Middle East Health: Is there a reluctance among women to undergo?
Dr Mothaffar Fahed Rimawi: There are several studies that shows even in the West womenís level of anxiety goes up before a mammogram and then comes down to baseline. If a woman has an abnormal mammogram it never goes back to baseline anxiety - sheís still more nervous about mammograms than before. Of course, the schedule needs to be discussed with the womanís primary care giver or gynaecologist to come up with a screening programme that works for them and also being aware of their breasts, performing self-examinations.
Middle East Health: What advances have been made in the past 10 years with regards to diagnosis and treatment of breast cancer?
Dr Mothaffar Fahed Rimawi: Breast care in the last 10 years has changed quite a bit. Equipment has improved tremendously - itís moved from analogue mammograms to digital to 3D-mammograms, which essentially provides a lot more images - almost like slicing through the breast like you slice through a loaf of bread. For very little or no extra radiation than the regular mammogram, they can detect smaller tumours and more tumours at an earlier stage. It can also work for women whose breasts are really dense. Thereís more use of MRI machines to screen high-risk women. In terms of treatment thereís been several drugs studied and approved in several countries in the last 10 years that have improved outcomes, that have helped save lives, such as trastuzumab and pertuzumab, which are anti-HER2 agents. There are drugs that help stop the cell cycle like palbociclib. Thereís been a number of targeted therapies that have been studied and approved in the last 10 years that have made a real difference for patients with breast cancer. Also in the last 10 years we have improved our strategies for anti-estrogen therapy, which has been a very effective strategy and also there are more medicines available for the prevention of breast cancer in women who are high risk. All in all, the past 10 years have been transformative and I predict the next 10 years will be even more transformative - where we enter the age of more tailored, more personalised treatment and where we are able to treat a proportion of women with less treatment and yet maintain their outcomes and develop drugs for women with more aggressive tumours that require more treatment.
Middle East Health: Does Baylor St Lukeís Breast Center provide specialist treatment that is not available elsewhere?
Fahed Rimawi: What we have that is unique is a true multidisciplinary
approach, where medical oncologists, the surgeons, reconstructive surgeons,
the genetic counsellors, dieticians, support staff, radiologists, are
all in the same administrative structure and clinical structure. Everyone
sees patients in the same space, itís an integrated centre, itís one space
where women come in for all aspects of care, prevention, diagnosis and
follow-up. We also have a survivorship programme to help with the long-term
side effects of the treatment. Since we are a medical school we have one
of the worldís leading programmes in breast cancer research. We are major
co-sponsors of the San Antonio Breast Cancer Symposium - which is the
largest breast cancer meeting in the world. Our patients have plenty of
opportunities for clinical trials, with new and experimental approaches,
which are very promising. We have the number one genetics department in
the US, with a very robust genetics and genomics programme, thatís unique
to us. One of our philosophies is partnerships. Our patients can receive
services they canít receive elsewhere, however, we do work with local
communities, whether in the US or worldwide, and if they can get a proportion
of care closer to home then they should do that, where their social support
is and where theyíre comfortable. We have a strong tradition in education
and training; we have a long tradition of training scientists and physicians
to specialise in breast cancer care and research. We believe in training
and education as a global message. We also believe in the impact of research,
this is something the region is starting to pay attention to and I hope
will build on, which is the importance of building research programmes
from the laboratory to the clinic, that would study breast cancer and
the challenges unique to every individual region and country in the region
and develop solutions, scientific and operational, that actually fit the
region. Having been born and raised in Jordan Iím connected to the region
and we are excited at the prospect of helping in these efforts. I see
a lot of growth and attention to health in the GCC. I know, having grown
up and being educated in Jordan, that Jordan gives a lot of attention
to health care and Lebanon has a tradition of excellence in this area.
Progress has been made but thereís still room for improvement. Everybody
recognises that thereís more focus now on education and training programmes
to train physicians locally and keep them in the region, but also be connected
internationally to others to share progress. Generally, Iím optimistic
and heartened by what Iíve seen here and in countries in the region. Iím
hoping thereíll be some regional collaboration and cooperation. I think
paying attention to womenís heath, such as screening, is an important
part of womenís rights and empowering women, which Iím passionate about.
Baylor St Lukeís Medical
Center International Services
|Date of upload: 16th Jul 2016|
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