Update of Breast Cancer Profile in Indonesia

Introduction
Slide 4
The number of cancer patients in Indonesia are increasing over time. It is estimated that in 2020,
with population over 270 (two hundred seventy) million people, total number of new cancer
patients are more than 396 (three hundred ninety six) thousand patients, and the number of
deaths are approximately around 234 (two hundred thirty four) thousand patients. The most
common type of cancer that suffered by the patients is breast cancer with total number 16.6%
(sixteen point six percent) followed by cancer of cervix, lung, colorectal, and liver.

Slide 5

Based on Indonesian Basic Health Survey Report that is done by Health Ministry of Indonesia
every five year, it is found that there is a rising number in cancer prevalence in Indonesia from
1.4 (one point four) per 1000 population in 2013 to 1.49 (one point four nine) per 1000
population in 2018. So where are they live? Indonesia is a vast country with more than 17
(seventeen) thousand islands. The majority of cancer patients are live in the urban area. There is
also a rising number of new cases of cancer in rural area from 2013 to 2018 nearly more than
50%. This matter becomes a problem because it was difficult to conquer all of the rural areas in
Indonesia.

Slide 6

Then based on the data that is obtained from the survey, female is three folds more than male
suffering the cancer, and 30% of cancer that is suffered by the female is breast cancer. It is
calculated that in 2020, the incidence of breast cancer is more than 60 (sixty) thousand cases
where is 42.1 cases per 100.000 populations, with mortality rate is 20 (twenty) thousand cases
where is 17 cases per 100.000 populations. The second most cases of cancer are cervical cancer
at 23.4 cases per 100.000 populations with an average death rate of 13.9 cases per 100.000
populations. Because of this, Indonesia government make a campaign for early detection and
screening of breast and cervical cancer.

Slide 7
Data that is compiled in Asian Country found that five countries with the highest incidence of
breast cancer are Israel with 80.5 cases per 100.000 populations, followed Lebanon, Armenia,
Kazakhstan, and Singapore with 65.7 cases per 100.000. And Indonesia among Asian countries
is placed eighth and among south east Asian countries is placed third countries with most cases
of breast cancer, followed by Malaysia, Timor Leste, Thailand, Brunei Myanmar, Camcodia,
Laos with cases less than 25 cases per 100.000 populations.

Next we moved onto risk factors

Slide 10

It is been known that risk factors for breast cancer are divided into 2 modifiable and
nonmodifiable. Risk factors for radiation, alcoholism, nullipara, giving birth to their first child at
the age of 30 and being overweight are the 5 most common risk factors for breast cancer, while
nonmodifiable risk factors include being female, lobular type carcinoma in situ, location of
BRCA mutations, age and family history. most often on non-modifiable factors, this is quite a
contrast to patients in Indonesia, because most Indonesian patients come with a weight that is not
overweight, rarely have a history of alcohol, have quite a lot of children.

Slide 11

In Jogjakarta, UGM has conducted joint research by having more than 1000 patients, then also
1000 people found that the first-degree family history factor was the highest as a risk factor, had
an odd ratio of 33.92 followed by the second degree then the age of giving birth to the first child
was more than 30 years. Then what is interesting is that a high-calorie diet has a higher risk rate
than a high-fat diet. Therefore, the different risk factors will have an impact on the profile of
breast cancer and also breast cancer treatment in Indonesia.

Slide 12

With different risk factors, we find that the age of breast cancer patients in Indonesia is different
from that of developed countries. From several reports, the age range is between 35-55 years.
This is much different from developed countries where the highest age is 55-65 years. Several
research centers in Indonesia reported the average age. In Yogyakarta, it is reported that the age
is 48 years, Bandung is 45 years old, Padang is 50 years old and Surabaya is 49 years old.
Slide 13

This shows that young breast cancer has an aggressive phenotype with a larger proportion of
tumor size. Then there is also metastatic in the lymph nodes, and more distant metastatic. As
well as having a higher histological grade and the presence of angiolymphatic invasion. Bio-
molecularly this subtype at a young age has a high number for her2 positive and also the tnbc
subtype.

Slide 14

Based on the report of our center in Padang, from 694 patients we obtained that the number of
sub luminal type is 57.4%, while tnbc type is 23.1% dan her2 type is 9.8%, when added up with
luminal b and positive her2 the number is 29.6%. This shows that the breast cancer subtype in
our area has a more aggressive nature because of its younger age. We found that the number of
luminal subtypes was 57.4%, while TNBC was 23.1%, HER2+++ 9.8% and when added with
Luminal B HER 2+++ the number reached 29.6% and showed that the subtype of breast cancer
in our area They are more aggressive because they are younger. Likewise, reports from Sumadi,
Lukman, Anwar, et al reported that out of 144 breast cancer patients, it was found that the
number of positive hormonal receptors was only 38.60%. While HER 2 is positive 30,6 and
based on biomolecular classification triple negative is 38,20%, luminal 42,10%, and HER2 is
18.1% where luminal number is more dominant that shows prognostic factor in Indonesia is
poor.

Then we will discuss the problem of biomolecular characteristics.

Slide 17
Family history has long been known as an important factor in increasing the risk of breast
cancer. Quite a lot of genes were studied, but there are 2 genes that have a large proportion,
namely BRCA 1 and BRCA 2. From the total of all breast cancers, it is estimated that 5-10%
have a hereditary predisposition.

Slide 18

Indonesia has conducted several screenings for BRCA1 and BRCA2. It turned out that reports
from 116 cases were studied differently from developed countries, in fact in Indonesia the
incidence of mutations from BRCA2 is more frequent than BRCA1. Maybe later after this
presentation, dr. Sondang will explain to us all about the “Pattern of Gene Line Susceptibility
photogenic variant in Breast Cancer.

Slide 19

From our study of sporadic patients, we found something quite interesting. In breast cancer
patients in Indonesia, we found a fairly large number of hypermethylation in the BRCA1 gene
for sporadic breast cancer, where we found methylation in the BRACA1 promoter in 80% of the
sporadic breast cancer patients in the absence of family history. It needs to be investigated
further because the methylation of the gene promoter is caused by several factors, the most
important of which is the presence of toxic materials.

Slide 22

Unfortunately, most patients come to hospital with advance stage of breast cancer, more than
IIIA stage. This happened because of several factors:

- Ignorance
- Decreasing of self esteem
- Hard to reach health care facility

Regarding to Padang PARABOI Breast Cancer Registry, we can find that patients fall into
advanced stage are approximately 34%

Slide 23

While in the early-stage patients only around 40%, therefore breast cancer treatment in Indonesia
focuses on advance cases of young patients. There are several research reports that report the
results of breast cancer treatment at a young age in Indonesia. Of 1259 breast cancers, with a
median age of 51 years.

Slide 24

From the research data, it turns out that there are several factors that are characteristics of
treatment including surgery, chemotherapy, radiotherapy, hormone therapy and anti-Her-2
therapy, which in Indonesia is only given to patients with advanced stage of breast cancer, not
hidden cancer, then there is also the provision of bisphosphonate therapy. There are several
factors that cause a shorter Progression Free survival such as skin or chest wall involvement,
lymph node infiltration, negative hormonal receptors.

Slide 25

Negative hormonal sector, double negative hormonal sector and triple negative. These 4 factors
lead to reduce the survival rate from breast cancer. We have also conducted research on the
impact of using hormonal therapy for 6 months compared to 16 months and found by the
Indonesian system in breast cancer patients. From there, we found that survey coverage did not
have, had no difference in meaning, but at local cutaneous 12 months and 16 months, while for
metastases the difference was significant, so the use of trastuzumab for cancer in Indonesia is
used for 6 months instead of 12 months, which is used by developed countries.

Next up to development of breast cancer surgery in Indonesia

Slide 28-32

Surgery is being developed, especially breast cancer reconstruction, there have been many
pioneers, but our colleague dr. Bayu at Darmais Hospital has carried out many reconstructive
interventions based on microsurgery, using a perforator flab or using an intercostal artery
perforator as replacement. With advances in microsurgery, this is very important in improving
the quality of life of breast cancer patients, especially breast cancer at a young age in Indonesia.
We continue with the early detection program
Slide 35
Because breast cancer and cervical cancer account for more than 45 percent of women in
Indonesia, the Ministry of Health combined these screenings in one package and this program
has been proven to reduce morbidity and mortality. In Indonesia, program screening is carried
out in the following programs:

- Breast self-examination
- Clinical breast examination
Mammography and breast ultrasound

Slide 36

This program is known as multilevel marketing of breast and cervical cancer screening.
Slide 37
Because most of the socio-cultural factors detected from breast cancer and cervical cancer were
carried out by midwives and showed unsatisfactory results, in 2018 we were able to carry out
early detection steps throughout Indonesia, only 7.35 percent. This is a further challenge to
improve the rescue of early cases of breast cancer, so that it can provide better treatment results.

Now, we are arrived at conclusion

Slide 40
We can conclude that breast cancer is the most common cancer in Indonesia, the main risk
factors are family, age of the first pregnancy and high calories diets. From Mutation BRCA
reports, apparently mutation of BRCA 2 often happen more than mutation of BRCA1 and Its
reported value of methylation from promoter BRCA 1 in sporadic breast cancer. Breast cancer in
young age is dominant in Indonesia, include almost 60 cases. From subtype is derived luminal B
is the most common which followed by HER2, TNBC and Luminal A. currently, the number of
breast cancer screening conclude only 10% of Indonesia population. In Indonesia microsurgery
and super-microsurgery have been developed.