BREAST CANCER

OBJECTIVES:

• REDUCE MORTALITY RATES

• IMPROVE QUALITY OF LIFE INDEX

• IMPROVE MORBIDITY RATES

• IMPROVE STATISTICS OF THE STATE/COUNTRY

PREVALENCE:
• Breast cancer accounts for 14% of cancers in Indian women. It
is reported that with every four minutes, an Indian woman is
diagnosed with breast cancer.
• Post cancer survival for women with breast cancer was
reported 60% for Indian women, as compared to 80% in the
U.S. 
• Mortality-to-incidence ratio was found to be as high as 66 in
rural registries whereas as low as 8 in urban registries.
HER 2 EXPRESSION
• HER2 is a member of the human epidermal growth factor
receptor family. Amplification or over-expression of
this oncogene has been shown to play an important role in
the development and progression of certain aggressive types
of breast cancer. In recent years the protein has become an
important biomarker and target of therapy for approximately
30% of breast cancer patients.
BREAST CANCER PRESENTATION AT DIFFERENT AGE
HER2 EXPRESSION IN BREAST CANCER
 HER-2 TYPE
• 35% of HER2-positive patients reported recurrence in an
average duration of 36 months, whereas 25.88% of patients
diagnosed with HER2-negative showed recurrences in an
average duration of 48.8 months.
• There are a number of reasons that may explain the
aggressiveness of HER2-positive as compared to HER2-
negative including, but not limited to stages at diagnosis, size
and grade of tumour, lymph node involvement, ER/PR status,
overall health, smoker, non-smoker, response to therapy etc.
 TRASTUZUMAB

Trastuzumab is a monoclonal antibody.   Monoclonal antibodies are a

relatively new type of "targeted" cancer therapy. Antibodies are part of
the immune system. Normally, the body creates antibodies in response
to an antigen (such as a protein in a germ) entering the body. The
antibodies attach to the antigen in order to mark it for destruction by
the body's immune system. In the laboratory, scientists analyze specific
antigens on the surface of cancer cells (target) to determine a protein
to match the antigen. Then, using animal and human proteins,
scientists work to create a special antibody that will attach to the target
antigen. Antibodies will attach to matching antigens like a key fits a
lock. This technology allows treatment to target specific cells, causing
less toxicity to healthy cells. Monoclonal antibody therapy can be done
only for cancers in which antigens (and the respective antibodies) have
been identified.
 
• Trastuzumab works by targeting the HER2/neu receptor on
cancer cells. The HER2 gene produces a protein receptor on
the cell surface that signals normal cell growth by telling the
cell to divide and multiply. Some cancerous breast tissue has
too much HER2 (HER2/neu overexpression), triggering the
cells to divide and multiply very rapidly. Trastuzumab attaches
to the HER2 receptors to prevent cells from multiplying,
preventing further cancer growth and slowing cancer
progression. It may also work by stimulating an immune
mechanism. In addition, trastuzumab suppress angiogenesis
both by induction of antiangiogenic factors and repression of
proangiogenic factors.
• Breast cancer is the most common cancer among women in
India and accounts for 27% of all cancers in that country.
Overexpression of the oncogene human epidermal growth
factor receptor 2 (HER2/neu) is associated with poor prognosis
and high risk of recurrence. Addition of the HER2-targeted
monoclonal antibody trastuzumab to chemotherapy in
adjuvant treatment has been shown to improve disease-free
survival (DFS) by 50% and overall survival (OS) by 30%.
However, trastuzumab is an expensive drug. It was reported to
have been used in only 8.6% of eligible patients, half of who
were enrolled in a clinical trial.
• The low rate of Trastuzumab use raises the important
question of whether public resources should be used to make
this treatment routinely accessible in India.

• This question is highly relevant because of the recently

announced ambitious Indian health insurance program,
Ayushman Bharat, which includes coverage of chemotherapy
for cancer treatment under the Prime Minister’s Jan Aarogya
Yojana (PMJAY) component.
 
 COST
 
• The use of Trastuzumab for 1 year would incur an
incremental cost of INR 156,291 (US$2,235) and INR
178,877 (US$2,558)
 
• The lifetime and incremental costs per patient with
Trastuzumab were INR 3,37,935 (US$4,833) and INR
2,27,784 (US$3,258), respectively.
FIVE YEAR SURVIVAL RATE WITH TRASTUZUMAB
 SOLUTION
• Given the evidence from studies, it is recommended that
insurance schemes provide for 9-week trastuzumab treatment
for patients with HER2/neu-positive breast cancer.

• The National Pharmaceutical Pricing Authority should

consider reducing the price of trastuzumab by at least 35%,
such that 1-year trastuzumab use would also become cost
effective. The network of cancer hospitals as part of the
National Cancer Grid could develop a mechanism for common
procurement of chemotherapy drugs, which would likely bring
down prices
BIOSIMILARS:

• Trastuzumab comes with a relatively high price tag compared

with traditional cytotoxic chemotherapy and contributes to
healthcare budgets.
• Three engineered products related to trastuzumab—2
antibody-drug conjugates, ado-trastuzumab emtansine and
fam-trastuzumab deruxtecan-nxki, as well as the subcutaneous
trastuzumab/hyaluronidase—have since been approved and
have expanded the treatment options for this patient
population. The approval of 5 trastuzumab biosimilars as of the
end of 2019 holds the promise of considerable cost savings .
• Indian-based Pharmaceuticals have launched trastuzumab
biosimilars. The new product will bring down the cost of
breast cancer treatment by nearly 65%.

• Presently, the MRP of most of the trastuzumab brands in India

ranges between Rs.58, 000‒Rs.63, 000 per 440 mg vial. Based
on 18 cycles of trastuzumab therapy, cost of treatment is
about 10 lakh rupees. 65% reduction of cost will bring the
treatment cost to 4 lakh rupees, enabling many more patients
to benefit from trastuzumab treatment.
 
 SOCIAL IMPLICATIONS
• In India, it is the family that provides crucial support to a
woman with breast cancer during her ordeal with the disease
and its treatment.
• Breast cancer has implications on the psychosocial support
beyond the cancer patients alone, it includes the immediate
family and aspects of finance and social adjustments are
critical in addition to the routine medical aspects of the
disease.
KEY DECISION MAKERS FOR TREATMENT
PYSCHOSOCIAL PRESSURES
• A woman is expected to play different roles as daughter, wife, mother, or
mother-in-law based on the context. During the time of treatment (surgery,
chemotherapy, and radiation therapy), her ability to fulfill these roles and
responsibilities are severely impacted. Due to the treatment and its side effect,
the patient has to deal with multiple issues such as disfigurement of her body,
sexual intimacy with the husband, and the ability to care for her children. This
leads to psychological disturbance, 38% of the cancer patients are identified
with anxiety and depression, and also to distress, adjustment disorders,
delirium and posttraumatic stress disorder.

• Diagnosis of breast cancer poses a significant financial and psychosocial

burden not only on patients, but also on the immediate family members.
Family plays a vital role in the lives of breast cancer patients through managing
their finance, decision making, providing emotional support and remaining
involved throughout the course of the disease. Involving the family in planned
psychosocial interventions might produce better results than merely patient
focused strategies.
 
The financial, social, mental and familial pressure that a woman faces as a
cancer patient or cancer survivor in our country is very high. The resources
available to these women in our country are slim to none at best. The high
cost of cancer treatment along with the late presentation and neglect on
the patient’s side has led to the higher incidence of breast cancer fatalities
in our country. A multi pronged cohesive treatment and awareness
program is the only way to go forward.