AORTIC 2011, Cairo, Egypt 30 November–2 December 2011

Management of triple negative breast cancer in low resource countries

Dr Verna Vanderpuye – Korle Bu Teaching Hospital, Accra, Ghana

I gave a talk on the management of triple negative breast cancer in low resource countries. We know we are plagued with triple negative breast cancer, everybody is plagued with breast cancer as the number one cancer, I’m sure you know that, but it’s a particular type that tends to be quite difficult to manage which is the triple negative type. We unfortunately have quite a bit of that in Africa and in Ghana as well so we’re just discussing innovative ways. The developed country has gone far ahead of us in terms of targeted therapies. Unfortunately for us, most of our treatments are out of pocket, even for those who are covered under insurance that part of the treatment is not really under insurance and it’s going to take quite a bit of our health budget. So technically, since it really doesn’t cure, it’s quite difficult to justify the government spending so much money. Unfortunately the patients have to pay out of their pockets and that can be quite difficult, even for people who are supposedly getting high salaries, comparatively, in Africa. Unfortunately that is where we are, we don’t have enough money to treat our patents with the targeted therapies, even though for triple negative it is not working quite as well as they hoped to; there hasn’t been a winner so far but it’s quite a burden of disease to treat. Most people, it’s less than a third of their patients, for us it’s more than half of our breast cancer patients, especially young females and some of the males have triple negative breast cancer and it’s quite difficult.

Is there a higher prevalence of genetic predisposition in Ghana or are there other factors?

Not really, it’s still the same 5-10% genetic predisposition but I think there are environmental factors that we are not aware of, we don’t have that much detail so that is the problem. But there are some risk factors which we fit in perfectly like obesity, the average number of pregnancies, all that kind of thing.

What can be done to help with the lack of data and need for funding?

With cancer treatment it’s very difficult if there is no money because the patients have to pay out of their pockets so we just have to convince them. At the same time while you’re doing that, you have to remember that you might not be able to cure them so it’s not really justifiable asking them to sell their property to buy a drug that wouldn’t really cure them. So that makes it quite difficult and, like I said, for this particular type of cancer sometimes it’s better to just leave them alone after you’ve tried two or three chemotherapies that don’t work, sometimes it’s better to just leave them. For them it’s a lot of money and the more you go ahead, the more expensive the drug becomes and you know it’s not really going to do that much.

Are there any resources for palliative care?

Unfortunately we are still burdened with treating palliative care because there is not a separate unit for palliative care in Ghana so the oncologists still have to provide that so, unfortunately, we do that too. But it’s quite a lot of work for us and we don’t do such a good job in terms of the spiritual aspects, the psychosocial aspects, it’s more the medical and then maybe just advice. I see more of that because I think we need more of the psychologists for burnout so it’s quite difficult, yes.

Have pharmaceutical companies considered lowering prices or funding research?

Most of them are running a business so it’s really quite difficult and they also have their own economical problems, outside now, so it’s very difficult. But for my country, also, the problem is over the taxes on those drugs are quite high so if they could drop it down it would help. The problem is that even though the government drops down their taxes, the drug companies are not dropping their mark-ups so it’s quite unfair for the government to drop their income and you still keep your profit, that makes it quite difficult. So the two of them have to sit down together and agree how to do this.

In Ghana we keep talking about it, that maybe we could because in some countries there’s no tax, like in Kenya, so the drugs are cheaper there. In fact, sometimes the drugs are much cheaper in the US than they are in Africa. Even if you fly there, including your ticket and your living expenses, it’s still cheaper and we are really poor. It makes it quite a challenge, so I think they need to… why can’t we get the same prices as…? Because I’m sure even with American prices there must be a mark-up so why are we having to pay so much for our drugs? The taxes for import are still quite high so that’s the problem.

But for the targeted therapies, a few people have gone to get their drugs outside the country because it’s much cheaper. Or have had to go outside the country for those treatments because it’s still much cheaper.

Is there a need for political action between the government and the pharmaceutical companies?

I think so, I think the pharmaceuticals, and Novartis has a good programme for Gleevec where it’s free for a criteria of patients, I think they need to be able to do that because it’s quite unfair that somebody with HER2 positive breast cancer can get the drug that’s allowing people to live for ten years. You understand what I mean, in Africa if you have HER2 breast cancer you’re doomed particularly because you cannot afford Herceptin and it’s a life-saving drug. So it costs so much more, $100,000 or something a year, and if you’re supposed to be on it for life you know what that means – out of pocket, that’s quite difficult.

Also, the free access drugs stop in the US, I don’t know why. Even some of the clinical trials we are not eligible, because our patients would have access to some of these drugs if they were on clinical trials. So those are some of our problems because they usually just stop in South Africa or up in North Africa but the rest of Africa doesn’t really benefit from these clinical trials.