August 25, 2010 — Cancer is often considered to be a "rich man's burden," in that it is believed to primarily affect people living in wealthy nations. That is a myth that needs to be corrected.
Cancer is now a leading cause of death and disability in low- and middle-income countries, according to a report published online August 13 in the Lancet. Nearly two thirds of the 7.6 million cancer-related deaths occur in developing nations.
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| Dr. Julio Frenk (Photographer: Kent Dayton) |
Even though these nations account for almost 80% of disability-adjusted life-years lost to cancer, only about 5% of global cancer resources are spent in those nations. Thus, argues the team of 23 prominent public health experts who authored the report, it is time to end the assumption that cancer is a disease that affects the rich and develop strategies to close the gap between developed and developing countries.
More specifically, they advocate a "call to action" to put in place a global initiative similar to those geared toward HIV/AIDS, malaria, and other infectious diseases.
"The situation has become more complex," said coauthor Julio Frenk, MD, PhD, former Minister of Health of Mexico and current dean of the Harvard School of Public Health in Boston, Massachusetts. "Cancer was the priority of wealthy nations, infectious disease the problem of poor nations. It used to be more black and white."
We cannot act like we are living in the previous era and ignore the burden of cancer in these countries.
"But we cannot act like we are living in the previous era and ignore the burden of cancer in these countries," he told Medscape Medical News.
The authors emphasize that relatively inexpensive measures can be easily deployed for treatment, prevention, and early detection. They point out that in resource-poor countries that lack specialized services, experience has demonstrated that much can be done to prevent and treat cancer with off-patent drugs, community health workers and local clinicians, and application of regional and global mechanisms for financing and procurement.
Incidence Rising or More Awareness?
We are victims of our own success.
The growing proportion of cancer cases in low- and middle-income nations stems from 3 main factors, according to Dr. Frenk. "We are victims of our own success," he said in an interview. "More people are now surviving to an age when they are more likely to develop cancer."
Because of substantial efforts, diseases such as malaria and tuberculosis can be cured, and other disease such as AIDS can be controlled in the long term. "Individuals who may have died in childhood of an infectious disease or women who may have died in childbirth are now surviving," he said.
Although some cancers are prevalent in children and young adults, a large proportion of cancer cases occur in adults who are middle aged and older. As an example, breast cancer is rarely seen in teenage girls or women younger than 30 years. "But now we are seeing women living long enough to develop the disease," said Dr. Frenk.
Another factor is the transition in risk factors, he explained, such as the increased use of tobacco and the rising rate of obesity. In addition, changes in age at menarche and pregnancy patterns can affect breast cancer incidence; in some of these countries, these patterns are trending toward those of developed countries.
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| Dr. Lawrence Shulman (Photographer: Sam Ogden) |
The third factor is the "discovery effect," noted Dr. Frenk, in that more cancers are being detected and, thus, the number of cases is increasing.
Coauthor Lawrence N. Shulman, MD, pointed out that in the case of HIV in sub-Saharan Africa, when effective treatment programs were established, the number of "counted" patients rose rapidly as patients began to come for treatment. "We expect the same with cancer patients. In the sites where I work directly — Paul Farmer's Partners in Health Sites in Haiti, Rwanda, and Malawi — this already seems to be the case," said Dr. Shulman, chief medical officer and senior vice president for medical affairs at the Dana-Farber Cancer Institute in Boston.
He also noted that statistics on patients with cancer in many parts of the world "are not as good as we would like."
"Many countries do not have good tumor registries, or any tumor registries at all, and in many settings some patients with cancer never seek medical care and are therefore not counted," Dr. Shulman told Medscape Medical News. "So our cancer incidence estimates are likely to be lower than reality."
Global Task Force
The Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC) was launched in November 2009 by the Dana-Farber Cancer Institute; the Harvard Global Equity Initiative in Cambridge, Massachusetts; Harvard Medical School; and the Harvard School of Public Health. The objectives of this initiative are to design, implement, and evaluate innovative strategies for expanding access to cancer prevention, detection, and care.
As noted in the report, the GTF.CCC's strategy is to collaborate with and support existing initiatives; the task force will base much of its work on the lessons learned from previous endeavors. These include initiatives that address infectious diseases such as AIDS and tuberculosis, maternal/child health, sexual and reproductive health, and mental health.
In addition, their strategy calls for the "identification and exploitation of opportunities for synergy between these initiatives and cancer care and control, particularly in the context of health-system strengthening and the wide network of services devoted to the health of women and children."
If anything, cancer is simpler in many ways.
There is skepticism about the reality of stepping up access to an integrated system that incorporates early detection, diagnosis, treatment, and palliation/pain control in resource-poor nations, the authors note. Critics focus on the scarcity of funding and perceived obstacles to treatment, and argue that limited international resources should not be spent on expensive vaccines and cancer treatment.
The same skepticism was seen when initiatives were introduced to combat the AIDS epidemic in low-income nations, explained Dr. Frenk. "If anything, cancer is simpler in many ways," he said. "Many of the drugs are off patent and therefore less expensive. The drugs are also taken for a set time, not for life, as is the case with AIDS therapy."
Success Against the Odds
However, the prevailing belief, note the authors, is that it is virtually impossible to implement safe and effective cancer treatment in poor nations because of the shortage or absence of oncologists, specialized facilities, guidelines for treatment, and regulatory systems.
But the experts who coauthored the Lancet report challenge this skepticism by pointing to successful cancer treatment programs that have been initiated in extremely resource-poor countries, such as Malawi, Rwanda, and Haiti.
Partners in Health, a Boston-based nonprofit healthcare organization that was cofounded by Paul Farmer, MD, PhD, first author of the Lancet report and chair of the Harvard Medical School Department of Global Health and Social Medicine, has collaborated with national ministries of health to operate health centers and hospitals in rural, underserved areas. Currently, they serve catchment areas of 1,200,000 people in Haiti, 800,000 in Rwanda, and 175,000 in Malawi.
In the absence of oncologists, care is provided by teams of local physicians and nurses, with support and training from Harvard-based facilities (the Dana-Farber Cancer Institute, Harvard Medical School, and Brigham and Women's Hospital). These facilities have begun treating patients with a variety of cancers that generally respond to therapy, including breast, cervical, rectal, and squamous head and neck cancers, and Hodgkin's and non-Hodgkin's lymphoma and Kaposi's sarcoma.
"Where resources are limited, we are targeting diseases for which we currently have effective treatments that can be delivered in these sites and that cure patients or extend life significantly," said Dr. Shulman. "Burkitt's lymphoma in Africa, for example, is a highly curable cancer with relatively inexpensive chemotherapy, and we have shown that we can successfully do that. It affects children and young adults, so the gain in life expectancy and the pure humanitarian gain is tremendous."
The authors note that in Malawi, Cameroon, and Ghana, the total cost of a generic first-line chemotherapy agent with a 50% cure rate for Burkitt's lymphoma is less than $50 per patient.
The relief of suffering must be one of our major goals.
Conversely, for cancers for which effective treatment remains evasive, such as that of the pancreas, the emphasis in low- and middle-income nations will be on effective palliation, he explained. "I would say at this point that effective palliation is also not available in many of these settings, and the relief of suffering must be one of our major goals," said Dr. Shulman.
Prevention is a very important part of the paradigm, which includes implementing measures such as tobacco control programs and vaccination against hepatitis B and human papillomavirus, he added. "But even if we are extremely successful, immediately, with these programs, the incidence in cancer will not drop for decades. We need programs now to treat these patients."
Diagonal Approach
Two models have existed in healthcare, particularly in developing nations, explained Dr. Frenk. Vertical programs represent an isolated approach, in that they only target one or a few health problems; a horizontal model encompasses the healthcare system in general. But between the vertical and horizontal strategies, there is the diagonal approach.
"We are advocating a diagonal approach," said Dr. Frenk. "We need to target priorities, but at the same time strengthen the entire health system."
An example of a vertical approach is the eradication of smallpox, he pointed out. Although it represented a monumental public health feat and a great accomplishment of modem medicine, it nevertheless did not build up or improve local healthcare systems.
In contrast, the diagonal approach targets specific diseases, but at the same time is accompanied by a range of strategies that strengthen the entire system, such as the training and expansion of the health workforce, and integration and coordination with other disease programs.
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| Dr. Felicia Knaul |
"Strong healthcare systems are a prerequisite for treating cancer," said coauthor Felicia Knaul, PhD, director of the Harvard Global Equity Initiative and associate professor at Harvard Medical School. "Improving cancer treatment also improves the treatment of other diseases."
Palliation and pain control is one such example. "If we are successful in removing the barriers, then the treatment is useful for any person who is in pain or dying," she said.
Improving cancer treatment also improves the treatment of other diseases.
"A well-integrated primary care system can offer prevention and detection of precancerous conditions, as well as other diseases," she added. "We need to get away from the 'zero-sum' argument about which diseases to exclude and which to include, and instead start increasing resource availability and strengthening healthcare systems to meet the needs of patients."
On a personal level, Dr. Knaul was diagnosed with breast cancer in 2007 while living in Mexico City, and received treatment there. In Mexico, modern cancer therapies and diagnostic mammography are available in some places, but better access is needed.
But Mexico is one of a handful of countries that have incorporated cancer care and control into health-insurance programs geared to low-income people.
Although the delivery of cancer services in Mexico is still suboptimal and creative initiatives are needed to reach more patients and detect disease earlier, "the recognition of the growing burden of cancer and the opportunity for treatment has been transformed into action as part of continuing efforts to strengthen the health system," the authors write.
The research in this paper received no outside funding. Dr. Frenk and Dr. Shulman have disclosed no relevant financial relationships. Dr. Knaul reports being associated with a nonprofit program in Mexico (Tómatelo a Pecho); receiving honoraria from the Mexican Health Foundation, which has submitted research grant applications to GlaxoSmithKline and Roche; and has been nominated to become a board member (unpaid) for the International Union Against Cancer. Several other authors have made declarations, as noted in the paper.
Lancet. Published online August 13, 2010. Abstract
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Cite this: Call to Action: Cancer Needs to Be Addressed in Developing Countries - Medscape - Aug 25, 2010.
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