Improving Cancer Care in Resource-Poor Countries

August 27, 2010 — Can cancer be treated for a dollar a day? The question is becoming urgent because it is projected that over the next 10 years, 70% of all cancer cases will occur in the developing world.

Realistic treatment guidelines are needed for this population, say the authors of an essay published in the August 26 issue of the New England Journal of Medicine.

Even though the "top end" of the therapeutic spectrum is extensively covered by myriad guidelines, very little has been done to create a similar set of guidelines geared toward cost-effective cancer treatment or recommended therapeutic algorithms that can be used by poorly funded healthcare systems, write David J. Kerr, MD, DSc, and Rachel Midgley, MD.

Dr. Kerr, from the Sidra Medical and Research Center in Doha, Qatar, and Dr. Midgley, from the University of Oxford in the United Kingdom, note that in high-income nations, physicians are increasingly becoming "accustomed to the public debate" that surrounds the licensing of new and expensive cancer drugs. Many of these drugs, they add, are associated with marginal clinical benefits.

These debates "must appear odd to oncologists who practice in low-income countries," the authors write, where the most simple generic treatment is often beyond the financial means of the average person.

Not least of these is the need for financial prioritization.

Despite the growing awareness of the magnitude of the cancer burden in developing nations, the challenges of developing comprehensive national cancer plans are substantial, they note, adding that "not least of these is the need for financial prioritization."

For example, the amount spent in 2008 by the National Health Service in the United Kingdom was about $3000.00 per capita; in Kenya, the amount was $8.30.

A first step toward creating cancer-treatment guidelines in this setting is to establish an interdisciplinary task force to aid in their development, say the authors. "Such a task force would need to include experts in oncology, local and international health economics, and clinical pharmacology who would consider the impact of pharmacogenetics, pragmatic definitions of acceptable toxicity levels, nutritional status, and intercurrent illnesses."

In places where this type of data is lacking, they add, the task force can recommend the types of clinical trials and studies that would fill the gap.

Possibilities for Success

The essay comes hot on the heels of a study recently published in the Lancet, in which public-health experts called on the global community to address the rising incidence of cancer and cancer-related mortality in the developing world. The experts argued that a comprehensive cancer plan can be put in place in these nations, as was done to deal with the AIDS epidemic.

They described a number of feasible strategies to meet the challenge of cancer in low- and middle-income nations, such as focusing on cancers that are potentially curable, emphasizing prevention, using off-patent drugs, and training nurses, primary care doctors and other nonspecialists to administer care.

In a recent story in CancerWorld, which is published by the European School of Oncology, the work of Ian T. Magrath, MB, BS, president of the International Network for Cancer Treatment and Research (INCTR), is highlighted. Dr. Magrath has spent the past few decades focused on the treatment of malignant lymphomas and leukemias and on cancer in developing countries. He is best known for pioneering low-tech treatment protocols for Burkitt's lymphoma, a rare disease in the industrialized world but the most common childhood cancer found in Equatorial Africa.

Survival rates for Burkitt's lymphoma are now in the range of 60% to 70%, which is lower than in industrialized nations but similar to the rates seen in high-income countries 10 years ago and in current high-risk patients. "It may be that they're getting as good results as they realistically can, given the patient population and available resources," said Dr. Magrath in the article.

The INCTR is a not-for-profit, nongovernmental organization founded in 1998 by the International Union Against Cancer in Geneva, Switzerland, and the Institut Pasteur in Brussels, Belgium. It receives financial, technical, and intellectual support from the National Cancer Institute in the United States. The goals of the INCTR include helping control cancer in developing countries.

Dr. Magrath points out that the obstacles to good cancer care in resource-poor countries are completely different than those in wealthier nations, and emphasizes the necessity of understanding local resource limitations. "You have to be prepared to train and educate the professional staff — select a disease or discipline, and one or more centers, and try to develop those into centers of excellence or reference centers," he says.

These centers become resources in their own countries, and serve as training facilities and improve access to diagnosis, treatment, and palliative care in other countries.

Build on Existing Methods

In their essay, Drs. Kerr and Midgley point out that cost-effectiveness models are already in place to some degree. The World Health Organization (WHO), for example, has established a database on the cost-effectiveness of more than 700 health-related interventions. It uses the standard measure of disability-adjusted life-years, which allows the comparison of interventions within a particular field.

Economists evaluate the relative benefits of any new therapy by comparing the cost and effectiveness with existing treatments, the authors add. This approach could be modified to evaluate the cost-effectiveness of previously established chemotherapy regimens. Preference could be given to the drugs on the WHO's list of 17 "essential drugs for cancer therapy," they write; most of these agents have generic equivalents that offer the possibility of less costly treatment.

Another strategy would be to try "make more" of open-access projects, in which pharmaceutical companies have provided new drugs free of charge to poorer nations. If the programs are sufficiently flexible to answer key research questions about tolerability, effectiveness, and pharmacokinetics, the authors write, they can help refine feasible treatment in developing nations.

"So will we be able to treat cancer for a dollar a day?" ask Dr. Kerr and Dr. Midgley. "At one level, the answer might be yes, but we need to develop an evidence base that is appropriate to the capacity of available health funds."

Dr. Kerr and Dr. Midgley are board members of AFROX, a charity established to improve cancer control in Sub-Saharan Africa

N Engl J Med. 363;9:801-803.