Challenges of Cancer Control in Developing Countries

Current Status and Future Perspective

Vanita Sharma; Stewart H Kerr; Zsana Kawar; David J Kerr

Disclosures

Future Oncol. 2011;7(10):1213-1222. 

In This Article

Current Status of Cancer Control in Developing Countries

The WHO states that there are four key components to cancer control: cancer prevention, early detection, diagnosis and treatment and palliation. Developing countries face major challenges in each of these four areas. However, before proceeding to discuss these issues in more detail, it is important to first establish a definition for developing countries. Although the term 'developing country' is frequently used by leading international development organizations including UN agencies, the World Bank, World Trade Organization and WHO, there is no agreed single definition on what constitutes a developing country. There is no agreed uniform economic boundary between developing and developed countries – some organizations determine the boundary between developed and developing country on the basis of economic indicators like gross domestic product (GDP) or gross national income (GNI), whilst the UN and other organizations refer to the human development index (HDI). The terminology also does not recognize that there are often widely differing standards of living both between and within the countries defined as developing countries. Furthermore, it does not allow for the fact that there is not one simple route to development. However, for the purpose of this article, with these limitations duly noted, the term 'developing country' has been used. This article utilizes data compiled by the International Agency for Research in Cancer (IARC), thus when it uses the term 'developing country' it adopts the definition for less developed regions used by IARC, which includes all regions of Africa, Asia (excluding Japan), Latin America and the Caribbean, Melanesia, Micronesia and Polynesia.[103]

Global Disparities in Cancer Care

Cancer incidence and mortality varies significantly between developed and developing countries. However, a key challenge when attempting to define the scale of the problem of cancer control in developing countries is the lack of reliable statistics. Country-based cancer plans are required to demonstrate where a country's strengths and weaknesses lie in cancer care. Many developing countries also lack population-based cancer registries leading to assumptions being made as to the relative frequencies of the varying levels of different cancers based on global trends, which can be misleading and so efforts to improve cancer registries are required. Developing countries lack the funding to invest in comprehensive national cancer registeries. Thus, current statistics are based largely on figures from hospital-based registeries, however these are often incomplete and this lack of accuracy is further compounded by the under-reporting of cancer cases from those who do not come forward to treatment. IARC's Globocan project is the most comprehensive assessment of the global incidence of cancer that is available. According to Globocan 2008[104] the top five most frequent cancers in less developed countries in males and females are cancers of the lung (12.4% of new cases), stomach (10% of new cases), breast (9.7% of new cases), liver (8.8% of all new cases) and colorectum (7.1% of all new cases). The existing data demonstrates that there are some key differences that emerge in the pattern of cancer incidence. For example, as pointed out by Martin L Brown et al. "Developed countries often have relatively high rates of lung, colorectal, breast, and prostate cancer because of the earlier onset of the tobacco epidemic, the earlier exposure to occupational carcinogens, and the Western diet and lifestyle in such countries. In contrast, up to a fourth of cancers in developing countries are associated with chronic infections. Liver cancer is often causally associated with infection by the hepatitis B virus (HBV), cervical cancer is associated with infection by certain types of human papillomavirus (HPV), and stomach cancer is associated with Helicobacter pylori infection".[105]

By increasing the availability and access to vaccines like HPV and HBV, there could be significant opportunities to reduce cancer incidence and mortality in developing countries. Lung cancer is also largely preventable through tobacco ban policies. However, focusing on the whole spectrum of cancer control is crucial – including early detection, diagnosis and treatment and palliative care – and this article also explores how this can be carried out in countries with limited resources. There is considerable variety between the resources available for cancer control in developing countries and thus a single approach cannot be generalized; but there are some common problems and solutions, which will be explored by this article.

Cancer Prevention & Early Detection

Developing countries have to deal with an array of health problems with limited resources. The lack of resources and basic health infrastructure mean that most people in developing countries have no access to cancer screening, early diagnosis, treatment or palliative care.[3] For example, in Sub-Saharan Africa, there are few cancer services.[4] A majority of patients present with advanced disease that is not curable. The delay in presentation is often due to a variety of factors, but commonly include a lack of awareness of the signs and symptoms of cancer, a lack of money to travel to a hospital and cover the costs of diagnosis and treatment, which thus leads many to seek traditional treatments instead.[5] The problem of late presentation is not unique to Africa – it is seen in developing countries in other regions too. For example, a study on breast cancer in Malaysia showed 52.2% of newly diagnosed patients at the Queen Elizabeth Hospital (Kota, Kinabalu) presented with stages III and IV. Most of these women were diagnosed between the ages of 40 and 49 years; they were mostly from rural Malaysia, with little access to money and had little or no education.[6] By the time most patients come forward for treatment, palliative care is often the only option but with limited access to morphine in developing countries, for many people a diagnosis of cancer leads to a painful and distressing death.[7]

Treatment & Diagnosis

Another significant problem in combating cancer in developing countries is that even if cancers are caught early, the treatment options are both limited and expensive. In the UK, there are 18 dedicated cancer research centres and 34 cancer networks, and the population has free access to healthcare and the most up-to-date treatment along with access to all types of cancer specialists within the system. In developing countries, it is much harder to access cancer services. For example, Sierra Leone has no oncologists or treatment centers, India has 29 centers to treat a population of 1 billion and Ghana has six oncologists and two treatment centers to treat a population of 23 million. Another critical problem is the lack of oncologists and specialized cancer nurses in developing countries. Oncology and palliative care training is often limited in medical schools, which means that doctors and nurses often have to train outside their country. Few are able to afford to do this and the net effect is that there is a lack of sufficiently trained staff within developing countries to deal with the increasing demands of cancer cases within their countries. There is also limited access to radiotherapy. According to the International Atomic Energy Agency (IAEA), whilst developed countries usually have one radiotherapy machine per 250,000 people, most developing nations often have only one machine per seven million. The IAEA has also pointed out that although the developing world holds 85% of the world's population, they only have 2200 radiation therapy machines compared with the 4500 in the developed world.[8] Those developing countries that have access to radiotherapy, face considerable financial investment and up to 5 years are required to provide the necessary training, equipment set-up and maintenance, protocols and quality control.[8] However, these are the lucky countries – because 15 African countries do not have access to any radiotherapy treatment facilities at all.[8] For those cancer patients living in countries without radiotherapy, their only option is to travel to another country to access treatment, but few patients from these countries can afford the considerable expenses involved with seeking treatment abroad.

Cancer is an expensive disease to treat and many patients in developing countries – where there is limited or no access to health insurance – simply cannot afford to pursue treatment. Most live a hand-to-mouth existence and cannot afford to be ill. The patients and their families have to bear the full costs of their treatment. However, hospital admittance, investigative techniques, blood samples, scans, the drugs used to treat the cancer, as well as other treatment options such as surgery, chemotherapy and radiotherapy, are often prohibitively expensive. Families are often confronted with impossible dilemmas when making the decision as to whether they will pursue treatment. If the patient is the main bread winner of the family, then their family will struggle to afford to look after themselves and pay for treatment. If the patient is a mother, then whilst she is undergoing treatment her children are likely to be left without a carer and/or a second source of income, again leaving the family to struggle. In cases of childhood cancer, parents are left with the terrible dilemma of whether they pursue treatment, which might financially cripple the family and prevent them from being able to feed their healthy children. The lack of affordability of treatment means that in developing countries, there are high rates of treatment abandonment, with patients instead seeking alternative or traditional treatments (usually leading to premature death) and/or patients not presenting for treatment until the cancer is so advanced they can only receive palliation. Furthermore, in cases where people from low-income backgrounds pursue treatment, this often results in the family accumulating considerable debts, putting a significant financial burden on the whole family.[9]

Palliative Care

As so many patients present with advanced disease, the provision of palliative care for cancer patients in developing countries is critical. The WHO has declared that: "The majority of cancer patients will need palliative care sooner or later. In developing countries, the proportion requiring palliative care is at least 80%. Worldwide, most cancers are diagnosed when already advanced and incurable. For these patients the only realistic treatment option is pain relief and palliative care".[106]

However, there is a global shortage of morphine with 90% of the world's morphine supply being used by the USA, Canada, France, Germany, Australia, the UK and several other European countries, leaving little for the rest of the world.[10] For example, in a recent Human Rights Watch report on palliative care it was argued that: "In 2008 India used an amount of morphine that was sufficient to adequately treat during that year only about 40,000 patients suffering from moderate to severe pain due to advanced cancer, about 4% of those requiring it … Even most large cancer hospitals in India, including 18 of 29 government-designated lead cancer centers, do not have personnel trained to administer palliative care or morphine and other strong pain medications. This is particularly startling given that approximately 70% of the patients seen at these hospitals are at such an advanced stage of cancer upon arrival that they are beyond cure; palliative care and pain management is the only benefit they may still receive".[11]

Another major problem is that fears and misconceptions regarding addiction by governments and the medical profession further limits the availability of morphine in many developing countries. For example, in some African countries, the importation of opiates is illegal, which means that morphine (arguably the cheapest and best palliation drug) is difficult to obtain for the main tertiary hospitals within countries. There are often also stigmas and a lack of knowledge within the medical profession and general public about palliative care – for instance, fears that it could be a form of euthanasia and/or that patients could become addicted – and therefore in many developing countries palliative care is not being used effectively.[12] In order to change this and improve palliative-care access, the WHO has argued that it is critical to focus on policy change, education and improving drug availability.[107]

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