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

Future Perspective

As predicted by the WHO, the cancer burden in developing countries is set to increase as infectious diseases are brought under control, people live longer and shift to Western patterns of lifestyle. Unless attempts are made to improve cancer care in developing countries now, these countries will not be able to cope with this increase in cancer cases. However, the challenge of implementation of the necessary changes required to achieve this remain. Investment in training, equipment, education campaigns and the development of cheaper forms of cancer care are essential, as is the need to make policy changes at the national and international level. Nevertheless, there are ways to make relatively low-cost interventions that could save tens of thousands of lives in the future.

There is much that could be done to help improve cancer care and prevention in developing countries. For example, over a third of cancer deaths are due to preventable causes such as viral infection, poor nutrition and widespread tobacco use.[13] Educational campaigns regarding cancer prevention, encouraging changes in patterns of lifestyle such as stopping smoking, could thus have a key role in reducing the number of cancer cases,[14] and crucially, these are actions that can be implemented at low or no cost.

Increasing Access to HPV & Hepatitis B Vaccination

Some cancers can be linked to viruses such as HBV,[15] which leads to hepatocellular carcinoma and HPV associated with cervical cancer.[16] Access to vaccinations, such as the HBV and HPV vaccines, in developing countries could potentially help to save many thousands of lives in the future – but cost is a key barrier.[17] For example, cervical cancer is the second most common cause of cancer deaths for women in many African countries.[108] It is a disease that affects women in the prime of their lives, but most are unable to get any treatment and, far too often, they suffer a painful death, with paracetamol as the only form of palliation available. In the UK we are on the road to eradicating cervical cancer by improving access to screening and with the introduction of the HPV vaccine, but in Africa there is virtually no support to protect women from cervical cancer. According to Globocan 2008, Africa has four and a half times the incidence of cervical cancer compared with the USA and just over ten times the mortality despite the fact that almost every case is preventable through a program of screening, treatment and vaccination.[18] Widespread introduction of the HPV vaccine would eradicate 70% of all known cervical cancers within a generation, saving the lives of almost 200,000 women a year.[19] However, the costs of introducing the vaccine to Africa has been prohibitive, as a course of three vaccine inoculations costs approximately US$300 per girl, way beyond the health budget of all African governments.[20] However the pharmaceutical companies who produce the vaccine are committed to delivering the vaccine at a no-profit price for developing countries. The vaccine has also been approved by the Global Alliance for Vaccines and Immunisation (GAVI) and the WHO. Currently there is a need to conduct large scale feasibility studies to establish the protocol steps necessary to deliver the vaccine cost-effectively in African countries. PATH, supported by a grant from the Bill and Melinda Gates Foundation (WA, USA), has initiated research studies in India, Peru, Uganda and Vietnam on how to roll out the HPV vaccine, and studies by other organizations are also being planned. For example, Africa Oxford Cancer Foundation (AfrOx) is currently working to develop a program in collaboration with the Ghana Health Service.

Tobacco Control

If action is taken now, it would also be possible to avert the epidemic of tobacco-related morbidity and mortality manifest in the developed world and much of the developing world. Tobacco is thought to be responsible for up to 30% of all cancer deaths worldwide, but as Sir Richard Peto has argued, "tobacco consumption is the world's most avoidable cause of cancer".[21] Recent evidence suggests an increase in smoking in the developing world, especially among young people and women. Furthermore, decreasing markets for the tobacco industry in the developed world means that the tobacco industry will increasingly shift towards seeking new markets in the developing countries, where it sees enormous potential for growth. Use of chewed tobacco is high in some developing countries, especially in villages in rural areas. Efforts must be made to control this more traditional use of tobacco in order to avert cancers of the mouth and throat.[22] To educate civil society about the dangers of tobacco use and the benefits of cessation, special efforts are needed to educate young people, healthcare practitioners and policy makers. It is also necessary to adopt effective policies such as tax and price increases on tobacco, which will not only lower prevalence but also increase government revenues, which can be used to pay for tobacco control measures and other health and social programs. Other required policy changes include: the placing of effective warning labels on tobacco products; banning advertising and promotion of tobacco use; prohibiting smoking in public places; banning sales of single cigarettes; and prohibiting the sales of tobacco to the young. In order to implement effective tobacco control policies and programs, civil society must be mobilized in support of this issue. A key to this is the nomination of champions who will promote the cause of tobacco control. In both the developing and developed countries, such individual champions have proved to be essential in influencing policy makers, educating civil society and exposing and fighting the tactics of the tobacco industry.[23]

However, tobacco control efforts must focus not simply on reducing consumption by individuals, but must also address underlying issues relating to how the curtailment of tobacco production could have the adverse effect of increasing rural poverty. The production and availability of cheap tobacco relies on tobacco farmers in developing countries. However, these farmers usually rely on growing tobacco for their whole income. If they are to be discouraged from growing tobacco, it is crucial that they are provided with support to identify alternative crops that will be as profitable, as well as assistance with learning the relevant agricultural techniques required to grow new crops and investment will also be required to establish new distribution infrastructure.

To demonstrate the impact of tobacco control programs, surveillance data is also needed to track tobacco use and related behaviors, knowledge and attitudes. Without such data, evaluations of tobacco control programs are not possible. These studies have a crucial role in providing evidence for the retention and expansion of tobacco control programs.[109] For example, in Latin America many countries have passed a smoking ban in bars and restaurants. A study into the impact of 100% smoke-free law on health of hospitality workers from the city of Neuquen in Argentina carried out a pre- and post-ban study of 71 bars in Neuquen, with 80 workers managing to complete all required tests. The study showed that the smoking ban had had a positive effect on the respiratory health of the participants. The study has helped raise awareness of the benefits of a smoking ban, which has since been implemented throughout Argentina.[24]

Cancer Awareness Campaigns

A third of cancer cases are treatable if detected early.[110] A major reason why mortality rates from cancer are so much worse in developing countries is a lack of awareness of the signs and symptoms of cancer. Educational campaigns in developing countries to encourage awareness of the early signs and symptoms of cancer are thus vital; as well as improving access to screening such as breast and cervical screening. Efforts are being made to develop low-cost interventions in these areas. For example, the Union for International Cancer Control (UICC) through the annual World Cancer Day held on 4th February since 2000 has been encouraging advocacy efforts by nongovernmental organizations (NGOs) around the theme of cancer prevention. In 2011, AfrOx and the European Society of Medical Oncology (ESMO) have been working on a 1 year, joint 'Cancer Prevention 4 Africa Campaign' to improve people's understanding about the early signs of cancer to promote early detection and how simple lifestyle changes can greatly reduce the likelihood of developing many cancers.[111] The campaign consists of three components, an online video to encourage international collaboration; downloadable cancer awareness, prevention and early detection posters; and onsite knowledge sharing events. A series of cancer prevention and awareness posters are being piloted in Ghana in collaboration with the Ghana Health Service and Cancer Society of Ghana. These posters are freely available at www.afrox.org/cancerposters. The project will help develop a template for low-cost cancer awareness and prevention programs that can be replicated in other developing countries.[25]

Technological Developments

The potential for promoting early detection has also increased with the recent important technological developments such as the introduction of low-cost cervical screening, such as screen and treat methods using visual inspection with acetic acid (VIA) and the development of low cost DNA tests aimed at detecting HPV. An analysis was recently carried out on the accuracy of five cervical cancer screening tests:

  • VIA

  • Visual inspection with Lugol's Iodine (VILI)

  • Visual inspection with a magnifying device (VIAM)

  • Pap smear

  • High risk probe of hybrid capture-two assay (HC2)

They were assessed in 11 studies in India and Africa. A total of 58,000 women between 25 and 64 years of age took part in the study. The sensitivity of the VIA proved to be 79–83% with specificity of 85%, VILI approximately 10% more sensitive and equal on specificity. VIAM demonstrated the same results as VIA. The Pap smear showed the lowest sensitivity around 57% but high specificity of 95%. Finally the HC2 had a sensitivity of 62% and a specificity of 94%. This study shows that screening with VIA or VILI allows the detecting of cervical cancer on par or better than testing with a standard Pap smear or for the presence of high-risk HPV using HC2 assay, proving that a cost-effective screening program can be carried out in developing countries by properly trained staff.[26] However, improving access to screening alone will not be sufficient – more work will need to be to done to raise women's awareness of the importance of early detection. Studies in Ghana and Nigeria, for example, have demonstrated that even educated women can be reluctant to participate in available cervical screening, despite being knowledgeable about its importance. For instance, a recent study on the knowledge and practice of cervical cancer screening in Nigeria, interviewed 400 women on their knowledge of cervical cancer screening and asked if any of them had been screened. Only 76 (27%) were aware of cervical cancer screening. This study also demonstrated that there is a significant association between educational status and knowledge of cervical screening but surprisingly this association was not significant when it came to the women being screened for cervical cancer.[27]

International Advocacy

The expected rise of 17 million new cases of cancer every year, 60% of which will be in developing countries,[1] must be addressed before it becomes an even bigger burden and before survival rates in developing countries drop to a lower level than they already are. There is a growing awareness of the magnitude of the global disparities in cancer care and a sense of urgency regarding the need to take immediate action. However, finance remains a key challenge. Governments in developing countries have limited health budgets and thus have limited resources to deal with noncommunicable diseases (NCDs), such as cancer. They have to prioritize primary healthcare and controlling the heavy burden of infectious diseases such as HIV/AIDs, TB and malaria. Thus, leaving them with limited resources to cope with NCDs, such as cancer. The availability of funding from international donor agencies to support the improvement of cancer care in developing countries is hampered by the fact that cancer, like other NCDs, is not addressed by the millennium development goals. Although a heavy emphasis is rightly placed on communicable diseases, ignoring cancer and other chronic and NCDs will be detrimental as it will create future health burdens, which the current health systems will not be able to deal with. It is estimated that chronic and NCDs (cancer, diabetes, strokes and cardiovascular diseases), which account for two-thirds of deaths globally. 80% of NCDs occur in low- and middle-income countries and it is vital that there is greater focus on strengthening these healthcare systems to deal with this growing burden. Rather than trying to deliver cancer care or cardiac care or to manage diabetes separately, we need to take an approach in which we work laterally to strengthen primary healthcare systems. In doing so, we will make an impact on all chronic diseases. As developing countries begin to gain control over the spread of communicable diseases, chronic and NCDs will in time become the biggest health burden having the greatest impact on mortality rates.

International advocacy is thus required to galvanise the international community and individual governments to take the necessary measures. Lobbying of governments and health ministries needs to take place to emphasise how ignoring NCDs, especially cancer, will lead to a large future drain on funding and health infrastructure, ultimately leading to high mortality rates. A number of influential international advocacy meeting have already taken place. For instance, in 2007 the African Cancer Reform Convention, organized by AfrOx, was held in London, in which over 130 leaders in all aspects of world health and cancer control gathered for a 2 day meeting. Chaired by Professor David Kerr, Right Honourable Alan Milburn and Sir John Arbuthnott, the meeting discussed how comprehensive cancer care could be achieved in African countries.[112] This meeting built on two previous international conferences, held in 2006, which addressed the issue of the cancer burden in all developing countries – the Cape Town Meeting organized by the IAEA and the World Cancer Congress in Washington DC organized by the International Union Against Cancer, UICC. In 2007, at AfrOx's Cancer Reform Meeting, the London Declaration which calls for immediate action to bring comprehensive cancer care to African countries was signed by 19 health ministries and other key stakeholders such as representatives from WHO, IARC, World Bank, NGOs and the pharmaceutical industry – and demonstrated that the commitment and desire to improve cancer care in developing countries exists.[113]

There are also important international advocacy efforts being made regarding NCDs as a whole. This year, for only the second time in its history, the UN is having a high level summit on health. The topic that will be discussed is chronic diseases and NCDs, which has led to unprecedented international interest on this issue. The only time in the UN's history that it has met specifically to discuss health was around the AIDS epidemic. From that came UNAIDs and the extraordinary advances made globally against the AIDS epidemic. For those of us involved in chronic disease management, cancer, diabetes, cardiovascular disease and respiratory diseases, we have come together to form an NCD Alliance to lobby the UN Summit at the very highest level, so that action is taken when heads of state meet on 19–20 September 2011. The goal of the NCD Alliance is to ensure that the meeting will conclude with some measure outcomes and commitments to take action.[114]

Capacity Building & Strengthening Health Workforce

A major obstacle in the provision of adequate cancer care is the lack of trained healthcare professionals. In addition to providing on-the-job training programs for qualified doctors and nurses, support for introducing specialist training on cancer into the curriculum and syllabi of medical schools to train the next generation of health professionals is vital. Twinning partnerships between institutions from developed and developing countries provide one example of how international collaboration can be beneficial in supporting the development of sustainable in-country oncology training and education – with the proviso that such projects are locally led by local country experts. Institutional twinning partnerships provide the potential to expand the reach of oncology training programs in developing countries, utilizing a low cost, sustainable model for ongoing support. Healthcare twinning partnerships between resource rich and resource limited countries have been set up using a variety of models, with the end goal of these partnerships ultimately being the same – to share expertise and knowledge with the aim of helping to improve healthcare delivery in the resource-limited country.[115] Twinning partnerships can be set up to:

  • Provide training programs for doctors, nurses and/or other healthcare workers;

  • Help refine treatment protocols, so the patient receives best possible treatment within available resources;

  • Share educational and training resources;

  • Assist with community outreach programs with the aim of developing better patient resources and awareness raising initiatives.

The activities involved are tailored to the aims and objectives of the individual twinning partnership, but can include:

  • Providing training workshops in the resource-limited country, on a 'train the trainer' basis;

  • Work experience at a UK institution;

  • Online training and collaboration;

  • Sharing resources or helping to adapt resources for the resource-limited setting;

  • Ongoing mentoring support by email and phone.

When implementing these programs, it is essential that efforts are made to work in partnership with national governments and ministries of health, regional bodies such as the African Organization for Research and Training in Cancer (AORTIC) and other international and local NGOs, to avoid overlap and to ensure programs are locally led and sustainable.

Developing Novel Treatments

Finally, there also needs to be greater investment into developing novel and cheaper cancer treatments. Recently addressed in an article for the New England Journal of Medicine,[28] David Kerr and Rachel Midgley raise the question of whether or not it is possible to treat cancer for a dollar a day. They argued that this could potentially be possible, if we take a different approach to treatment protocols than we do in developed countries. The article argued that although most developing countries will have an elite that will demand the 'best care that money can buy', the average citizen cannot afford the simplest generic treatment. However, oncologists only have access to the latest online clinical guidelines promulgating 'optimal' therapy. The authors point out that very little has been done to develop evidence-based guidelines for cost-effective cancer treatment or recommended therapeutic algorithms for use in poorly funded healthcare systems. The authors thus recommend that work should be done to be done to develop cancer-treatment guidelines for low-income countries. For example, they argue that work could be done to: "…assess the cost–effectiveness of previously established chemotherapy regimens – for example, for breast cancer, the combination of oral cyclophosphamide, methotrexate and fluorouracil versus single-agent intravenous doxorubicin or paclitaxel; or for Burkitt's lymphoma, single-agent cyclophosphamide versus complex combination therapy. Preference could be given to the agents on the WHO's list of 17 'essential drugs for cancer therapy', most of which have generic equivalents that offer the possibility of less expensive treatment. Plots of efficacy versus cost could be used in various ways to define acceptable benefits for optimal resource use."

Finally, it is crucial to recognize that pharmaceutical companies have a key role in helping to facilitate more affordable access to treatment in developing countries. More work needs to be carried out to lobby pharmaceutical companies to increase the number of open access programs of novel new cancer therapies to developing countries. There have been some innovative and successful projects in which pharmaceutical companies have provided new drugs free of charge to poorer countries. The impact that these programs can have was illustrated when AstraZeneca, in partnership with Axios and the Ethiopian Ministry of Health, set up a program to strengthen the diagnosis and treatment capabilities of the Tikur Anbessa University Hospital in Addis Abada. AstraZeneca helped develop treatment guidelines, strengthen the referral system, set up an institutional cancer registry and donated both tamoxifen and anastrazole to the 3-year project, helping 3122 patients. Initiatives like these help increase the sustainability of cancer programs in developing countries. By proving to the local governments that intervention is both necessary and effective, it should hopefully ensure ongoing government support for future tenable programs.[116] It has also shown the potential that exists for establishing programs on a low-cost, sustainable scale using innovative new treatment modalities, combined with low-cost cancer drugs. More collaborations like this, between companies and governments, need to be expedited.

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