Globally, Women's Cancers Need a Fix, Not Just With Drugs

Megan Brooks

November 01, 2016

Global efforts are needed to end preventable deaths from breast and cervical cancer in low- and middle-income countries (LMICs), as country-led efforts have failed, say the authors of a three-paper series in The Lancet.

New estimates generated as part of the series — "Health, Equity and Women's Cancers" — show that the cost of inaction will be huge.

In 2012, nearly 1.7 million women were diagnosed with breast cancer worldwide and 522,000 died of the disease; 53% of cases and 62% of these deaths were in LMICs. A further 528,000 women were diagnosed with cervical cancer and 266,000 died, with about 85% of these diagnoses and 87% of these deaths occurring in LMICs.

If these trends continue, by 2030, the number of women with breast cancer worldwide will jump to nearly 3.2 million a year, while the number of women having cervical cancer will rise by at least 25% to more than 700,000, with the burden continuing to fall on women in LMICs.

"There is a widespread misconception that breast and cervical cancers are too difficult and expensive to prevent and treat, particularly in resource-poor countries where the burden of these diseases is highest. But nothing could be further from the truth," Lancet series team leader Ophira Ginsburg, MD, Women's College Hospital, University of Toronto, Ontario, Canada, said in a news release.

An entirely preventable disease. Dr Ophira Ginsburg

Cervical cancer is "an entirely preventable disease," Dr Ginsburg told Medscape Medical News. "The World Health Organization considers cervical screening and treatment of precancerous lesions as a 'best buy,' a very cost-effective intervention, that, along with HPV [human papillomavirus] vaccination for all girls, can spare millions of women from this terrible disease," she explained.

"Yet 10 years after HPV vaccines have been available, fewer than 3% of girls immunized so far are in the low- and lower-middle-income countries, the same places where screening has not yet been widely implemented. If all 12-year-old girls were immunized this year, 420,000 cervical cancer deaths could be averted," Dr Ginsburg said.

Strategies such as visual inspection with acetic acid to screen for cervical cancer and testing for oncogenic HPV types are also promising and cost-effective approaches to reduce the burden of cervical cancer in LMICs, the authors say.

As for breast cancer prevention, while mammography and late treatment of breast cancer may be unaffordable in LMICs, clinical breast examination screening and breast awareness campaigns are likely to be cost-effective in diagnosing early-stage breast cancer in LMICs, which could in turn help promote early treatment, the authors say.

According to Dr Ginsburg, a basic cancer control package could be introduced in LMICs for as little as $1.72 per person, equivalent to just 3% of current health spending in these countries.

Unnecessary Deaths and Disease, Including in US

Dr Ginsburg said that global resources for cancer are "overly focused on developing new and expensive cancer treatments, often with marginal benefit, which are entirely out of reach for most, while a relatively tiny investment can go a very long way to assist low- and middle-income countries in reducing premature mortality and morbidity, for the hundreds of thousands of women each year who develop breast, cervix, and other cancers."

The series authors say increased global political commitment and funding for breast and cervical cancers in LMICs is needed now. They note that opportunities for action exist in global health initiatives, including universal health coverage, the Sustainable Development Goals, and the World Health Organization Global Strategy for Women's, Children's and Adolescent's Health 2016-2030.

"The global community cannot continue to ignore the problem — hundreds of thousands of women are dying unnecessarily every year, and the need for affordable access to cancer care is projected to increase in the coming decades, as many of the poorest countries face rising rates of cancers," series coauthor Richard Sullivan, MD, PhD, professor of cancer and global health, King's College London, United Kingdom, said in the news release.

"Not only are the costs of essential cancer services for women lower than expected, but scale-up of diagnostic, surgical, and treatment services are a highly effective investment compared to the devastating economic cost to countries, communities, and families incurred by the serious shortfall in cancer care. This situation could be turned around by 2030 if the international community, policymakers, politicians, healthcare professionals, and patients address this issue now," Dr Sullivan added.

In a Lancet Comment, Otis Brawley, MD, chief medical and scientific officer for the American Cancer Society (ACS), and Sally Cowal, ACS senior vice president for global health, say there are "real opportunities to avert deaths and decrease human suffering and the global oncology community is obligated to exploit these opportunities. As this Series highlights, key to the control of cancers in many places is building a sustainable infrastructure for the provision of care and dissemination of proven evidence-based cancer control interventions."

They add, "Providing good cancer treatment requires adequate numbers of trained health-care professionals and infrastructure beyond what is currently available in many areas of the world. Building a sustainable cancer control program will take time, but this Series shows what actions are needed to deliver safe, equitable, and affordable care for women's cancers."

Even in the United States, "there are real problems with quality healthcare and availability of quality healthcare" for some groups, Dr Brawley told Medscape Medical News. "We at ACS have even published that the US has had a 35% decline in breast cancer mortality from 1990 to 2014 but 12 states have not had a 10% decline."

"There is increased access to breast and cervical screening and treatment, but this does not mean all women are able to take advantage of it," Dr Brawley explained. "It is well established," he said, that the overwhelming majority of the 4000 Americans each year who die of cervical cancer did not have screening done in the decade or so before diagnosis. These women are generally poor, less educated and have access issues."

Dr Brawley believes it's important to engage in global efforts to prevent cases of breast/cervical cancer around the world. "I do not discriminate by nationality or race. I see a group of humans who need help, be they American or non-American," he said. "We do learn from international work and that knowledge helps us in the US."

He added, "As we export our bad habits, be it bad diet, reliance on automobiles (less exercise) or cigarettes, I do feel we Americans have a greater moral responsibility to help with diseases that result from them."

This work had no commercial funding. Dr Ginsburg, Dr Sullivan, and Dr Brawley have disclosed no relevant financial relationships. A complete list of author disclosures is given with the original articles.

Lancet. Published online November 1, 2016.


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