Wake-up Call: Global Demand for Chemo Will Double by 2040

Pam Harrison

May 09, 2019

Almost all countries in the world will face serious problems in their ability to deliver chemotherapy to cancer patients by the year 2040, warns a new study.

The demand for chemotherapy will double in the next 20 years, the study predicts. It estimates that the number of patients across the world who will require first-line chemotherapy will increase from 9.8 million in 2018 to 15 million in 2040, an increase of 53%.

"The rising cancer burden and the increasing demands for chemotherapy globally will be major health crises during the next 20 years," the study concludes.

"We hope our projections are a wake-up call for the medical oncology community globally as well as governments," lead author Brooke Wilson, MSc, University of New South Wales, Sydney, Australia, told Medscape Medical News in an email.

"[Our findings] should prompt officials to review current numbers of cancer physicians and current capacity to deliver chemotherapy in their own countries and estimate the expected gap by 2040," she added.

The study was published online May 8 in the Lancet Oncology.

Calculations for the global incidence of 29 cancer types in 183 countries were made using GLOBOCAN 2018, a database developed by the International Agency for Research on Cancer.

The 29 cancer types included in the analysis account for most cases of cancer worldwide. The most common indications for chemotherapy are lung cancer, at 16.4%, followed by breast cancer, at 12.7%, and colorectal cancer, at 11.1%.

On the basis of best-practice guidelines and their estimates of the demand for chemotherapy, the authors calculated optimal chemotherapy use, as well as global requirements for a physician workforce to deliver that chemotherapy.

Worldwide in 2018, 57% of patients with cancer required first-line chemotherapy, the authors note.

"In 2040, the number of new cases of cancer is projected to rise to 26 million globally," study authors report. Of those cases, an estimated 15 million will require chemotherapy.

This represents a 53% increase from 2018 levels if chemotherapy is optimally delivered around the world in accordance with current guidelines.

The largest proportion of patients who will need chemotherapy in 2040 will be residing in upper-middle-income countries, the authors note.

An estimated 75% of the additional cancer patients who will need chemotherapy in 2040 will be living in low- and middle-income countries (LMICs), they add.

These LMICs will find the increase in demand for chemotherapy an "enormous challenge," said Wilson. She feels that physicians elsewhere have an obligation to help, whether that be via training partnerships, hospital twinning programs, or remote and on-site support for difficult cases.

Of the 15 million people who will need chemotherapy in 2040, 35% will reside in eastern Asia, 11.5% will reside in south central Asia, and 9.5% will live in northern America.

The greatest proportional growth in the need for chemotherapy between 2018 and 2040 is projected to occur in eastern Africa (115% increase), middle Africa (114% increase), western Africa (100% increase), and western Asia (99% increase).

The highest demand for chemotherapy in 2040 will be in China, which will account for more than one quarter of all global chemotherapy needs.

Physician Workforce

Assuming that globally in 2018, each physician treated 150 new patients who required chemotherapy, 65,219 cancer physicians would have been needed.

"In 2040, we estimated that 99,897 cancer physicians will be required [but] estimates range from 49,949 to 149,846, depending on workload," the authors comment.

Some 31.4% of the cancer physicians projected for 2040 will be working in high-income countries; 67.2% of cancer physicians needed in 2040 will be in LMICs.

China will have the greatest need for cancer physicians in 2040, followed by the United States and India.

Wilson noted that the researchers' estimates of the need for cancer physicians in the United States in 2040 are lower than the number of physicians currently registered with the American Society of Clinical Oncology.

"Thus, at least based on our metric, the US is likely to have sufficient numbers of cancer physicians to meet demand in 2040," she said.

On the other hand, LMICs already do not have enough cancer physicians to serve cancer patients' needs, and without appropriate action now, "this deficit will only grow in the coming decades," Wilson predicted.

Far From Optimal

The study authors point out that the use of chemotherapy even in high-income countries is far from optimal even now and that the gap between actual and optimal use of chemotherapy in LMICs is even greater.

Furthermore, the model upon which current projections were based includes only first-course chemotherapy needs, not the need for subsequent lines of treatment, they point out.

The lack of trained personnel to deliver cancer services in many countries now is also a major barrier to cancer care delivery.

"Realistically, adherence to guidelines is likely to be low in many LMICs due to lack of resource availability, trained personnel, drug availability, social factors, and cost, and this will have a direct negative impact on patient survival," Wilson predicted.

"Nevertheless, we feel that optimal provision of care is a benchmark that we should strive to reach for all persons, regardless of country of origin or income level," she said.

The authors comment that, to their knowledge, this study is the first to provide an estimate of current and future chemotherapy demands and workforce requirements — both worldwide and by region and country — on the basis of evidence-based guidelines.

Accompanying Editorial

In an accompanying editorial, Melina Arnold, PhD, and Isabelle Soejomataram, PhD, who are both at the International Agency for Research on Cancer, Lyon, France, hope that "this study will help to further guide policy makers and stakeholders in priority settings involved in setting up health infrastructure and strengthening and educating the future workforce."

However, they suggest that the projections could either underestimate or overestimate the real need for chemotherapy in the future.

The authors generated estimates of future needs for chemotherapy on the basis of characteristics of cancer patients residing in high-income countries, but these patients may differ substantially from patients in low-income settings.

For example, in low-income countries, cancer may be diagnosed at a much later stage. The editorialists cite a study (Int J Cancer, in press) that found that in 12 sub-Saharan African countries, 65% of breast cancer patients were diagnosed with stage III or IV disease; by contrast, in the United States, only 36% of patients had stage III or IV disease.

Because chemotherapy is critical in the treatment of advanced breast cancer, future chemotherapy needs that are projected by this model may well underestimate the real need for chemotherapy in 2040, the editorialists point out.

Conversely, the approach taken by the study's authors, in which estimates were based on theoretical levels of the need for chemotherapy in accordance with current treatment guidelines, might have led them to overestimate cancer patients' future needs.

No funding was obtained for this study. The authors and editorialists have disclosed no relevant financial relationships.

Lancet Oncol. Published online May 8, 2019. Abstract, Editorial

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