Volume 19, Number 2, European Edition - February 2014
Cancer in Low- and Middle-Income Countries—We Need to Close the Divide
Felicia M. Knaul,a,b Maja Pleic,a Mark Lawler,c
aHarvard Global Equity Initiative, Boston, Massachusetts, USA; bHarvard Medical School, Boston, Massachusetts, USA; cCentre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, United Kingdom
Disclosures of potential conflicts of interest may be found at the end of this article.
The State of Oncology 2013
The State of Oncology 2013 Report , launched at the recent European Cancer Congress in Amsterdam, Netherlands, highlights the burgeoning growth of cancer worldwide, with dramatic increases predicted in incidence, mortality, and morbidity, particularly in countries such as China, India, and Nigeria, and precipitating a potential global epidemic in cancer over the next 20–30 years. The report also emphasizes that, despite the much vaunted progress in cancer research and its translation, considerable numbers of patients throughout the world will not benefit from these developments.
All Cancer Patients Are Not Equal
The treatment of childhood leukemia is one of the success stories of cancer care. Or is it? From the vantage point of a high-income country such as Canada, this statement is certainly true: 9 of 10 children will survive their disease and live long and fruitful lives. Contrast this with the situation in the poorer countries of the world (e.g., Zimbabwe), where more than 90% of children die of this “curable” cancer, despite the significant advances that have occurred in its treatment over the last 20 years and the fact that the medicines required to treat the disease are almost all off patent and thus inexpensive [2, 3]. For women with cervical cancer, the most preventable cancer in women and highly curable if treated at an early stage, mortality rates are 12-fold higher in the poorest countries of the world when compared with the wealthiest [2, 4]. For breast cancer, effective screening programs that underpin early detection, followed by multimodality therapeutic approaches and systemic treatment, have led to greatly increased survival for women in high-income countries, whereas for their counterparts in poorer countries, late presentation with aggressive metastatic disease inevitably leads to a painful death [3, 5]. Furthermore, for all cancers, combating the pain sequelae represents a significant hurdle in low- and middle-income countries (LMICs). In sub-Saharan Africa in 2008, for example, more than 1.3 million people died in pain from cancer or HIV/AIDS, yet medical opioids were offered to only 85,000 patients . Patients dying in pain from cancer or HIV-associated illnesses receive just 54 mg of opioid per death in the poorest countries in the world compared with a figure of 97,400 mg (a startling 1,800-fold difference) in the richest countries in the world .
These worrying statistics reflect a global cancer divide, fueled by the concentration of risk factors and preventable suffering in poor populations, inequalities in access to appropriate cancer care in LMICs, and the challenges of transferring advances in science and medicine to the poorer nations on our planet . Equally troubling is the pervasive perception that cancer is mainly a disease of developed countries (a so-called disease of the rich) and is not a significant health issue in poorer countries; in fact, the current and emerging data absolutely contradict this assertion. In 2008, 55% of the 12.7 million cancer cases and 64% of the 7.6 million cancer deaths in the world occurred in LMICs, accounting for almost 80% of the global cancer burden . Projections indicate that these figures will expand to almost 27 million new cancer cases and 17 million deaths by 2030 [8, 9]. Yet despite this overwhelming and exponentially increasing cancer burden, only 5% of global cancer resources are available to LMICs , emphasizing not only the economic imperative but also the moral imperative to close this cancer divide .
The Cancer Divide: Perpetrating the Myth That Nothing Can (or Should) Be Done
The global disparities outlined above reflect the challenges faced by local health systems that are ill-equipped to provide even basic cancer care, a failure of rich countries to recognize the emerging cancer challenge, and a failure of us all to collectively address the significant disparities that have contributed to this escalating burden. How has this happened? Regrettably, one of the critical components that has fueled this collective failure—the “cancer divide”— has been the widely held belief that cancer care and control in LMICs is “(i) not necessary, (ii) not affordable, (iii) not attainable, and (perverse though it might seem) (iv) not appropriate,” given the high burden of communicable diseases in these countries . The first myth has been dispelled by the burgeoning cancer incidence and mortality rates indicated above, but what about the other three? The issue of cost, although relevant, is perhaps overstated, given that the majority (∼90%) of standard cancer drugs for prevalent treatable cancers are now off patent, and much can be achieved at relatively low cost (in many cases, less than U.S. $100 [€73.70] per treatment course) . For example, the combined drug total costs of covering the combined unmet needs for drugs to successfully treat childhood acute lymphoblastic leukemia, cervical cancer, and Hodgkin’s lymphoma in LMICs approaches only U.S. $115 million (€85.6 million) [2, 4]. Although the insufficiency of human and physical resources in LMICs present a major challenge to providing quality cancer care, innovative solutions exist and have been shown to work in-country. The incorporation of early detection programs for breast and cervical cancer into antipoverty, maternal, and child health programs; the embedding of twinning programs between hospitals in LMICs and high-income countries; the integration of telemedicine approaches; and the provision of appropriate pain control are but a few examples of low-cost, low-resource measures with potentially high impact . Appropriately designed, country-specific cancer control and care programs (CCCPs) can also expand infrastructure and strengthen health system capacity with beneficial spill-over effects for other populations and diseases (e.g., expanding access to pain control for cancer patients strengthens access for all patients fortifies surgery platforms), including communicable diseases (e.g., treatment and prevention of cancer-related infections) .
The Cancer Divide: Highlighting the Evidence That Much Can Be Done
Although an atmosphere of pessimism tended to undermine early efforts to improve cancer care delivery in LMICs, a number of initiatives have demonstrated how much can be achieved when there is political will on the parts of the relevant stakeholders. Three examples emphasize the potential (and the will) to succeed. In childhood cancer, the St. Jude Children’s Research Hospital International Outreach Program involves twinning between centers of excellence in developed countries and 19 partner institutions in 14 developing countries . This mentorship approach involves a combination of targeted education and training, teleconference and Web conference consultations for real-time access to specialist care (and, more important, subspecialist care), and a series of online educational resources . In El Salvador, this twinning approach has helped underpin an increase in survival rates for childhood acute lymphoblastic leukemia from 10% to 60% in the first 5 years of the collaborative program . Inclusion of childhood cancers in the Seguro Popular universal health insurance program in Mexico (which also includes highly effective packages for breast, cervical, colon, prostate, and testicular cancers as well as for non-Hodgkin’s lymphoma) led to a twofold increase in 30-month survival from 30% to 68% . In Rwanda, where the government considers health care a basic human right that should be available to all Rwandan citizens, a high-coverage national immunization program for human papillomavirus was introduced in collaboration with private sector partners in 2011 .
Closing the Cancer Divide: Where Do We Go From Here?
Dispelling the cancer myths outlined above has been an important first step in closing the cancer divide. Cancer in LMICs is now seen in much in the same light as AIDS was a number of years ago, with similar myths suggesting that nothing could be done. The success in treating HIV infection demonstrates that with strong patient advocacy and a unity of purpose among all stakeholders, we can effect significant health care change at a global level. But we need to act now. Introducing a series of effective, low-cost interventions in cancer care and control must be a priority for all LMIC health systems. Prevention measures are a key component of the CCCPs. According to “The Tobacco Atlas,” 80% of the world’s smokers live in LMICs . In addition to rigorous implementation of the Framework Convention on Tobacco Control measures , there is also significant potential for action in reducing alcohol consumption, increasing physical activity, and where possible, promoting a more balanced and healthy diet. But we must not simply promote and implement a “prevention only” agenda. CCCPs in LMICs must address the full spectrum of the cancer continuum, including primary prevention, early detection, diagnosis, treatment, survivorship care, palliation, and end-of-life care. Only then will we truly deliver a global initiative on cancer that will benefit the poorer nations of the world. The philosophy of “little can be done” should be dispatched to the wastebin of past indifference. This is the era of “Yes, we can!”
Correspondence: Felicia M. Knaul, Ph.D., Harvard Global Equity Initiative, 651 Huntington Avenue, FXB Building 632, Boston, Massachusetts 02115, USA. Telephone: 617-432-7937; E-Mail: email@example.com
This article is based in part on the publication, “Closing the Cancer Divide: An Equity Imperative,” edited by F.M. Knaul, J.R. Gralow, R. Atun, and A. Bhadelia (Cambridge, MA: Harvard Global Equity Initiative/Harvard University Press, 2012) and on an interview with F.M.Knaul that can be found online (http://europeanperspectives.theoncologist.com).
Conception/Design: Felicia M. Knaul, Maja Pleic, Mark Lawler
Manuscript writing: Felicia M. Knaul, Maja Pleic, Mark Lawler
Final approval of manuscript: Felicia M. Knaul, Maja Pleic, Mark Lawler
Felicia M. Knaul: GlaxoSmithKline, Pfizer Inc, Sanofi S. A., Nadro S.A., Chinoin Pharmaceutical Products (RF). The other authors indicated no financial relationships.
(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (ET) Expert testimony; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board
1. Boyle P, Sullivan R, Zielinski C et al eds. The State of Oncology 2013 Report. Lyon, France: International Prevention Research Institute, 2013.
2. Knaul FM, Gralow JR, Atun R et al. Closing the cancer divide: Overview and summary. In: Knaul FM, Gralow JR, Atun R et al, eds. Closing the Cancer Divide: An Equity Imperative. Cambridge, MA: Harvard Global Equity Initiative/Harvard University Press, 2012:3-28.
3. Gralow JR, Krakauer E, Anderson BO et al. Core elements for provision of cancer care and control in low and middle income countries.In: Knaul FM, Gralow JR, Atun R eds. Closing the Cancer Divide: An Equity Imperative. Cambridge, MA: Harvard Global Equity Initiative/Harvard University Press, 2012:123-165.
5. Forouzanfar MH, Foreman KJ, Delossantos AM et al. Breast and cervical cancer in 187 countries 2 European Perspectives between 1980 and 2010: A systematic analysis. Lancet 2011;378:1461-1484.
6. O’Brien M, Mwangi-Powell F, Adewole IF et al. Improving access to analgesic drugs for patients with cancer in sub-Saharan Africa. Lancet Oncol 2013;14:e176-e182.
7. Liberman J, O’Brien M, Hall W et al. Ending inequities in access to effective pain relief? Lancet 2010;376:856-857.
8. Boyle P, Levin B, eds.World Cancer Report 2008. Lyon, France: International Agency for Research on Cancer, 2008.
9. Bray F, Jemal A, Grey N et al. Global cancer transitions according to the Human Development Index (2008-2030):Apopulation-basedstudy. Lancet Oncol 2012;13:790-801.
10. Farmer P, Frenk J, Knaul FM et al. Expansion of cancer care and control in countries of low and middle income: A call to action. Lancet 2010;376:1186-1193.
11. Knaul FM, Bhadelkia A, Rodriguez-Galindo R et al. Twinning in pediatric oncology: Models for the innovative use of information and communication technology to bridge distance. In: Knaul FM, Gralow JR, Atun R et al, eds. Closing the Cancer Divide: An Equity Imperative. Cambridge, MA: Harvard Global Equity Initiative/Harvard University Press, 2012:187-189.
12. Hazin R, Qaddoumi I. Teleoncology: Current and future applications for improving cancer care globally. Lancet Oncol 2010;11:204-210.
13. KnaulFM,González-PierE,Gómez-DantésOetal. The quest for universal health coverage: Achieving social protection for all in Mexico. Lancet 2012; 380:1259-1279.
14. Binagwaho A, Wagner CM, Gatera M et al. Achieving high coverage in Rwanda’s national human papillomavirus vaccination programme. Bull World Health Organ 2012;90:623-628.
15. Shafey O, Eriksen M, Ross H et al. The Tobacco Atlas. 3rd ed. Atlanta, GA: American Cancer Society, 2009.
Editor’s Note: A deep “cancer divide” exists between high-income countries and low-and middle income countries (LMICs). Closing this divide is challenging and requires a change in health care strategy. Unity of purpose and effective partnerships among all stakeholders are required. Introducing a series of effective, low-cost interventions in cancer care and control must be a priority for all health systems in LMICs.