Creating a Roadmap for Global Cancer Care
April 8, 2015
“Cancer is a death sentence.” “It is too complicated and dangerous to treat cancer patients in poor places.” “Cancer treatment is too expensive.”
Put forth by Dr. Lawrence Shulman of the Dana-Farber Cancer Institute, these were among the myths surrounding cancer care in low and middle income countries (LMIC) explored at the 2015 Symposium on Global Cancer Research in Boston. Co-hosted by the National Cancer Institute (NCI), Dana-Farber Cancer Institute, and the Consortium of Universities for Global Health (CUGH), the gathering took place on March 25, prior to the start of the 6th Annual CUGH Global Health Conference.
Over the course of the day, presenters worked not only to discredit these misconceptions, but to bring the nature of this global disease into stark relief: cancers comprise an increasing burden of morbidity and mortality and warrant action on an international scale. At present, cancers cause more than 15% of deaths around the world, with the majority of new cases occurring in Africa, Asia, and Latin America. But as highlighted by Dr. Ami Bhatt of Stanford University, just 5% of global cancer funds currently go toward 80% of cancer-burdened populations.
Tackling cancer in LMIC will require an approach that differs from what has taken place in the U.S. The lack of robust health care systems in many places poses a major challenge in and of itself. In recognizing that there remain large gaps in knowledge of cancer in low-resource settings, experts sounded a consistent theme at the symposium – as well as a CUGH plenary discussion on non-communicable disease – of the need to increase global understanding of the problem at hand. Refining estimates of cancer prevalence, strengthening implementation science in LMIC, and costing of core components of prevention and treatment can each work to generate interest and motivate a global response.
Improving data on the true burden of cancer: On day 2 of the CUGH Conference, Dr. Susan Shurin of NCI outlined major epidemiological gaps that hamstring efforts to address non-communicable disease. While there are global and country-level estimates for many cancers, she stressed that there remains a lack of detailed incidence and prevalence data broken down by geography, gender, socioeconomic status, and ethnicity. Having better data, she noted, would help to “identify interventions that would make a big difference.” While initial estimates have helped to rebut the notion of cancer as an affliction exclusive to developed societies, refining these numbers can clarify the true burden of the disease, and more detailed subnational data can unmask regional disparities and more effectively tailor programming.
Demonstrating efficacy and utility of cancer care in low-resource settings: In the symposium’s keynote address, Dr. Shulman declared “to have the biggest impact […] you don’t need new scientific discoveries,” but to “bring the tools we currently have at our disposal to the many cancer patients who have no access.” According to Dr. Shulman, the benefits of strengthening implementation science in this sense are two-fold: working to improve care for patients and prove to funders that cancer prevention and treatment are worthwhile investments. For example, the high burden of HPV and cervical cancer in Sub-Saharan Africa demonstrates the need for further pursuit of implementation science. Given that the vaccines Gardasil and Cervarix have proven effective in preventing HPV 16 and 18, responsible for 70% of cervical cancers, advancing delivery mechanisms to expand coverage of these vaccines, along with innovative methods for screening and treatment, can reduce the number of preventable deaths.
Costing of an essential package for cancer: Financing of cancer prevention and treatment efforts in LMIC remains a particularly daunting challenge. The continuum of cancer care is both complex and resource-intensive: there is a need to train and pay oncologists, maintain equipment for pathology, procure chemotherapy drugs, and provide palliative care. According to Dr. Sue Horton of the University of Waterloo, assembling an essential package of interventions can incentivize country and donor spending by drawing attention to a handful of key investments. The package she presented included tobacco control measures, Hepatitis B and HPV vaccinations, screening for cervical cancer and treating precancerous lesions, opportunistic screening and treatment of early stage breast cancer, treating selected pediatric cancers, and palliative care for all cancers. Annually, the per capita cost ranged between $1.67 for low income countries and $5.72 for upper middle income countries. While Dr. Horton stressed that this package represents a first step in expanding cancer programming and will need to be refined, it helps countries to better plan if there is a dollar amount involved.
While it may seem like there is no precedent for expanding cancer care in LMIC, Dr. Shulman identified some useful lessons to be drawn from the international response to HIV. He cited that many of the misconceptions surrounding global cancer are reminiscent of a number of now debunked myths surrounding the right of Africans to access antiretroviral therapy (ART); in the late 1990s and early 2000s, many considered ART too expensive an investment and argued that patients would fail to adhere to the regimen. These ideas were proven wrong by researchers and clinicians such as Paul Farmer, who demonstrated that providing ART in low-resource settings such as rural Haiti was possible, as well as life-saving. The results of such studies, as well as better data on the epidemic, sparked dramatic increases in funding for HIV/AIDS and established the expectation that people, regardless of where they live, should have access to ART.
The comparison between global cancer and HIV is undeniably fraught. But the quick ascendance of HIV as a top global health priority demonstrates that a similar scale-up in cancer care is possible if the interest and resources are mobilized. The symposium portrayed that given the right tools, it is a reachable goal to make accessible and high-quality cancer care in LMIC the norm, rather than the exception.