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MSH

Cancer: Unforeseen Public Health Priority in Developing Countries


Felicia Marie Knaul,

JANUARY 24th, 2011 CAMBRIDGE, MA

Harvard Global Equity Initiative, Harvard Medical School; GTF.CCC Tomatelo a Pecho; Fundacin Mexicana para la Salud

Latin American nations, much of eastern Europe and central Asia, China, India, many other parts of south Asia, and even countries in Africa, [are] facing a painful double burden of diseasenot only the persistence of infectious threats, child and maternal mortality, and undernutrition, but also the emergence of new dangers, notably diabetes, obesity, cardiovascular disease, stroke, cancer, mental ill-health, and injuries. This double burden requires a double response, a predicament that places huge responsibilities on the stewards of JULIO systems. national health FRENK & RICHARD HORTON HEALTH REFORM IN MEXICO SERIES; THE LANCET, 2006

From evidence

to anecdote

July, 2007

January, 2008

Harvard, Breast Cancer in Developing Countries Nov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor

From anecdote

to evidence

OUTLINE:
1. Evidence to anecdote to evidence

2. Cancer in LMICs: so much more can be done


3. Innovation example: breast cancer, Mexico

The opportunity to survive should not be an accident of geography or defined by income. Yet it is. But . there is scope for action.
~ case fatality (incidence/mortality)
63% 60 48%
Breast

52%
48% 37%

40

40%

Cervix

38%

24% 20

Low-income countries

Lower middle

Upper middle

High-income countries

Source: Author estimates based on IARC, Globocan, 2008 and 2010. Quote: HRH Princess Dina Mired

Countries with similar levels of income have very different case fatality. WHY?
100

Breast cancer
80

Lethality SSA

Rate x 100,000

60

LAC SAs EECA EAP


Djibouti Qatar

40

MENA

EUR NAM HIC

20

0 3 3.5 4 4.5 GDP per capita (Dollars $ log scale) 5

Mandate: Design, develop and implement global, regional and local strategies to improve the financing, procurement and delivery of cancer care, control, treatment and palliation in a sustainable 27 members manner applying innovative representing the global health and service delivery models appropriate to health systems cancer in the developing world. communities

Convened in Nov 2009 By HSPH, HMS, HGEI, DFCI

White Paper for policy and strategy & Lancet Commission Report
A strategic document focused on providing a road-map and evidence-based recommendations for program development, local and global policy making and research priorities to expand access to cancer care and control in lower and middle-income countries.
Authored by; GTF.CCC experts from the cancer care and global health communities convened by the Harvard School of Public Health, the Harvard Medical School, the Harvard Global Equity Initiative and the Dana-Farber Cancer Institute.

Logical Framework for GTF.CCC White Paper & Lancet Report


Analytic Evidence Tools and advocacy

Rationale
Global distribution of cancer burden

Framework

Drugs, Vaccines Services (essential components)

Economics of investing in cancer care and control

Actions and strategies: global and local

Innovative delivery models

Pricing & Evidence for decision Procurement making mechanisms Implementation

Innovative financing models

Stewardship and global governance

Innovation Initiatives - pilot programs in Haiti, Rwanda, Malawi, Jordan, Mexico to inform work in an iterative fashion

Challenge and disprove the myths about cancer


M1. Unnecessary: Not a health priority in LMICs M2. Impossible: Nothing we can do about it M3. Inappropriate: Challenging cancer implies taking resources away from other diseases of the poor` with proves CE interventions M4: Unaffordable

For children & adolescents 5-14 cancer is

#2 cause of death in wealthy countries #3 in upper middle-income #4 in lower middle-income and # 8 in low-income countries

Distribution of childhood cancer globally by level of income (< 15)


Level of Income Low Low middle Upper middle High Incidence Mortality Population

21% 50% 15% 15%

27% 55% 15% 5%

20% 57% 13% 10%

More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries that use less than 5% of the world resources.

Lethality by cancer type and country income


1

Case fatality approximated by mortality/incidence

Children <15

Adults (15+)

0.8

0.8

0.6

0.6

0.4

0.4

0.2

0.2

0 Low income Lower middle income Upper middle income High income Low income Lower middle income Upper middle income High income

Breast

Leukaemia

Cervix uteri Hodgkin lymphoma Non - Hodgkin lymphoma Prostate

All cancers

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

Testis

5/80cancer desquilibrium
(Frenk/Lancet 2010)
Almost 80% of the DALYs (disabilityadjusted life-years) lost worldwide to cancer are in LMICs, yet these countries have only a very small share of global resources for cancer ~ 5% or less. worse in certain regions:
Africa: only 02% of global cancer medical costs, 1% of global spending on health, 64% of new cancer cases, and 15% of the global population

Differential and inequitable mortality


Cancers that can be prevented Cancers that can be detected early and cured Cancers that can be treated successfully Pain and suffering

Concentration of mortality: example Cervical cancer


275,000 deaths worldwide; 88% in LMCs

HPV Vaccine

Children orphaned by cervical cancer


Source: Paul Farmer., 2009

The cancer of poverty


Cancer is a disease of rich and poor
Yet, the burden is increasingly of the poor:

Death from preventable and treatable cancer is `more exclusive` to the poor Avoidable pain and suffering particularly at end of life is only permitted for the poor Financial impoverishment from the costs of care and effects of the disease is concentrated among the poor

IT CAN BE DONE: From evidence to action: Innovation Initiative Partnerships in LMICs


Treating cancer in LMICs using innovative delivery and financing:
task sharing and shifting Infrastructure shifting Application of technology of communication Social Protection and health insurance

Models:
ACCESS QUALITY
FINANCIAL PROTECTION

Low-income: Rwanda-Malawi-Haiti

Lower middle-income: Jordan


Upper middle-income: Mexico

Initial views on MDR-TB treatment, c. 1996-97


In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries. WHO 1996
MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease. WHO 1997

Source: Paul Farmer., 2009

Outcomes in MDR-TB patients in Lima, Peru receiving at least four months of therapy
failed therapy died 8% 8%

Making common cause with WHO:


Reduced prices of second-line TB drugs
Drug % Decline in price 1997-9

abandon therapy 2%

cured 83%

Amikacin Ethionamide Capreomycin Ofloxacin

90% 84% 97%

All patients initiated therapy between Aug 96 and Feb 99


Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

98%

Source: Paul Farmer, 2009

Rural Rwanda, Burkitts lymphoma

0 oncologists

Regimen of vincristine, cyclophospha mide, intrathecal methotrexate

Central Haiti
Status post-CHOP in Central Haiti: Still in remission three years later
Source: Paul Farmer., 2009

OUTLINE:
1. Evidence to anecdote to evidence 2. Cancer in LMICs: so much more can be done

3. Innovations: breast cancer, Mexico

The epidemic of breast cancer:


Unforseen challenge in LDCs
Some 45% of the more than 1 million new cases of breast cancer diagnosed each year, and more than 55% of breast-cancer-related deaths, occur in low- and middle-income countries.* Such countries now face the challenge of effectively detecting and treating a disease that previously was considered too uncommon to merit the allocation of precious health care dollars.
Source: Porter, P. (2007). "Westernizing Womens Risks? Breast Cancer in Lower-Income Countries." New England Journal of Medicine 358(3):4
Curado MP, Edwards B, Shin HR, et al., eds. Cancer incidence in five continents. France: International Agency for Research on Cancer, 2007.

Myth .versus ..reality: breast cancer in LMICs

a disease of developed countries and wealthy women.

More than half of cases and almost 2/3 of deaths deaths occur in the developing world.

a disease of

older women less of a health priority than cervical cancer.

large proportion of cases and 60% of deaths in women < 54. More deaths and DALYs lost to breast cancer, in all developing regions other than SEAsia and SSAfrica.

Among women 15-59 Breast cancer is globally

#1 cause of death in wealthy countries #2 in middle-income countries and # 5 in low-income countries


(IARC, GLOBOCAN, 2008/10)

In developing regions, breast cancer


Most frequent cause of cancer-related death
in developing and developed regions 268,000 of the 458,000 deaths per year are in LIMCs: 58% Most common cancer in developed and developing regions 4.4 million women alive (diagnosed): how many in developing regions? 2008: 1.38 million new cases; 50% of which are from LIMCs 10.9% of all incident cancers second to lung
(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).

LMICs:

younger women, high death rates,

In LIMCS, a much higher proportion of diagnosis and death is in women <55


LIMCs Age at diagnosis High-income countries

15-44

37%

63%

64%

36%

45-54 >55

Age at death

7%

59%

22%
78%

15%

Mexico: key evidence


Since 2006 breast cancer is the #2 cause of death among women age 30 to 54 years; and the leading tumor-related cause. In 2006, women between 30 an 65 years were more likely to die of breast than cervical cancer. In 1980 the risk of dying from cervical cancer was twice as high as breast cancer. Only 5-10% of cases are detected in stage 1 or in-situ, compared to approximately 60% in US.

Mortality and age at death: breast and cervical cancer in Mexico 1955-2007
16

Rate per 100,000 women adjusted for age

60 58

Average age (years)

12 56

8 54
4 52 50

Cervix Breast

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2008

1985

1955

1960

1965

1970

1975

1980

1990

1995

2000

2005

2006: BC>CC.
for the first time in more than 5 decades.

Gap = ~2 years.
As of the early 80s, the average age at death from BC is lower than CC.

Fuente:Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de mama
en Mxico, 1979-2007. FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretara de Salud de Mxico.

2008

Breast cancer and Seguro Popular.

As of Feb 2007 all Mexican women diagnosed with breast cancer have the right to financial protection in health for breast cancer treatment

Early Detection = survival


Stage at diagnosis
0-1

Survival rates, US ACS


98%

2-3 4

84% 27%

Mexico: 5-10% in stage 0-1; 60-70% in III-IV


Fuente: American Cancer Society. Breast Cancer Facts & Figures, 2007-2008. Atlanta, GA. : American Cancer Society, Inc., y Secretara de Salud. Programa de Accin: Cncer de mama. Mxico, D.F.

IMSS Mxico: 40-50% of cases are detected in stages III-IV. 85+ in II+
50%
30% 10%
1992 2002 2006

Stage I

Stage II

Stage III & IV

Why?
Health, social and health system barriers

Barrier 1: Inequity in addition to lack of overall access and utilization 28%

30%

20%

21% 22%
16%

24%

10%

0%
+ Poorest Q1 Least poor Q2 Q3 Q4 QV
Fuente: ENSANUT, 2006

Only 1 in 5 women 40-69 report a preventive health visit including mamography 2006

Barrier 2: Poor quality services

women diagnosed with bc reported problems with providers when seeking diagnosis.
In routine, annual repro health/OBGYN visit/ PAP screening, there was no BCE Physician insisted woman was overreacting and sent her home with no diagnosis Health professionals and first-level care providers report lack of sensitivity of health personnel relating to the requests of women regarding breast health
RESULTS FROM A NATIONAL QUALITATIVE STUDY NIGENDA ET AL, 2009

Barrier 3: myth and machisco

Barrier 4 : Lack of financial protection for early detection.


Since February of 2007, every Mexican woman has the right to financial protection (full health insurance) for the treatment of breast cancer. Seguro Popular de Salud. Yet, early detection is only covered for those already insured and difficult to access and there is a threat of a change NOM and early detection is unaffordable: mammography, biopsy and pathology - at the most subsidized level in a public hospital - costs more than one month of subsistence income.
Fuente: Groot et al, 2006. TheBreastJournal

Identify and apply innovations in country- and health system-specific delivery mechanisms
Optimize human and physical resources and harness the primary and secondary levels of care:

Task shifting/sharing (ex. BCE)


Infrastructure shifting (ex. chemotherapy) Mobilize communication technology (remote/teleconsultation for quality and safety; telesynergy)

Project and objectives


Objectives:
1) Downstage 2) Expand access to care closer to home 3) Increase data-for-decisionmaking, evaluation and monitoring

Breast cancer Morelos, Jalisco and Nuevo Leon

Nuevo Len

Morelos Jalisco

Core project components


1) 2) Expand potential for early detection Training of health promoters Improved referral system Training of primary care-level physicians and nurses (11) Expand potential for care and treatment in secondary level hospitals Supervision and capacity building from tertiary to secondary district hospitals Centers for chemotherapy and survivorship secondary and primary level Acreditation of secondary centers so SPSS can finance 3) Increase data-for-decision-making, evaluation and monitoring Improved or new registries Evaluation and monitoring

Participating institutions:
Comisin Nacional de Proteccin Social en Salud Ministry of Health of Jalisco, Morelos, Nuevo Leon National Cancer Institute of Mexico

National Institute of Public Health


Cncer de mama: Tmatelo a pecho Mexican Health Foundation

The Global Task Force on Expanded Cancer Care and Control in Developing Countries through the Secretariat based at the Harvard Global Equity Initiative: HSPH, HMS, DFCI

MSH

Cancer: Unforeseen Public Health Priority in Developing Countries


Breast
Felicia Marie Knaul,

JANUARY 24th, 2011 CAMBRIDGE, MA

Harvard Global Equity Initiative, Harvard Medical School; GTF.CCC Tomatelo a Pecho; Fundacin Mexicana para la Salud

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