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Closing divides:

Health System Responses to the


challenge of breast and cervical cancer
Princess Margaret Hospital
Nassau, Bahamas
February 23, 2017

Dr. Felicia Marie Knaul


Miami Institute for the Americas and Miller School of Medicine, University of Miami
Fundacin Mexicana para la Salud and Tmatelo a Pecho
Duality:
evidence and advocacy
Evidence-based Advocacy-
advocacy inspired
evidence

Action:
Patients, projects, programs, policies
January, 2008
June, 2007
Global Task Force on Expanded
Access to Cancer Care and Control
in Developing Countries

= global health + cancer care


Closing the Cancer Divide:
An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary I: Should be done
M2. Unaffordable
M3. Impossible
II: Could be done
M4: Inappropriate III: Can be done
1: Innovative Delivery
2: Access: Affordable Meds, Vaccines & Techs
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
Challenge and disprove the
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APPROPRIATE
M4: Impossible POSSIBLE
Womens cancer is
Globally Caribbean
Cervical Breast

#1 cancer women & 2nd


overall #1 cancer for women
Among top 5 causes for & 4th overall
women in middle
income countries
#2 cancer for women
#2 cancer of women &
5th overall & 4th overall
6th of women in middle
income countries

Source: Estimates based on data from Globocan 2012 & IHME, 2015
Breast cancer in LMICs: myths
and realities

disease of older A large proportion of cases and


deaths perhaps the majority
women
happens in women <54

disease of developed The majority of cases and


countries deaths occur in the developing
world

lower priority than More deaths and DALYs lost


due to breast cancer in all
crevical cancer
developing regions except the
most poor
In LMICs a very large % of Breast Cancer
cases and deaths are in women <55
Low income Latin America High Income
Diagnosis

33%
Age at

66% 62%
15-39

40-54

>55
Age at
Death

34%
67% 61%
Fuente: Estimaciones de los autores basadas en IARC, Globocan 2012
Breast Cancer affects young women,
in addition to older women
Age of breast cancer detection in LAC,
2012
45- 15-
54 44
50%

25%

0
DOM R.

MEXICO

CHIL
SAL

BEL
PERU

COL

SUR
ECU

BOL
BRA
PAR

VEN

ARG
NIC

CUB
HAI

GUY

URU
HON

GUA

PAN

CR

Fuente: Con base en datos de GLOBOCAN 2002. Source: Own estimates based on data from IARC, GLOBOCAN 2012.
... And 50% of breast cancer deaths occurs in
women under 55 years.
Age of breast cancer mortality in LAC, 2012

15-44 45-54
50%
Mexico
Guatemala

Argentina
Nicaragua

Venezuela
Paraguay
Honduras

Panam

Surinam
Colombia

Uruguay
Guyana
Ecuador

Bolivia
Hait

El Salvador

Belice

Chile
Cuba
CR
Dom. R.
Brazil
Peru

Source: Own estimates based on data from IARC, GLOBOCAN 2012.


The Cancer Transition
Double burden for health systems
Mirrors the epidemiological transition
LMICs increasingly face both infection-
associated cancers, and all other cancers.

Cancers increasingly only of the poor, are


not the only cancers affecting the poor
LMICs account for 90% of cervical and 70%
of breast cancer deaths. Both are leading killers
especially of young women.
Leading causes of death among women
aged 15 to 49 years, select LAC, 2015
Chile Costa Rica Mxico Brasil

Bolivia Ecuador Per Colombia

Source: Global Burden of Disease Study 2015. IHME.


The cancer transition: by income, region:
breast and cervical cancer 1980-2010
BC cases (I)
300
264
252 BC deaths (M)

200 CC cases (I)


% Change in incidence

179 177
and mortality

CC deaths (M)
113 115
96
100
43 68 68

37 31 35
19
0

-14 -14
Caribbean Low Middle High income
income income
Source: Knaul, Arreola, Mendez. estimates based on IHME, 2012.
Mortality rank: breast and cervical cancer
Women 15 to 49, countries by income level
1 Breast cancer
Jamaica 2 Diabetes
3 Cervical cancer 11
4 HIV/AIDS other
10 5 Ischemic heart
Number of cause of death

disease

8
in the age group

0
& the Gren

St. Lucia

Suriname
Dominica

Grenade
Jamaica
Guyana
Bolivia

Belice

St. Vicent

Canada
Antigu

Trinida
a&

Barbad

d&
Tobago
Baham
os

as
Barbud
Low Lower- Upper-
High income
incom middle middle
Cancer transition in Mexico
Trends in mortality from breast and cervical
cancer
Mexico
age adjusted mortality rate

16
Rate per 100,000 women

0
1985
1955

2005

2013
Cervical cancer Breast cancer
Source: Estimaciones propias basada en Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and
Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2012)
Source: Data extracted from CI5plus.
Mortality: cervix and breast cancer in
Mexican States (1979-2013)
18 Distrito Federal Nuevo Len
18
16 16
14 14
12 12
Mortality per 100,000 women

10 10
8 8

6 6

4 4
2
2
0
0
1979

1985

1990

1995

2000

2005

2013

2013
20 25
18 Puebla Oaxaca
16
20
14
12
15
10
8
6 10
4
2 5
0
0
1979

1985

2005

2013
1990

1995

2000
2013

Source: Estimaciones propias basadas en datos de DGIS. Base de datos de defunciones 1979-2013. SINAIS. Secretara de Salud.
The Cancer Divide:
Both Health & Equity Imperative
Cancer is a major disease of both rich and poor;
yet it is increasingly the poor who suffer:
1. Exposure to risk factors
2. Preventable cancers (infection)
Facets

3. Treatable cancer death and disability


4. Stigma and discrimination
5. Avoidable pain and suffering
The Opportunity to Survive (M/I) Should Not
Be Defined by Income

Survival inequality gap


100% 100% Breast

Cervix
Children Testis

Prostate
India
Non-
hodkins
China
Hodkins
India
Tyroid
China

Leukaemia Canada

All cancers Canada

LOW HIGH LOW HIGH


INCOME INCOME INCOME INCOME

In Canada, almost 90% of children with


leukemia survive.
In the poorest countries only 10% survive.
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
The Opportunity to Survive M/I
is, but should not be, defined by income.
5
0
inequality gap

4
Haiti
0
Survival

USA+Cda

Guyana
Jamaica

2
0 Bahamas
Cervical
Breast

0
Low Lower Upper High
Income Middle Middle Income

Almost 90% of Canadian childhood leukemia patients survive


Source: Knaul, Arreola, Mendez.In the
estimates based poorest
on IARC, Globocan,countries
2010. only 10% survive.
Trends in the US and Canada
EEUU (1975-2012) y Canada (1986-2015)
160 Incidence
140

120 White Mortality


Rate per 100,000

45

100

Canadia 40
80 Black n

Rate per 100,000


60 30 Blac
k
Canadia
40
n Whit
20
20
e

0
19

19

85

90

19
95

20
00

20
05

20
10
20
12
75

80

19

19

10
Ao
20
15

201
201
198

198

199

200

200

201
197

199

5
2
5

0
Ao
Fuente: Breast cancer Facts & figures 2015-2016. ACS, 2016; y Canadian Cancer
Global trends in breast cancer
mortality
30

USA
Age-adjusted mortality rate

Canad
Australi
a

Colombia Mexico

0
1975 1980 1985 1990 1995 2000 2005 2010 2014 2025
?
Source: Data extracted from CI5plus.
Detection + Treatment= Survivorship:

Survivorship in the
Detection by
USA according to
state
ACS
0-1 98%
2-3 84%
4 27%

WITH TIMELY AND


PROPER TREATMENT
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.
Challenge and disprove the
myths about cancer

M1. Unnecessary NECESSARY


M2. Unaffordable AFFORDABLE
M3. Inappropriate APPROPRIATE
M4: Impossible POSSIBLE
The costs of inaction are huge: Invest
IN action
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% global GDP

1/3-1/2 of cancer deaths are avoidable:

2.4-3.7 million deaths,


of which 80% are in LIMCs
Prevention and treatment offer
potential world savings of
$ US 130-940 billion
The costs to close the cancer divide are
and may be less than many fear:
All but 3 of 29 LMIC priority cancer
chemo and hormonal agents are off-patent
Pain medication is cheap
Prices drop: HepB and HPV vaccines
Delivery & financing innovations can
aggregate purchasing and stabilize
procurement
Prices can drop:
through effective global action, aggregate platforms
and public- private collaboration

Cost of one dose of HPV vaccine, 2016, USD:

Private sector: $ 67.oo


PAHO Strategic Fund: $ 8.50
GAVI: $ 5.oo

2006: $US130 /dose! HPV Vaccine


Challenge and disprove the
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate
APPROPRIATE
M4: Impossible POSSIBLE
Women and mothers in LMICs
face many risks through the life cycle
Women 15-59, annual deaths

Mortality
Breast Cervical
in Diabetes
- 35% childbirth
cancer cancer
in 30
years

291,000 195,000 131,000 139,000


(900) (1100) (700) (800)

= 465,000 (2600)
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
Applies a diagonal
approach to avoid
the false dilemmas
between disease
silos that
continue to plague
global health
The Diagonal Approach to
Health System Strengthening
Rather than focusing on either disease-specific
vertical or horizontal-systemic programs, harness
synergies that provide opportunities to tackle
disease-specific priorities while addressing
systemic gaps and optimize available resources
Diagonal strategies:
Positive externalities: X = > parts
Compound benefits: increase effectiveness at given cost
Bridge disease divides using a life cycle response
Exploit existing platforms
Diagonal Strategies:
Positive Externalities
Promoting prevention and healthy
lifestyles:
Reduce risk for cancer and other diseases
Reducing stigma for womens cancers:
Contributes to reducing gender
discrimination.
Investing in treatment produces champions
Challenge and disprove the
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE

M3. Inappropriate APPROPRIATE

M4: Impossible POSSIBLE


Worldwive wave of reforms to achieve
UHC
Universal Health Coverage:
all people should obtain needed health
services
prevention, promotion, treatment,
rehabilitation, and palliative care
without risking economic hardship or
impoverishment (WHO, WHR 2013).
Diagonalizing Cancer Care:
Financing & Delivery
1. Financing: Integrate cancer care into
national insurance and social security
programs
2. Delivery: Harness platforms by integrating
breast and cervical cancer prevention,
screening and survivorship care into MCH,
SRH, HIV/AIDS, social welfare and anti-
poverty programs.
Breast cancer: care continuum

Primary Early Palliative


Diagnosis Treatment Survivorship
Prevention Detection Care

Mexico: Exemplary investment in prevention


of risk factors and treatment but.
late detection and little access to survivorship
or palliative care.
Expansion of Financial Coverage:
Seguro Popular Mxico

Affiliation:
2004: 6.5 m
2014: 55.6 m

Diseases and Interventions:


Benefits Package
Vertical Coverage
Benefit package:
2004: 113
2014: 285
59 in the
Catastrophic
Illness Fund Horizontal Coverage:
Beneficiaries
Seguro Popular now includes
cancers in the national,
catastrophic illness fund
Universal coverage by disease with an
effective package of interventions
2004/6: HIV/AIDS, cervical, ALL in kids
2007: pediatric cancers; breast cancer
2011: Testicular, Prostate and NHL
2013: Ovarian and colorectal
Seguro Popular and breast cancer:
Evidence of impact
The human faces:
National Institute
Guillermina Avila
of Cancer:
treatment
adherence
2005: 200/600
2010: 10/900
Breast Cancer early detection: Delivery failure
2nd cause of death, women 30-54
5-10% of cases detected in stage 0-1
Poor municipalities: 50% Stage 4; 5x rate for rich

Late detection by state Stage 1 Stage 2


% cases detected in 50% Stage 3 Stage 4
stage 4
40%
< Low
> Medium 30%

> High
20%

10%

0%
High Medium Low Very Low

Source: Authors estimates with database from IMSS, 2006.


Juanita:
Advanced metastatic breast cancer
as a result of a series of missed
opportunities and barriers to access

br
Engage the primary level of care for early
detection and management of breast cancer
Diagonalizing delivery:
Inclusion of early detection of breast
cancer in Opportunities program
Capacitation and
orientation guide for
beneficiaries of
Oportunidades program
includes information about
breast cancer 2009/10
3 million copies for
promoters and trainers
Reached 5.8 million families
= more than 90% of poor
households
Diagonalizing Delivery: Training primary care
promoters, nurses and doctors in early detection
of breast cancer

Health Promoters
8 Risk Score (0-10)
Significant increase in
7
knowledge, especially among
*

5
health promoters and in clinical
4
breast examination
(Keating, Knaul et al 2014, The Oncologist)
3
Pre Post 3-6 month
ADDITIONAL RESOURCES

Early Breast Cancer Detection A Job for Everyone health


promoters.
Results for Health Promoters, 2010
The train the trainer model significantly improved knowledge
and comprehension in every group of health promoters.
1) understand breast cancer as a health problem,
2) learn how to perform CBE, and
3) learn about breast cancer risk factors, symptoms, family
history and treatment.
New knowledge is retained (3-6 months)
Significant potential for involving community and
professional health promoters in early detection and
management of breast cancer

The Oncologist,
http://theoncologist.alphamedpress.org/content/early/2014/09/17/theoncologist.2014-0
Challenge: from survival to
survivorship, de la
sobrevivencia a la
Be an
optimist
optimalist
Closing divides:
Health System Responses to the
challenge of breast and cervical cancer
February 23, 2017
Miami Institute of Americas, University of Miami

Dr. Felicia Marie Knaul


Miami Institute for the Americas and Miller School of Medicine, University of Miami
Fundacin Mexicana para la Salud and Tmatelo a Pecho

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