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Closing the Cancer Divide:

Challenges and Opportunities


Global Oncology Symposium:
Cancer Care in Resource Challenged Environments
The University of Texas MD Anderson Cancer Center
Monday, May 8, 2017
Houston, Texas

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
Closing the Cancer Divide:
An Equity Imperative
Expanding access to cancer care and control in LMICs:

M1. Unnecessary I: Should be done


M2. Unaffordable
II: Could be done
M3. Impossible
M4: Inappropriate III: Can be done
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. Inappropriate
II: Could be done
M4: Impossible 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


The Cancer Transition

Mirrors the epidemiological transition


LMICs increasingly face both infection-
associated cancers, and all other cancers.

LMICs account for the majority of most


cancer deaths.
Cancers increasingly only of the poor, are
not the only cancers affecting the poor
Source: IHME. GBD 2015.
For kids 5-14 cancer is:

#1 cause of death in wealthy countries


#3 in upper middle-income
#6 in lower middle-income
and # 7 in low-income countries
More than 85% of pediatric cancer cases
and 90% of deaths occur in LMICs.
Source: IHME. GBD 2015.
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 most insidious injustice:
the pain divide
Non-methadone, Morphine-equivalent
opioid consumption per death from
HIV/AIDS or cancer in pain:
Poorest 10%: 179 mg
Wealthiest 10% : 99 mil mg

355 mil mg 144 mil mg

China: 1,865
India: 467
333 mil mg
S. Leone: <1
Haiti: 75 Uganda: 761

Jordan:
Mexico: 14,000
Argentina:
3,500 Bolivia:
13,600 Source: Based on Treat the pain
764 (http://www.treatthepain.com )
Challenge and disprove the
myths about cancer

M1. Unnecessary NECESSARY


M2. Unaffordable AFFORDABLE
The costs of inaction are huge: Invest
IN action
Total economic cost of cancer:
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
Many necessary medications are
inexpensive
Prices drop
Delivery & financing innovations can
aggregate purchasing, stabilize
procurement and reduce price
Prices can drop:
through effective global action, aggregate platforms
and public- private collaboration

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

Market price: $ 67.00


PAHO Strategic Fund: $ 8.50
GAVI: $ 5.00

2006: $US130 /dose! HPV Vaccine


Champions
- The economics of hope:
Drew G. Faust
President of Harvard University
30+ year breast cancer
survivor Nobel
Prize-
Recipient
Amartya
Sen,
Cancer
survivor
diagnosed in
India 70+
years ago
Challenge and disprove the
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APPROPRIATE
Successes treating other diseases:
MDR-TB treatment
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


Making
Outcomes in MDR-TB patients in
Lima, Peru receiving at least four common cause
months of therapy
with WHO:
Reduced prices
of second-line
TB drugs
% Decline in
Drug
price 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%
All patients initiated therapy
between Aug 96 and Feb 99 Ofloxacin 98%
Mitnick et al, Community-based therapy for multidrug-resistant
tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.
Source: Paul Farmer, 2009
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

= 465,000
Source: Estimates based on IHNE, 2015.
Apply a diagonal approach
to avoid the
false dilemmas between
disease and
Prevention vs cure silos
that 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
Benefits:
Bridge divides using a life cycle response
Positive externalities: womens cancer programs fight
gender discrimination; pain control is 4all and
strengthens surgical platforms
Synergies with Universal Health Coverage
Diagonalizing Cancer Care:
Financing & Delivery
1. Financing: Integrate cancer care into
national social insurance and social
security programs and reforms, e.g.
Mexico and China
2. Delivery: Integrate cancer prevention,
survivorship and palliative care into
existing primary care platforms and anti-
poverty programs.
Challenge and disprove the
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APPROPRIATE
M4: Impossible POSSIBLE
Mexico:
Success in preventing cervical cancers.
Emerging challenge of breast cancer
16 Trends in mortality from
breast and cervical cancer
( 1955-2014 )

8
Mortality rate x 100,000

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 (1979-2014)
Global trends:
breast cancer mortality
30

USA
Age-adjusted mortality rate

Canada
Australia

Colombia Mexico

0 2025?
1975 1980 1985 1990 1995 2000 2005 2010 2014

Source: Data extracted from CI5plus.


Mexico before 2004
Almost half of Mexican
households lacked health
insurance, which limited access
to care, reduced opportunities to
pool risks, and generated
catastrophic expenses
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
2012: Ovarian and colorectal
Mexico: guarantees
treatment
Every Mexican

woman has the right


to financial
protection for
breast cancer
treatment
Globally-recognized
innovation
Expansion of Financial Coverage:
Seguro Popular Mxico

Affiliation:
2004: 6.5 m
2016: 54.9 m

Diseases and Interventions:


Benefits Package
Vertical Coverage
Benefit package:
2004: 113
2016: 287
61 in the
Catastrophic
Illness Fund Horizontal Coverage:
Beneficiaries
Seguro Popular and breast cancer:
Evidence of impact
Adherence to treatment/loss to follow up:
<2007: 30%
2008+: 6%
Human faces of impact:
Guillermina
Abish

Source: Arce-Salinas C, et al Rev Invest


Clin 64:9-16, 2012
Breast cancer: care continuum

Primary Early Palliative


Prevention Detection Diagnosis Treatment Survivorship
Care

Mexico: Exemplary investment in prevention


of risk factors and treatment but.
late detection, long lag time between
diagnois and treatment and little access to
survivorship or palliative care.
5-year Breast cancer survivorship: USA
and Mexico
Survivorshi
INCAN Mexico City
Stage p USA
(2007+) (1990-99)
(ACS)
I 98% (>80%) 97% (14%) 82% (10%)
II-III 84% 82% (73%) 59% (87%)
IV 27% 36% (13%) 15% (3%)

WITH TIMELY AND


APPROPRIATE TREATMENT
Sources: ACS. Facts & figures, 2015-2016. Reynoso-Noveron, Mohar et al, Journal of Global Oncology, 2017;
Breast Cancer early detection:
Delivery failure
2nd cause of death, women 30-54
10-15% of cases detected in Stage I
Poor municipalities: 50% Stage 4; 5x rate for rich

50% I II
III IV

High %
Stage IV

Po
or 0%
Marginalized High Access
Barrier: Low quality primary care
services
One in every two women diagnosed with breast
cancer reported problems with medical attention in
the diagnostic process
Did not receive breast clinical examination or
information in their routine annual exam & pap test
Doctor did not value the importance of signs and
symptoms manifested by the woman, and sent her
home without a diagnosis
Both primary care providers and specialists
recognized the lack of sensitivity of health care
providers to the womens needs

RESULTS FROM A NATIONAL QUALITATIVE STUDY


Nigenda et al.
Diagonalizing Delivery: Engage and Train primary
care promoters, nurses and doctors in early
detection of breast cancer

> 16,000
Health Promoters
8 Risk Score (0-10) Significant increase in knowledge,
7 *
among health promoters,
6
especially
5
in clinical breast examination
4
(Keating, Knaul et al 2014, The Oncologist)
3 3-6 month
Pre Post
PAISES SOCIOS

ARGENTINA 3
10 pases BRASIL 3
COSTA RICA 3

COLOMBIA 2
ECUADOR 1
EL SALVADOR 1
MXICO 4
PER 2
URUGUAY 1
VENEZUELA 2
PRESIDENCIA
TOTAL 22
2016-18
Be an
optimist
optimalist

We can close global cancer divides


Closing the Cancer Divide:
Challenges and Opportunities
University of Miami Miller School of Medicine
International Medicine Institute
William J. Harrington Medical Training Programs
Friday, May 5, 2017
Miami, Florida
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
Change in the distribution by income level of Breast
and Cervical cancer mortality in Mexico
1980-2013
40
in the distribution by income by states

31.6
30 Favor de checar
20 17.1 la nota en
seccin de
10 5.3 notas
0

-10 Low & middle -9.1


-20 income states
-21.8
-24.3
-30
Low and middle income
HighHigh income
income states
Population Cervical Breast

Source: Knaul, Arreola, Mendez. estimates based on DGIS, DEFUNCIONES 1979-2013, Secretara de Salud, Mxico.
Juanita:
Advanced metastatic breast cancer
as a result of a series of missed
opportunities and barriers to access

br
Leading causes of death among women
aged 15 to 49 years, select LAC, 2015
Chile Costa Rica Mxico Brasil

ama ya no es la 2a causa??
vor de quitar boliva e insertar haiti
Bolivia Ecuador Per Colombia

Source: IHME. GBD 2015.


Rural Rwanda, Burkitts lymphoma
Regimen of
0 oncologists
vincristine,
cyclophosp
hamide,
intrathecal
methotrexat
e

Central Haiti
Status post-
CHOP in Central
Haiti:
Still in remission
three years later
Source: Paul Farmer., 2009
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.
Increasing access to pain control
Better access for all patients in need
Strengthens surgical platforms
Investment in health grew from 2000-2014
In 2015-16, it dropped by approximately 3% (real)
USD
$677
70 700 (6.3% PIB)
USD 665
$588 646
634
(6.3 % PIB) USD
60 60157.3
57.1 600 $652
577
55.6
52.9
(6.1% PIB)
543 51.8

adir afiliacion 2016


50 508 500
478
453 43.5

6.3% del pib aunque haya subido?


USD
$424
40

31.1
400

e mantiene el %
Accumulated affiliation (Million)
(6 % PIB) Public health expenditure per capita US$
30 27.2 300

21.9
20 200
15.7

11.4
10 100
5.3

0 0
Worldwive wave of reforms
to achieve UHC
Universal health coverage (UHC):
all people should obtain needed
health services
prevention, promotion, treatment,
rehabilitation, and palliative care
without risking economic hardship or
impoverishment (WHO, WHR 2013).