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Closing the cancer divide:

Expanding Access to Care & Control

Eye-for-Pharma LATAM 2018
May18, 2018: Miami, FL

Dr. Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico
Closing cancer divides:
Affordable and achievable
health, equity & economic imperative.
Synergistic, diagonal strategies,
guided and inspired by patient voices
need to be
developed & implemented.
January, 2008
June, 2007
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 & Tech’s
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
Leading causes of death among women
15 to 49 years, select LA countries, 2016
Chile Costa Rica México Brasil

Bolivia Ecuador Perú Colombia

Source: IHME. GBD 2016

The cancer divide
• Suffering and death from cancer disproportionately affect
the poor: a glaring, unacceptable difference b/w countries.
• Disparities in outcomes bely inequities in access to care
and differences in underlying socio-economic conditions.
• Lethality is highest in low-income countries for almost all
cancers that are screening-detectable or treatable.
• The incidence of infection-associated cancers is inversely
associated with income
• The opportunity to survive cancers that are amenable to
treatment is closely correlated with country income.
• Fueled by progress in cutting-edge science and medicine in
high-income countries.
• Shrouded in the myth that cancer is a disease of the
wealthy, the divide remains understudied and undertreated.
The Cancer Divide:
Both Health & Equity Imperative
Cancer is a major health challenge for rich & poor;
Yet, it is the poor who increasingly suffer:
1. Exposure to risk factors
2. Preventable cancers (infection)
3. Treatable cancer death and disability
4. Stigma and discrimination
5. Avoidable pain and suffering
The most insiduous injustice: The Pain Divide
Distributed opioid morphine-equivalent mg/patient & (% of SHS palliative care need)

Poorest 50%: 1%
Wealthiest 10%: 90%
124 mg (8%)

314 mg (16%)
55,704 mg (3150%)

Mexico: Nigeria: 43 mg (4%)
0.8 mg (0.2%)
562 mg (36%)
74 mg (6%)

Source: Author calculations using INCB (2010-13) and GHE 2015 (, . See Data Appendix for methods.
The Opportunity to Survive (M/I)
Should Not Be Defined by Income
100% 100%
Survival inequality gap

Children Cervix

Haití India Testis





In Canada ≅90% of kids with leukemia survive.

In the poorest countries only 10% survive.
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010. Source: IARC. Globocan, 2012
Global avoidable mortality,
by conceptual approach
Empirical Approach Feasibility Social Justice
Approach Approach
65 years 75 years

% avoidable mortality
30 50 36 45

% avoidable mortality
40 67 47 58
(16 cancers)

5 cancers - lung, liver, stomach, colorectal, and breast-

account for almost 75% of all avoidable cancer deaths
in LMICs overall and worldwide

Knaul, Arreola, Rodriguez et al, 2018. Avoidable mortality: the core of the global cancer divide.
Forthcoming. Journal of Global Oncology.
“Avoidable” cancer deaths:
Breast and Cervical,
Numeros correctos?
The Americas and Checar
LMICs nues
JGO paper
Breast Cervical

Latin America
and the 57% 64%
Low and middle
75% of breast
income 75% 95%
95% of cervical
Challenge and disprove the
myths about cancer

M1. Unnecessary

M2. Unaffordable
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”:

Prevention and treatment offer

potential world savings of
$ US .1 to almost 1 billion
The costs to close the cancer divide are and
may be less than many fear:
Almost all LMIC priority cancer chemo
and hormonal agents are off-patent
Pain medication is cheap
Prices drop: HepB and HPV vaccines
Delivery & financing innovations
aggregate purchasing to reduce price and
stabilize procurement
Annual estimated cost of closing the access abyss and
meeting the global palliative care need for morphine

• At current
prices: $US600
• At best
prices: $US145
• For all children with SHS in low income countries:
$US 1,034,000
Prices can drop:
through effective global action, aggregate
platforms and public- private collaboration

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

Private sector: $ 67.00

PAHO Strategic Fund: $ 8.50
GAVI: $ 5.00

¡US: $US150 /dose! HPV Vaccine

Challenge and disprove the
myths about cancer
M1. Unnecessary

M2. Unaffordable

M3. Inappropriate
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

Diagonal strategies major benefits:  X = >  parts

Lower cost-benefit ratios
Bridge disease divides using a life cycle response
Generate positive externalities: e.g. healthy life styles,
women’s cancer programs fight gender discrimination;
pain control 4all
Diagonal Strategies:
Positive Externalities
Promoting prevention and healthy lifestyles:
Reduce risk for cancer and other diseases
Reducing stigma for women’s cancers:
Contributes to reducing gender discrimination.
Increasing access to pain control
Better access for all patients in need
Improves surgical platforms
‘Diagonalizing’ Cancer Care:
Financing, Delivery & Evidence
1. Financing: Integrate cancer care into national
social insurance and social security programs
and reforms,
2. Delivery: Integrate cancer prevention,
survivorship and palliative care into existing
primary care platforms, e.g. Maternal and Child
Health, HIV/AIDS, and anti-poverty programs.
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).

In the challenging context of rapid and

complex epidemiological transition, and
while battling fragmented health systems
Challenge and disprove the
myths about cancer
M1. Unnecessary

M2. Unaffordable

M3. Inappropriate

M4: Impossible
The Economist
Expansion of Financial Coverage:
Seguro Popular México, 2004-2018
• 2004: 6.5 m

Diseases and Interventions:

• 2017: 53.5 m

Benefits Package
Vertical Coverage
Benefit package:
• 2004: 113
• 2018: 294
• 65 in the
Illness Fund Horizontal Coverage:
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
Seguro Popular and breast cancer:
Evidence of impact
Adherence to treatment:
2005: 200/600
2010: 10/900

Human faces of impact:

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
< Low
> Medium 30%

> High


High Medium Low Very Low
Source: Authors’ estimates with database from IMSS, 2014
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 knowledge,
7 *

among health promoters,
4 in clinical breast examination
(Keating, Knaul et al 2014, The Oncologist)
Pre Post 3-6 month
Diagonalizing delivery:
Inclusion of early detection of breast cancer in
the cash transfer, anti-poverty program Prospera

• Training materials for beneficiaries includes information about

early detection of breast as well as cervical cancer
• 3 million copies for promoters and trainers
• Reaches more than 90% of poor households in rural areas
Mexico: Cartilla Nacional de Salud de la Mujer
offered to all women 20 -59
ULACCAM Regional Observatory
scorecard: examples of indicators
Has a national
Does the country have….
cancer plan
1. A National cancer plan and national
women´s cancer plans
2. A national cancer registry including
women´s cancer
3. Integration of women´s cancer into Yes

women´s health plans Yes, not updated

4. An office for women´s cancer in the No

Ministry of Health No information
5. Offial “norms” for women´s cancer issued
by the MoH, and updated every 5 years
6. Number of registered NGOs working on Preliminary data
women´s cancer
Be an
optimist Ju


We can close global cancer divides

Closing the cancer divide:
Expanding Access to Care & Control
Eye-for-Pharma LATAM 2018
May18, 2018: Miami, FL

Dr. Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico

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