Expansion of cancer care and control in countries of low and middle income: a call to action

Summary

Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda.

Introduction

Once thought to be a problem almost exclusive to the developed world, cancer is now a leading cause of death and disability, and thus a health priority, in poor countries. Low-income and middle-income countries now bear a majority share of the burden of cancer, but their health systems are particularly ill prepared to meet this challenge.1, 2, 3, 4, 5, 6 The rising proportion of cases in these countries is caused by population growth and ageing, combined with reduced mortality from infectious disease. In 1970, 15% of newly reported cancers were in developing countries, compared with 56% in 2008.⁴ By 2030, the proportion is expected to be 70%.2, 4, 6 Almost two-thirds of the 7·6 million deaths every year from cancer worldwide occur in low-income and middle-income countries, making cancer a leading cause of mortality in these settings.2, 6 Furthermore, increases in age-adjusted mortality rates have been recorded in certain developing regions and for specific cancers, such as breast cancer.⁷

Low survival rates in poor countries and improved survival in developed countries contribute to the disparity in the burden of cancer deaths. Overall, case fatality from cancer (calculated as an approximation from the ratio of incidence to mortality in a specific year) is estimated to be 75% in countries of low income, 72% in countries of low-middle income, 64% in countries of high-middle income, and 46% in countries of high income.² Survival is closely and positively related to country income for certain cancers—such as cervical, breast, and testicular cancer, and acute lymphoblastic leukaemia in children—and hence the scope for action on these diseases is particularly large (figure).

Wealthy countries have made major strides in the fight against certain cancers, particularly in the past three decades. In the USA, both cancer incidence and mortality have declined since peaks in the early 1990s because of heightened awareness, prevention, earlier detection, and the availability of new and more effective treatment regimes.8, 9 Although little progress has been made in the treatment of some cancers, such as pancreatic and lung cancer, low-cost and effective treatment options are available for several malignancies, including cervical, breast, and testicular cancer, and childhood leukaemia. Unfortunately, these interventions for early detection and treatment remain inaccessible for many people in developing countries.

For many cancers, future changes in incidence, survival, and mortality rates will greatly depend on whether key risk factors can be controlled in low-income and middle-income countries. In these countries, major risk factors such as smoking continue to rise, awareness of the importance of screening and early detection is low, and stigma associated with cancer and the financial barriers of poverty prevent many people from seeking preventive services or care at early stages. Without substantially increased prevention, through strong antitobacco campaigns and vaccination against human papillomavirus (HPV) and hepatitis B virus, and a focus on early detection, growth of the cancer burden in these countries could make treatment virtually unaffordable in the long term.

Thus, the world faces a huge and largely unperceived cost of inaction around cancer in developing regions, which merits an immediate and large-scale global response. Yet, only a small proportion of global resources for cancer are spent in countries of low and middle income: several studies have reported an estimate of 5% (see webappendix for further details).2, 10, 11 By contrast, these countries together account for almost 80% of the disability-adjusted life-years lost worldwide to cancer.¹ Cancer is an underfunded health problem and an important cause of premature death in resource-poor settings, resulting in this staggering “5/80 cancer disequilibrium”.¹²

International attention and financial resources to resource-poor settings have increased especially in the past 10 years, resulting in an impressive expansion in the availability of treatment for patients with certain infectious diseases, most notably AIDS. However, cancer remains sorely neglected. Public, private, and multilateral donors spend relatively little on efforts to expand cancer prevention, diagnosis, and treatment in these countries compared with other diseases. Furthermore, cancer is notably absent from the global health agenda,¹³ including key global health targets such as the Millennium Development Goals (MDGs).

A global call to action for cancer in low-income and middle-income countries is beginning to emerge, led by international agencies, academic institutions, and non-governmental organisations and associations.14, 15, 16, 17 However, concerted action is needed from the global health community, together with the participation of local governments and extensive primary health-care networks to achieve an effective response. The agenda for action should catalyse expansion of cancer care, control, and prevention with strategies that are appropriate to the health systems of low-income and middle-income countries, accessible to patients with low incomes, and integrated into national health insurance systems. This agenda must include increasing access to drugs for treatment and palliation, expansion of coverage for preventive and diagnostic services, including vaccines, and development and implementation of innovative health-care delivery options to support rapid scale-up.