Challenges and Opportunities for Cancer Care and Control in LMICs

Pharmaceutical Policy Research Seminar, Department of Population Medicine March 28, 2012
Felicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICs Mexican Health Foundation Tmatelo a Pecho

Closing the Cancer Divide:

A Blueprint to Expand Access in LMICs
I: Much should be done II: Much could be done III: Much can be done
1: Innovative Delivery 2: Access to Affordable Medicines, Vaccines & Technologies 3: Innovative Financing: Domestic and Global 4: Evidence for Decision-Making 5: Stewardship and Leadership

From anecdote
to evidence

January, 2007 June, 2008

Juanita:
Advanced metastatic breast cancer is the result of a series of missed opportunities
br

From anecdote

to evidence

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

= global health + cancer care

Closing the Cancer Divide:

A BLUEPRINT TO EXPAND ACCESS IN LMICs

Applies a diagonal approach to avoid the false dilemmas between disease silos -CD/NCD- that continue to plague global health

Challenge and disprove the myths about cancer/NCD/Chronic illness

Expanding access to cancer care and control in low and middle income countries: M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate Should, Could, and Can.. be done

The Cancer Transition

Mirrors the overall epidemiological transition protracted and polarized*:
LMICs increasingly face both cancers associated with infection, and all other cancers. Cancers that were once considered only of the poor, now cease to be the only cancers of the poor. (e.g. cervical & breast cancer)
* Frenk et al

The cancer transition in LMICs: breast and cervical cancer

LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers especially of young women.
% Change in # of deaths 1980-2010
53%

19%

20%

0%

LMICs

High income
-31%

Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition within countries:

breast and cervical cancer mortality
16

Mexico
1955 - 2008

Costa Rica
1995 - 2005

0
0

25

Oaxaca
1979-2008

25

Nuevo Leon
1979-2008

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
More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries.

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:
1. Exposure to risk factors 2. Preventable cancers (infection) 3. Death and disability from treatable cancer 4. Stigma and discrimination 5. Avoidable pain and suffering

Facets

Risk factor concentration: Obesity Epidemic in countries such as Mexico

% women 20-49 years
60 57

2006 1999 1988

8 2 2
Adequate Malnutrition

Overweight
37 29

36 37 25

Obesity

32 25 10

10

Incidence and mortality of cervical cancer

(adjusted rate per 100,000 women)
Incidence
Mortality

Incidence ratio Russia Central and Eastern Europe Less developed regions More developed regions World 19.3 21.3 25.7 13.2 22.0

Mortality ratio 8.6 9.0 14.1 4.6 11.2

The Opportunity to Survive (M/I) Should Not Be Defined by Income

100%

Children

Adults Survival inequality gap

Leukaemia

Russian

All cancers LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME

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

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10%.

Cancer especially in Stigma: women and children - adds a layer of discrimination onto ethnicity, poverty, and gender.

The most insidious example of injustice is access to pain control

Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain by income level Poorest 10%: 54 mg; Richest 10%: 97,400 mg

Expanding access to cancer care and control in LMICs:

A) Should be done:
Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

The Diagonal Approach to Health System Strengthening

Rather than focusing on disease-specific vertical programs or only on horizontal system constraints, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps.
Optimize available resources so that the whole is more than the sum of the parts. Bridge the divide as patients suffer diseases over a lifetime, most of it chronic.

Why diagonal?
Shared risk factors Success and life cycle Common need for strong health systems platforms Efficiency Economic development Social justice

Women and mothers in LMICs face many risks through the life cycle Women 15-59, annual deaths
- 35% in 30 years
Mortality in childbirth Breast cancer Cervical cancer Diabetes

342,900

166,577

142,744

120,889

= 430, 210 deaths

Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

A Diagonal Strategy:
Delivery: Harness platforms by integrating cancer prevention, screening and survivorship support into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programs.

Promoting prevention and healthy lifestyles: Reduce risk for cancer and many other diseases Promoting access to education for children w/ CI
Reduces poverty, contributes to social development

Diagonal Strategies: Positive Externalities

Reducing stigma for womens cancers: Contributes to reducing gender discrimination

Introducing child cancer treatment

Improves hygiene and reduce intra-hospital infections

Pain control and palliation Reducing barriers to access is essential for cancer, for other diseases, and for surgery.

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

Investing In CCC: We Cannot Afford Not To

Health is an investment, not a cost Tobacco is a huge economic risk: 3.6% lower GDP Total economic cost of cancer, 2010: 2-4% of global GDP Prevention and treatment offers potential world savings of $ US 131-850 billion mostly due to productivity gains and reducing suffering

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths Of which 80% are in LIMCs

Investing In CCC: The costs to close the cancer divide may be less than many fear:
All but 3 of 29 LMIC priority, candidate cancer chemo and hormonal agents are off-patent: many < $100 / course Cost of drug treatment, cervical cancer + HL + ALL(k) in LMICs / year of incident cases: $US 280 m Pain medication is cheap

Prices drop:
HPV 2011 from $US 100 /dose to GAVI $5 PAHO $14

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done: affordable C) Can be done
Myth 4: Impossible

Champions
Drew G. Faust
President of Harvard University 22+ year BC survivor

Nobel Amartya Sen,

Cancer survivor diagnosed in India 50 years ago

Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Champions from LMICs: Mxico

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

In developing countries, people with multidrugresistant 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
% Decline in price 1997-9

abandon therapy 2%

cured 83%

Drug

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

Investing In CCC: We Cannot Afford Not To

Health is an investment, not a cost Tobacco is a huge economic risk: 3.6% lower GDP Total economic cost of cancer, 2010: 2-4% of global GDP Prevention and treatment offers potential world savings of $ US 131-850 billion mostly due to productivity gains and reducing suffering

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths Of which 80% are in LIMCs

Success in treating several cancers. Mexico: cervical cancer.

16

12

0 1965 1975 1985

1955

1995

2008

Source: 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 (1979-2006)

Rural Rwanda: 0 oncologist

Burkitts lymphoma

Embryonal Rhabdomyosarcoma

Source: Paul Farmer., 2009

St. Judes International Outreach Program

20+ countries
El Salvador 5-year survival rate for children with ALL increased from 10% to 60% during the first five years of collaboration Cure4Kids/Oncopedia Over 31,000 users in more than 183 countres

Financing innovations: Domestic

Integrate CCC into national insurance programs to express previously suppressed demand, beginning with cancers of women and children: Mexico, Colombia, Dominican Republic, Peru China, India, Taiwan Rwanda, Kenya

A diagonal approach to social insurance and childhood cancers

Horizontal Coverage: Beneficiaries

Increase in population coverage + expansion of package of services

~100%

# of covered services
275
262 266

Households affiliated to Seguro Popular

85% 61% 53% 42%
10.5 millones 14.7 millones

89%

249
~17.2 millones de familias

3.5 millones

9% 2004 1.5

2006 5.1 millones

7.3 millones

20%

9.1 millones

30%

15.4 millones

146 113

2005

2007

2008

2009

2010

2012

2004

2005

2006

2007

2008

2009

2010

Source: Comisin Nacional de Proteccin Social en Salud, 2012

2012

2011

2011

Mexico Seguro Popular: diagonal, financial protection for catastrophic illness

Accelerated, universal, vertical coverage by disease with a package of interventions 2004/5: ALL in children, cervical, HIV/AIDS 2006: All pediatric cancers then all children and newborns for almost everything 2007: Breast cancer 2011: Testicular cancer, prostate and NHL

Seguro Popular and cancer: Evidence of impact

Since the incorporation of childhood cancers into the Seguro Popular
30-month survival ALL: 30% to almost 70%

Breast cancer adherence to treatment:

2005: 200/600 2010: 10/900

Access to medicines an anecdote

Regional and Global Financing: potential

Leverage integrated, innovative, scalable financing mechanisms - Global Fund and GAVI Diagonal partnerships: pink ribbon red ribbon NRMNCH platforms provide models Every Woman, Every Child for:
broad-based international partnership Commitment-based funding aggregation

Aggregate purchasing and sustainable procurement through existing funds and platforms
UNICEF PAHO

Be an optimist optimalist

Expanding access to cancer care and control in LMICs: Should, Could, and Can be done

Horizontal and vertical financial protection strategies: Seguro Popular and SSPH, Mexico
Benefits: covered interventions
Catastrophic Illness ACCELERATED VERTICAL COVERAGE: Ex: childrens cancer, breast cancer, HIV/AIDS

Package of essential personal services

Insurance for a new generation Community Health Services eg nutrition and vaccinations

Poor

Beneficiaries: Population covered

Rich