Closing the Cancer Divide: Strategies for Action

May 17, 2012 Pfizer Medical, New Yorkd

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 and is being done

From anecdote
to evidence

January, 2007 June, 2008

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

= global health + cancer care

GTF.CCC
Members

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

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 Cancer Transition

Mirrors the overall epidemiological transition
LMICs increasingly face both cancers associated with infection, and all other cancers. Cancers that are increasingly only of the poor, are not the only cancers of the poor.
* 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.

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. 2. 3. 4. 5. Exposure to risk factors Preventable cancers (infection) Treatable cancer death and disability Stigma and discrimination Avoidable pain and suffering

Facets

Exposure to risk factors: Daily Tobacco Smoking

60

Men Women

% of population

40

Both sexes

20

Lower Upper High Low middle middle income Age-standardized prevalence of risk factor in adults aged 15+ years

Incidence and mortality of cervical cancer

(adjusted rate per 100,000 women)
Incidence Mortality

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

100%

Children

Adults Survival inequality gap

Leukaemia

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.

Survivorship care is nonexistent.

The most insidious injustice: lack of access to pain control

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

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

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.

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 delivery?

Shared risk factors Co-morbidity Life cycle approach Efficiency: Common need for strong health system platforms Knowledge sharing and inter-institutional collaboration Economic development Social justice

A Diagonal Strategy:
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.

Diagonal Strategies: Positive Externalities

Promoting prevention and healthy lifestyles: Reduce risk for cancer and many other diseases Reducing stigma around womens cancers: Contributes to reducing gender discrimination Promoting access to education for children w/ cancer Reduces poverty, contributes to social development Introducing cancer treatment for children Improves hygiene and reduces intra-hospital infections Pain control and palliation Reducing barriers to access is essential for cancer as well as for 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

`5/80 cancer disequilibrium

(Frenk/Lancet 2010)

Almost 80% of the DALYs lost worldwide to cancer are in LMICs, yet these countries have only a very small share of global resources for cancer ~ 5% or less.

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 - 80% in LIMCs

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

Pain medication is cheap Prices drop: HPV 2011 from $US 100 /dose to:
GAVI $5 and PAHO $14

Market potential is underutilized and undeveloped Purchasing is fragmented and procurement is unstable Delivery innovations are unexploited

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

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 Abandon 8%
therapy 2%

Making common cause with WHO: Reduced prices of second-line TB drugs

Drug
% Decline in price 1997-9

Died 8%

Cured 83%

Amikacin Ethionamide Capreomycin

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.

Ofloxacin

98%

Source: Paul Farmer, 2009

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

Rural Rwanda: 0 oncologist

Burkitts lymphoma

Embryonal Rhabdomyosarcoma

Source: Paul Farmer., 2009

St. Judes International Outreach Program

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

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)

Financing innovations: Domestic

Integrate CCC into national insurance and social security 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 financing

Horizontal Coverage: Beneficiaries

Increase in population coverage + expansion of package of services

Households affiliated to Seguro Popular
85% 61% 53%

~100%

# of covered services
275
262 266

89%

249
~17.2 millones de familias

42% 30% 20%

3.5 millones 7.3 millones 10.5 millones 14.7 millones 15.4 millones

9%
1.5

5.1 millones

9.1 millones

146 113

2004

2005

2006

2007

2008

2009

2010

2012

2004

2005

2006

2007

2008

2009

2010

2011

2011

Source: Comisin Nacional de Proteccin Social en Salud, 2012

2012

Mexico Seguro Popular:

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

Horizontal and vertical financial protection strategies: Seguro Popular, Mexico

Benefits: covered interventions
Catastrophic Illness

ACCELERATED VERTICAL COVERAGE: Ex: childrens cancer, breast cancer

Package of essential personal services

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

Poor Beneficiaries: Population covered

Rich

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

Program to reduce barriers: Breast cancer, Mexico

Results: promoters, nurses, doctors

Challenge: from survival to survivorship

Be an optimist optimalist

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

FALL: @Harvard U Press

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