closing the cancer divide: opportunities for expanding cancer cre and control in lmics 190712

7/31/2019 Closing the Cancer Divide: Opportunities for expanding cancer cre and control in LMICs 190712

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Closing the Cancer Divide:Opportunities for Expanding Cancer

Care and Control in LMICsJuly 19th, 2012

Princess Margaret Summer Rounds Series,

Princess Margaret Hospital, Toronto

Felicia Marie Knaul, PhD Harvard Global Equity Initiative,Global Task Force on Expanded Access to Cancer Care and Control in LMICs

Mexican Health FoundationTmatelo a Pecho


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From anecdote

to evidence


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Juanita:Advanced metastatic breastcancer is the result of a seriesof missed opportunities


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From anecdote

to evidence


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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 andis being done


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Applies a diagonalapproach to avoid

the false dilemmas between disease silos

-CD/NCD- thatcontinue to plagueglobal health

Closing the Cancer Divide:A BLUEPRINT TO EXPAND ACCESS IN LMICs


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Global Task Force on ExpandedAccess to Cancer Care and

Control in Developing Countries

= global health + cancer care


13/51GTF.CCCMembers


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A) Should be done:

B) Could be done:

C) Can be done

Myth 1. Unnecessary

Myth 2. Inappropriate

Myth 3. Unaffordable

Myth 4: Impossible

Expanding access to cancercare and control in LMICs:


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Mirrors the overall epidemiologicaltransition

LMICs increasingly face both cancersassociated with infection, and all othercancers.

Cancers that are increasingly only of the poor, are not the only cancers of the poor.

The Cancer Transition

* Frenk et al


16/51Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition in LMICs:breast and cervical cancer

53%

20%19%

-31%

0%

LMICs Highincome

% Change in # of deaths1980-2010 LMICs account for

>90% of cervicalcancer deaths and

>60% of breastcancer deaths.

Both diseases areleading killers

especially of young

women.


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#2 cause of death in wealthy countries

#3 in upper middle-income#4 in lower middle-income

and # 8 in low-income countriesMore than 85% of pediatric cancer cases and 95% of

deaths occur in developing countries.

For children & adolescents

5-14 cancer is


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Cancer is a disease of both rich and poor;yet it is increasingly the poor who suffer:

1. Exposure to risk factors2. Preventable cancers (infection)

3. Treatable cancer death and disability4. Stigma and discrimination5. Avoidable pain and suffering

The Cancer Divide:An Equity Imperative

F a c e

t s


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Age-standardized prevalence of risk factor in adults aged 15+ years

Men

Women

Both sexes

% o

f p o p u

l a t i o n

0

20

40

60

Lowincome

Lowermiddle

Uppermiddle

High

Exposure to risk factors:Daily Tobacco Smoking

Source: WHO. The Global Status Re ort on Noncommunicable Diseases 2010.


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MortalityIncidence

Incidence and mortality of cervical cancer

(adjusted rate per 100,000 women)


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Adults

Leukaemia

All cancers

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

Children

LOW

INCOME

HIGH

INCOME

S ur

vi v al

i n e q u al i t

y g a p

LOW

INCOME

HIGH

INCOME

100%

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

In Canada, almost 90% of children withleukemia survive.

In the poorest countries only 10%.


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Stigma:Cancer especially in

women and children - adds alayer of discrimination onto

ethnicity, poverty, and

gender.

Survivorshipcare is non-

existent.

Th i idi i j i


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The most insidious injustice:lack of access to pain control

Non-methadone, Morphine Equivalent opioidconsumption per death from HIV or cancer in pain:

Poorest 10%: 54 mg per deathRichest 10%: 97,400 mg per death

d


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A) Should be done:

B) Could be done:

C) Can be done

Myth 1. Unnecessary

Myth 2. Inappropriate


Myth 4: Impossible



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Women and mothers in LMICsface many risks through the life cycle

Women 15-59, annual deaths

Diabetes

120,889

Breast

cancer

166,577

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

Cervical

cancer

142,744

Mortalityin

childbirth

342,900

- 35%in 30years

= 430, 210 deaths


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The Diagonal Approach toHealth System Strengthening

Rather than focusing on disease-specific verticalprograms or only on horizontal systemconstraints, harness synergies that provideopportunities to tackle disease-specific prioritieswhile addressing systemic gaps.

Optimize available resources so that the whole ismore than the sum of the parts.

Bridge the divide as patients suffer diseases over a

lifetime, most of it chronic.


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Why diagonal delivery?Shared risk factorsCo-morbidityLife cycle approachEfficiency: Common need for strong healthsystem platformsKnowledge sharing and inter-institutional

collaborationEconomic developmentSocial justice


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Delivery : Harness platforms by integratingbreast and cervical cancer prevention,screening and survivorship care into MCH,SRH, HIV/AIDS, social welfare and anti-poverty programs.

Example: Rwanda MoH working with Merck

and Qiagen

A Diagonal Strategy:

Di l St t i


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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 discriminationIntroducing cancer treatment for children

Improves hygiene and reduces intra-hospital infections

Promoting access to education for children w/ cancerReduces poverty, contributes to social developmentPain control and palliation

Reducing barriers to access is essential for cancer aswell as for for other diseases and for sur er .

E di


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A) Should be done: necessaryand appropriate

B) Could be done:

C) Can be done


Myth 4: Impossible



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`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 verysmall share of global resources forcancer ~ 5% or less.


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Investing In CCC:We Cannot Afford Not To

Health is an investment, not a costTobacco is a huge economic risk: 3.6% lower GDP

Total economic cost of cancer, 2010: 2-4% of global GDPPrevention and treatment offers potential world savingsof $ US 131-850 billion mostly due to productivitygains and reducing suffering

1/3-1/2 of cancer deaths are avoidable :2.4-3.7 million deaths

- 80% in LIMCs

Th l h di id


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The costs to close the cancer dividemay be less than many fear:

All but 3 of 29 LMIC priority cancer chemo and hormonalagents are off-patent: many < $100 / courseCost of drug treatment: cervical cancer + HL + ALL(kids)

in LMICs / year of incident cases: $US 280 mPain medication is cheapPrices drop: HPV 2011, $100/ to GAVI $5 & PAHO $14

Market potential is underutilized and undeveloped:purchasing is fragmented and procurement is unstableDelivery innovations are unexploited including healthtechnology policy

di


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A) Should be done: necessary

and appropriateB) Could be done: affordable

C) Can be doneMyth 4: Impossible


I iti l i MDR TB


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Initial views on MDR-TBtreatment, c. 1996-97

MDR-TB is tooexpensive to treat inpoor countries ; it

detracts attention andresources from treatingdrug-susceptibledisease. WHO 1997

Outcomes in MDR-TBpatients in Lima, Perureceiving at least four

months of therapy

All patients initiated therapybetween Au 96 and Feb 99

Cured83%

Abandontherapy2%

Failedtherapy

8%

Died8%

Ch i


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Harvard Breast Cancer in Develo in Countries Nov 4 `09

ChampionsNobel Amartya Sen ,

Cancer survivor diagnosed in India50 years ago

Drew G. FaustPresident of Harvard University

22+ year BC survivor


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Rural Rwanda: 0 oncologist

Source: Paul Farmer., 2009

Burkitt

slymphoma

EmbryonalRhabdomyosarcoma

f ll d


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Centres of Excellence andstrong country programs

Butaro Cancer Center of

Excellence, Rwanda; withPIH and DFCI

King Hussein CancerCenter

l


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St. Judes InternationalOutreach Program

Twinning in 20+ countries El Salvador: 5-year survival for children

with ALL increased from 10% to 60% infive years

Cure4Kids/Oncopedia Over 31,000 users in more than 183

countries

Success in treating several


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Mexico: cervical cancer.

Source: Knaul et al. 2008. Re roductive Health Matters and u dated b Knaul Arreola-Ornelas and Mndez based on WHO data WHOSIS 1955-1978 and Ministr o Health in Mexico 1979-2006

0

4

8

12

16

1955 1 9 6 5

1 9 7 5

1 9 8 5

1 9 9 5

2008

Success in treating severalcancers.

Fi i i i


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Financing innovations:Domestic

Integrate CCC into national insurance andsocial security programs to

express previously suppressed demand beginning with cancers of women and children:Mexico , Colombia, Dominican

Republic, PeruChina, India, TaiwanRwanda, Kenya

A diagonal approach to social


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Horizontal Coverage: Beneficiaries

A diagonal approach to socialinsurance and cancer

Horizontal and vertical


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Horizontal and verticalfinancial protection strategies:

Seguro Popular, Mexico

Beneficiaries: Population covered

B e n e f

i t s : c o v e r e

d i n t e r v e n

t i o n s

Catastrophic Illness

ACCELERATED VERTICAL COVERAGE:Ex: childrens cancer, breast cancer

Package of essential

personal services

Community Health Services eg nutrition and vaccinations

Poor Rich

Insurance for a new generation

l d


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# of covered servicesin Seguro Popular

Source: Comisin Nacional de Proteccin Social en Salud, 2012

SPS: Increase in population covered+ expansion of package of services

Households affiliatedto Seguro Popular

2 0 0 6

2 0 0 4

~100%

2 0 1 2

2 0 0 5

~ 1 7 . 2

m i l l i o n

f a m

i l i e s

9%

30%

20%

42%

1 . 5 3

. 5 m

i l l o n e s

5 . 1

m i l l o n e s

7 . 3

m i l l o n e s

53%

9 . 1 m

i l l o n e s

2 0 0 7

2 0 0 8

61%

1 0 . 5

m i l l o n e s

2 0 0 9

85%

1 4 . 7

m i l l o n e s

2 0 1 0

+113

146

249262

266

2 0 0 6

2 0 0 4

2 0 1 2

2 0 0 5

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

275

2 0 1 1

89%

2 0 1 1

1 5 . 4 m

i l l o n e s

Mexico Seguro Popular:


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Mexico Seguro Popular:financial protection for catastrophic

illnessAccelerated, universal, vertical coverage by diseasewith a package of interventions

2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers then all children

2007: Breast cancer2011: Testicular cancer, prostate and NHL

Seguro Popular and cancer:


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Seguro Popular and cancer:Evidence of impact

Childhood cancerscoverage of new cases increased, 3% to 55%

36-month survival: 50% for ALL and 75% for HLAbandonment of treatment: 6%

Breast cancer adherence to treatment:

2005: 200/6002010: 10/900

Anecdote: visit to a pharmacy

Mexican Champion: Abish Romeo


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Mexican Champion: Abish Romeotreatment through Seguro Popular


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Juanita:Advanced metastatic breastcancer is the result of a seriesof missed opportunities

Program to reduce


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Program to reducebarriers:

Breast cancer, Mexico

Results: promoters nurses doctors


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Results: promoters, nurses, doctors

Challenge: from survival to survivorship


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Be anoptimist

optimalist

Expanding access to cancer care and control in

closing the cancer divide: opportunities for expanding cancer cre and control in lmics 190712

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