final lincoln bc global disparities 060612

7/31/2019 Final Lincoln BC Global Disparities 060612

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Breast Cancer:Global DisparitiesClosing the Gap: Addressing Disparities in Breast Cancer

Lincoln Medical and Mental Health Center, NYJune 7, 2012

Felicia Marie Knaul, PhD


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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs

M1. Unnecessary

M2. Unaffordable

M3. ImpossibleM4: Inappropriate

Much

Should

Could, and

Can ...

Challenge and disprove the

myths about cancer

.be done


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Global Task Force on Expanded

Access to Cancer Care and

Control in Developing Countries

= global health + cancer care


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From anecdote

to evidence


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January, 2008

June, 2007


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br

Juanita:Advanced metastatic breast

cancer is the result of a series of

missed opportunities


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From anecdote

to evidence


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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 cancer

care and control in LMICs:


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Breast cancer:

myths and realities

It is a disease ofdeveloped

countries

It is a disease ofolder women

It is of lowerpriority than

cervical cancer

The majority of cases

and deaths occur in the

developing world

A large proportion ofcases and deaths

perhaps the majority

happens in women


13/37Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition in LMICs:

breastand cervicalcancer

53%

20%19%

-31%

0%

LMICs High

income

% Change in # of deaths1980-2010LMICs account for

>90% of cervical

cancer deaths and

>60% of breast

cancer deaths.

Both diseases are

leading killers

especially of young

women.


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#1 cause of death in wealthy countries

#2 in middle-income countries

# 5 in low-income countries

Among women aged 15-59

Breast 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 factors

2. Preventable cancers (infection)

3. Death and disability fromtreatable cancer

4. Stigma and discrimination

5. Avoidable pain and suffering

The Cancer Divide:

An Equity Imperative

Fac

ets


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Adults

Leukaemia

All cancers

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

Children

LOW

INCOME

HIGH

INCOME

Sur

vival

inequa

lity

gap

LOW

INCOME

HIGH

INCOME

100%

The Opportunity to Survive (M/I)

Should Not Be Defined by Income

In Canada, almost 90% of children with

leukemia survive.

In the poorest countries only 10%.


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Stigma:

Cancerespecially in

women and children - adds a

layer of discrimination ontoethnicity, poverty, and

gender.

Survivorship

care is non-existent.

i i i i j i


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The most insidious injustice:

lack of access to pain controlNon-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


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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



W d h i LMIC


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Women and mothers in LMICs

face 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

Mortality

in

childbirth

342,900

- 35%in 30

years

= 430, 210 deaths


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The Diagonal Approach to

Health System Strengthening

Rather than focusing on disease-specific vertical

programs or only on horizontal system

constraints, harness synergies that provideopportunities to tackle disease-specific priorities

while 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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Delivery: Harness platforms by integrating breast andcervical cancer prevention, screening and survivorship

care into MCH, SRH, HIV/AIDS, social welfare and

anti-poverty programs.

A Diagonal Strategy:

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


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A) Should be done:

necessary and appropriate

A) 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

(disability-adjusted life-years) lostworldwide to cancer are in LMICs,

yet these countries have only a very

small share of global resources for

cancer ~ 5% or less.


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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 GDPPrevention 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


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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

Prices drop: HPV 2011 from $US 100

/dose to:GAVI $5 and PAHO $14

Pain medication is cheap


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A) Should be done:

necessary and appropriateA) Could be done:

affordableC) Can be done

Myth 4: Impossible



Ch i


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Harvard Breast Cancer in Develo in Countries Nov 4 `09

Champions

Drew G. Faust

President of

Harvard University

And

22+ year BC

survivor


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In developing countries, people with multidrug-resistant tuberculosis usuallydie, because effective treatment is often impossible in poor countries. WHO 1996

Initial views on MDR-TB

treatment, c. 1996-97

Source: Paul Farmer., 2009Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis

in Lima, Peru. NEJM 2003; 348(2): 119-28.

Outcomes in MDR-TB patients in Lima,

Peru receiving at least 4 months of therapy

MDR-TB is too expensive to treat in poor

countries; it detracts attention and resources from

treating drug-susceptible disease. WHO 1997

Cured

83%

Abandon

therapy 2%

Failed

therapy

8%

Died

8%

PIH R l R d 0 l i t


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PIH Rural Rwanda: 0 oncologist

Source: Paul Farmer., 2009

Burkitts

lymphoma

EmbryonalRhabdomyosarcoma


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Mexico: cervical cancer.

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)

0

4

8

12

16

19551965

1975

1985

1995 2005

Success in treating several cancers.


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Mexico: summary of facts

Since 2006, breast cancer is the second leading

cause of death among women aged 30 to 54

years of age and the principal cause of death

due to tumors.

Seguro Popular: since 2007 all women

diagnosed with breast cancer have verycomplete access to treatment with financial

protection

Mexican Champion: Abish Romeo


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Mexican Champion: Abish Romeo

treatment through Seguro Popular


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Only 5-10% of cases in Mexico are

detected in Stage 1 or in situ

- 50% of women from poor

municipalites are diagnosed in stage 4

compared to 10-15% of women fromwealthy areas

Education to reduce barriers:


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Education to reduce barriers:

promoters, nurses, doctors

Challenge: from survival to survivorship


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Challenge and disprove the

minimalists:

Myths about breast cancer,cancer& NCD

M1. Unnecessary: NECESSARY

M2. Inappropriate: APPROPRIATE

M3.Unaffordable: AFFORDABLEM4. Impossible: POSSIBLE


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Be anoptimist

optimalist

Expanding access to cancer care and control in

LMIC Sh ld C ld d C b d

final lincoln bc global disparities 060612

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