High-income countries (defined by the World Bank as Gross National Income in dollars per capita per year), such as the United Kingdom and the United States of America are experiencing improved cancer outcomes. This is due to a variety of factors, such as screening and prevention measures along with evidence-based treatment strategies. Sadly not all low-to-middle-income countries such as many in sub-Saharan Africa, have yet shared the same improvements in outcomes.
Cancer is an example of a non-communicable disease and reducing deaths from these types of illnesses are a high priority of the United Nations 2015-2030 Sustainable Development Goals. Unfortunately, most cancers are only curable if they are detected at an early stage before they have spread. Cancer kills a disproportionately high number of people in low and middle-income countries where people tend to present at more advanced stages of the disease. This happens for a variety of reasons, such as lack of awareness of presenting symptoms of cancer and lack of access to well-developed healthcare systems. There are over 8 million deaths globally each year from cancer and 65 per cent of these are people living in low to middle-income countries. Due to the lack of universal health coverage in many of these low resource settings, people with cancer find themselves self-funding treatment, which can have catastrophic effects on their personal finances.
Improved cancer control in low to middle-income countries will likely involve a collaborative multi-faceted approach. One of the challenges is with the lack of available data, so the scale of the problem in many regions may not be accurate. In Africa, for example, only eleven per cent of the population are covered by cancer registries, which note how many people are diagnosed.
Treating cancer is expensive and complex, therefore prevention where possible is incredibly important. The preventable cancers where the biggest impact is likely to be possible are those related to tobacco such as lung cancer and those related to viruses. Smoking is one of the biggest preventable causes of cancer globally and around 80 per cent of the world’s smokers live in low and middle-income countries. Prevention measures could include tobacco control campaigns (with increasing excise tax being the most effective mechanism) and assistance for those who want to quit. Of the viruses that can cause cancer many can be prevented by vaccination eg Human Papilloma Virus which causes cervical cancer, human hepatitis viruses B and C that cause liver cancer, and for HIV which increases cancer risk but for which there is currently no effective vaccine, control of the disease by anti-virals reduces cancer prevalence.
The establishment of resource-sensitive guidelines, that will be feasible and cost-effective in these settings will also be important. Breast cancer screening programmes using mammography, for example, may work in high resource settings, but may not be appropriate in many parts of the world for a variety of reasons. What has been shown to be successful in some areas are programmes to improve breast awareness and self-examination techniques. Cervical cancer screening is another example; smear tests using Papanicolaou staining are widely used in wealthier countries to screen for signs of cervical cancer; Healthcare workers in India have shown that by staining the cervix with acetic acid and then performing visual inspection which shows pre-cancerous changes is both feasible and effective in reducing mortality. The Breast Health Global Initiative has already published resource specific breast cancer guidelines, which outline feasible, effective and sustainable interventions to improve outcomes. The United States of America’s National Comprehensive Cancer Network has recently published a framework for resource stratification to improve oncology outcomes.
Successful improvements to cancer outcomes will require robust national cancer plans being established. These plans will likely look different in different countries as factors such as money available to spend, cultural background and competing priorities differ. Successful twinning partnerships formed between high income and low to middle-income countries have been made across the world, such as the improved outcomes seen in childhood leukaemias since the collaborative relationship between St Judes Cancer Center in the USA and 14 low resource countries. It will also important to share good practice between different low resource countries. Cancer care will likely be incorporated into wider healthcare and anti-poverty programmes where shared causative factors commonly exist, with diagonal approaches more favoured, where many healthcare issues are addressed together eg. young women’s health in all its aspects including empowerment, birth control, breastfeeding education, HIV prevention, breast cancer awareness, cervical cancer prevention.
Access to cancer treatment is a necessity for cancer-related survival and quality of life to improve. Two Lancet Oncology Commissions have highlighted that half of cancer patients will need radiotherapy as part of their treatment, but only a fraction of people in low resource settings can access a radiotherapy machine. A Global task force has been established to address this. More than 80 per cent of cancer patients will need surgery during their treatment which in some instances will be a curative procedure, but less than a quarter will have access to safe, affordable and timely surgery. Availability of the drugs on the WHO Essential Medicines List (which includes anti-cancer therapies along with supportive and palliative care medicines) should be a priority. Cheap off-patent drugs such as Tamoxifen can hugely improve breast cancer outcomes and quality of life and availability to drugs such as this will make a real difference. With the more expensive drugs and equipment, it may be that the cancer community learns from the HIV community where bulk purchase across many countries drove prices down.
How can we reduce the brain drain that leads to many of a country’s most talented medical and nursing professionals leaving to work in the wealthy west? The World Health Organisation estimates that Africa, for example, has 24 per cent of the global cancer cases, but only 3 per cent of global healthcare workers. And if the specialist radiotherapists, medical oncologists and surgeons are not available, can we utilise the skills of nurses and other healthcare professionals who choose to stay in their communities?
Patient advocacy in low resource settings is hugely important too, but to create patient advocates, you need to have cancer survivors. Many international and national groups with an interest in this area and along with health care professionals and people with cancer are determined to help make this happen.
Dr Susannah Stanway is speaking today the RSM conference on cancer control in low and middle-income countries.
- The global cancer fightback - 16th August 2016
