Cancer control in low- and middle-income countries: time for action

Introduction

The myth that advancing cancer care is only relevant to high-income countries must be dispelled. Cancer accounts for nearly one in six deaths worldwide, more than the combined number due to HIV, malaria and TB. ¹ Cancer incidence is expected to rise from 12.7 million in 2008 to 20.3 million by 2030. ² The burden of mortality disproportionally affects less-developed regions where 65% of cancer mortality currently occurs. ³

Societal and economic transition has led to significant changes in the pattern of cancer incidence worldwide. Globally, a reduction in infection-related cancers such as cervical and stomach cancer can be seen where levels of human development increase. Unfortunately, this reduction is offset by the increasing incidence in cancers more associated with reproductive, hormonal, dietary and lifestyle factors such as female breast, prostate, lung and colorectal cancers. ² Due to both lifestyle factors and increasing longevity, the largest increase in cancer incidence, proportionally, is expected in low-income settings where there are fewer resources available. ³

A collaborative, forward-thinking and global approach is therefore required for successful cancer control. This article highlights the key themes emerging in global oncology and discusses future perspectives for prevention and control.

Economic challenges

Cancer is an expensive disease. However, the argument that it is too expensive to be addressed effectively in low- and middle-income countries is short-sighted. The expected dramatic increase in cancer incidence, the huge cost of inaction, and the resultant morbidity and mortality must be weighed against the cost of implementing cancer control programmes proactively. ⁴ The cancer management model in high-income countries has become a complex and costly system. However, some of the greatest costs are associated with novel cancer drugs, for which impact on overall survival is often very limited or even not known. ⁵ For example, of the 48 new regimens approved by the US Food and Drug Administration between 2002 and 2014, a median overall survival of 2.1 months was achieved. ⁶ The focus in high-income countries on novel therapeutics and personalised medicine does much to promote the outdated view that cancer care is prohibitively expensive for low- and middle-income countries where significant gains can be made from implementing existing evidence-based prevention strategies and therapies.

Economic challenges to cancer control differ significantly between countries. In high-income countries, for example, workforce typically accounts for a significant proportion of healthcare budgets, whereas in low- and middle-income countries, the greatest burden of cost is often related to equipment and physical resources. Out-of-pocket spending for individuals also differs significantly between different regions. Even when adequate cancer services exist, out-of-pocket spending can still act as a significant barrier to accessing cancer treatment, particularly in countries lacking sufficient health insurance policies or in those with inadequate public services. In India, for example, the additional expenditures incurred on inpatient care in households affected by cancer is equivalent to 36–44% of annual household spending. ⁷ High prices facilitated by current patent laws are an ongoing issue that must be faced by high- and low-income countries alike. However, a large percentage of cancers can be treated adequately with generic drugs. Design and implementation of regional and international pricing and procurement mechanisms are likely to offset some of the financial burden of cancer drugs; however, such mechanisms are yet to be realised on a large scale. ⁴

Early diagnosis, screening and prevention

Late diagnosis of cancer is associated with poor survival. ⁸ A focus on early disease detection therefore offers significant potential to reduce morbidity and mortality. Reducing the burden of late disease also reduces the cost of cancer care both in terms of healthcare spend and losses through economic productivity. Screening is an integral part of early detection and there are impressive examples of implementation of effective cancer screening programmes in resource-limited settings. One such example has demonstrated the successful use of visual inspection with acetic acid to expand screening to thousands of women across Zambia. ⁹ Prevention is also key given that the majority of cancers are associated with lifestyle or environmental factors. It is thought that half of cancers could be prevented by applying existing knowledge more effectively. ¹⁰ Approximately 2.2 million cancers in 2012 were estimated to be due to carcinogenic infections, many of which are preventable with vaccination including those against human papilloma virus and hepatitis B. ¹¹ A focus on prevention through vaccinations or lifestyle modification such as smoking cessation are likely to be more cost-effective than developing services to treat advanced stage disease. A strategic focus on both prevention and early detection has huge potential to impact on the impending cancer epidemic.

Health systems and services development

Delivery of cancer care is dependent on many inter-connected services. For example, radiotherapy service provision is key to cancer management with approximately half of all cancer patients able to benefit from radiotherapy, including curative therapy. ¹² However, radiotherapy machines can only achieve that potential when used by suitably trained personnel and where running costs and the maintenance of equipment is affordable and achievable. Similarly, the success of adjuvant radiotherapy is dependent on effective surgery, highlighting the importance of developing surgical capacity. It has been estimated that without improvement in surgical services for cancer care, global economic losses from cancers amenable to surgical treatment will total US$12 trillion by 2030. ¹³

Pathology services also underpin cancer diagnostics, but as recently as 2014, it was reported that 39 of 47 countries examined in sub-Saharan Africa had no laboratories that were accredited to international quality standards. ¹⁴ Establishing correct diagnoses is an integral part of global cancer control and pathology should therefore be prioritised. Innovative health partnerships between low- and high-income countries offer promise towards improving pathology services while facilitating local capacity building and the development of a sustainable infrastructure. The African Strategies for Advancing Pathology is an example of collaborative umbrella organisation that brings together regional pathology colleges across Africa with stakeholders and organisations in high-income countries. ¹⁵

Palliative care is another fundamental service central to cancer care that also transects chronic disease on a larger scale. Particularly in settings where a high proportion of patients present with advanced disease, providing good symptom control and end-of-life care is imperative. To date, however, palliative care remains underfunded and is often a research-poor and neglected discipline in low- and middle-income countries.

In developing cancer care systems, centralisation may lead to increased efficiency and reduced waste but may come at the cost of geographic inequality. In addition, algorithms may be implemented to simplify and rationalise care where multiple providers and components exist in a pathway. However, this will depend on whether many countries are able to rationalise their therapeutic geographies which are, today, extraordinarily heterogeneous. The advantages of simplified pathways include reducing provider costs as well as minimising financial and logistical challenges associated with patients attending multiple appointments which is a recognised burden leading to significant loss to follow-up and advanced disease at presentation. For example, one study in Zambia found that only 59.2% of women referred with positive visual inspection with acetic acid attended for further evaluation. ¹⁶ Models focusing on streamlining services may work towards tackling poor follow-up rates associated with many screening programmes in resource-limited settings. Due to inherent complexity and the sheer number of essential services that are required, there are no ‘quick-fix’ solutions in cancer control. However, a drive to improve health services more comprehensively can also be seen as a positive by-product of improving cancer care, but this will require significant governance changes to the way both public and private sector cancer care are regulated.

Research and technology

At the turn of the millennium, The Global Forum for Health Research described the ‘10/90 gap’ in which less than 10% of global spending on health research was devoted to diseases or conditions that account for 90% of the global disease burden. ¹⁷ The impact of this gap is greatest in low- and middle-income countries and unfortunately, almost two decades later still very much exists. ¹⁸ Research is essential not only to identify effective interventions and areas of need but also to inform health policy. Robust scientific research is a powerful tool with which to gain investment into services. Research also provides an opportunity for capacity building, an essential element of sustainable service development.

Technology is dramatically reshaping healthcare systems. It brings huge scope and significant challenges to radically improve healthcare systems in both resource-rich and resource-limited settings. One area where technology may have a significant impact in low- and middle-income countries is in developing a more protocolised approach to cancer care; for example, synoptic reporting in radiology and pathology. Technology can also be used for remote reporting of radiology and pathology. Such approaches can enable remote areas to gain access to services that are otherwise unavailable.

Although enormously promising, technology-centric cancer systems can rapidly lead to overutilisation, inequality and a reduction in systems value. This especially applies to low- and middle-income countries where political, economic and social complexities often lie at the heart of health inequalities as opposed to paucity in the uptake of technology. As such, exciting technology should not draw attention away from key issues underpinning disease and cancer control strategies. In all cases, implementation of technology must be sensitive to local systems and must also be integrated such that it allows for sustainability, capacity building and health system strengthening.

Collaboration and partnership working

Establishing global health cancer care partnerships is a vital component of improving outcomes in oncology. Collaboration and networking has the potential to act as a powerful tool in catalysing change and bringing about long-lasting friendships; however, it remains a simple concept that is often far more complex in reality. Collaborative approaches and partnerships can provide platforms through which expertise, skills and knowledge can be shared between countries and organisations to improve healthcare systems. Nevertheless, these must feel and act in a way that avoids onco-colonialism and local priorities being overridden by the wealthier partner. One of the key components of collaborative projects is that they are locally driven and are specifically focused to the healthcare needs of low- and middle-income countries. To achieve sustainability, partnerships are often long-term arrangements that require significant commitment.

There are several benefits of collaborative models and partnerships, some of which include support with diagnostic pathways, procurement of affordable therapies, research capacity development and education. Many initiatives have demonstrated the powerful and wide-ranging benefits of collaborative partnerships; from a programme training physicians to perform radical hysterectomies for women with gynaecological cancer to overarching collaborative groups such as AORTIC and Indian CREDO program that seek to improve outcomes through collective efforts focused on national cancer control programmes and research capacity. ¹⁹

Policy and leadership

The increasing burden of cancer in low- and middle-income countries has led to an explosion of health system development and activity, especially in the private sector. With such rapid evolution comes intrinsic vulnerabilities such as fragmentation, limited coordination, equality, value and affordability. ²⁰ Service development equipped to take on the challenge of cancer in low- and middle-income countries must be driven by rational political, clinical and patient engagement around national cancer control planning that is properly funded and operationalised.

Healthcare policy makers must embrace cancer as an important priority to facilitate global health goals more broadly. In May 2005, the World Health Assembly resolved that all countries should develop and implement national cancer control programmes. The World Health Assembly in 2017, involving more than 40 countries, 18 sponsors and 11 non-government organisations called on all partners to assist with national cancer control programmes and implementation. It recommended actions including developing and implementing national cancer control programmes, reducing risks through policies such as those targeting tobacco use and ensuring the cancer workforce has appropriate skills and improving data to inform decision-making. Time and words have been spent yet there still remains a major gap between these, the realities of domestic funding in many low- and middle-income countries and the willingness of high-income research funders, whether philanthropic or federal, to see global cancer control as a major area for overseas development assistance funding.

Strengthening systems to control cancer requires greater public spending especially given the anticipated increasing expectations of health and well-being in the future. In fact, increases in costs of delivering cancer care are likely to rise in parallel to costs associated with other diseases. Therefore, cancer must be funded not only as its own entity but also through greater financial commitment to social and medical systems (e.g. surgery and pathology) that underpin chronic disease, healthcare system development and public health interventions.

Conclusion

The health, social and economic challenges of the global cancer epidemic, both historical and contemporary, must be met by a holistic and integrated approach. Evolving populations both in terms of size and demographics, coupled with a shifting economic and political landscape, amount to a large and complex challenge.

New radical and creative approaches are required. Robust research is needed to drive and shift agendas, with collective and effective leadership facilitating change. Capacity building is essential to strengthen health systems and ensure the best services are equitably offered to patients globally. A focus on intervention in the early stages of cancer, reducing risk factor exposure and strengthening health services will act as a strong foundation for the future.