Preventing and treating cancer in poorer countries -- so much can be done, even without expensive on-patent drugs and equipment

A group of leading cancer and public health experts are calling for a global movement on cancer care and prevention in low- and middle-income countries (LMIC), similar to the HIV/AIDS movement that has transformed care in those nations in the past decade. The authors of this Health Policy paper published Online First in The Lancet say that so much can be done using generic, off-patent drugs, education of populations, and better training of doctors and community workers. The paper is written by Dr Felicia Knaul, Harvard Global Equity Initiative, with first authors Dr. Paul Farmer, Harvard Medical School, and Drs. Julio Frenk, Harvard School of Public Health and Lawrence Shulman, Dana-Farber Cancer Institute,Boston, MA, USA, as conveners of the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC) and co-authored by the members of the GTF.CCC.

Cancer is no longer primarily the burden of high-income countries. In 1970, 15% of newly reported cancers were in LMIC, compared with 56% in 2008, expected to rise to 70% in 2030. Almost two thirds of the 7.6 million annual cancer deaths worldwide occur in LMIC, making it a leading cause of mortality. The inequity of cancer care is further demonstrated by the case fatality from cancer (estimated incidence to mortality ratio), which is 75% in low-income countries, and 46% in high-income countries. As Princess Dina Mired of Jordan, Honorary Co-President of the GTF.CCC and co-author of the paper, says*: "Our focus is on fixing the harsh inequity and disparity that exists with cancer treatment between the developed and the developing world. Having the chance to live should not be an accident of geography."

According to Julio Frenk, in most parts of the world cancer is a sorely neglected health problem and a significant cause of premature death. "To correct this situation we must address the staggering 5/80 cancer disequilibrium", says Frenk*, referring to the fact that LMIC account for almost 80% of the burden of disease due to cance, yet receive only 5% of global resources devoted to deal with this emerging challenge.

A number of initiatives can target these disparities without using expensive on-patent drugs or other equipment. Smoking, a big risk factor for many cancer,continues to rise in many LMIC, so education via antitobacco campaigns could have a huge impact; as could education about the importance of early detection and screening. Another intervention with huge potential is vaccination against human papillomavirus (HPV) (to prevent cervical cancer), and also hepatitis B virus (to prevent liver cancer). Both of these are currently too expensive to be included in the health programmes of LMIC.

GTF.CCC aims to support existing initiatives, and particularly take advantage of those that allow synergy between cancer care and control and other diseases via health system strengthening. It will also support the WHO Framework Convention on tobacco control, and efforts to improve diet, nutrition, and healthy lifestyles, as well as those reducing exposure to environmental risk factors for cancer. For those cancers that are not treatable, such as pancreatic cancer, the paper calls for entitlement—often unmet in LMICs—for palliative drugs to mitigate their suffering.

The authors say: "Many of the cancers that pose the greatest burden in low-income and middle-income countries are amenable to treatment with drugs of proven effectiveness that are off-patent and can be manufactured generically at affordable prices. These drugs should be a focus of cancer treatment programmes, rather than expensive on-patent drugs." They give tamoxifen for breast cancer as an example of a cheap off-patent drug. They add that in Malawi, Cameroon, and Ghana, the total cost of a generic first-line chemotherapy drug with a 50% cure rate for Burkitt's lymphoma has been reported as less than US$50 per patient.

The authors give examples of what is possible in LMIC. Colombia and Mexico, both middle-income countries, have wide-ranging cancer care covered by national health insurance policies which particularly target poor people. And an international partnership of Partners In Health and the Dana-Farber Cancer Institute, Harvard Medical School, and Brigham and Women's Hospital, working in rural Malawi, Rwanda, and Haiti, is proving that absence of cancer specialists can be surmounted even in the poorest settings. Partners in Health, in partnership with national health ministries, operates health centres and hospitals in rural districts. With support and training from the Harvard-based facilities, these centres and hospitals have begun delivering chemotherapy to patients with a variety of treatable malignant diseases including breast, cervical, rectal, and squamous head and neck cancers, Hodgkin's and non-Hodgkin lymphoma, and Kaposi's sarcoma. Jordan's King Hussein Cancer Centre is another example of what can be achieved in LMIC.

As Farmer notes*: "There are clearly effective interventions that can prevent or ease suffering due to many malignancies, and that is surely our duty as physicians or policy makers or health advocates."

The authors propose that cancer care and control become rapidly and broadly available as quickly as possible, with the focus on cancers that can be prevented or cured, or, in the case of neither, palliated. More immediately, they propose:

1. Simultaneous implementation of large-scale demonstration programmes in the next few years to define and build new infrastructure, train health professionals and paraprofessionals, and harness the opportunities of technology and especially telecommunications to overcome many on-site limitations in resources.
2. Design and implementation of regional and global pricing and procurement mechanisms to offer individual countries the opportunity to participate in collective, multi-country negotiation to secure reduced prices for essential services, drugs, and vaccines.
3. Identification and implementation of innovative financing mechanisms, which should decisively expand the financial resources available for prevention, treatment, and palliation of cancer in the developing world.

They conclude: "We can no longer differentiate between diseases of the poor and the rich... Poor people endure a double burden of communicable and non-communicable chronic illness, requiring a response that is well integrated into the health systems of low-income and middle-income countries. Extension of cancer prevention, diagnosis, and treatment to millions of people with or at risk of cancer is an urgent health and ethical priority. A bold research, financing, and implementation agenda is essential for the international community to fill the gaping voids in cancer care and control worldwide."

To contact the lead authors in this report, please contact:

Jen Goldsmith, Advisor to the GTF.CCC, Harvard Global Equity Initiative. T) +1 617.285.5397E) Jen_Goldsmith@harvard.edu

Andrew Marx, Director of Communications, Partners in Health, T) +1 617.998.8977 E) amarx@pih.org

David Cameron, Associate Director of Public Affairs, Media Relations, Harvard Medical School. T) +1 617 432 0441 E) david_cameron@hms.harvard.edu

For full Health Policy, see: http://press.thelancet.com/cancerlmic.pdf

Notes to editors: *quotes direct from paper authors not found in text of full paper