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Closing the Cancer Divide: Partnership for action

Third Technical Meeting Advisory Group on Increasing Access to Cancer Radiotherapy Technology in LMICs International Atomic Energy Agency, Vienna June 22, 2012
Felicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICs Mexican Health Foundation Tmatelo a Pecho

From anecdote
to evidence

January, 2007 June, 2008

Advanced metastatic breast cancer is the result of a series of missed opportunities

From anecdote

to evidence

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 and is being done

Closing the Cancer Divide:


Applies a diagonal approach to avoid the false dilemmas between disease silos -CD/NCD- that continue to plague global health

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

= global health + cancer care


Expanding access to cancer care and control in LMICs: A) Should be done:

Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

The Cancer Transition

Mirrors the overall epidemiological transition
LMICs increasingly face both cancers associated with infection, and all other cancers. Cancers that are increasingly only of the poor, are not the only cancers of the poor.
* Frenk et al

The cancer transition in LMICs: breast and cervical cancer

LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers especially of young women.
% Change in # of deaths 1980-2010





High income

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

For children & adolescents 5-14 cancer is

#2 cause of death in wealthy countries #3 in upper middle-income #4 in lower middle-income and # 8 in low-income countries
More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries.

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:
1. 2. 3. 4. 5. Exposure to risk factors Preventable cancers (infection) Treatable cancer death and disability Stigma and discrimination Avoidable pain and suffering


Incidence and mortality of cervical cancer

(adjusted rate per 100,000 women)
Incidence Mortality

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



Adults Survival inequality gap



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

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10%.

The most insidious injustice: lack of access to pain control

Non-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

Expanding access to cancer care and control in LMICs: A) Should be done:

Myth 1. Unnecessary

Myth 2. Inappropriate B) Could be done:

Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

Women and mothers in LMICs face many risks through the life cycle Women 15-59, annual deaths
- 35% in 30 years
Mortality in childbirth Breast cancer Cervical cancer Diabetes





= 430, 210 deaths

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

The Diagonal Approach to Health System Strengthening

Rather than focusing on disease-specific vertical programs or only on horizontal system constraints, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps.
Optimize available resources so that the whole is more than the sum of the parts. Bridge the divide as patients suffer diseases over a lifetime, most of it chronic.

Why diagonal delivery?

Shared risk factors Co-morbidity Life cycle approach Efficiency: Common need for strong health system platforms Knowledge sharing and inter-institutional collaboration Economic development Social justice

A Diagonal Strategy:
Delivery: Harness platforms by integrating breast and cervical cancer prevention, screening and survivorship care into MCH, SRH, HIV/AIDS, social welfare and antipoverty programs.

Example: Rwanda MoH working with Merck

and Qiagen

Diagonal Strategies: Positive Externalities

Reducing stigma around womens cancers: Contributes to reducing gender discrimination Introducing cancer treatment for children Improves hygiene and reduces intra-hospital infections Pain control and palliation Reducing barriers to access is essential for cancer as well as for for other diseases and for surgery.

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

`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 very small share of global resources for cancer ~ 5% or less.

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 GDP Prevention 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 - 80% in LIMCs

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 /pc Prices drop: HPV 2011 from $US 100 /dose to
GAVI $5 and PAHO $14

Market potential is underutilized and undeveloped Purchasing is fragmented; procurement is unstable Delivery innovations are unexploited especially telemedicine and twinning Health technology policy is underdeveloped

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done: affordable C) Can be done
Myth 4: Impossible

Initial views on MDR-TB treatment, c. 1996-97

MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease. WHO 1997

Outcomes in MDR-TB patients in Lima, Peru receiving at least four months of therapy
Failed therapy Abandon 8%
therapy 2%
Died 8%

Cured 83%

All patients initiated therapy between Aug 96 and Feb 99

Nobel Amartya Sen,
Cancer survivor diagnosed in India 50 years ago

Rural Rwanda: 0 oncologist

Burkitts lymphoma

Embryonal Rhabdomyosarcoma

Source: Paul Farmer., 2009

St. Judes International Outreach Program

Twinning in 20+ countries
El Salvador: 5-year survival for children with ALL increased from 10% to 60% in five years Cure4Kids/Oncopedia Over 31,000 users in more than 183 countries

Success in treating several cancers.

Mexico: cervical cancer.
16 12

1965 1975 1985




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)

Financing innovations: Domestic

Integrate CCC into national insurance and social security programs to express previously suppressed demand
beginning with cancers of women and children:

Mexico, Colombia, Dominican Republic, Peru China, India, Taiwan Rwanda, Kenya

Mexico Seguro Popular:

financial protection for catastrophic illness
Accelerated, universal, vertical coverage by disease with a package of interventions 2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers then all children

2007: Breast cancer

2011: Testicular cancer, prostate and NHL

Seguro Popular and cancer: Evidence of impact

Since the incorporation of childhood cancers into the Seguro Popular
30-month survival ALL: 30% to almost 70%

Breast cancer adherence to treatment:

2005: 200/600 2010: 10/900

Mexican Champion: Abish Romeo treatment through Seguro Popular

Share information prices, projects If you lack $ for treatment, diagnosis Demand induced supply Make tough choices where access is low Improving other components of the CCC continuum can liberate resources for RT Apply diagonal solutions: prime example is an MoH Health Technology Unit Multi-sectoral partnerships: AGaRT

Be an optimist optimalist

Expanding access to cancer care and control in LMICs: Should, Could, and Can be done