Transforming Health Systems to Meet the

Challenge of Breast Cancer and Chronic Care:

A Diagonal Approach

reast Cancer in the Arab World

March 23, 2015; Amman, Jordan

Felicia Marie Knaul

Harvard Global Equity Initiative

Harvard Medical School
Global Task Force on Expanded Access to Cancer Care and Control
Mexican Health Foundation
Tmatelo a Pecho
Union for International Cancer Control (UICC)

Duality:
evidence and advocacy
Evidence-based
Advocacy

Advocacyinspired
Evidence

Action:
Patients, projects, programs, policies

January,
2008
June, 2007

From anecdote

to evidence

Global Task Force on Expanded

Access to Cancer Care and Control
in Developing Countries

= global health + cancer care

GTF.CCC: a Harvard University-KHFC Partnership

Foto: with Amanda Berger to whom the book is dedicated

Closing the Cancer Divide:

An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate

I: Should be done
II: Could be done
III: Can be done

1: Innovative Delivery
2: Access: Affordable Meds, Vaccines & Techs
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership

The Cancer Transition

Double burden for health systems
Mirrors the epidemiological transition
LMICs increasingly face both infectionassociated cancers, and all other cancers.
Cancers increasingly only of the poor, are
not the only cancers affecting the poor
LMICs account for >90% of cervical and 70% of
breast cancer deaths. Both are leading killers
especially of young women.

Breast cancer is
The most common cancer of women globally and
the second most common cancer overall
1.7 million new cases /year = 11% of all cancers
4.8 million women live breast cancer (diagnosed)
522,000 deaths per year
Is among the top 5 causes of death in middle
income countries
1 in 8 women in the US will have BC in their lives
Source: Estimates based on data from Globocan 2012

In LMICs a very large % of Breast Cancer

cases and deaths are in women <55
Age at
Diagnosis

Low income

66%

Latin America

62%

High Income

33%
15-39
40-54

Age at
Death

>55

34%
67%

61%
Fuente: Estimaciones de los autores basadas en IARC, Globocan 2012

The Cancer Divide:

An Equity Imperative

Facets

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

Survival
inequality gap

The Opportunity to Survive

Mortality/Incidence is,
but should not be, defined by income.
5
0
4
0

48%
40%

2
0

38%
24%

Low
Income

High
Income

Almost 90% of Canadian childhood leukemia patients survive

the
only 10% survive.
Source: Knaul, Arreola, Mendez.In
estimates
based poorest
on IARC, Globocan,countries
2010.

The most insidious injustice:

the pain divide
Non-methadone, Morphine Equivalent
opioid consumption per death from HIV
or cancer in pain:
Poorest 10%: 179 mg
Richest 10%: 99 mil mg
US/Canad: 344 mil mg
355 mil mg

India: 467 mg

333 mil mg
Africa

Mexico:3
,500 mg

Jordan: 14,000 mg
Latin America

Source: Estimaciones propias Knaul F.M. Arreola H, et.al.,

basado en datos de: Treat the pain and INBC
(http://www.treatthepain.com )

Challenge and disprove the

myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE

The costs to close the cancer divide are

and may be less than many fear:
All but 3 of 29 LMIC priority cancer
chemo and hormonal agents are off-patent
Pain medication is cheap
Prices drop: HepB and HPV vaccines
Delivery & financing innovations can
aggregate purchasing and stabalise
procurement

The costs of inaction are huge:

Invest IN action
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% global GDP

1/3-1/2 of cancer deaths are avoidable:

2.4-3.7 million deaths,
of which 80% are in LIMCs

Prevention and treatment offer

potential world savings of
$ US 130-940 billion

Champions
the economics of hope:
Drew G. Faust
President of Harvard U
25+ year BC survivor

Nobel
Amartya
Sen,
Cancer
survivor
diagnosed
and treated
in India 65
years ago
Harvard, Breast Cancer in Developing Countries,
10 `09

Challenge and disprove the

myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APPROPRIATE

Women and mothers in LMICs

face many risks through the life cycle
Women 15-59, annual deaths
- 35%
in 30
years

Mortality
in
childbirth

291,000

Breast
cancer

Cervical
cancer

150,000195,000

105,000131,000

Diabetes

110,000139,000

= 373,000 465,000
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

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

The Diagonal Approach to

Health System Strengthening
Rather than focusing on either disease-specific vertical or
horizontal-systemic programs, harness synergies that
provide opportunities to tackle disease-specific priorities
while addressing systemic gaps and optimize available
resources
Diagonal strategies:
Positive externalities: X = > parts
Compound benefits to increase effectiveness at a given cost
Bridge disease divides using a life cycle response
Exploit existing platforms
Avoid the false dilemma of disease silos

Diagonal Strategies:
Positive Externalities
Promoting prevention and healthy
lifestyles:
Reduce risk for cancer and other diseases
Reducing stigma for womens cancers:
Contributes to reducing gender
discrimination.
Investing in treatment produces champions

Worldwive wave of reforms to

achieve UHC
Universal Health Coverage:
all people should obtain needed health
services
prevention, promotion, treatment,
rehabilitation, and palliative care
without risking economic hardship or
impoverishment (WHO, WHR 2013).

An effectiveUHC response to chronic illness

must integrate interventions along the
Continuum of disease:
1.
2.
3.
4.
5.
6.

Primary prevention
Early detection
Diagnosis
Treatment
Survivorship
Palliative care

.As well to each

Health system function
1. Stewardship
2. Financing
3. Delivery
4. Resource generation

eUHC requires an integrated response along

the continuum of care and within each
core health system function
Stage of Chronic Disease Life Cycle /components CCC
Health System
Functions

Stewardship

Financing

Delivery
Resource
Generation and
evidence
buliding

Primary
Prevention

Secondary
prevention/
early
detection

Diagnosis

Treatment

Survivorship/
Rehabilitation

Palliation/
End-of-life care

Challenge and disprove the

myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APPROPRIATE
M4: Impossible
POSSIBLE

Expansion of Financial Coverage:

Seguro Popular Mxico
Affiliation:

Benefit package:
2004: 113

2014: 285
59 in the
Catastrophic
Illness Fund

Benefits Package

2014: 55.6 m

Vertical Coverage
Diseases and Interventions:

2004: 6.5 m

Horizontal Coverage:

Beneficiaries

Seguro Popular now includes

cancers in the national,
catastrophic illness fund
Universal coverage by disease with an
effective package of interventions
2004/6: HIV/AIDS, cervical, ALL in
children
2007: pediatric cancers; breast
2011: Testicular, Prostate and NHL
2013: Ovarian and colorectal

Seguro Popular and breast cancer:

Evidence of impact
National Institute
of Cancer:
treatment
adherence
2005: 200/600
2010: 10/900

The human faces:

Guillermina Avila

Breast Cancer detection:

Delivery failure
# 2 killer of
women 30-54
5-10% detected
in Stage 0-1
Poor
municipalites:
50% Stage 4; 5x
the rate for rich

% diagnosed in Stage 4 by state

Rich

Poor

Juanita: Advanced
metastatic breast cancer - a
series of missed opportunities at
the primary level of care

Breast cancer incidence and mortality

rate per 100000

Breast cancer incidence and

mortality, USA, 19402000.
160
140
120

Introduction of adjuvant
chemo/hormonal Rx

Introduction of
mammography

Promotion of
breast self-exam

Incidence

100
80
60

Mortality

40
20
0
1940

1950

1960

1970

1980

1990

2000

YEAR
Shulman, Willett, Knaul et al: Based on the Connecticut SEER data base

Diagonalizing Delivery: Training primary

care promoters, nurses and doctors in
early detection of breast cancer

Health Promoters
Risk Score (0-10)

6
5
4
3

Significant increase in
knowledge, especially among
health promoters and in clinical
breast examination
(Keating, Knaul et al 2014, The Oncologist)

Pre

Post

3-6 month

HGEI-Lancet Commission on Global Access to Pain

Control and Palliative Care

=
Global Health
and Health
Systems

Palliative care
specialists

Goal: Alleviate Avoidable

Pain & Suffering

Lasting survivorship challenges

for young women:
1.
2.
3.
4.
5.

Fear/uncertainty surrounding fertility

Body image perception challenges
Employment discrimination and its impact
Loss of social networks
Unmet primary and psych care needs
Employment discrimination

a
a person
person with
with cancer,
cancer, no
no one
one wants
wants to
to employ
employ them.
them. Because
Because we
we are
are no
no longer
longer useful.
useful.
I
I like
like to
to speak
speak the
the truth
truth when
when II go
go to
to ask
ask for
for aa job.
job. II tell
tell them,
them, II had
had cancer
cancer and
and II have
have to
to go
go
to
to appointments,
appointments, they
they tell
tell me,
me, we
we dont
dont allow
allow absences,
absences, Thanks,
Thanks, see
see you
you later.
later.

Body image, psychosocial needs change w time

They
They always
always tell
tell me,
me, dress
dress up,
up, make
make yourself
yourself up,
up, do
do this,
this, and
and II say,
say, for
for what?
what? For
For what
what now?
now? II
have
become..
depressed.
..
not
depression,
as
I
told
you,
a
lack
of
interest.
have become.. depressed. .. not depression, as I told you, a lack of interest.

the
the first
first years
years did
did not
not affect
affect me..
me.. II did
did not
not care
care now
now itit is
is affecting
affecting me.
me. For
For aa year,
year, II have
have been
been
seeing
myself
and
not
accepting
myself,
it
is
very
hard
for
me
to
accept
myself
as
a
I
now
am..
seeing myself and not accepting myself, it is very hard for me to accept myself as a I now am..

Evidence-based policy:
Findings and recommendations
Survivorship care is absent in LMICs, yet context-specific
In LMICs survivorship care will become increasing needed
as epidemiological transition proceeds and reform
increases health care coverage and access.
Survivorship care must be integrated into UHC and each
health system function (stewardship, financing, delivery, capacity building)
Educate policy-makers about long-term care and
quality-of-life issues including legal protection
Capacity building for physicians, nurses,
other health care providers and promoters at
the primary level

Preliminary training results: 10,000 primary

care physicians and nurses, 2014

Calificacin
(% de puntos logrados por score)

90

Nurses
N=2,243

Physicians
N=4,872

Signs and symptoms

85

Risk Factors

Global

80

CBE and BSE

Survivorship ??

75

PRE

POST

PRE

POST

eUHC requires an integrated response along

the continuum of care and within each
core health system function
Stage of Chronic Disease Life Cycle /components CCC
Health System
Functions

Stewardship

Financing

Delivery
Resource
Generation and
evidence
buliding

Primary
Prevention

Secondary
prevention/
early
detection

Diagnosis

Treatment

Survivorship/
Rehabilitation

Palliation/
End-of-life care

Be an
optimist
optimalist

Transforming Health Systems to Meet the

Challenge of Breast Cancer and Chronic Care:
A Diagonal Approach

reast Cancer in the Arab World

March 23, 2015; Amman, Jordan

Felicia Marie Knaul

Harvard Global Equity Initiative

Harvard Medical School
Global Task Force on Expanded Access to Cancer Care and Control
Mexican Health Foundation
Tmatelo a Pecho
Union for International Cancer Control (UICC)