Health System Responses To Women's Cancers in The Americas

San Antonio Breast Cancer
Symp, Dec 5, 2017
Health System Responses to

Womens Cancers in the Americas:
Closing Divides to Achieve
Universal Health Coverage
San Antonio Breast Cancer Symposium
December 5, 2017
Dr. Felicia Marie Knaul

Miami Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Fundacin Mexicana para la Salud; Tmatelo a Pecho
This
This presentation presentation
is the is theofintellectual
intellectual property the presenter.property of the presenter.
Contact: fknaul@miami.edu Contact:
for permission to fknaul@miami.edu
reprint and/or distribute. for permission to reprint and/or distribute.
Symp, Dec 5, 2017
Closing divides around

womens cancer
is a health, equity & economic imperative;
affordable and achievable through
diagonal approaches.
Synergistic strategies combining
womens rights, health and cancer
platforms need to be
developed & implemented.
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
Symp, Dec 5, 2017
PAISES SOCIOS
ARGENTINA 3
10 pases BRASIL 3
COSTA RICA 3
22 NGOs 2
COLOMBIA
ECUADOR 1
EL SALVADOR 1
MXICO 4
PER 2
URUGUAY 1
PRESIDENCIA VENEZUELA 2
2016-18
TOTAL 22
Symp, Dec 5, 2017
Outline
1. Growing health
priority for LAC
2. Health systems strengthening through
a diagonal approach
3. Examples from Mexico
Symp, Dec 5, 2017
Percentage of DALYs by cause

grouped by world region
100%
8 10 9
15 16
80% 21
41 41
60%
62
85
40%
71
20% 45 49
22
0% 6
Africa Middle East Low and LAC High
Middle Income
Income Countries
Countries
Injuries Non-communicable Communicable, maternal and nutritional
Source: Estimates by the LAC Health Observatory based on data from WHO, 2004.
Symp, Dec 5, 2017
In Latin America and the Caribbean,
demographic and epidemiologic transitions
have been rapid and profound
In just over 40
years, LAC will
achieve the aging
rates that most
European countries 66% 70%
took over two
centuries to reach. Communicable
Life expectancy has Non-
increased from Communicable
approx 30 in 1920,
25% Injuries
to over 75 today
18%
In only a few 12%
decades, causes of 9%
death changed 1980 2010
dramatically.
Source:
This Cepal,is2012.
presentation The epidemiologic
the intellectual profile
property of the of Latin
presenter. America
Contact: and the Caribbean:
fknaul@miami.edu challenges,
for permission limits,
to reprint and
and/or actions.
distribute.
Symp, Dec 5, 2017
The cancer transition: by income, region:

breast and cervical cancer,
% change 1980-2010 BC cases (I)
300
264
252
BC deaths (M)
236
CC cases (I)
% Change in incidence
200 177
144
and mortality
CC deaths (M)
115
96
100
68 68
44 42 31 35
19
0
-14 -14
Latin America Low Middle High
Source: Knaul, Arreola, Mendez. estimates based on IHME, 2012. income income income
Symp, Dec 5, 2017
Leading causes of death among women

15 to 49 years, select LA countries, 2015
Chile Costa Rica Mxico Brasil
Bolivia Ecuador Per Colombia
Source: IHME. GBD 2015.

Symp, Dec 5, 2017
Mexico: Success reducing cervical cancer

death. Emerging challenge of breast cancer.
16 Trends in mortality from

breast and cervical cancer
( 1955-2014 )
Mortality rate x 100,000
0
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2014
Source: Estimaciones propias basada en 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 (1979-2014)
Symp, Dec 5, 2017
Mortality: cervix and breast cancer in

Mexican States (1979-2013)
18 Distrito Federal Nuevo Len
18
16 16
14 14
12 12
Mortality per 100,000 women
10 10
8 8
6 6
4 4
2 2
0 0
1979
1985
1990
1995
2000
2005
2013
1979
1985
1990
1995
2000
2005
2012
2013
20 25
18
Puebla Oaxaca
16 20
14
12 15
10
8 10
6
4 5
2
0 0
2013
1979
1985
1990
1995
2000
2005
2011
1979
1985
1990
1995
2000
2005
2013
Source: Estimaciones propias basadas en datos de DGIS. Base de datos de defunciones 1979-2013. SINAIS. Secretara de Salud.
Symp, Dec 5, 2017
In LMICs a very large % of Breast Cancer cases

and deaths are in women <55
Low income Latin America High Income
Diagnosis
Age at
33%
66% 62%
15-39
40-54
>55
Age at
Death
34%
67% 61%
Fuente: Estimaciones de los autores basadas en IARC, Globocan 2012
Symp, Dec 5, 2017
Avoidable breast cancer deaths:

by country group, 2016
Country group Breast
Latin America and the 57% (24,500)

Caribbean
75% of breast
LMICs
95% of cervical
Symp, Dec 5, 2017
Trends in breast cancer mortality:

USA, Canada, Australia,
Mexico, Colombia
USA
Age-adjusted mortality rate
Canada
Australia
Colombia Mexico
0 2030?
1975 1980 1985 1990 1995 2000 2005 2010 2014
Source: Data extracted from CI5plus.
Symp, Dec 5, 2017
Outline
1. Growing health priority for LAC
2. Health systems
strengthening
through a diagonal
approach
3. Examples from Mexico
Symp, Dec 5, 2017

All people must obtain the health services they
require - prevention, promotion, treatment,
rehabilitation and palliative care - without the risk
of impoverishment (WHO)
a wave of global reforms in the tough context

of a complex epidemiological transition, and
with highly fragmented health systems
Symp, Dec 5, 2017
An effective UHC response to chronic illness

must integrate interventions along the
Continuum of disease:
1. Primary prevention
2. Early detection
3. Diagnosis
4. Treatment
.As well through each
5. Survivorship
6. Palliative care Health system function
1. Stewardship
2. Financing
3. Delivery
4. Resource generation
Symp, Dec 5, 2017
The challenge of chronicity: 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 Secondary
Functions Primary prevention/ Survivorship/ Palliation/
Diagnosis Treatment
Prevention early Rehabilitation End-of-life care
detection
Stewardship
Financing
Delivery
Resource
Generation and
evidence
buliding
Symp, Dec 5, 2017
Coverage of breast cancer treatment

in Latin America (source ESMO)
Adjuvant Breast: Chemo/Biol Metastatic Breast: New/Biol

Trastuzumab
Cycloph (IV)
Trastuzumab
NAB pacllt.
MTX (tap)
MTX (IV)
Epirub.
Pertuz.
Everol.
Babep.
CarbP.
TDM-1
Dogt
Doxo
Padit
Lapat
BEV.
5FU
Country
Argentina
Brazil
Chile
Colombia
Mexico
Peru
Free Full cost to patient

Partly insured Not avaiable
Source: ESMO International Consortium Study of the Availability of anti-neoplastic medicines.
Symp, Dec 5, 2017
Coverage of breast cancer in select LAC

countries by control-care continuum:
complex analysis
Stage of Chronic Disease Life Cycle /components CCC
Palliation/
Primary Secondary Survivorship/
Diagnosis Treatment End-of-life
Prevention prevention Rehabilitation
care
Costa Rica
Mxico Partially Partially
Colombia Partially Partially Partially
Dominican
Rep.
Peru
Symp, Dec 5, 2017
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 add value:
Exploit existing platforms e.g. anti-poverty programs
Compound, which means increase effectiveness at a given cost
Generate positive externalities
Bridge disease divides using a life cycle response
Avoid the false dilemma of disease silos
Diagonalizing Cancer Care:

Symp, Dec 5, 2017
Financing & Delivery

1. Financing: Integrate cancer care into national social
insurance and social security programs and reforms
2. Delivery: Integrate cancer prevention, survivorship
and palliative care into existing primary care
platforms, anti-poverty programs and HIV/AIDs.
3. Pain control and palliative care: reducing barriers to
access for cancer care improves access for all, and
strengthens surgical platforms
4. Advocacy: integrate advocacy around womens
cancer to harness & catalyze womens health and
empowerment, health system reform, & SDGs
Symp, Dec 5, 2017
Outline
1. Growing health priority for LAC
2. Health systems strengthening through
a diagonal approach
3. Examples from
Mexico
Symp, Dec 5, 2017
Expansion of Financial Coverage:

Seguro Popular Mxico
Affiliation:
2004: 6.5 m
Diseases and Interventions:

2016: 54.9 m
Benefits Package
Vertical Coverage
Benefit package:
2004: 113
2016: 287
61 in the
Catastrophic
Illness Fund Horizontal Coverage:
Beneficiaries
Symp, Dec 5, 2017
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 kids
2007: pediatric cancers; breast cancer
2011: Testicular, Prostate and NHL
2012: Ovarian and colorectal
Symp, Dec 5, 2017
San Antonio Breast Cancer Symposium, December 5-9, 2017
Seguro Popular and breast cancer:

Evidence of impact
Adherence to treatment:
2005: 200/600
2010: 10/900
Human faces of impact:
Guillermina
Abish
This
intellectual property the presenter. property of the presenter.
Contact: fknaul@miami.edu Contact:to fknaul@miami.edu
for permission reprint and/or distribute. for permission to reprint and/or distribute.
Symp, Dec 5, 2017
Breast cancer: care continuum
Primary Early Palliative

Prevention Detection Diagnosis Treatment Survivorship
Care
Mexico: Exemplary programs for prevention

of risk factors and investment in treatment
but.
late detection, long lag time between
diagnosis and treatment, and little access to
survivorship or palliative care.
Symp, Dec 5, 2017
5-year survival, breast cancer:

USA and Mexico
Survivorship INCAN Mexico City
Stage USA (ACS) (2007+) (1990-99)
I 98% (>80%) 97% (14%) 82% (10%)

II-III 84% 82% (73%) 59% (87%)
IV 27% 36% (13%) 15% (3%)
WITH TIMELY AND

APPROPRIATE TREATMENT
Sources: ACS. Facts & figures, 2015-2016. Reynoso-Noveron, Mohar et al, Journal of Global Oncology, 2017;
Flores Luna et al, 2008
Symp, Dec 5, 2017
Breast Cancer early detection:

Delivery failure
2nd cause of death, women 30-54
10-15% of cases detected in Stage I
Poor municipalities: 50% Stage 4; 5x rate for rich
I II
50% III IV
High %
Stage IV
0%
Marginalized High Access
Source: Authors estimates with database from IMSS, 2014
Symp, Dec 5, 2017
Barrier: Low quality primary care services

of women diagnosed with breast cancer reported
problems with medical attention in the diagnostic process
Did not receive BCE or information in their

routine annual exam & pap test
Doctors understated the importance of signs
and symptoms manifested by the women,
and sent them home without a diagnosis
NATIONAL QUALITATIVE STUDY Nigenda et al.
Symp, Dec 5, 2017
Diagonalizing Delivery: Engage and Train primary care

promoters, nurses and doctors in early detection and
post-treatment management of breast cancer
> 16,000
Health Promoters
8 Risk Score (0-10) Significant increase in knowledge,
7 *
among health promoters,
6
especially
5
in clinical breast examination
4
(Keating, Knaul et al 2014, The Oncologist)
3
Pre Post 3-6 month
Symp, Dec 5, 2017
The most insidious injustice: Distributed opioid

morphine-equivalent (and
the pain divide: estimated met need for
http://www.thelancet.com/commissions palliative care) Morphine in
mg/patient, 2010-2013
/palliative-care Russia:
124 mg (8%)
Canada:
68,194 mg (31 x)
Western Europe:
18,316 mg (8 x) China:
314 mg (16%)
USA:
55,704 mg (31 x)
Haiti:
5.3 mg (0.8%)
India:
43 mg (4%)
Australia:
40,636 mg (19 x)
Mexico: Bolivia:
562 mg (36%) 74 mg (6%)
Uganda:
53 mg (11%)
Source: Knaul, Farmer, Krakauer, et al. Alleviating the access abyss in palliative care and pain reliefan imperative of universal health coverage. The Lancet, 2017.
Symp, Dec 5, 2017
Access to DOME in Mexico
562 mg per patient with

palliative care need
(serious health related
suffering)
Unment need:
64% palliative care need
95% of all pain contron
Symp, Dec 5, 2017
Coverage of pain control as a component

of palliative care in Mexico
Last 6 months of life for all
In Seguro Popular
- Medicines, primary level of care:
- Acetylsalicylic acid, ibuprofen, morphine, paracetamol,
lidocaine, midazolam, propofol, sevoflurane, vecuronium
- Medicines, second level care:
- Buprenorphine, oxycodone, tramadol + medicines
availabe at primary level
- Medicines for covered cancers, in tertiary hospital
settings:
- All the medicines that are available at secondary level
Symp, Dec 5, 2017
What is still missing in breast cancer

coverage in Mexico?
Health Components of the continuum of care
System
Primary Secondary Survivorship/ Palliation and End-of-
Functions Prevention Prevention
Diagnosis Treatment
Rehabilitation Life Care
Fourth phase of systemic reform

Stewardship National Cancer Plan
National Cancer Registry
Fragmentation by institution
Financing Rigidity and lack of alignment between the 1st, 2nd, and 3rd levels of care
Inflexible system: Lack of portability
Lack of articulation between the 1st, 2nd, and 3rd levels of care
Service Packages of services designed without considering opportunities by level of care
Delivery The basic list of medicines moving away from being essential/basic: should concentrate on
drugs without patents, except where there are no effective alternatives
Diagnosis, survival and palliative care neglected in 1st and 2nd levels, overloaded in the 3rd level
Under-utilization of human resources in 1st level for detection, survival and palliative care
Resource Lack of research on practices, methods, protocols, and implementation and evaluation of health
programs and policies: Mexico falls in between the recommendations for poor countries and
Generation the adoption of recommendations in high-income countries, but we do not have the evidence
we need to solve it.
Symp, Dec 5, 2017
Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities
Symp, Dec 5, 2017
Health System Responses to

Womens Cancers in the Americas:
Closing Divides to Achieve
San Antonio Breast Cancer Symposium
December 5, 2017
Dr. Felicia Marie Knaul

Miami Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Fundacin Mexicana para la Salud; Tmatelo a Pecho
This
intellectual property the presenter.property of the presenter.
Contact: fknaul@miami.edu Contact:
for permission to fknaul@miami.edu
reprint and/or distribute. for permission to reprint and/or distribute.

Health System Responses To Women's Cancers in The Americas

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Health System Responses To Women's Cancers in The Americas

Transféré par

Droits d'auteur :

Formats disponibles

San Antonio Breast Cancer

Symp, Dec 5, 2017

Health System Responses to

Dr. Felicia Marie Knaul

Closing divides around

Percentage of DALYs by cause

The cancer transition: by income, region:

Leading causes of death among women

Bolivia Ecuador Per Colombia

Source: IHME. GBD 2015.

Mexico: Success reducing cervical cancer

16 Trends in mortality from

Mortality: cervix and breast cancer in

In LMICs a very large % of Breast Cancer cases

Avoidable breast cancer deaths:

Country group Breast

Latin America and the 57% (24,500)

Trends in breast cancer mortality:

Universal Health Coverage

a wave of global reforms in the tough context

An effective UHC response to chronic illness

The challenge of chronicity: an integrated

Coverage of breast cancer treatment

Adjuvant Breast: Chemo/Biol Metastatic Breast: New/Biol

Free Full cost to patient

Coverage of breast cancer in select LAC

Mxico Partially Partially

Colombia Partially Partially Partially

The Diagonal Approach to

Diagonalizing Cancer Care:

Financing & Delivery

Expansion of Financial Coverage:

Diseases and Interventions:

Seguro Popular now includes

Seguro Popular and breast cancer:

Breast cancer: care continuum

Primary Early Palliative

Mexico: Exemplary programs for prevention

5-year survival, breast cancer:

I 98% (>80%) 97% (14%) 82% (10%)

WITH TIMELY AND

Breast Cancer early detection:

Barrier: Low quality primary care services

Did not receive BCE or information in their

Diagonalizing Delivery: Engage and Train primary care

The most insidious injustice: Distributed opioid

Access to DOME in Mexico

562 mg per patient with

Coverage of pain control as a component

What is still missing in breast cancer

Fourth phase of systemic reform

Health System Responses to

Dr. Felicia Marie Knaul

Vous aimerez peut-être aussi