Closing the Cancer Divide:

Lessons from Women’s Health

Global Oncology: A continuing lecture series presented by Sylvester
Comprehensive Cancer Center and the University of Miami Institute for
Advanced Study of the Americas
Focused discussions on improving cancer control, health economics and the
world around us
Medical Grand Rounds
January 31, 2018

Dr. Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico
#WorldCancerDay #WeCanICan #CancerAdvocacy
www.worldcancerday.org
January, 2008
June, 2007
 Global Task Force on Expanded
Access to Cancer Care and Control
in Developing Countries

= global health + cancer care

 Closing the Cancer Divide:
An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary I: Should be done
M2. Unaffordable
M3. Impossible
II: Could be done
M4: Inappropriate III: Can be done
1: Innovative Delivery
2: Access: Affordable Meds, Vaccines & Tech’s
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
 Outline
1. Growing equity and
health priority
2. Health systems strengthening through
a diagonal approach
3. Examples from Mexico
4. Opportunities to become engaged
@University of Miami
 Women and mothers in LMICs
face many risks through the life cycle
Women 15-59, annual deaths

Mortality
Breast Cervical
in Diabetes
- 35% cancer cancer
childbirth
in 30
years

291,000 195,000 131,000 139,000

= 465,000
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
 Demographic and epidemiologic transitions
have been rapid and profound: LATAM

In just over 40
years, LAC will
achieve the aging
rates that most
European countries 66% 69%
took over two Communicable
centuries to reach.
Non-
Life expectancy has
Communicable
increased from
approx 30 in 1920, Injuries
to over 75 today 25%
In only a few 16% 15%
decades, causes of 9%
death changed 1980 2016
dramatically.
Source: IHME. GBD 2016.
 The Cancer Transition
Mirrors the epidemiological transition
LMICs increasingly face both infection-
associated cancers, and all other cancers.

LMICs account for the majority of most

cancer deaths.
Cancers increasingly only of the poor, are
not the only cancers affecting the poor
Leading causes of death among women
15 to 49 years, select LA countries, 2016
Chile Costa Rica México Brasil

Bolivia Ecuador Perú Colombia

Source: IHME. GBD 2016

 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
Méndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2014)
 Mortality: cervix and breast cancer in
Mexican States (1979-2013)
18 Distrito Federal Nuevo León
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. Secretaría de Salud.
 “Avoidable” cancer deaths:
Breast and Cervical,
The Americas and LMICs

Income Region Breast Cervical

Latin America and the 57% (24,500) 64% (17,950)

Caribbean

75% of breast
LMIC´s
95% of cervical
 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.
 Late Detection:
Latin America and USA

Lat
Stage Brazil Chile Colom Mexico Peru Urug´y USA
Am

I 18% 20% 22% 12% 18% 40% 21% 80%

II-III 72% 74% 67% 81% 75% 58% 71% 19%
IV 10% 6% 11% 7% 7% 2% 7% 1%

Sources: Justo, Wilking, Johnsson, Luciani, Cazab, 2014, The Oncologist; and ACS. Facts & figures, 2015-2016.
 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
 Outline
1. Growing health priority for LAC

2. Health systems
strengthening
through a diagonal
approach
3. Examples from Mexico
4. Opportunities to become engaged
@University of Miami
 Universal Health Coverage
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
 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
 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
 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:
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 primary care platforms,
maternal and child health and anti-poverty programs.
3. Advocacy: integrate advocacy around women´s
cancer to harness & catalyze women´s health and
empowerment, health system reform, & SDGs
4. Pain control and palliative care: reducing barriers to
access for cancer care improves access for all, and
strengthens surgical platforms
 Outline
1. Growing health priority for LAC
2. Health systems strengthening through
a diagonal approach

3. Examples from
Mexico
4. Opportunities to become engaged
@University of Miami
Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities
 Expansion of Financial Coverage:
Seguro Popular México
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
 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
Seguro Popular and breast cancer:
Evidence of impact
Adherence to treatment:
2005: 200/600
2010: 10/900

Human faces of impact:

Guillermina
Abish
 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.
 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
Barrier: Low quality primary care services
½ 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.
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 3-6 month
Pre Post
 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.
 Outline
1. Growing health priority for LAC
2. Health systems strengthening through
a diagonal approach
3. Examples from Mexico

4. Opportunities to
become engaged
@University of Miami
Visit worldcancerday.org/materials for social media packages,
toolkits, infographics, factsheets, posters and other ways to get involved…
 Salas virtuales:

•Inglés:

https://goo.gl/akBXbT

•Español:

https://goo.gl/bKNFdL

•Portugues:

https://goo.gl/ArDsgW
 PAISES SOCIOS

ARGENTINA 3

10 countries BRASIL 3
COSTA RICA 3
22 NGOs COLOMBIA 2
ECUADOR 1
EL SALVADOR 1
MÉXICO 4
PERÚ 2
URUGUAY 1
PRESIDENCIA VENEZUELA 2
2016-18
TOTAL 22
 Student engagement
opportunities: a few examples
• Global: NCDfree, UICC young leaders
• UM: DOCS, Physicians for Human Rights
• Lancet Commission on Palliative Care and
Pain Relief – Launch Symposium @ UM
April 5-6
• Global cancer research
– Global Oncology & International Programs
– @ UMIA
• Avoidable cancer mortality
• Women’s cancer transition and stigma
 CHW BC Education Project
• Engaging community health workers in South Dade to
promote early detection of breast cancer among female
farmworkers
– Project aims: understand role of community health
workers in this population, and train to educate on BC
early detection and access to healthcare
– Based on previous “train-the-trainer” work in Mexico
(Tomatelo a Pecho)
 SCCC Global Oncology - UMIA
Global Cancer Control Conference
Student Travel Award
• One UM student per year (for 3 years) will receive travel support
(airfare, hotel, and registration)
• For World Cancer Day 2018: to attend the Toronto Global Cancer
Control Conference, March 1-3, 2018
• To apply: submit a one-page personal statement indicating your
interest and what you wish to achieve by attending the TGCCC
• Please submit by Wednesday, February 7th to:
nmrodriguez@miami.edu
 Closing the Cancer Divide:
Lessons from Women’s Health
Global Oncology: A continuing lecture series presented by Sylvester
Comprehensive Cancer Center and the University of Miami Institute for
Advanced Study of the Americas
Focused discussions on improving cancer control, health economics and the
world around us
Medical Grand Rounds
January 31, 2018

Dr. Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico