International community must approach cancer as a global health priority

Harvard Medical SchoolAug 16 2010

Once thought to be a problem primarily in the developed world, cancer is now a leading cause of death and disability in poorer countries. Almost two-thirds of the 7.6 million cancer deaths in the world occur in low- and middle-income countries.

A paper to be published online in the Lancet on Monday, August 16, asserts that the international community must now discard the notion that cancer is a 'disease of the rich' and instead approach it as a global health priority. This "call to action" paper is authored by Paul Farmer, chair of the HMS department of global health and social medicine; Julio Frenk, dean of the Harvard School of Public Health (HSPH); Felicia Knaul, Director of the Harvard Global Equity Initiative (HGEI) and HMS associate professor of social medicine; and Lawrence Shulman, chief medical officer at Dana-Farber Cancer Institute (DFCI) and HMS associate professor of medicine at DFCI.

Additional authors comprise 19 other leaders from the global health and cancer communities representing the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC), including honorary co-Presidents Lance Armstrong and HRH Princess Dina Mired of Jordan. GTF.CCC was launched in November of 2009 by HMS, HSPH, HGEI and DFCI.

"The provision of adequate health care in settings of poverty is by definition difficult, but the past two decades have taught us that setting our standards high can help bring new resources to bear on old problems," says Farmer, who is also executive vice president, and cofounder, of Partners In Health. "The integration of cancer prevention and care where both are needed is precisely what we need to do if we are to make the response to the challenge as global as cancer itself. 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."

Comparing cancer fatality rates between low- and high-income countries reveals stark disparities. By some estimates, fatality rates in low-income countries are 75 percent, in lower middle-income 72 percent, and in upper middle-income 64 percent. In contrast, high-income countries experience a 46 percent fatality rate. This enormous difference in survival--particularly large for many highly treatable and curable cancers such as cervical, breast, testicular and acute lymphoblastic leukemia in children--denote the scope of action.

"The gaps in access to cancer care and control are one of the greatest challenges in global health in the world," says Knaul. "As a person living with cancer, diagnosed in a developing country, I believe we must address this glaring inequity. Evidence shows that this can be done." Many of the more than 4 million deaths from cancer each year in low- and middle-income countries can be averted through early detection and treatment. Millions more people with advanced or untreatable cancer but without access to palliative care will die with great and preventable suffering, often leaving those surviving them impoverished from attempting to meet even the most basic costs of the disease.

This suffering and needless loss of life will persist without a rapid recalibration of global and local response. 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,' that is, the fact that low- and middle-income countries account for almost 80 percent of the burden of disease due to cancer yet receive only 5 percent of global resources devoted to deal with this emerging challenge." The authors, speaking on behalf of the GTF.CCC, propose, and are working toward, the following:

• Raise global awareness of the impact of cancer on developing countries, creating a call to action on both the global and national level.
• Define the packages of essential services and treatments needed to provide care in low-resource settings for cancers that can be cured or palliated with currently available therapies.
• Increase access to the best treatment for cancer through the procurement of affordable drugs and services.
• Reduce human suffering from all cancers through universal access to pain control and palliation.
• Develop and evaluate successful service delivery models in different economic and health system settings and share the lessons and evidence globally.
• Expand the leadership, stewardship and evidence base for implementing the most efficient approaches to cancer care and control in developing countries.

As Princess Dina Mired of Jordan, Honorary Co-President of the GTF.CCC, confirms, "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."

The extension of integrated cancer prevention, diagnosis and treatment to millions of people at risk of or living with cancer is an urgent health and ethical priority. The authors argue - citing data from resource-constrained settings - that the unacceptable gap between poor and rich can be reduced through a bold research, financing and implementation agenda that combines global and local efforts.

According to Larry Shulman, "Access to life-saving cancer care is a human right, and must be brought to those in developing countries. We have shown we can do this in the treatment of other illnesses, and we can and must do this with cancer care. This should be viewed as an imperative rather than as an option."