Cancer is the second leading cause of death worldwide, and the global burden is on an inexorably upward trajectory. For the year 2012, there were 14.1 million new cancer cases and 8.2 million cancer-related deaths worldwide.1 It is predicted that by the year 2035, there will be 23.9 million new cancer cases and 14.6 million cancer-related deaths.1
Although the global cancer burden may be rising worrisomely, in some countries, there are signs of hope. We have made some significant strides in the management of cancer. From the days of radical mastectomy pioneered by Dr. William Steward Halsted and considered the standard of care for decades, we now look for reasons to justify this procedure.
Once considered prohibitively morbid, procedures such as pancreatectomy2 and hepatectomy3 are now performed with mortality rates less than 5%, with a meaningful chance of prolongation of life and occasional cures.
Nearly 60 years after the discovery of one of the veteran foundational warhorses of chemotherapy (fluorouracil, synthesized by Dushinsky et al in 1957 at Duke University4), we have witnessed an explosion in the introduction of new chemotherapeutic agents. Neutropenic fevers, once frequently fatal, are now managed successfully. At one time, radiation therapy was just as damaging to the patient as the tumor it was used to treat. With fractionation, superselective targeting, and other advances, we are able to treat tumors with radiation therapy more effectively.
Beyond Just Survival or Palliation
Having established effective and safe treatment practices for cancer care in all disciplines, we now have the luxury to focus on other variables beyond just survival or palliation. Far from just resecting the tumor alone in breast cancer, we are now able to focus on cosmetic endpoints and quality of life. It is not uncommon to spend more time discussing when the patient can return to competitive sports than on the details of the operative approach.
Low- to middle-income countries account for nearly 57% of all cancer cases and nearly 67% of all cancer-related deaths worldwide.— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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For several cancers, we are able to determine the appropriate chemotherapeutic drug based on the presence or absence of particular mutations. It is likely that in the near future, we may become mutation-based cancer doctors and practice in mutation-based clinics instead of organ system–based clinics. Checkpoint inhibitors have added an entire new paradigm to cancer care, and it is highly likely that we are barely scratching the surface. We are able to administer chemotherapeutic agents worth thousands of dollars for an incremental survival benefit sometimes measured in days and weeks.
Although we may not have concocted the “magic bullet” to treat all cancers yet, we have come a long way from calling it a death sentence for everyone. We may not have cured cancer, but we have managed to convert some cancers into chronic diseases. Patients with cancers involving the breast or colon may continue to live active and productive lives, even if they have not entirely parted ways with their disease. It is likely we will continue to convert more and more cancers to chronic diseases before we find any magic bullets. This is clearly reflected in the significant improvement in the 5-year survival for all cancers in the United States, which increased from 49% (1975–1977) to 55% (1987–1989), and even further to 69% (2005–2011).
Less Optimism in Other Parts of the World
This somewhat optimistic picture in our developed part of the world is in stark contrast to what happens in low- to -middle-income countries, where a majority of people live on approximately $10 or less per day. Low- to-middle income countries account for nearly 57% of all new cancer cases and nearly 67% of all cancer-related deaths worldwide.1
Although the majority of the global burden of disease afflicts these low- to-middle income countries, fewer operations are performed there. There are far fewer physicians per 100,000 population and fewer operating rooms. Very few patients in low- to middle-income countries can afford to visit a physician, let alone pay for expensive surgery or chemotherapeutic agents. Nearly 75% to 80% of patients with cancer in these countries will present at an advanced stage, beyond a point where curative therapy is possible and sometimes so advanced even palliation is not possible.
Clearer Picture of Misfortune
It is very easy to be perplexed and wonder why things could not be done differently to improve cancer care in low- to middle-income countries. But going through a likely scenario of cancer affecting a family in one of these countries may provide a clearer picture of the misfortune these individuals experience.
A family with children more than likely has a single breadwinner and a single homemaker. Despite increasing literacy rates and improving economic conditions, any understanding of disease could be at a bare minimum, and any knowledge of cancer may not exist at all. In countries such as India and China, which we know will witness a large rise in cancer burden, 40% to 70% of the population live in rural areas (67% in India and 43% in China).4 Very few cancer awareness campaigns penetrate these rural areas, and an awareness of the early signs of cancer is nonexistent. The presence of a family breadwinner does not imply that anything is in abundance.
The income generated from backbreaking work such as tilling the land or any other manual labor barely suffices to make ends meet. This meagre income is used to feed (scarcely a meal a day) and barely clothe the family and to cover all expenses. Education is a luxury, and few can afford to send their children to school. In these countries, where government-supported safety-net systems are nonexistent or inadequate, missing a day’s work is just not fathomable. Further, these individuals may not have the financial resources or any trappings of modern day living, but they certainly have abundant dignity and would never consider living off borrowed means.
If a breadwinner or a homemaker develops cancer, it is easy to see how he or she will present for medical attention at an advanced stage. Lack of awareness of the grave nature of early symptoms prevents these individuals from even knowing there could be something seriously wrong. More often than not, symptoms are ignored in the hope the ailment will go away on its own, without having to incur an expense they cannot afford. Some countries still consider cancer a taboo subject, which only adds to the innate cultural tendency to ignore the early warning signs. When symptoms persist and worsen, they may not have the time or money, or both, to seek medical attention. The inability to work deprives the breadwinner of the income needed to feed his children and cover other necessities. So the breadwinner and the homemaker continue to work until the symptoms of the disease incapacitate them, by which time it is usually too late for curative treatment.
Dismal Predictions for the Future
It is worrisome that the majority of the current global cancer burden affects the low- to middle-income countries where families such as the one described here live. It is predicted that this predilection for cancer to afflict the low- to middle-income countries preferentially will only worsen in the future.
There are several reasons for this, but one could be the accumulation of cancer-causing environmental risk factors over a relatively compressed time. It took more than a century for the United Kingdom to increase its life expectancy from 47 years in 1901 to 78 years in 2001.4 In contrast, over the same period, the life expectancy in India increased almost threefold (24 years in 1901 to 63 years in 2001).5 Similarly, in the Western world, cancer-causing environmental risk factors accumulated over a period of several decades, providing the time to understand and initiate any mitigating strategies when feasible. In contrast, development in the low- to middle-income countries has accelerated in staccato bursts, with very little time to appreciate the seriousness of the environmental-based cancer risk factors introduced into their societies.
These unfortunate souls might be happy to have neutropenic fever … if only they could afford it.— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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So, although we in the high-income countries may have the good fortune and ability to ponder nuances of cancer care beyond survival, there are millions of people in low- and middle-income countries—a large part of our world—who are ravaged by cancer, with few to no resources for early diagnosis and treatment. They may be helpless but are stoic in their dignity, which can only come from years of living under pervasive adversity. We in the more developed part of the world are blessed with so much of everything. Certainly we have the opportunty to help, but we must increase our efforts. Unless we change something, most people in low- to middle-income countries who develop cancer will continue to die prematurely as a result of their illness.
For many of these individuals, their daily struggle is not whether to use the last penny they have to pay for chemotherapy in an effort to survive another day in the future, but rather how to put a morsel of food on the plate for their children to survive today. These unfortunate souls might be happy to have neutropenic fever … if only they could afford it. ■
DISCLOSURE: Dr. Are reported no conflicts of interest.
Dr. Are is Jerald L & Carolynn J. Varner Professor of Surgical Oncology & Global Health; Associate Dean for Graduate Medical Education (DIO); and Vice Chair of Education Department of Surgery, University of Nebraska Medical Center, Omaha.
1. International Agency for Research on Cancer: GLOBOCAN 2012. Available at http://globocan.iarc.fr/Default.aspx. Accessed August 17, 2017.
2. Cameron JL, He J: Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg 220:530-536, 2015.
3. Sadot E, Groot Koerkamp B, Leal JN, et al: Resection margin and survival in 2368 patients undergoing hepatic resection for metastatic colorectal cancer: Surgical technique or biologic surrogate? Ann Surg 262:476-485, 2015.
4. Dushinsky R, Pleven E, Heidelberger C: The synthesis of 5-fluoropyrimidines. J Am Chem Soc 79:4559-4560, 1957.
5. Roser M: Life expectancy. Our World in Data. Available at ourworldindata.org/life-expectancy. Accessed August 17, 2017.