Low- and middle-income countries bear a larger share of the global cancer burden than does the developed world,” said Greta Massetti, PhD, Associate Director for Science, Centers for Disease Control and Prevention (CDC) Division of Cancer Prevention and Control and Co-Chair of the National Cancer Policy Forum workshop “Cancer Care in Low-Resource Areas,” held recently in Washington, DC.
The same applies to poor areas in developed countries, which also suffer a disproportionate burden of cancer risk, incidence, and mortality. Cultural and socioeconomic factors exacerbate the problem and contribute to disparities. “Cancer mortality can be reduced, but outcomes vary significantly because control infrastructure is highly variable among and within countries,” she said. Cancer control comprises prevention, detection, and diagnosis coupled with informed decision-making, treatment, outcomes research, and survivorship.
These factors are affected by what Dr. Massetti called crosscutting issues: communications, surveillance, social determinants of health disparities, genetic testing, decision-making, dissemination of evidence-based interventions, quality of care, epidemiology, and measurement, all of which tend to be in shorter supply and of poorer quality in low- and middle-income countries.
In fact, despite the larger death toll from cancer, a large portion of health-related funding from private organizations and from U.S. and European governments to low- and middle-income countries is invested in treatment and prevention of infectious diseases like HIV/AIDS, tuberculosis, and malaria. For example, according to Dr. Massetti:
- HIV/AIDS care receives $6.2 billion, with 2.1 million deaths.
- Tuberculosis care receives $903 million, with 1.1 million deaths.
- Malaria care receives $1.3 billion, with 711,000 deaths.
- Cancer care receives $168 million, with 4.8 million deaths.
Prevention is even more critical. “Thirty percent of all cancer deaths are preventable,” said Dr. Massetti. “This is especially true with regard to tobacco use, which causes 22% of all cancer deaths and 71% of lung cancer deaths worldwide. Viral infections such as hepatitis B and C and human papillomavirus (HPV) are responsible for almost 20% of cancer deaths in low- and middle-income countries. Moreover, 80% of cancers in these countries present at a stage when cure is impossible and palliation is the only treatment.”
Challenges in Prevention, Control, and Early Detection
Thomas J. Bollyky, Senior Fellow for Global Health, Economics, and Development, Council on Foreign Relations, raised three critical questions: (1) Are cancers and other noncommunicable diseases a crisis in low- and middle-income countries? (2) What is the U.S. interest in addressing that crisis? (3) What is a practical, cost-effective role for collective action?
The answer to the first question is a resounding yes. There has been a steep rise in cancer since 1990, from 18% of all deaths worldwide to almost 28% in 2012, and most of that increase has occurred in Africa and Asia. Noncommunicable disease–related deaths are rising faster than the population is increasing, and noncommunicable diseases are appearing in younger people with worse outcomes and increasing mortality. Moreover, the rise of noncommunicable diseases exceeds the decline of infectious diseases.
The United States should have an interest in the worldwide cancer crisis, but that interest is not reflected in U.S. aid programs—at least not yet, said Mr. Bollyky. “We have no dedicated programs or national budget, although there are small-scale, ad hoc efforts to integrate objectives into U.S. global health programs. However, only $10.8 million was spent this way in 2013.”
Investments to address noncommunicable diseases would support economic development and trade because low- and middle-income countries represent about half of global growth since the 2008 financial crisis. The 2011 World Economic Forum estimated that noncommunicable diseases will represent $21.3 trillion in losses in developing countries in the next 2 decades. Therefore, helping these countries address their health crises can build fruitful partnerships with allies and prevent economic disaster.
For the third question—how to help—Mr. Bollyky suggested:
- Increase U.S. investments in the areas where effective interventions already exist and where an existing U.S. aid infrastructure can be leveraged to improve access in low- and middle-income countries, such as international tobacco, HPV vaccination and screening, and hepatitis B immunization
- Increase U.S. investments in the diseases where effective interventions exist but require adaptation for wider use in low-infrastructure and resource settings in developing countries, such as for breast and stomach cancers, leukemia, and children’s cancers
- Greater U.S. cooperation with developing countries and the private sector on improving population- based prevention of modifiable behavioral risks and developing lower cost chronic care strategies
Kathleen M. Schmeler, MD, Associate Professor, Department of Gynecologic Oncology, MD Anderson Cancer Center, used cervical cancer as an example. In the United States, there are 12,900 new cases of cervical cancer each year, with 4,100 deaths. It is the 14th most frequent cancer among women. In low- and middle-income countries, it is one of the leading causes of cancer death, especially in Mexico, South America, and sub-Saharan Africa. Each year, 400,000 women die of the disease globally. Cervical cancer rates are also high in underserved areas of the United States, such as the Texas-Mexico border where cervical cancer rates are 31% higher than in nonborder counties.
About 1.3 million people live in four counties in Texas on the Mexican border; 90% of these people are Hispanic, 40% of whom live in poverty. Less than 5% of eligible women receive cervical cancer screening, and loop electrosurgical excision procedure services are available only 1 day a month. The rate of cervical cancer is 31% higher than the national average.
While these are dismal statistics, Dr. Schmeler also painted a more positive picture regarding the availability of HPV vaccine in the United States. It is recommended for all girls and boys 11 and 12 years of age and requires three doses over 6 months. Despite the fact that the vaccine must be given prior to the onset of sexual activity, it has been 93% to 98% effective in preventing cervical dysplasia/cancer and is very safe.
The downside is that there are no school-based HPV vaccination programs; it must be done privately. Thus, only 40% of girls complete the vaccination series, as do 21.6% of boys. In Australia, Canada, and the United Kingdom, the rate is more than 70%, likely due to school-based vaccination programs.
Cervical cancer screening systems in the United States require a significant infrastructure including a pathologist for diagnosis, which is a critical problem in much of Africa. Per pathologist, there are 15,108 people in the United Kingdom and 19,232 people in the United States. Contrast that with 200,000 to 500,000 people per pathologist in South Africa and Botswana, 5 million in Niger and the Congo—and none in Somalia and Chad.
One way to partially counteract this dearth is developing new technology such as high-resolution microendoscopy, an optical imaging system developed by Rebecca Richards-Kortum, PhD, at Rice University that allows for point-of-care diagnosis of precancerous lesions. It can be performed by nonphysician health workers and can be combined with a loop electrosurgical excision procedure or cryotherapy for a single-visit treatment approach.
Improvements Not Easy but Possible
In Botswana, HPV had become an increasing problem, said Doyin Oluwole, MD, MRCP, FRCP, FWACP, CEO, Global Health Innovations and Action Foundation. “Overworked health staff were focused on childhood immunization and said that HPV vaccination could not begin until 2017. Moreover, there was neither a national injection safety policy nor use of autodisabled syringes. Management of stock was inadequate, and it was difficult to purchase HPV vaccine at a price below what was offered by manufacturers.”
Nevertheless, there were opportunities to decrease the incidence of HPV infection. The Ministry of Health provided leadership in advocacy and oversight and government allocated resources for training and purchase of vaccine. A national cervical cancer control program was supported through public-private partnerships, including the U.S. government via the President’s Emergency Plan for AIDS Relief ($3 million); the World Bank for HPV vaccination ($385,000); ASCO for improved histology testing; American Society for Colposcopy and Cervical Pathology for training; Becton, Dickinson and Company for donation of 100,000 autodestruct syringes; Merck and Company for donation of 7,800 doses of HPV quadrivalent vaccine (Gardasil) in 2013 and 44,000 in 2014; and the Bill & Melinda Gates Foundation/CDC Foundation for analysis of cervical cancer data systems.
Results were tangible and sustainable: Botswana developed a national policy on cervical cancer control. The government now fully owns and leads the HPV vaccination program, and the cervical cancer control program is embedded in the national budget. Evaluation of the current plan (2012–2016) will use findings to plan for the next 5 years—with National Cancer Institute support.
Dr. Schmeler also described the Extension for Community Healthcare Outcomes (ECHO) program established in 2003 by Sanjeev Arora, MD, FACP, FACG, of the University of New Mexico, Albuquerque, and Ernest Hawk, MD, MPH, of The University of Texas MD Anderson Cancer Center, Houston, in response to a hepatitis C crisis in New Mexico. The mission of Project ECHO is to expand care in rural and underserved areas through telementoring.
The problem was twofold: Rural providers did not know how to treat hepatitis C virus, and their patients were unable to travel to university specialists. So the project identified primary care providers from 16 rural clinics and 5 prisons in New Mexico and began a telementoring program.
The program consists of a weekly teleconference, where providers from community clinics present cases and feedback is given by university specialists, including hands-on training. Project ECHO compared 407 patients with hepatitis C virus treated at a university hospital to 21 rural clinics and prisons. There was no difference in cure rates between the two groups and no difference in serious adverse events.
Project ECHO has been so successful that it has been expanded to Uruguay, Colombia, Mexico, El Salvador, Guatemala, Peru, and Brazil—and in Africa to Zambia and Mozambique.
Sociocultural Considerations
Vivien D. Tsu, PhD, MPH, Associate Director of Reproductive Health at PATH and Affiliate Professor of Epidemiology at the University of Washington, Seattle, said that culture is a matter of beliefs, customs, practices, and behaviors shared by a group, whereas the social realm includes education, income, occupation, ethnicity, race, religion, political affiliation, and geography. All of these factors can be determinants of illness and health in various ways and on various levels, and all influence health interventions. Good outcomes are most likely achieved when interventions take sociocultural factors into consideration.
“We strive to make all health care effective, efficient, acceptable, and available equitably, but for cancer prevention and control, social and cultural factors make this particularly challenging,” said Dr. Tsu. She said there is a strong stigma attached to cancer because of its lethality, lack of understanding of the disease process, and fear of contagion. “Cancer prevention has a long time lag prior to its benefit, and many cultures are fatalistic and not future oriented. Moreover, the high cost of treatment leads to inequitable access.”
Specifically, breast and cervical cancer deaths have outstripped maternal mortality and continue to rise, and in many areas of the world, there are escalating differences between rich and poor. There are, however, opportunities for prevention and control—for breast cancer, through early detection, and for cervical cancer, through HPV vaccination, screening, and treatment for precancer.
Factors related to sexuality play a critical role in the development of these cancers and can affect a woman’s willingness to seek treatment for breast or genital symptoms, and many women fear that they will be blamed for their disease. They also fear loss of sexual function, fertility, and their breast(s). Some women may even be too modest to be examined in the first place.
Electra D. Paskett, PhD, Marion N. Rowley Professor of Cancer Research and Director, Division of Cancer Prevention and Control, The Ohio State University, Columbus, found similar problems in southeastern Ohio.
The region, she said, is considered part of Appalachia, where only 24% of women aged 50 to 74 received a mammogram in the past year. The abnormal Pap test rate for the United States is 3% to 4%; in Gallia County, Ohio, an Appalachian county, it is 18% to 22%, and only about 60% followed recommendations for follow-up care. Barriers to the test, as well as other types of health care, include lack of insurance, poor health literacy, travel and financial concerns, and the need to interrupt the traditional function of women—to be home all the time. As a result, breast cancer is more likely to be diagnosed at a later stage in this area, compared to rates in urban women.
One solution to the problem is the use of a multifaceted program such as the Forsyth County Cancer Screening Project, which increased breast and cervical cancer screening among poor and minority women. It was funded in 1992 to work in low-income communities in two cities in North Carolina. “Our goal was to take health-care messages to the people and listen to their concerns. We used lay health advisors, church groups, one-on-one meetings, anything we thought would get the message out,” said Dr. Paskett.
It worked. The rate of mammography increased by 18% and of Pap testing by 21%. More recently, patient navigators, lay-persons who are trained to assess and resolve individual barriers to return for follow-up care following an abnormal screening test coached patients about what test results meant, accompanied them to a hospital or clinic, made phone calls to schedule follow-up appointments and arrange transportation, and taught them how to be their own navigators.
“Cost is still a barrier that affects asking for help, but a navigator can sometimes find ways around that problem too,” said Dr. Paskett.
Tobacco Control
“Tobacco is the leading cause of cancer, and lung cancer is the leading cause of all cancer deaths,” said Michael P. Eriksen, ScD, MSc, Dean of the School of Public Health, Georgia State University, Atlanta. It’s not just smoking; smokeless tobacco has become a global problem, used in at least 70 countries by more than 300 million people. Southeast Asia has the worst problem—89% of the world’s users live there and have the highest attributable disease burden. In India, smokeless tobacco use exceeds cigarette smoking.
Smoking prevalence varies widely around the world, said Stella A.
Bialous, RN, DrPH, Associate Professor in Residence, Social and Behavioral Sciences, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco. Globally, it dropped slightly between 2007 and 2013, and men smoke about five times as much as women. In high-income countries, the disparity between men and women is less than 50%, but in low- and middle-income countries, the differences are staggering: Men smoke eight to nine times more than women.
As smoking prevalence decreases in the United States and Europe, the tobacco industry is aggressively seeking new consumers in low- and middle-income countries—and finding them. “Tobacco sales are increasing, and the industry may seem monolithic and indestructible, but it is not,” Dr. Bialous said.
To counteract the effort, the World Health Organization (WHO) led the development of the WHO Convention on Tobacco Control in February 2005 as a response to the global tobacco epidemic. In addition to decreasing the number of smokers, this United Nations public health treaty encouraged governments to thwart tobacco industry efforts and believes there is a fundamental and irreconcilable conflict between the industry’s interests and public health policy interests. It encouraged everyone dealing with the tobacco industry to operate in an open and above-board manner, and because the tobacco industry’s products are lethal, the treaty emphasizes that these companies should not be granted financial or other incentives to establish or run their businesses.
Of the 193 countries in the world, 180 are belong to the Convention as of October 2015. The United States is not one of them.
The WHO Framework Convention on Tobacco Control measures assist countries in reducing the demand for tobacco by monitoring use and prevention policies; protecting people from tobacco smoke; helping cessation; warning about the dangers of tobacco, enforcing bans on advertising, promotion, and sponsorship; and raising taxes on tobacco. But regardless of how many treaties are signed, unless people quit smoking, tobacco deaths will continue to rise dramatically, to about 520 million (this [the number of deaths] is cumulative in 100 years and not per year or decade) by 2050. Even if the proportion of young adults who begin to smoke is halved by 2020, 500 million of them will still die by 2050. If adult consumption is halved by 2020, 340 million will still die.
Despite these gloomy predictions, “Cessation is a pivotal policy on an individual level,” said Dr. Bialous. “It is evidence-based, it saves lives, it is cost-effective, and lung cancer patients who quit survive longer.”
The tobacco industry must be continually monitored and measures developed to counter its influence, she added. Health professionals, especially in oncology, must actively encourage patients to stop smoking. ■
Disclosure: Drs. Massetti, Bollyky, Schmeler, Tsu, Paskett, and Eriksen reported no potential conflicts of interest. Dr. Bialous has received funding from Bristol-Myers Squibb Foundation and Pfizer IGLC.
