It has been well documented that noncommunicable diseases, including cancer, cardiovascular disease, and diabetes, now pose the greatest health threat to people living in low- and middle-income countries, surpassing infectious diseases like HIV/AIDS as the leading cause of death and disability.¹ More recent data show how consequential the shift has been in these countries and present a bleak forecast of what may lie ahead.

According to new research, in 2015, noncommunicable diseases accounted for 70% of the total deaths in low-resourced countries, increasing from 31.4 million in 2000 to 39.5 million in 2015, especially among people between the ages of 30 and 70. And these numbers are expected to rise as communicable diseases continue to be successfully controlled and a constellation of factors, including the acceleration of urbanization—in 2017, for the first time, more than half the people in low- and middle-income countries live in cities²—limited access to preventive care, air pollution, poor nutrition, and unhealthy lifestyle choices, fuel the development of noncommunicable diseases such as cancer.³

Recent estimates by GLOBOCAN on the incidence and mortality rates from cancer around the world show that cancer has overtaken cardiovascular disease as the leading cause of death in 48 countries—and cancer is expected to overtake heart disease as the predominate cause of death in the United States in 2020.⁴ In an additional 65 countries undergoing major developmental transitions, cancer is the second to fourth leading cause of death, and it is expected to rise to the first position over the next few decades.⁵

To blunt these trends and address the social and economic disparities that contribute to the global burden of cancer and other noncommunicable diseases, in 2015, the United Nations General Assembly adopted the 2030 Agenda for Sustainable Development and its Sustainable Development Goals. The agenda formally recognizes that noncommunicable diseases constitute a major health and development challenge that impacts every aspect of sustainable growth, including economic, social equity, and environmental protection, and aims to reduce premature mortality from cancer, heart disease, and diabetes by one-third by 2030.

To support these efforts, in 2017, the Union for International Cancer Control (UICC) assembled an international coalition of organizations, including ASCO, to launch C/Can 2025: City Cancer Challenge (www.uicc.org/what-we-do/convening/ccan-2025-city-cancer-challenge), which seeks to increase access to quality cancer treatment and reduce premature deaths from noncommunicable diseases by 25% by 2025.

Cary Adams, MBA, BSc (Hons)

In a wide-ranging interview with The ASCO Post, Cary Adams, MBA, BSc (Hons), Chief Executive Officer of UICC in Geneva, talked about the progress being made to improve cancer outcomes around the world and to reach the goals set by the United Nations to reduce the global burden of noncommunicable diseases over the next decade as well as the challenges ahead.

In the Vanguard of Global Awareness

Please talk about the efforts of UICC to improve cancer outcomes in low- and middle-income countries.

For the past 10 years, UICC has been in the vanguard of raising global attention to a set of noncommunicable diseases that are not just high-income country problems, but are emerging as a significant burden in low- and middle-income countries as well. In 2009, we helped launch the NCD Alliance, which works with organizations in more than 170 countries to improve the prevention of noncommunicable diseases, and we continue to be a major contributor in this effort.

Since the Global Action Plan on noncommunicable diseases was adopted in 2013 and a World Health Assembly resolution on cancer prevention and control was secured in 2017, our activity at UICC has fundamentally changed from bringing attention to the issue of noncommunicable diseases to specifically targeting action at a national level. When I look back on the past decade, I feel great pride at what our community has achieved, including pushing for three high-level meetings on noncommunicable diseases and a target to reduce cancer deaths by 25% by 2025 for all governments; the growing impact of the NCD Alliance; and, more recently, the launch of a new cancer organization, the City Cancer Challenge Foundation.

“The world recognizes the problem we face and has set global targets to pursue. As a result, we are seeing greater attention on cancer in all countries.”

— Cary Adams, MBA, BSc (Hons)

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We have also advocated successfully for an update of the 2005 Cancer Resolution; a new resolution was adopted by the World Health Assembly in 2017, and it provides guidance to countries on strengthening national cancer control. At the same time, we have also worked to include a greater number of cancer medicines on the World Health Organization’s (WHO) Model List of Essential Medicines, as well as assisted in the development of the list of priority medical devices for cancer management; along with the Essential Medicines list, this priority list is intended to provide evidence-based guidance to countries to create their own national lists of Essential Medicines and Technologies.

We should all be proud that we have achieved so much as a community. The world recognizes the problem we face and has set global targets to pursue. As a result, we are seeing greater attention on cancer in all countries.

Closing the Global Cancer Divide

Approximately two-thirds of all cancer deaths occur in low- and middle-income countries. What needs to be done in these countries to enable more cancer prevention and greater access to treatment when cancer does occur to close the global cancer divide?

Over the past decade, there has been a general awareness across low- and middle-income countries of the large and growing burden of noncommunicable diseases. A total of 70% of cancer deaths currently occur in those countries, and by 2030, the number of new cancer cases is expected to increase more than 80%, which is double the rate expected in high-income countries.⁶ Many low- and middle-income countries are unable to deal with this growing burden because they do not have strong health systems, nor health-care workforce, facilities, and medicines in place.

The global attention drawn toward cancer, and other noncommunicable diseases, has made governments in low- and middle-income countries recognize they have a problem that needs to be addressed through developing national cancer control plans, seeking funding for implementation, and investing in the core health-care infrastructure. This will not be easy because many countries are still facing a difficult time addressing the health-care burden of communicable diseases. In some countries that still have high rates of communicable diseases, such as HIV/AIDS, tuberculosis, and malaria, as well as other infectious diseases, emphasis remains on controlling these diseases, whereas the prevalence of noncommunicable diseases is growing, leading to the double burden of communicable and noncommunicable diseases.

Nonetheless, we are seeing that low- and middle-income countries recognize the challenge cancer will pose to health systems in the future. And, thus, they are developing national cancer control plans and increasingly turning their attention to prevention and early detection.

Improving Access to High-Quality Care

There are a number of factors that go into poor survival rates in these countries, including persistent poverty, civil wars, mass displacement, late-stage presentation of disease, and a shortage of cancer specialists, as well as modifiable contributors to cancer, such as high rates of smoking, obesity, and alcohol use. What can UICC and professional societies such as ASCO do to help reduce barriers to accessing high-quality cancer care and provide education in cancer prevention and in the benefits of early detection?

“UICC, ASCO, and other international organizations play a critical role in educating, training, supporting, and raising public awareness on the early signs of cancer.”

— Cary Adams, MBA, BSc (Hons)

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The first thing UICC can do is reach out to cancer organizations in low- and middle-income countries and invite them into our community. UICC has grown from about 350 cancer organizations 10 years ago to well over 1,100 now, and many of those organizations are in low- and middle-income countries. Once these countries are in the UICC family of organizations, we are able to provide the knowledge and expertise we have across our community. We can also engage them in such activities as World Cancer Day, held on February 4 each year, when they can receive great resources to help them determine ways to profile cancer in their country. Moreover, they gain access to our fellowship programs, the World Cancer Leaders’ Summit, and the World Cancer Congress, as well as information about how advocacy can be used to create policy change and secure greater investment in cancer.

Like ASCO, UICC provides a lot of training support for those countries that are clearly lacking in oncology knowledge, expertise, as well as technical and financial resources. UICC, ASCO, and other international organizations play a critical role in educating, training, supporting, and raising public awareness on the early signs of cancer, so people can present at an earlier stage, when their cancer is more likely to be cured.

Paying for the Cost of Cancer Care

A recent report⁷ by WHO on the pricing of cancer medicines and its impact found that, among other factors, without health insurance, cancer treatment is unaffordable for many patients. What are your thoughts on this finding?

We totally support the global focus provided by WHO on improving universal health coverage around the world. The United Nations has set universal health coverage as a target among its Sustainable Development Goals to be achieved by 2030.

UICC is working diligently with WHO to ensure that the Essential Medicines list is regularly updated, and we have contributed to the development of an Essential Technologies list, which sets the minimum core infrastructure that all countries should have in place to treat the most common cancers. Most of the drugs on the Essential Medicines list are off patent, so they should be accessible and affordable. We know they work and can save lives.

In the context of universal health coverage and in the requirements set out in a country’s national cancer control plan, we expect most governments to have cancer drugs on the Essential Medicines list and diagnostic tools to treat patients. So, it is important that we argue for cancer treatment and care to be embedded in the discourse on universal health coverage if this leads to a national plan for the country. Cancer should not be left behind.

Is UICC working with pharmaceutical companies to reduce the cost of drugs in low- and middle-income countries?

The pharmaceutical industry has signaled its ambition to make cancer drugs and other medicines available in low- and middle-income countries, and we all share that ambition. The WHO report questions the way in which the industry makes pricing decisions, suggesting there is plenty of scope to increase availability and reduce the prices of more innovative drugs. It demands improved dialogue and transparency, and that is where UICC can play a role. We hope that the outcome of this increased focus on the issue will be greater availability of generic and innovative cancer medicines around the world at a price that is affordable in all contexts—saving lives and giving hope to millions.

Implementing Treatment Solutions

Earlier you talked about the launch of C/Can 2025: City Cancer Challenge. Comprehensive cancer centers are underway in Cali, Colombia; Kumasi, Ghana; Asunción, Paraguay; and Yangon, Myanmar, and you have recently extended your network of cities in Brazil, Georgia, and Rwanda. Please talk about the progress so far in these cities.

The City Cancer Challenge is quite an innovative initiative. It has now been launched as a stand-alone foundation in Geneva, and we are very proud of the new board and staff who will take this great initiative forward. When we first designed it and shared it with our colleagues at ASCO, it was clear that we were intending to put in place something that was novel and different from previous initiatives. C/Can creates momentum among those involved in oncology care, including medical professionals, patients, and government officials, who all pull together to identify their priorities. They then draw on the international community, including UICC and ASCO, to help them address those priorities.

As mentioned, Cali, Kumasi, Asunción, and Yangon have already gone through this process; and a set of priorities that are supported by their governments, patients, local medical professionals, and cancer treatment centers have been agreed upon. So, we have already achieved a great deal by bringing some cohesion to the issue.

The demand from other cities around the world to establish their own City Cancer Challenge is growing, and the ambition is to reach 20 cities by 2020, scaling up to a global community of cities and partners working together to design, plan, and implement cancer solutions over the next 10 years. Every time the City Cancer Challenge Foundation goes into a city of more than 1 million people, it is inspired to improve cancer care there and gives hope to large populations of patients, city by city, around the world. UICC continues to work closely with the Foundation, giving it every chance to increase its impact over time.

Measuring the Effectiveness of Cancer Control Programs

What results are you seeing through the collaborative efforts of UICC, partner organizations, and individual governments to enact national cancer control programs to improve oncology care and reduce cancer deaths in low- and middle-income countries?

That’s an opportune question because at the end of this past year, the team at UICC and the International Cancer Control Partnership conducted research⁸ to review the current published national cancer control plans to see how effective they are in terms of implementation of the principal approaches to cancer control: prevention, such as tobacco control; early detection; diagnosis and treatment; and palliative care. When we looked at data from research that we conducted in 2013, which is the last time we conducted that type of research, we found that around the world, only 66% of countries had a national cancer control plan in place. Now, that number is up to 81%, which is really good news.

We now know which plans are specifically cancer control plans and which ones are imbedded with a general noncommunicable disease plan. That’s important to know because it reflects the work we’ve been doing on a global level to raise the focus on the rise in noncommunicable diseases, including cancer, in these countries and the importance of having disease control plans in place.

“The demand from other cities around the world to establish their own City Cancer Challenge is growing, and the plan is to reach 20 cities by 2020.”

— Cary Adams, MBA, BSc (Hons)

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For example, we know that 41% of the countries reviewed had both national cancer control plans and noncommunicable disease plans, whereas another 41% only noncommunicable disease plans, and the remainder had national cancer control plans alone. What we are seeing is a real improvement in the way governments are documenting their ambition in addressing heart disease, diabetes, and cancer.

In our research, we found that more than half of the countries mentioned the need to budget cancer-related plans, but only 10% provided details about how the plan would be funded and budgeted. To achieve the Sustainable Development Goals target by 2030, there must be greater emphasis on setting realistic priorities, determining their cost, and ensuring a sustained budget for cancer control. We also need to monitor the implementation of the plans and see whether they are resulting in more skilled oncologists, more radiotherapy equipment, more cancer treatment centers, more pathologists, and more palliative care units.

However, I am optimistic this is a really good sign that the rising burden of cancer is being taken more seriously by more countries around the world and that realization will lead to improvements in care for patients and a reduction in cancer deaths. ■

DISCLOSURE: Dr. Adams reported no conflicts of interest.

REFERENCES

1. Council on Foreign Relations: The Emerging Global Health Crisis: Noncommunicable Diseases in Low- and Middle-Income Countries, Task Force Report No. 72. New York, Council on Foreign Relations Press, 2014.

2. Bollyky TJ: The future of global health is urban health. Council on Foreign Relations, January 31, 2019. Available at https://www.cfr.org/article/future-global-health-urban-health. Accessed April 30, 2019.

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7. World Health Organization: Technical report: Pricing of cancer medicines and its impacts: A comprehensive technical report for the World Health Assembly Resolution 70.12: operative paragraph 2.9 on pricing approaches and their impacts on availability and affordability of medicines for the prevention and treatment of cancer. World Health Organization. 2018. Available at https://apps.who.int/iris/handle/10665/277190. Accessed April 30, 2019.

8. Romero Y, Trapani D, Johnson S, et al: National cancer control plans: A global analysis. Lancet Oncol 19:e546-e555, 2018.