Although the National Cancer Act of 1971 has resulted in tremendous advances in cancer research, which have led to sharp declines in cancer mortality in the United States—from 1991 to 2018, there has been a 31% decrease in overall cancer death rates—and more than 17 million cancer survivors,1 much of this progress has not translated globally. According to the World Health Organization (WHO), globally, there are an estimated 20 million new cases of cancer and 10 million deaths from cancer. If current trends continue, the world will see a 60% increase in cancer cases over the next 2 decades, with the greatest increase (about 81%) occurring in low- and middle-income countries.2
The reasons for the disparity between high- and low-income countries are many. They include a lack of access to new treatments and high-quality cancer care; a lack of cancer prevention strategies, including tobacco cessation programs and vaccination against human papillomavirus and hepatitis B to prevent liver cancer; oncology workforce shortages; and late-stage presentation of disease. WHO is predicting that at least 7 million lives could be saved over the next decade if certain conditions, such as the implementation of universal health care, are met.2
Elisabete Weiderpass, MD, MSc, PhD
To gain an international perspective on the impact of the National Cancer Act and the potential improvements in cancer care in low- and middle-income countries over the coming decades, The ASCO Post talked with Elisabete Weiderpass, MD, MSc, PhD, Director of the International Agency for Research on Cancer (IARC).
Worldwide Impact of the National Cancer Act
Please talk about the impact the National Cancer Act of 1971 has had on cancer care worldwide, especially in low- and middle-income countries.
Although there is much to celebrate about the progress made in decreasing mortality rates in the United States over the past 50 years due to the National Cancer Act, there are inequities and disparities in the number of cancer cases and deaths between countries and within countries. Low- and middle-income countries bear a larger burden of cancer mortality than high-income countries, with as many as 70% of cancer deaths occurring in low- and middle-income countries, mainly as a result of population aging and population increases. In addition, these countries have fewer resources allocated to cancer research; a rising rate of cancer incidence due to improvements in life expectancy from reduced infectious disease mortality; and increased exposure to other risk factors common in high-income countries, such as smoking tobacco, physical inactivity, and changes in dietary patterns.
The National Cancer Institute (NCI) recognized the need to raise awareness about and take action against cancer in low- and middle-income countries, achieve a better understanding of the current and future burden of cancer in these countries, and take appropriate and feasible next steps in cancer control. Consequently, most low- and middle-income countries have noncommunicable disease or cancer control programs in place to promote primary prevention by tackling major carcinogens. Improvements in infection-related cancers are also to be expected. Lessons learned from the United States in preventing, diagnosing, and treating cancers, as well as in reducing inequality in cancer care, should be shared with low- and middle-income countries to tackle the same problem. Additional research is needed in the field of prevention and early diagnosis, and testing interventions will be the next phase of research in low- and middle-income countries.
Every country faces common challenges in the delivery of cancer care, irrespective of its income status, and there is a huge potential for an exchange of knowledge.— Elisabete Weiderpass, MD, MSc, PhD
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Reducing the Global Cancer Burden
What improvements do you see happening in low- and middle-income countries over the next 10 to 20 years and beyond that might result in reducing the cancer burden and increasing cancer survivorship?
The cancer burden will indeed increase over the next few decades in low-resource countries as the population ages. International, regional, and national cancer control and research programs are increasingly identifying and supporting ways to prevent cancer from occurring in the first place.
Most low- and middle-income countries have a noncommunicable disease or cancer control program in place to promote primary prevention by tackling major carcinogens. Tobacco remains a large contributor to cancer deaths, and the WHO Framework Convention on Tobacco Control provides a roadmap for reduced exposure to tobacco smoke and regulation of the contents of tobacco products.3 Low- and middle-income countries minimally affected by the tobacco smoking epidemic will be wise to protect that status quo and learn from the lessons of the immense lung cancer and other cancer deaths experienced by many Western countries.
Improvements in infection-related cancers are also to be expected. Human papillomavirus vaccination programs are now underway in more than 100 countries, and antiretrovirals have reduced cancer risks in people living with HIV/AIDS.
Less certain will be the evolution of changes in diet, physical activity, and nutrition as countries transition. In terms of cancers originating from environmental and occupational carcinogens, there are strong possibilities to reduce these exposures and consequential cancer risks, but greater knowledge of local exposure sources and how to avoid them is needed.
In parallel, we can expect improvements in cancer mortality and survivorship of cancers less amenable to prevention, but potentially they are associated with a good prognosis if diagnosed and treated early. Breast cancer in women is the key cancer type in this context.
The WHO Global Breast Cancer Initiative was launched on International Women’s Day 2021 (March 8) and is set to fuel programs, funding, and partnerships to achieve early appropriate diagnosis and treatment of this cancer. This must be a critical priority for all governments in all countries. Unlike the longer time needed for program investments in primary prevention to see visible results in declining cancer risks, effective secondary prevention programs can show improvement, including saving lives, in 5 years or less.
Overcoming Inequality in Cancer Care
How can high-income countries like the United States help improve cancer care for patients in low- and middle-income countries?
Every country faces common challenges in the delivery of cancer care, irrespective of its income status, and there is a huge potential for an exchange of knowledge. One such challenge is inequality in access to cancer prevention, early detection, and management services. Sections of the population bear a disproportionate burden of cancer due to social, economic, and environmental disadvantages. Deliberate efforts have been made recently in the United States to measure cancer health disparities, identify the factors contributing to these disparities, and conduct research to find solutions to address the problem.
Establishing a similar program as the NCI’s Center to Reduce Cancer Health Disparities in low-resource countries and training the next generation of researchers will go a long way toward minimizing cancer disparities in these countries. Lessons learned in the United States in reducing inequality in cancer care should be shared with low- and middle-income countries, so they can tackle the same problem. Such exchanges can be mutual.
It would also be helpful to foster international twinning partnerships, which are collaborative relationships between a university department or cancer program in the United States and a cancer program/facility in a low-resource country. This is a great example of a mutual transfer of expertise, skills, and knowledge. Such a twinning model was pioneered by the St Jude Children’s Research Hospital in Memphis and has made a great impact in improving childhood cancer care in many countries.
Finally, strengthening collaborative research between the United States and low-resource countries would be mutually beneficial. Several research programs at the IARC have demonstrated the power of research collaboration between a low- or middle-income country and the United States to improve cancer prevention globally. Supported by research funding from the NCI and IARC, researchers have developed an affordable and simple technology called thermal ablation to treat cervical precancers and evaluated it in Zambia, East Africa. This technology was subsequently recommended by WHO and is being widely used in low- and middle-income countries. There are many such examples of how these collaborations are benefiting patients with cancer.
Improving Cancer Survivorship
How optimistic are you that worldwide efforts to reduce the cancer burden in low-resource countries will be successful in improving cancer survivorship in these countries?
Our global data indicate that, by 2040, there will be 30.2 million new cases of cancer and 16.3 million cancer-related deaths worldwide.4 More than half of new cases and two-thirds of cancer deaths will occur in low- and middle-income countries, where access to early, accurate diagnosis and quality care is woefully lacking. It is time to act, and it is time to act now.
Although our understanding of cancer is unprecedented, cancer continues to be a leading cause of death, largely because of a lack of application of known interventions. A comprehensive response that promotes prevention, early detection, treatment, and pain control is critical to saving lives.
The growing cancer burden has especially harsh consequences for women due to gender discrimination, stigma, and cultural taboos. A woman who develops breast cancer in the United States or the United Kingdom has an 85% to 90% chance of survival; in many low-income counties, her odds of survival are as low as 10% to 25%.5
Health systems in low-resource countries are overwhelmed with competing priorities, and many providers of care are unprepared to deal with the growing epidemic of cancer. However, innovative, interdisciplinary programs are being piloted in these settings throughout the Americas, Asia, and sub-Saharan Africa. Some have already shown great promise to reduce death and disability from breast and cervical cancers while strengthening primary care and health systems overall. Control of breast and cervical cancers should be viewed as a “best buy” investment opportunity to reduce health expenditures.
The growing cancer burden has especially harsh consequences for women due to gender discrimination, stigma, and cultural taboos.— Elisabete Weiderpass, MD, MSc, PhD
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Preparing for the Next Pandemic
The COVID-19 pandemic has had a devastating effect on cancer care and will likely result in tens of thousands more cases of advanced cancers diagnosed due to delayed screenings and treatment. This pandemic has also exposed the importance of international cooperation to curb the spread of viral infection. What lessons have been learned to ensure the continuation of optimal cancer care during future pandemics?
In the past year, COVID-19 has become a global pandemic, with nearly 133 million COVID-19 cases reported worldwide and about 3 million deaths.6 Patients with cancer are directly impacted by the virus, as studies reported poorer outcomes compared with patients without cancer.7 So far, the evidence seems to point to a 25% increased case mortality,7 as well as a higher risk of hospitalization and complications, particularly among recently diagnosed patients with cancer. This higher case mortality seems further increased for those with hematologic malignancies and lung cancer. Additionally, the pandemic has exacerbated existing challenges in health systems and hospitals and affected services across the cancer continuum, from prevention, diagnosis, cancer screening, and treatment to palliative care.8
In addition, implementation of nonpharmaceutical intervention strategies by countries to control the spread of the coronavirus has also prompted a multitude of lifestyle changes, such as changes in dietary patterns and more sedentary lifestyles, which may potentially impact the future burden of cancer. An in-depth understanding of the impact of the COVID-19 pandemic is essential to providing evidence-based health policies that serve to reduce health system delays and assist in strategies that can mitigate future deterioration of the cancer burden.
To inform on mitigation and recovery strategies, IARC jointly founded the COVID-19 and Cancer Global Modelling Consortium, with the aim to configure modeling platforms that support decision-making in cancer control, both during and after the pandemic.9 Clearly, there is an urgent need for studies that use representative populations, standard data collection methods and tools, and high-quality recorded data to evaluate the direct and indirect impact of COVID-19 on the short- and long-term cancer burden.
Population-based cancer registry operations were also impacted by COVID-19, especially those in low-resource countries; minimizing this impact is a key element to achieving high-quality estimates. The consortium is coordinating efforts to synthesize the growing evidence of these impacts and will continue to strive for rapid dissemination of estimates to inform national strategies and clinical judgments as well as to support patient decision-making while facing lockdowns and potential irregular access to treatment and care providers.9
DISCLOSURE: Dr. Weiderpass reported no conflicts of interest.
REFERENCES
1. American Cancer Society: Facts & Figures 2021 Reports Another Record-Breaking 1-Year Drop in Cancer Deaths. Available at www.cancer.org/latest-news/facts-and-figures-2021.html. Accessed April 26, 2021.
2. World Health Organization: WHO outlines steps to save 7 million lives from cancer. Available at www.who.int/news/item/04-02-2020-who-outlines-steps-to-save-7-million-lives-from-cancer. Accessed April 26, 2021.
3. WHO Framework Convention on Tobacco Control. Available at www.who.int/fctc/text_download/en/. Accessed April 26, 2021.
4. International Agency for Research on Cancer/World Health Organization: Cancer Tomorrow. Available at https://gco.iarc.fr/tomorrow/en. Accessed April 26, 2021.
5. Ginsburg OM: Breast and cervical cancer control in low and middle-income countries: Human rights meet sound health policy. J Cancer Policy 1:e35-e41, 2013.
6. Johns Hopkins University & Medicine: Coronavirus Resource Center. Available at https://coronavirus.jhu.edu/map.html. Accessed April 26, 2021.
7. Saini KS, Tagliamento M, Lambertini M, et al: Mortality in patients with cancer and coronavirus disease 2019: A systematic review and pooled analysis of 52 studies. Eur J Cancer 139:43-50, 2020.
8. Greenwood E, Swanton C: Consequences of COVID-19 for cancer care—A CRUK perspective. Nat Rev Clin Oncol 18:3-4, 2021.
9. COVID-19 and Cancer Global Modelling Consortium. Available at https://ccgmc.org. Accessed April 26, 2021.
