The fight against cancer has made remarkable progress worldwide over the past decade. Through corporate investment in research and technology, the incidence of cancer and death rates in developed nations have steadily declined. The number of people living longer and fuller lives after a cancer diagnosis is higher than ever.1 In contrast, the situation in developing countries is different.2
As a result of structural inequities and financial burdens, certain segments of the Bangladeshi population suffer disproportionately from adverse health conditions, such as cancer.3 Recently in Bangladesh, eight divisional comprehensive cancer care centers, new academic centers, and a national cervical cancer and breast cancer screening program have been established to reduce cancer disparities. Furthermore, fostering greater collaboration between all stakeholders in pursuit of health equity is essential. To ensure that advanced infrastructures and research-driven advances benefit everyone, regardless of race, ethnicity, gender, socioeconomic status, or location, we must ensure that everyone must play a role in eradicating disparities.
Muhammad Rafiqul Islam, MBBS, MD
In Bangladesh, we have experienced some progress against cancer in recent decades. However, overall cancer incidence and mortality are increasing steadily across all population groups.4 Moreover, disparities across the cancer continuum remain a significant public health challenge in Bangladesh.
Compared with the urban population, medically underserved populations continue to share a disproportionate burden for certain types of cancer. Although disparity in cancer-related deaths between urban and rural populations has been narrowing, the rural population still has the highest rate of overall cancer mortality.5 On the other hand, people living under persistent poverty or in rural areas continue to face serious structural barriers and/or systemic inequities in their access to quality health care.6
Social Determinants of Health and Tumor Genetics
To understand and address cancer health disparities, researchers are using a framework of interrelated and overlapping factors called social determinants of health.7 The key components of the social determinants of health are socioeconomic factors such as education and income; modifiable factors such as tobacco use and physical inactivity; psychological factors such as stress and mental health; environmental factors such as housing and transportation; health-care access and experiences; and biological and genetic factors. Social determinants of health may have an influence at individual, community, and population levels to drive comprehensive health outcomes.
Tobacco use, obesity, lack of physical activity, alcohol consumption, infection with specific pathogens, and exposure to carcinogens in the environment are the major cancer risk factors in Bangladesh. Dhaka, the capital city of Bangladesh, is the top-ranked polluted city in the world.8 The living environment plays a significant role in the behavior and exposure that lead to cancers.9 Disadvantaged populations are also less likely to maintain behaviors that reduce cancer risks, such as a healthy weight, diet, and physical activity.
Studies of tumors’ genetic and microenvironmental changes have historically been conducted primarily on Europeans. Because of the lack of representation of underrepresented groups in these studies, we have been unable to fully understand the genetic predispositions that lead to a higher risk of cancer incidence and mortality or increased aggressiveness in certain groups like east Asians. These groups have the highest frequency of EGFR gene alterations, whereas African and European groups have the lowest frequency.10
By identifying genetic, epigenetic, and other changes that occur in patients with cancer from different ancestral groups using diverse laboratory research models and creating large and inclusive databases, we will gain a better understanding of how different ethnic groups and geographic variations lead to cancer. Research into this crucial factor influencing cancer health disparities has not been fully explored in Bangladesh, but there is an urgent need to do so.
Challenges in Cancer Screening for Early Detection
In Bangladesh, the Ministry of Health and Family Welfare and other professional societies carefully weigh the benefits and potential harms of screening for certain types of cancer to issue population-level screening guidelines. The Directorate General of Health Services recommends that individuals at average risk of developing cancer receive breast and cervical screening. The National Institute of Cancer Research & Hospital as well as other cancer service providers are following the standard guidelines for cancer screening.
Yet many disparities in cancer screening exist for medically underserved populations. Some of these disparities result from screening guidelines based on studies with predominantly Western and European participants. Cancer-focused professional organizations should routinely evaluate the evidence and adjust their guidelines accordingly in such areas. Some cancer screening disparities stem from systemic and structural barriers. Cultural beliefs and lack of knowledge about cancer screening also play a role in cultivating disparities in cancer screening.
Steps to overcome these disparities among medically underserved populations include the following:
Research and Treatment for Cancer: Far Behind
To the best of our knowledge, Bangladesh is not a part of any of the phase I or II clinical trials of cancer drugs. All stakeholders in the medical research community must work together to identify interventions that ensure equitable participation for ensuring the unprecedented advances against cancer and population benefits.
Even though advances in cancer treatments have been significant in recent years, medically underserved populations often face severe and multilevel barriers to quality cancer treatment. Most patients cannot afford even the most basic chemotherapy. Moreover, most of the facilities are limited to urban areas.11 Ensuring multilevel interventions and utilizing patient navigation can address the current disparities in cancer treatment and improve outcomes for all patients.
Challenges in Cancer Survivorship
Around 40% of cancer survivors reside in the area referred to as the Indo-Pacific, including Bangladesh. As we do not have a population-based cancer registry, the exact number of survivors is unknown. Despite the unique experiences of every cancer survivor, medically underserved populations bear a disproportionate burden of the adverse effects of cancer survivorship. The cancer-related side effects experienced by medically underserved populations are higher than those in urban areas.12
Financial toxicity is one of the significant contributors to poor health-related quality of life. It is common for patients with cancer to skip medication, follow-up appointments, and/or get into debt due to high out-of-pocket costs. Approximately 43% of households cover health-care costs through property sales, borrowing, or family assistance. Therefore, every year, five million Bangladeshis fall below the poverty line because their out-of-pocket health-care costs are so high.13
Cancer survivorship in Bangladesh presents many challenges with diverse needs and health-system capabilities. Developing clinical services and research priorities must start with addressing the unique medical, social, and cultural needs of the populations served. A comprehensive approach is critical to improving quality of life, enhancing adherence to follow-up care, identifying financial concerns, providing equitable health care, and reducing cancer care costs.
Overcoming Disparities: From Diverse Workforce to Public Policy
Health equity requires continued efforts to increase diversity across the cancer care and research workforce. Health-care workers have become more diverse in recent years. Despite this, the representation of other cancer-associated faculties and institutions throughout the country in cancer research and care has not kept pace with trends in the Bangladeshi population and contributes to cancer health disparities. In Bangladesh, one university, three medical colleges, one college, and one institute offer cancer-related postgraduation courses. Approximately 30 cancer treatment centers now provide a wide range of services to the population.
To eradicate health disparities in a resource-constrained area like Bangladesh, we must maximize our resources. The development of substantial public health policies has contributed to reducing cancer health disparities over the past 20 years. In the past 30 years, strong tobacco control regulations have been implemented, and the number of smokers has decreased.14 It is possible to eliminate cervical cancer in Bangladesh by increasing awareness of human papillomavirus (HPV) vaccinations and cancer screenings. The government’s support of collaborative initiatives with academic institutions and community-based organizations will strengthen equitable partnerships between service providers and recipients. All stakeholders must continue working together to address historically underserved groups’ health-care needs.
A Call to Action
A call to action on policymakers and other stakeholders committed to eliminate cancer health disparities should include the following steps:
Bangladesh strives to eliminate cancer health disparities as a pioneer and leader of countries in south Asia in fulfilling the sustainable development goals. Implementing the recommendations will eliminate systemic inequities and demographic injustices that hinder health equity. The government of Bangladesh is committed to combating disparities, privileges, and discrimination in cancer care and to supporting policies to ensure equitable access to quality cancer care.
Dr. Islam is Assistant Professor and clinical researcher, Medical Oncology, National Institute of Cancer Research & Hospital, Bangladesh.
DISCLOSURE: Dr. Islam reported no conflicts of interest.
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