“Inequities are a major obstacle in delivering safe, timely, respectful, and affordable cancer care globally,” commented moderator John Varallo, MD, MPH, FACOG, of the Global Surgery Foundation, at the Union for International Cancer Control (UICC) World Cancer Congress (WCC) 2024 in Geneva.1
During the “Promoting Equity, Quality, and Value in Global Cancer Care” session, Chandrakanth Are, MD, MBA, FRCS, FACS, of the University of Nebraska Medical Center, Omaha; Christopher Booth, MD, FRCPC, of Queen’s University, Kingston, Ontario; Miriam Mutebi, MMed, MSc, of Aga Khan University, Nairobi, Kenya; and Hanaa Serry, of the Baheya Foundation for Early Detection and Treatment of Breast Cancer, Giza, Egypt, proposed practical, commonsense solutions to address disparities.
Improving Access to Cancer Surgery
“Cancer surgery is one of the most effective tools in cancer care within a multidisciplinary care construct,” Dr. Are commented. This understanding, along with the statistic that less than 25% of patients will have access to safe, timely, and affordable cancer surgery—which will lead to a cumulative gross domestic product loss of nearly $6.2 trillion by 2030—was a driving force behind the launch of the first Lancet Oncology Commission on Global Cancer Surgery.2
According to Dr. Are, “this was a landmark moment…, [because] surgery is no longer an afterthought, but quite a bit of work still needs to be done.” He thus introduced two approaches for improving access to cancer surgery and outcomes: “moonshot thinking,” which “pushes the boundaries of science,” and “groundshot thinking,” which is “pragmatic and realistic.”
“With that in mind, the second Commission was proposed,” Dr. Are remarked. “It focuses on what is already available and making it more efficient and streamlined in a resource-efficient, contextualized manner, so it may be applied to as many regions of the world as possible.”
The second Commission was built upon an analysis of the first, leading to the identification of nine solutional domains (eg, the role of surgery/surgeons and research) and their subsequent contextualization to each of the six World Health Organization (WHO) regions.3 Based on those domains, the authors of the second Commission conceived eight action items focusing on clinical care, research, education, upscaling workforce, incorporation of principles of patient safety and quality improvement, ensuring continuous professional development, promoting well-being, and ensuring surgical care is not interrupted by catastrophic events.
Dr. Are concluded: “Access to effective cancer surgery should not be a privilege for a few but instead a societal necessity for all. The solutions to address this grave humanitarian imbalance need not always be astronomical in thought or cost. We hope the second Commission addresses this inequity through simple, pragmatic, and reality-grounded solutions that can relate to every part of the world.”
Focusing on ‘Outcomes That Matter’ in Medical Oncology
Improving access to cancer surgery is only part of the challenge, as inequities also exist within the realm of medical oncology. Dr. Booth commented that, in this modern era marked by complexities in pharmaceutical economics and a disproportionate number of randomized clinical trials originating from high-income countries, many of the “most important” drugs are inaccessible to much of the world. He added that just about a quarter of newly approved medicines improve overall survival, with the aggregated benefit of approximately 3 months carrying caveats of clinical toxicity, financial toxicity, time toxicity, and an efficacy-effectiveness gap.
“We set a course for what we called ‘Common Sense Oncology,’ which is driven by the idea that we think cancer care, research, and policy should be oriented around outcomes that matter,” Dr. Booth commented. The guiding principles of this grassroots movement focus on access to quality care as a basic human right, patient and societal vs purely industry needs, patient and public involvement, survival and quality of life, shared decision-making, fair pricing, equity in access to quality care, and comprehensive patient-centered care.4
Dr. Booth concluded: “Improvements in the generation, interpretation, and communication of evidence will help move our field closer to a future in which a patient’s outcome is not determined by where they live, what they can afford, or the strength of a marketing campaign.”
Addressing Gender Inequities in Cancer Care
“People might ask: Why [discuss] women, cancer, and equity? I think, even just looking at the basic data, we start to see the rise of disparities,” commented Dr. Mutebi.
In agreeing with Dr. Booth that care should be looked at through a “value-based lens” and acknowledging it can be expensive anywhere in the world, she asked: How do we provide cost-effective care to women with cancer without “breaking the bank”? And how do we ensure its quality is maintained? A Lancet Commission on women and cancer was launched to address these and other urgent questions at the intersection of social inequality, cancer risk and outcomes, and the status of women in society.5
Dr. Mutebi remarked that “in many countries, regardless of geographic region or economic resources, women are more likely than men to lack the knowledge and the power to make informed cancer-related health-care decisions. Women are [also] more likely to risk financial catastrophe due to cancer, with dire consequences for their families, even if quality cancer care is available.”
To help with these inequities, the second Commission thus built a framework of solutions around the existing decision-making, knowledge, and economic asymmetries. It outlined practical actions with the power to impact education, research, policy, health systems, cancer care delivery, and advocacy for everyone, regardless of gender, socioeconomic status, or geographic location.
“Some of the talks we had through the course of this conference have underscored the need for data,” Dr. Mutebi commented, adding that it is particularly crucial to ensure reporting on sex, gender, and other sociodemographic factors. She furthermore emphasized other key priorities, such as conducting research to analyze factors that disproportionately affect women, designing and implementing gender- and intersectional-transformative strategies to increase equitable access to early detection, integrating a gender competency framework into the education and training of the cancer workforce, and co-creating accessible and responsive health systems.
Dr. Mutebi concluded: “The progress to universal health coverage—variable depending on the region of the world—must continue…[and] be framed through the lens of value. There are expanding opportunities for increasing equity globally, and there needs to be intentional investment in the workforce and health systems. Equity must take into account cultural and context concerns.”
Breast Cancer Surgery: Exploring the Patient Perspective
Ms. Serry, who described herself as a “passionate advocate for patient empowerment,” began her discussion by addressing the emotional impact of receiving a breast cancer diagnosis. She commented: “[Health-care providers need to] provide an environment where women can safely ask all their questions and get honest answers regarding their prognosis and treatment options, so they can feel confident and comfortable in their long treatment journey. This will help them to adhere to treatment; in the end, it [leads to] better patient outcomes.”
Ms. Serry outlined approaches for overcoming the obstacles patients may face during their treatment: establishing support systems, providing compassionate and empathetic care, patient navigation programs, and personalized treatment plans, and fostering hope and resilience. She further emphasized the positive impact of early detection and screening programs.
“I encourage all women and patients to speak up for themselves, as this makes all the difference,” Ms. Serry concluded. “[I also] encourage providers to prioritize patient-centered care.”
DISCLOSURE: The webinar was presented in partnership with the Global Forum of Cancer Surgeons. Dr. Varallo, Dr. Booth, Dr. Mutebi, and Ms. Serry reported no conflicts of interest. Dr. Are serves as Chief Executive Officer of the Global Forum of Cancer Surgeons and on the Board of Scientific Advisors of the National Cancer Institute.
REFERENCES
1. Promoting equity, quality and value in global cancer care (webinar). Union for International Cancer Control World Cancer Congress 2024. Presented September 18, 2024.
2. Sullivan R, Alatise OI, Anderson BO, et al: Global cancer surgery: Delivering safe, affordable, and timely cancer surgery. Lancet Oncol 16:1193-1224, 2015.
3. Are C, Murthy SS, Sullivan R, et al: Global cancer surgery: Pragmatic solutions to improve cancer surgery outcomes worldwide. Lancet Oncol 24:E472-E518, 2023.
4. Booth CM, Sengar M, Goodman A, et al: Common sense oncology: Outcomes that matter. Lancet Oncol 24:833-835, 2023.
5. Gisburg O, Vanderpuye V, Beddoe AM, et al: Women, power, and cancer: A Lancet Commission. Lancet 402:2113-2166, 2023.
