Cancer: the new challenge for health care in the developing world

Cancer care in poorer countries is beset by lack of attention, political will and resources.

The more common traditional health concerns of the developing world are infectious disease and malnutrition. Yet over the past two decades, the incidence, disease burden and risk for cancer-related mortality in low- and middle-income countries has increased dramatically.

Cancer is now the second leading cause of death worldwide and accounts for more deaths than HIV/AIDS, tuberculosis and malaria combined. With a few exceptions, cancer patients in the developing world are far more likely to die of their disease than those in wealthy countries. Half of the estimated 10 million new cancer cases occur in developing countries every year and that number has been predicted to rise to 70% by 2020.

What do industrialized nations owe to developing countries when it comes to cancer care?

To make matters worse, an estimated 75% of patients in developing countries have advanced or incurable cancers at diagnosis. According to study results published in The Journal of Clinical Oncology in 2006, the overall mortality-to-incidence ratio for men in the developing world is 0.75 compared with 0.54 in the developed world. For women in the developing world, the ratio is 0.65 compared with 0.45 for women in the developed world.

A 2004 review published in Breast Cancer Research found that women with the lowest risk for breast cancer, which has historically included women in developing countries, have experienced the largest increase in breast cancer risk.

“The numbers are alarming and speak for themselves,” said Bhadrasain Vikram, MD, chief of the clinical radiation oncology branch at NCI and former head of radiotherapy-applied radiation biology for the International Atomic Energy Agency of the United Nations. “There are more cancer patients now in the developing world than the developed world. While the survival rates in developed countries have progressively improved in the past few decades, in developing countries the situation is still dire. The clear majority of deaths from cancer, and obviously the suffering from cancer, is now concentrated in the developing world,” he told HemOnc Today.

Eduardo Cazap, MD, is president of the Latin American and Caribbean Society of Medical Oncology. Photo by Stella Bremer

Changing risks

There are multiple reasons behind this explosion in cancer, and tobacco use is a well-acknowledged culprit. Some blame the spread of Western lifestyle habits, others blame increasing lifespans, and yet others point to a lack of political will and medical infrastructures to address the problem. Whatever the cause, it’s difficult to speak in general terms about dozens of nations encompassing 80% of the world’s population. The experts who spoke to HemOnc Today agreed that cancer prevention is nearly nonexistent in the developing world, detection is rare and treatment usually comes too late and is inefficient.

Eduardo Cazap, MD, president-elect of the International Union Against Cancer and president of the Latin American and Caribbean Society of Medical Oncology (SLACOM), said the increase is related in part to the aging of the population and improvements in medical care in poorer nations.

“As a result of both, you will have more old people in these populations,” he said, speaking from his office in Buenos Aires. Another factor in the equation is immigration from rural to urban areas. “Around 1950, two-thirds of the population was living in the country. Today, more than 60% are living in urban areas and the projection is that 15 years from now, 70% of the world population will live in big cities. This relates to pollution, contaminants and changes in food quality.”

Cazap went on to say that more of the world now eats the way Americans typically do — diets including food that is highly processed and high in sugar — and some of the increased incidence is related to changes in diet.

Tobacco is the real villain in this tale, however, according to Cazap and Derek Raghavan, MD, PhD, chairman and director at Cleveland Clinic’s Taussig Cancer Center.

“Forty percent of the world’s new smokers are in China and India. What this tells us is that the tobacco companies are targeting overseas countries,” he said. “It’s the same old campaign: Smoke and you’ll be cool. It becomes an opiate of the masses.

“In parallel with the increased incidence of smoking, there is a lack of tax burden — we tax the blazes out of cigarettes and they don’t in China — and the masses are smoking more than ever before,” he told HemOnc Today.

Raghavan pointed out that reducing the incidence of smoking related-cancers and cancer deaths is not impossible. A report issued by the CDC in December 2008 showed that smoking decreased by 0.8% per year from 1999 to 2005 among all Americans. The rate of cancer deaths for men dropped by 1.5% annually from 1993 to 2001, and 2.0% annually from 2001 to 2005. For women, cancer-related deaths decreased by 0.8% per year from 1994 to 2002, and 1.6% per year from 2002 to 2005.

An ounce of prevention ...

Whenever possible, preventing cancer is preferable to treating it; convincing people to give up tobacco is better than treating cancers caused by tobacco. The problem is that there are very few successful cancer prevention programs operating in the developing world, according to Vikram.

“The short answer is no,” Vikram said when asked if any nation or non-governmental organization had implemented a successful cancer prevention program in the developing world. “WHO has made tobacco control a priority, but the main beneficiaries of robust tobacco control so far have been richer countries, and the implementation of tobacco control in the poorer countries leaves a lot to be desired.

“Other than that, if you look at the preventive tools available to us, Pap smears have been used the longest. In most developing countries, they simply have not been implemented on a population-wide basis because they require an infrastructure that doesn’t exist in those countries,” he said. “There have been pilot projects here and there, but on a population-wide basis, implementation has not occurred in almost any low- or middle-income country up to this point.”

Other detection and screening programs are similarly few and far between, even though such programs could save lives and dollars. Results of a study conducted by the Alliance for Cervical Cancer Prevention Cost Working Group published in The New England Journal of Medicine in 2005 concluded that visual inspection or HPV DNA might be viable low-cost alternatives to cytology-based screening. Goldie et al argued that a few as two screenings for women aged 35 to 45 years could decrease the global deaths from cervical cancer by as much as 50%.

When SLACOM polled breast cancer experts in 100 Central and South American nations about the breast cancer prevention efforts of their respective countries, 95 respondents reported that their countries had no such programs.

“The majority of Latin American countries are in the middle- or low-middle–income level, and in these types of countries, the situation is based on diagnosis and treatment and usually does not happen in an organized manner,” Cazap said. “Research is very limited, practically doesn’t exist, and prevention is also limited to some very, very intermittent actions from the government. That means more advanced stage at diagnosis because there are no prevention actions, and the total cost to society is much higher because patients require more complex resources for more advanced stages of disease.”

In addition to a lack of programming, physicians who hope to screen for cancers must convince usually poor and poorly educated people of the importance of cancer screening, something that is difficult to do without educated professionals. Researchers polled 285 doctors and nurses at Mulago Hospital, Uganda’s national referral and teaching hospital, about their knowledge, attitudes and practices towards cervical cancer screening. Mutyaba et al found that fewer than 40% of respondents knew the risk factors for cervical cancer. Of women respondents, 65% did not feel susceptible to cervical cancer and 81% had never been screened.

Vikram points out that there is still a stigma attached to cancer in many societies, especially cancers in women.

“You have to have a national effort,” he said. “You have to have some robust advocacy groups willing to do the work on the ground, and then you have to make sure there are people who are trained to provide these preventive services so that when you find a cancer early, you do have the facilities and wherewithal to send the patient for appropriate treatment by people who know how to give appropriate treatment. It becomes a whole health systems issue,” he said.

Political will

The experts interviewed for this story agreed that, at least in Central America, South America and Asia, the biggest roadblock to improving cancer care is not just a lack of resources but also a lack of political will. Cazap notes that WHO made its first international declaration on cancer only four years ago.

“Cancer is not on the WHO agenda,” he said. “It’s included in the branch of chronic diseases and there is no cancer expert in WHO in Geneva. The situation is exactly the same in the Americas. The Pan-American Health Organization has no cancer in the agenda. The organization has some pilot programs for cervical cancers and a few others, but not a global agenda for cancer.”

“GNP available for health care is different in countries like India, Pakistan, Bangladesh, China,” Raghavan added. “Infant mortality is still a major problem. Access to food is still a big problem and so governments with limited resources are not necessarily going to allocate resources for just, say, a year or two years of prolongation of life when the same dollars might allow for the maintenance of a healthy life.”

Cazap pointed out that preventive measures such as HPV vaccination sometimes need decades to show efficacy, and few politicians are willing to wait that long to see a return on investment. He went on to say that governments and NGOs have focused on acute health care needs and for good reason. But as those problems become less pressing, the focus has not shifted to chronic medical issues.

“Today the situation has changed and the organizations and the governments are not following the change with the same vigor,” he said. “They are far from the moment when it is necessary to realize it is time to make a serious change in the health care decisions, otherwise the situation with cancer will be explosive and out of control.”

A continent in crisis

The situation in the nations of Africa, particularly sub-Saharan Africa, may have already reached the explosive stage. The continent is expected to account for more than 1 million new cancer cases every year. The cure rate for childhood cancers is only 5% compared with almost 80% in the developed world, and an estimated one-third of cancer deaths are attributable to preventable causes such as viral infection and poor nutrition.

Comparatively, many African nations are poorer, less educated and less stable than anywhere else in the world and cancer care is consequently worse than anywhere else in the world.

An estimated 80% of African cancer patients present with incurable disease. Gondos et al, in a 2004 study looking into survival in Zimbabwe, found that the maximum five-year relative survival rate was only 54.9% for black Zimbabweans, and the absolute survival rate was only 49%. Patients diagnosed with liver cancer had an absolute survival rate of 1.1% after five years.

“The five-year survival estimates for black Zimbabwean cancer patients are in fact among the lowest values reported from a population-based cancer registry,” the researchers wrote. “White Zimbabweans experienced a much higher survival than black Zimbabwean cancer patients. Nevertheless, both groups of Zimbabwean cancer patients had much lower five-year survival than cancer patients living in the United States.”

Another study by Gondos et al, published in British Journal of Cancer in 2005, found similarly low five-year survival rates in Uganda.

The Kampala Cancer Registry was established in 1951, though it was suspended between 1980 and 1989 due to political unrest. Uganda is also one of the few nations on the continent to have a national cancer plan and the only one to have a nationwide integrated palliative care program. Nonetheless, the highest five-year relative survival rate recorded was 46.9% for patients with prostate cancer. The highest five-year absolute survival rate was 38.4% for patients with breast cancer. No patients diagnosed with nasopharynx, stomach or lung cancer survived past five years.

“These survival figures are even lower than most previously published survival estimates,” the researchers wrote.

They noted that the country is desperately poor — annual per capita health spending is estimated to be $36, and 40% of the population survives on less than $1 per day — and that there is a severe lack of resources and trained physicians and nurses.

“Although shocking, these survival estimates are unfortunately not surprising,” wrote Gondos et al. “In 1998, there were only two radiotherapy units and one chemotherapy unit in the country, and only an estimated 5% of patients had access to these facilities. Further constraints are posed by the lack of medical personnel; in Kampala, there are only approximately 50 doctors per 100,000 people.”

In an editorial published last July on SciDev.net, Twalib Ngoma, MD, executive director of the Ocean Road Cancer Institute in Dar es Salaam, Tanzania, said all African countries suffer from a lack of financial resources. Only a single hospital in Botswana has a cancer department. Radiotherapy is available to less than 20% of the continent’s population.

“In Ethiopia, in a country of 65 million people, there was only one oncologist a few years ago,” Vikram said. “He hadn’t taken a vacation in more than 10 years. We couldn’t even bring him to conferences for training because there was nobody else to take care of the patients.”

It is impossible to discuss cancer in Africa without considering the impact of HIV/AIDS. Sierra Leone has one of the highest rates of HIV infection on the continent at 24%, and as a result has the highest incidence of Kaposi’s sarcoma.

Results of a study published in 2000 evaluating 4,883 patients diagnosed with cancer or cardiovascular disease at three hospitals in Johannesburg found strong correlations between HIV infection and Kaposi’s sarcoma (OR=21.9; 95% CI, 12.5-38.6), non-Hodgkin’s lymphoma (OR=5.0; 95% CI, 2.7-9.5), cervical cancer (OR=1.6; 95% CI, 1.1-2.3) and vulvar cancer (OR=4.8; 95% CI, 1.9-12.2).

Reasons for optimism

As dismal as the situation is, there is some cause for optimism. The Program of Action for Cancer Therapy, a division of IAEA, is helping several nations establish cancer control plans. The London Declaration on Cancer Control in Africa issued in 2007 lays out concrete steps toward combating the disease and Vikram cites Ghana, a nation wealthier than most in Africa, but still one in which 28.9% of the population lives below the poverty level, as a country where the tide is slowly turning in the right direction.

“There are two cancer clinics now where a few years ago there were none,” he said. “They start out as treatment facilities, but you have in those treatment facilities people who think about cancer with most of their time, and then they can start using the treatment clinic as a home for outreach activities, prevention activities, palliative care, advocacy and trying to convince the powers that be that this is an area deserving of attention.”

Tackling the problem

The London Declaration on Cancer Control in Africa grew out of a 2007 meeting between 130 health care, government and NGO leaders to address the growing problem of cancer on the continent. The resulting declaration lists Six Essential Steps that they described as cornerstones of comprehensive cancer control programs:

• Cancer surveillance/registries and national cancer plans.
• Prevention programs.
• Early diagnosis and screening programs.
• Treatment.
• Palliative care.
• Training and research.

Vikram said the NCI is trying to establish a kind of cancer expert corps of clinicians and researchers who are willing to dedicate a part of their time to mentor their counterparts in developing nations.

The agency is working with ASCO, ASTRO, the Oncology Nursing Society and institutions with established international outreach programs such as St. Jude Children’s Research Hospital and the military to attract volunteers and sponsors.

“At the NCI we can be sort of a clearing house to match volunteers with appropriate places in the developing world where there is a need and a will, help them develop relevant research projects and access NIH funding to undertake research,” he said. “That would build capacity to do research. It’s a potential win-win situation in that you generate new knowledge and at the same time create the capacity to do research in that country that will help patients everywhere in the long run.” – by Jason Harris

What, if anything, does the developed world owe to the developing world when it comes to cancer care?

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