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

Poor nations are falling further and further behind

Zeba Aziz, MD

I have been making an annual pilgrimage to ASCO for the past 20 years. Each year I learn things that I could not back home in Lahore, but over the past few years I have seen the gap between the Western world and Pakistan grow when it comes to research and treatment of cancer patients. In the United States, even two months of PFS and OS are important, new targeted therapies are the order of the day and economics, until now, were not a major concern. In Lahore, I spend much of my time trying to gather funds for patients who come in much too late and lack the funds to get even basic treatment.

The global cancer burden is rapidly increasing, especially in developing countries. Living and working in a developing country is an experience that cannot be imagined from the relative comfort of the developed world. Quality cancer care is available only to a chosen few. Women come in with large-ulcerated breasts because there was no money to go to doctors. Children have bone tumors so large that they cannot walk. Anemic young men come in with leukemias and nothing to pay for treatment.

Palliative care and pain control are administered in 50% of cases. Patients get aggressive chemotherapy only when resources are available or when treatment will significantly impact life. The chasm between the industrialized countries, with over 90% of the world’s resources, and the low-income countries, with 5% or less, is widening day by day.

How can wealthier nations help their low- and middle-income counterparts?

Education: Community education, physician education and patient education form a kind of holy trinity of cancer treatment and prevention. Education should also focus on smoking hazards, environmental pollution, infectious diseases and use of substandard materials in our diet, etc. The younger generation, which comprises the bulk of our population, should be targeted. This can be achieved through print matter, television, radio, and now, the Internet.

Cancer Prevention/Screening: The World Health Organization estimates that one-third of cancers can be prevented, and one-third could be treated if diagnosed early enough, if access to knowledge and treatment were widely available. The majority of cancers related to lifestyle and environment can be prevented or their incidence decreased through antismoking campaigns or vaccinations. We desperately need pragmatic protocols for screening and early detection of several cancers. Breast self-examination and clinical breast examination are important alternatives to mammography, which many people can't afford even when the technology is available. Pap smears for cervical cancers are cheap and effective for early detection, and prevention of hepatitis B and C.

Treatment Options: Cancer patients are treated on a variety of protocols developed in developed countries. Help from the so-called "first world" in developing indigenous protocols that are developed keeping in mind resources, biology of the disease and the patient biology will go a long way toward fighting disease in poor countries.

Do industrialized countries owe anything to the poor and the downtrodden of the world? The answer is yes, since we are talking about human life and compassion. We will need Herculean efforts just to see the proverbial light at the end of the tunnel.

Zeba Aziz, MD, is Head of the Department of Oncology at Allama Iqbal Medical College—Jinnah Hospital in Lahore, Pakistan.

The developed world has failed in its duty to look after the less fortunate

Richard R. Love, MD

This is the major issue of our time. We haven't been our brother's and sister's keepers in the cancer world as much as we should. We owe a lot, and we should be far more concerned about our fellow travelers if only out of pure selfishness.

By a large degree, there is a tremendous amount that can be learned that can be used to help us. There is more to learn that can help us understand these diseases better, understand how to treat them better. This is separate from the fact that problems that you don't help deal with in other people's backyards soon end up in your backyard. We’re connected and we recognize that more every day. We recognize that when dealing with cancer.

The common kinds of questions that people ask when asking about the developing world are the costs of pharmaceuticals. My view of this situation is that we need some different market models for bringing some of our new and, we think, dramatically more effective agents to bear on larger populations. Bill Clinton and his people with the Clinton HIV/AIDS Initiative have managed to do some of this for AIDS and we could do a lot more about this for cancer if we chose to. The problem is not pharmaceutical companies; they have their models and way of doing things. The problem is the rest of us who haven't been willing to stick our necks out and start pushing and saying, "Look, there are some other ways we, like the AIDS people, can do business."

ASCO as an organization has been really quite remiss in not paying a lot more attention to foreign populations, to global bioethical issues, to pharmaceutical issues. Instead of trying to explore ways the cancer community can be more independent from the pharmaceutical community, ASCO seems to be moving in the opposite direction.

Clearly, philanthropy is changing a bit now because of the economic downturn, but there are a lot of people who would like to be Bill and Melinda Gates wannabes in the cancer world if people would come to them with some rigorous thinking about public health and how to benefit underserved populations across the globe in terms of specific interventions.

We need to be in our "research mode" far more broadly. That doesn't mean that everything needs to be a clinical trial, but as I read the criticism that's written in the development literature by people like William Easterly who wrote "White Man's Burden," we've been in the planning mode far too often and not enough in our search and researcher mode. In cancer medicine we seem to think we can take the same thing we do in New York and apply it in Dakar and it's going to work. That's the same kind of thing Easterly is talking about. Instead, we need to be in search and researcher mode.

Richard R. Love, MD, is Director of International Oncology at The Ohio State University Comprehensive Cancer Center—James Cancer Hospital and Solove Research Institute.