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Closing the Cancer Divide:
Strategies for ActionMay 17, 2012
Pfizer Medical, New Yorkd
Felicia Marie Knaul, PhDHarvard Global Equity Initiative,
Global Task Force on Expanded Access to
Cancer Care and Control in LMICs
Mexican Health FoundationTmatelo a Pecho
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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs
I: Much should be done
II: Much could be done
III: Much can be and
is being done
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From anecdote
to evidence
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January, 2008
June, 2007
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Global Task Force on Expanded
Access to Cancer Care and
Control in Developing Countries
= global health + cancer care
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Applies a diagonal
approach to avoid
the false dilemmasbetween disease silos
-CD/NCD- thatcontinue to plague
global health
Closing the Cancer Divide:A BLUEPRINT TO EXPAND ACCESS IN LMICs
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A) Should be done:
B) Could be done:
C) Can be done
Myth 1. Unnecessary
Myth 2. Inappropriate
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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Mirrors the overall epidemiologicaltransition
LMICs increasingly face both cancersassociated with infection, and all other
cancers.
Cancers that are increasingly only of thepoor, are not the only cancers of the poor.
The Cancer Transition
* Frenk et al
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The cancer transition in LMICs:
breastand cervicalcancer
53%
20%19%
-31%
0%
LMICs High
income
% Change in # of deaths1980-2010LMICs account for
>90% of cervical
cancer deaths and
>60% of breast
cancer deaths.
Both diseases are
leading killers
especially of young
women.
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#2 cause of death in wealthy countries
#3 in upper middle-income#4 in lower middle-income
and # 8 in low-income countriesMore than 85% of pediatric cancer cases and 95% of
deaths occur in developing countries.
For children & adolescents
5-14 cancer is
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Cancer is a disease of both rich and poor;
yet it is increasingly the poor who suffer:
1. Exposure to risk factors
2. Preventable cancers (infection)
3. Treatable cancer death and disability4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide:
An Equity Imperative
Face
ts
E i k f
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Age-standardized prevalence of risk factor in adults aged 15+ years
Men
Women
Both sexes
%o
fpopulation
0
20
40
60
Low
income
Lower
middle
Upper
middle
High
Exposure to risk factors:
Daily Tobacco Smoking
Source: WHO. The Global Status Re ort on Noncommunicable Diseases 2010.
I id d li f
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MortalityIncidence
Incidence and mortality of
cervical cancer(adjusted rate per 100,000 women)
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Adults
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Sur
vival
inequa
lity
gap
LOW
INCOME
HIGH
INCOME
100%
The Opportunity to Survive (M/I)
Should Not Be Defined by Income
In Canada, almost 90% of children with
leukemia survive.
In the poorest countries only 10%.
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Stigma:
Cancerespecially in
women and children - adds a
layer of discrimination ontoethnicity, poverty, and
gender.
Survivorship
care is non-existent.
Th t i idi i j ti
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The most insidious injustice:
lack of access to pain controlNon-methadone, Morphine Equivalent opioid
consumption per death from HIV or cancer in pain:
Poorest 10%: 54 mg per death
Richest 10%: 97,400 mg per death
E di t
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A) Should be done:
B) Could be done:
C) Can be done
Myth 1. Unnecessary
Myth 2. Inappropriate
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
W d h i LMIC
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Women and mothers in LMICs
face many risks through the life cycle
Women 15-59, annual deaths
Diabetes
120,889
Breast
cancer
166,577
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
Cervical
cancer
142,744
Mortality
in
childbirth
342,900
- 35%in 30
years
= 430, 210 deaths
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The Diagonal Approach to
Health System Strengthening
Rather than focusing on disease-specific vertical
programs or only on horizontal system
constraints, harness synergies that provideopportunities to tackle disease-specific priorities
while addressing systemic gaps.
Optimize available resources so that the whole ismore than the sum of the parts.
Bridge the divide as patients suffer diseases over a
lifetime, most of it chronic.
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Why diagonal delivery?
Shared risk factors
Co-morbidity
Life cycle approach
Efficiency: Common need for strong healthsystem platforms
Knowledge sharing and inter-institutional
collaborationEconomic development
Social justice
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Delivery: Harness platforms byintegrating breast and cervical
cancer prevention, screening andsurvivorship care into MCH,
SRH, HIV/AIDS, social welfareand anti-poverty programs.
A Diagonal Strategy:
Di l St t i
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Diagonal Strategies:
Positive ExternalitiesPromoting prevention and healthy lifestyles:
Reduce risk for cancer and many other diseases
Reducing stigma around womens cancers:
Contributes to reducing gender discriminationPromoting access to education for children w/ cancer
Reduces poverty, contributes to social development
Introducing cancer treatment for childrenImproves hygiene and reduces intra-hospital infections
Pain control and palliation
Reducing barriers to access is essential for cancer as
well as for for other diseases and for sur er .
E di t
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A) Should be done: necessary
and appropriate
B) Could be done:
C) Can be done
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
` /80 i i i i
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`5/80 cancer disequilibrium(Frenk/Lancet 2010)
Almost 80% of the DALYs lost
worldwide to cancer are in LMICs,yet these countries have only a very
small share of global resources for
cancer ~ 5% or less.
I i I CCC
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Investing In CCC:
We Cannot Afford Not To
Health is an investment, not a cost
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% of global GDPPrevention and treatment offers potential world savings
of $ US 131-850 billion mostly due to productivity
gains and reducing suffering
1/3-1/2 of cancer deaths are avoidable:
2.4-3.7 million deaths
- 80% in LIMCs
Th t t l th di id
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The costs to close the cancer divide
may be less than many fear:
All but 3 of 29 LMIC priority cancer chemo and hormonalagents are off-patent: many < $100 / course
Cost of drug treatment: cervical cancer + HL + ALL(kids)
in LMICs / year of incident cases: $US 280 mPain medication is cheap
Prices drop: HPV 2011 from $US 100 /dose to:
GAVI $5 and PAHO $14Market potential is underutilized and undeveloped
Purchasing is fragmented and procurement is unstable
Delivery innovations are unexploited
E di t
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A) Should be done: necessary
and appropriateB) Could be done: affordable
C) Can be doneMyth 4: Impossible
Expanding access to cancer
care and control in LMICs:
Initial views on MDR TB
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In developing countries,people with multidrug-
resistant tuberculosis usually
die, because effective treatment
is often impossible in poor
countries. WHO 1996
Initial views on MDR-TB
treatment, c. 1996-97
Source: Paul Farmer., 2009
MDR-TB is too expensive to
treat in poor countries; it
detracts attention and resources
from treating drug-susceptible
disease. WHO 1997
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Outcomes in MDR-TB
patients in Lima, Peru
receiving at least fourmonths of therapy
Mitnick et al, Community-based therapy for multidrug-resistanttuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.
All patients initiated therapy
between Aug 96 and Feb 99
Source: Paul Farmer, 2009
Drug % Decline inprice 1997-9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Making common
cause with WHO:
Reduced prices ofsecond-line TB drugs
Cured
83%
Abandontherapy
2%
Failed
therapy
8%
Died
8%
Ch i
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Harvard Breast Cancer in Develo in Countries Nov 4 `09
ChampionsNobel Amartya Sen,
Cancer survivor diagnosed in India50 years ago
Drew G. Faust
President of Harvard University22+ year BC survivor
Ch i f LMIC M i
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Champions from LMICs: Mxico
R l R d 0 l i
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Rural Rwanda: 0 oncologist
Source: Paul Farmer., 2009
Burkitts
lymphoma
Embryonal
Rhabdomyosarcoma
St J d I t ti l
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St. Judes International
Outreach Program
Twinning in 20+ countries
El Salvador: 5-year survival for children
with ALL increased from 10% to 60% in
five years
Cure4Kids/OncopediaOver 31,000 users in more than 183
countres
Success in treating several
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Mexico: cervical cancer.
Source: Knaul et al. 2008. Re roductive Health Matters and u dated b Knaul Arreola-Ornelas and Mndez based on WHO data WHOSIS 1955-1978 and Ministr o Health in Mexico 1979-2006
0
4
8
12
16
19551965
1975
1985
1995
2008
Success in treating several
cancers.
Fi i i ti
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Financing innovations:
DomesticIntegrate CCC into national insurance and
social security programs to
express previously suppressed demandbeginning with cancers of women and children:
Mexico, Colombia, Dominican
Republic, PeruChina, India, Taiwan
Rwanda, Kenya
A diagonal approach to social
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Horizontal Coverage: Beneficiaries
A diagonal approach to socialinsurance and financing
I i l ti
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# of covered services
Source: Comisin Nacional de Proteccin Social en Salud, 2012
Increase in population coverage +
expansion of package of services
Households affiliated
to Seguro Popular
2006
2004
~100%
2012
2005
~17.2
millonesdefamilias
9%
30%
20%
42%
1.5 3
.5millones
5.1millones
7.3millo
nes
53%
9.1m
illones
2007
2008
61%
10.5
millones
2009
85%
14.7
millones
2010
+113
146
249262
266
2006
2004
2
012
2005
2007
2008
2009
2010
275
2011
89%
2011
15.4millones
Mexico Seguro Popular:
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Mexico Seguro Popular:financial protection for catastrophic
illnessAccelerated, universal, vertical coverage by disease
with a package of interventions
2004/5: ALL in children, cervical, HIV/AIDS
2006: All pediatric cancers then all children and
newborns for almost everything
2007: Breast cancer
2011: Testicular cancer, prostate and NHL
Seguro Popular and cancer:
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Seguro Popular and cancer:
Evidence of impact
Since the incorporation of childhood
cancers into the Seguro Popular
30-month survival ALL: 30% to almost 70%
Breast cancer adherence to treatment:
2005: 200/6002010: 10/900
Access to medicinesan anecdote
Horizontal and vertical
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Horizontal and vertical
financial protection strategies:
Seguro Popular, Mexico
Beneficiaries: Population covered
Benefits:
coveredinte
rventions
Catastrophic Illness
ACCELERATED VERTICAL COVERAGE:
Ex: childrens cancer, breast cancer
Package of essential
personal services
Community Health Services eg nutrition and vaccinations
Poor Rich
Insurance for a new generation
J it
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Juanita:Advanced metastatic breast
cancer is the result of a series
of missed opportunities
Program to reduce
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Program to reducebarriers:
Breast cancer, Mexico
Results: promoters nurses doctors
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Results: promoters, nurses, doctors
Challenge: from survival to survivorship
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Be anoptimist
optimalist
Expanding access to cancer care and control in
LMICs: Should, Could, and Can be done
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@amazonFALL: @Harvard U Press