Post on 02-Jul-2015
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eden strategy institute
HEA L TH CAR E
As ia ’s Quiet War on Lung Cancer S O C I A L I N N O V A T I O N P L A Y B O O K S E R I E S
14 million people around the world are diagnosed with cancer each year
Source: Cancer Research UK 2014 eden strategy institute | 2
BACKGROUND
Source: Cancer Research UK 2014 eden strategy institute | 3
Lung 13%
Breast 12%
Bowel 10%
Prostate 8%
Others 57%
Most Common Cancers Worldwide
Lung cancer, the most common form of cancer, accounted for 1.8 million cases in 2012
1.8 m New Lung Cancer Cases Worldwide (2012)
BACKGROUND
This is a serious issue in Asia, with the region taking up more than 60 percent of all lung cancer cases
Source: Globocan 2012, Eden hospital interviews & analysis eden strategy institute | 4
India
Singapore
China
S.Korea
Japan
Taiwan
Hong Kong
Philippines
Laos
Vietnam
Cambodia
Thailand
Pakistan
Afghanistan
Nepal
Mongolia N.Korea
Malaysia
Sri Lanka
<499
500-‐999
1,000-‐1,999
2,000-‐5,999
6,000-‐9,999
10,000-‐19,999
20,000-‐39,999
40,000 -‐100,000
>100,000
Butan
Blangladesh
Indonesia
Myanmar
Lung Cancer Incidence within Asia (2012)
Countries with High Lung Cancer Incidence in Asia
Country Lung Cancer Incidence
China 725,359
India 145,000
Japan 94,855
Indonesia 34,695
Turkey 24,479
South Korea 22,869
Vietnam 21,844
Thailand 19,501
North Korea 13,851
Philippines 12,061
Taiwan 9,783
Others 66,418
OUR STUDY
eden strategy institute | 5
This paper draws insights from the latest developments on the ongoing baVle against lung cancer in China, Taiwan, India, and South Korea
CAUSES OF LUNG CANCER: SMOKING
Lung cancer is primarily driven by smoking, and is highly prevalent in countries such as China, India, Indonesia, and South Korea
There are one billion smokers in the world, with more than 70 percent in Asia
Source: WHO, Eden hospital interviews & analysis eden strategy institute | 6
CAUSES OF LUNG CANCER: SMOKING
China, for instance, consists of more than 300 million smokers, with smokers as young as two years old
Source: WSJ (2013), Photo Credit: Reuters eden strategy institute | 7
“The average age at which Chinese people start smoking is four to five years younger in 2002 compared to 1984”
Ministry of Health China
CAUSES OF LUNG CANCER: SMOKING
India produces 700 billion bidis annually, and consumes almost all of them locally
Source: The Times of India (2008), Photo Credit Paul Hamilton – Bidi Maker eden strategy institute | 8
“Bidi may contain lesser tobacco than cigareAes – 0.2 grams, but delivers as much or more tar and nico4ne”
Dr P C Gupta Healis Sekhsaria Ins]tute for Public Health
India
CAUSES OF LUNG CANCER: SMOKING
Korea has one of the highest proporYons of male smokers, despite the country’s relaYvely small populaYon
OECD
S. Korea
17 percent of teenage males is ligh]ng up a_er their daily classes
Source: OECD (2013), Photo Credit: iPark3 – Smoking talks eden strategy institute | 9
Male Smoking ProporYon
CAUSES OF LUNG CANCER: NON-‐SMOKING
Apart from smoking, non-‐smokers in Asia are also contracYng adenocarcinoma lung cancer due oncogenic mutaYon
Source: Eden hospital interviews & analysis, Photo Credit: Ed Uthman – Adenocarcinoma of lung, FNA eden strategy institute | 10
“Adenocarcinoma cancer mainly affects the terGary bronchus and bronchioles, areas which are harder to diagnose with tradiGonal methods”
Respiratory Specialist Taiwan
CAUSES OF LUNG CANCER: NON-‐SMOKING
This is compounded with the effects of air polluYon from the different sources within Asia
Second-‐Hand Smoke Forest Fire
Asbestos & Radon gas from building materials Industrial PolluYon
Cooking Oil ParYcles
Indonesia has over 3,000 fire alerts in from 20th February to 11th March in 2014
Source: World Resources Institute (2014), The World’s Worst Pollution Problems (2012), World Health Organization’s Tobacco-Free Initiative (2010) eden strategy institute | 11
Despite the toxicity of white asbestos, China and India are sYll heavily using it for building materials
India, for example, has produced over 60,000 tons of industrial waste over the last decade
Chinese-‐style cooking contributed ~30% to indoor concentraYon of parYcles from 0.5 to 5μm
Asia has one of the highest number of people exposed to secondhand smoke
CAUSES OF LUNG CANCER: NON-‐SMOKING
China, for instance, has witnessed a rise in non-‐smoking lung cancer cases due to severe air polluYon in the past few years
eden strategy institute | 12
“Lung cancer caused by exposure to air polluGon is increasing”
Wang Ning Deputy Director of Cancer Center
China
CAUSES OF LUNG CANCER: NON-‐SMOKING
Taiwan, which has a generally low smoking rate, is also seeing high incidences of non-‐smoking lung cancer due to second-‐hand smoke
“ 96% of women do not smoke, but are inhaling 4 to 5 4mes a week more second-‐hand smoke at home than in the work place”
2010 Adult Smoking Behavior Survey Bureau of Health Promo]on
Taiwan 60% 80%
40%
20%
0
1000
2000
3000
4000
5000
6000
7000
Male Female Non-‐Smoking Lung Cancer Smoking related Lung Cancer
New Lung Cancer Incidence by gender and type of cancer in Taiwan (2010)
Source: Eden hospital interviews & analysis eden strategy institute | 13
LUNG CANCER DEATHS
IntervenYons for lung cancer are especially criYcal due to the high lung cancer death rates
Source: Cancer Research UK 2014 eden strategy institute | 14
Lung 13%
Breast 12%
Bowel 10%
Prostate 8%
Others 57%
Most Common Cancers Worldwide 14.1 million new cancer cases
Most Common Cancers Deaths Worldwide 8.2 million cancer deaths
Lung 19%
Liver 9%
Stomach 9%
Prostate 8%
Others 55%
1.8 m New Lung Cancer Cases Worldwide (2012)
1.6 m Lung Cancer Deaths Worldwide (2012)
LUNG CANCER PATIENT PATHWAY
In analyzing the drivers of lung cancer deaths, we found that most countries in Asia already have clear paYent pathways
Source: Eden hospital interviews & analysis eden strategy institute | 15
1. IniYal Screening
v v v
Radiologists
• Chest X-‐Ray • Chest CT ExaminaGon • MRI Check • Bone Scan
Treatment with surgery
Central: Pulmonologist • Brush & Forceps Bronchoscopy • X-‐ray bronchoscopy (C-‐arm) • EBUS – TBNA • EBUS-‐Radial Peripheral: Interven]onal Radiologist • CT-‐guided TTNA
Hard-‐to-‐reach areas: Thoracic Surgeons • VATs • Thoracoscopy • MediasGnoscopy • Wedge ResecGon
• PET-‐CT: Radiologists • EBUS TBNA: Pulmonologists
2. Medical Imaging
3. Biopsy
4. Staging (If unsure whether tumor has spread)
Suspected cases
Watchful waiYng • 3-‐ 6 months of watchful wai]ng
Regular follow-‐ups
PosiYve Diagnosis
Non-‐PosiYve & Inconclusive Diagnosis Non-‐cancer
False negaGve Misdiagnosis
5. Decision to Operate
Stage 1 & 2 Operable
Stage 3 & 4 Inoperable
Chemotherapy treatment
Tumor Size
>2cm • No problem in
locaGng tumor • PaGents may
sGll opt for surgery
• Watchful waiGng
<1cm
3. Lab test • Pathology • Histology
• Difficult to diagnose using non-‐surgical methods
1-‐2 cm
Exhibit: Gold Standard PaYent Pathway for Lung Cancer Diagnosis
CHALLENGES IDENTIFIED
However, high death rates remain due to lack of screening, inconsistent skill levels among doctors, and limitaYons of exisYng tools
Source: Eden hospital interviews & analysis eden strategy institute | 16
1. IniYal Screening
v v v
Radiologists
• Chest X-‐Ray • Chest CT ExaminaGon • MRI Check • Bone Scan
Treatment with surgery
Central: Pulmonologist • Brush & Forceps Bronchoscopy • X-‐ray bronchoscopy (C-‐arm) • EBUS – TBNA • EBUS-‐Radial Peripheral: Interven]onal Radiologist • CT-‐guided TTNA
Hard-‐to-‐reach areas: Thoracic Surgeons • VATs • Thoracoscopy • MediasGnoscopy • Wedge ResecGon
• PET-‐CT: Radiologists • EBUS TBNA: Pulmonologists
2. Medical Imaging
3. Biopsy
4. Staging (If unsure whether tumor has spread)
Suspected cases
Watchful waiYng • 3-‐ 6 months of watchful wai]ng
Regular follow-‐ups
PosiYve Diagnosis
Non-‐PosiYve & Inconclusive Diagnosis Non-‐cancer
False negaGve Misdiagnosis
5. Decision to Operate
Stage 1 & 2 Operable
Stage 3 & 4 Inoperable
Chemotherapy treatment
Tumor Size
>2cm • No problem in
locaGng tumor • PaGents may
sGll opt for surgery
• Watchful waiGng
<1cm
3. Lab test • Pathology • Histology
• Difficult to diagnose using non-‐surgical methods
1-‐2 cm
Inconsistent skill levels and
misdiagnosis
Limita]ons of exis]ng methods & equipment
Lack of awareness and early screening
leading Exhibit: Gold Standard PaYent Pathway for Lung Cancer Diagnosis
Due to the lack of noYceable symptoms, many paYents usually get diagnosed and treated at a late stage of lung cancer
Source: Eden hospital interviews & analysis eden strategy institute | 17
Lack of awareness and early screening
leading
Inconsistent skill levels and misdiagnosis
Limita]ons of exis]ng methods & equipment
Country % of Late Stage Cancer
Average 77.8
China 80.0
Taiwan 80.0
India 85.0
Korea 66.0
CHALLENGES IDENTIFIED
Free screening for lung cancer remains unavailable in Asia for the public, unlike screening for breast and cervical cancer
Source: Eden hospital interviews & analysis eden strategy institute | 18
Inconsistent skill levels and misdiagnosis
Limita]ons of exis]ng methods & equipment
CHINA
TAIWAN INDIA S. KOREA
Free Lung Cancer Health Screening
No No No No
Free Breast Cancer Screening
Yes Yes Yes Yes
Free Cervical Cancer Screening
Yes Yes Yes Yes
Countries Studied
Lack of awareness and early screening
leading
CHALLENGES IDENTIFIED
In addiYon, the level of skills among doctors appears to be inconsistent across countries, and even within the same country
Source: Eden hospital interviews & analysis eden strategy institute | 19
Lack of awareness and early screening
leading
Inconsistent skill levels and misdiagnosis
Limita]ons of exis]ng methods & equipment
“There is a limitaGon to how far we can go in to the lung using CT-‐guided TTNA. It’s usually only 5cm from chest wall”
Respiratory Specialist
Taiwan
“If the radiologist is experienced enough, then every posiGon is possible. ComplicaGon would not be serious”
Respiratory Specialist Taiwan
Different level of skills with CT-‐guided TTNA
Different amount of Yme required to conduct biopsy
“Doctor can find the tumor using EBUS usually within ten seconds. The enGre procedure will be completed within ten minutes”
Pulmonologist Taiwan
“We take around 30 to 40 minutes per EBUS-‐TBNA test”
Pulmonologist Korea
CHALLENGES IDENTIFIED
In developing markets like India, lung cancer is commonly misdiagnosed as tuberculosis, leading to late treatment
Source: Eden hospital interviews & analysis eden strategy institute | 20
Lack of awareness and early screening
leading
Inconsistent skill levels and misdiagnosis
Limita]ons of exis]ng methods & equipment
Symptoms of Pulmonary Tuberculosis • Persistent cough that brings up phlegm, which may be bloody
• Mild to significant breathlessnessXD • Lack of appe]te and weight loss • High temperature of 38ºC (100.4ºF) or above • Night Sweat • Extreme ]redness or fa]gue, accompanied with pain
*Symptoms in common with lung cancer
Misdiagnosis of Lung Cancer as Tuberculosis “66% of the lung cancer paGents get treated for TB”
Pulmonologis India – Delhi
“Most paGents are diagnosed with TB and come to the pulmonologists at a later stage, by when their condiGon has already worsened”
Pulmonologist, India -‐ Mumbai
CHALLENGES IDENTIFIED
ExisYng medical imaging tools are limited in their ability to detect early stage lung cancer
Source: Eden hospital interviews & analysis eden strategy institute | 21
Lack of awareness and early screening
leading
Inconsistent skill levels and misdiagnosis
Limita]ons of exis]ng methods & equipment
Chest CT Scan PET CT Scan Chest X-‐Ray MRI Scan Bone Scan
CHALLENGES IDENTIFIED
Method Uses electromagne]c radia]on to generate images of ]ssues and structures inside the body
Creates 3D picture of the inside of the body with mul]ple x-‐ray
Uses magne]c fields to produce detailed images of the body
Radioac]ve glucose injected into body to find tumors
Uses a radioac]ve tracer to look at the inside of the bone
Func]on Ini]al test to detect abnormal shadowing within lungs
To provide precise informa]on about size, shape and posi]on of any lung tumors/enlarged lymph nodes
Metastasis detec]on for brain
Typically used for staging. Full body tes]ng for cancer
Metastasis detec]on for bones
Strengths Quick, simple & cheap Ability to spot very small lung tumors, and help determine exact loca]on and extent of tumors
Ability to see size and loca]on of lung cancer metastases
Ability to test for metastasis
Ability to test for metatasis
Limita]ons Unable to detect small lung tumors
Insufficient to confirm cancer
Rarely used for lungs as lung is always moving
Costly. High false posi]ve for tuberculosis pa]ents
Replaced by PET CT scan to find lung cancer that has spread to the bones
TradiYonal biopsy tools are olen only able to reach up to terYary bronchi, with problems accessing parts near the nerves and heart
Source: Eden hospital interviews & analysis eden strategy institute | 22
Lack of awareness and early screening
leading
Inconsistent skill levels and misdiagnosis
Limita]ons of exis]ng methods & equipment
Primary & Secondary Bronchus can be reached with tradiYonal biopsy tools
Lung regions that are difficult to access
TerYary Bronchus, that can be reached with bronchoscopes & EBUS RP
TradiYonal Bronchoscopy
EBUS radial probe (RP)
EBUS radial probe (RP): Blind
CHALLENGES IDENTIFIED
Source: Eden hospital interviews & analysis eden strategy institute | 23
SOLUTION SPACE
Successfully tackling lung cancer requires close collaboraYon among governments, hospitals, and various stakeholders for shared benefits
Government Hospitals
Doctors Medical Device Companies
NGOs
Insurance Companies COUNTRY
LUNG CANCER STRATEGY
• Raising awareness of lung cancer and its links with smoking
• Advoca]ng / subsidizing free screening for high risk individuals
• Raising awareness on risk of smoking and benefits of early screening
• Assessing healthcare economics of subsidizing lung cancer diagnosis and treatment
• Capacity building to ensure consistency of skills and reduce cases of misdiagnosis
• Conference s to share best prac]ce cases
• Working with hospitals and government to provide comprehensive coverage for lung cancer screening
• Sharing of knowledge and training • Con]nual learning and upgrading of skills
• R&D on improving lung cancer biopsy and treatment
Medical Schools
• Collabora]ng with medical device companies to conduct research
• Consistent method of providing training to doctors
Source: Want China Times (2012) Taipei Times (2012), Ministry of Health and Welfare (2014) Photo Credit: Taiwan Health Promotion Administration (2012) eden strategy institute | 24
The government in Taiwan, for instance, has worked together with hospitals and clinics in local communiYes on a series of smoking cessaYon campaigns through educaYon and support
“Thanks to the program, an es4mated NT$900 million (US$30.1million) in medical expenditure will be save in the short term and a much greater amount in the long term”
Taiwan Former Premier Jiang Yi-‐Huah
SOLUTION SPACE
EducaYon Regulatory Changes
Support & Counseling Financial IncenYve • First smoke-‐free hospital
network in the Asia-‐Pacific region in 2010, with 113 ins]tu]ons joining
• 2,151 hospitals providing new Quit Smoking Services
Impact (Since 2012) • Served 630,000 people • Helped more than 160,000 people to quit
• “Quit Smoking, Smoke-‐free Taipei Program” provides 4 weeks of free medica]on and medical advise
• Program funding by Na]onal Health Insurance scheme
• Extended smoke-‐free areas to include most enclosed work-‐places and public places
• Adding graphic health warnings to cigarese packages and banning of tobacco adver]sements
• Media campaigns on public awareness and secondhand smoke exposure
Source and Photo Credit: Norwalk Hospital (2014) eden strategy institute | 25
Norwalk hospital, in the US, also offers free low-‐dose lung CT screening for high risk paYents to encourage early diagnosis
Qualifying criteria • Aged between 55 and 80 • Have smoked within the last 15 years • Have a 30+ pack year smoking history
“Researchers found that screening with low-‐dose lung CT screening significantly reduced the mortality rate from lung cancer by 20 percent”
Norwalk Hospital (2014)
Free Lung Cancer Screening Program Includes: • Low-‐dose lung CT screening • Scan of the coronary arteries • Three personalized smoking cessa]on
classes for current smokers who wish to quit
SOLUTION SPACE
Source: Eden medical device company and hospital interviews & analysis eden strategy institute | 26
Breakthroughs in lung cancer biopsy technologies can also address the limitaYon of exisYng methods Employing EBUS radial probe together with ENB as a safer and more comfortable early stage peripheral diagnosis tools
Primary & Secondary Bronchus can be reached with tradiYonal biopsy tools
Lung regions that are difficult to access
TerYary Bronchus, which can be reached with bronchoscopes & EBUS RP
TradiYonal Bronchoscopy
ENB
EBUS radial probe (RP)
EBUS radial probe (RP): Blind
ENB (Blind)
Bronchioles, which can be reached with EBUS RP and ENB
Endobrochial Ultrasound Bronchoscopy Radial Probe (EBUS RP)
Electromagne]c Naviga]on Bronchoscopy (ENB)
SOLUTION SPACE
Source: NY Daily News (2014), Photo Credit: American Friends of Tel Aviv University eden strategy institute | 27
The possibility of a breathalyzer for lung cancer diagnosis is also in its research and development stage
SOLUTION SPACE
Preventable deaths from lung cancer can be reduced with widespread awareness-‐building smoking and early screening, subsidized lung cancer screening on a systemaYc level, adopYon of recent technological advancements, and capacity-‐building among medical teams
eden strategy institute | 28
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