Breast Cancer in LMICs: Meeting the Challenge of Closing the Cancer Divide.”

8/2/2019 Breast Cancer in LMICs: Meeting the Challenge of Closing the Cancer Divide.

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Breast Cancer in LMICs:Meeting the Challenge ofclosing the cancer divide

Felicia Marie KnaulFebruary 14, 2012


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From anecdote

to evidence


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January, 2008

June, 2007


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Con jf en harvard

Harvard School of Public Health


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From anecdote

to evidence


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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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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs

I: Much should be doneII: Much could be done

III: Much can be done

1: Innovative Delivery

2: Access to Affordable Medicines,

Vaccines & Technologies

3: Innovative Financing: Domesticand Global

4: Evidence for Decision-Making

5: Stewardship and Leadership


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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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Challenge and disprove the

myths about cancer

M1. Unnecessary

M2. Unaffordable

M3. ImpossibleM4: Inappropriate

Should,

Could, andCan..

Expanding access to cancer care and control in

low and middle income countries:


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The divide is the result of concentrating riskfactors, preventable disease, suffering,impoverishment from ill health and deathamong poor populations.

fueled by progress in cutting-edge science andmedicine in high-income countries.

The Cancer Divide:disparities in outcomes

between poor and rich directly related to inequitiesin access and differences in underlying socio-

economic and health conditions.


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Mirrors the overall epidemiologicaltransitionprotracted and polarized*:

LMICs increasingly face both cancersassociated with infection, and all other

cancers.

Cancers that were once considered only ofthe poor, now cease to be the only cancers

of the poor. (e.g. cervical & breast cancer)

The Cancer Transition

* Frenk et al


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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 factors2. Preventable cancers (infection)

3. Death and disability fromtreatable cancer

4. Stigma and discrimination

5. Avoidable pain and suffering

The Cancer Divide:

An Equity Imperative

Fac

ets

Ri k f t t ti


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Risk factor concentration:

Obesity Epidemic, Mexico

10

60

8

32

57

25

10

2

37

25

36 37

29

2

Malnutrition Adequate

Overweight

Obesity

1988

1999

% women 20-49 years

2006


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MortalityIncidence

Incidence and mortality of cervical cancer(adjusted rate per 100,000 women)

Incidenceratio

Mortalityratio

Russia 19.3 8.6

Central and Eastern Europe 21.3 9.0

Less developed regions 25.7 14.1

More developed regions 13.2 4.6

World 22.0 11.2

Th id i f b t


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The epidemic of breast cancer:Unforseen challenge in LDCs

Some 45% of the more than 1 million new cases of breastcancer diagnosed each year, and more than 55% of breast-

cancer-related deaths, occur in low- and middle-income

countries.*

Such countries now face the challenge of effectivelydetecting and treating a disease that previously was

considered too uncommon to merit the allocation of

precious health care dollars.

Source: Porter, P. (2007). "Westernizing Womens Risks? Breast Cancer in

Lower-Income Countries." New England Journal of Medicine 358(3):4

Curado MP, Edwards B, Shin HR, et al., eds. Cancer incidence in five continents. France: International

Agency for Research on Cancer, 2007.


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In developing regions, breast cancer

Most frequent cause of cancer-related death in developing and

developed regions

leading cause if death especially for young women

268,000 of the 458,000 deaths per year are in LIMCs: 58%

Most common cancer in developed and developing regions

4.4 million women alive (diagnosed): how many in developing

regions?

2008: 1.38 million new cases; 50% of which are from LIMCs

10.9% of all incident cancerssecond to lung

(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).


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Breast cancer: myths and realities

It is a disease ofdeveloped countries

It is a disease ofolder women

It is of lower prioritythan cervical cancer

The majority of cases anddeaths occur in the

developing world

A large proportion of casesand deathsperhaps the

majorityhappens in

women


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~40% occur in pre-menopausal

women (55

Age of

Diagnosis

Age ofDeath

Source: Author estimates based on IARC, Globocan, 2008 and 2010.

33%

20%54%

66.6%

34.2%65%

The cancer transition in LMICs:


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Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.


breast and cervical cancer 1980-2010

53%47%

20%24%

19%

-31%

60%

-40%

0%

40%

80%

LMICs High income

BC cases

BC deaths

CC cases

CC deaths

% Change in incidence and mortality



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Source: Knaul Arreola Mende . estimates based on IHME 2011.

LMICs as % of global incidence and mortality

Breast

Cervical



0%

30%

60%

90%

1980 2010 1980 2010

52%

59%

49%

63%

79%

87%82%

88%

The Cancer Transition Me ico and Costa Rica:


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Source: Knaul et al., 2008. Reproductive Health Matters, and updated byKnaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-

1978), and Ministry of Health in Mexico (1979-2006)

1995 2000 2005

Costa Rica 1995 - 2005

Breast cancer

Cervical cancerSource: Instituto Nacional de Estadstica y Censos, Ministerio de Salud,Unidad de Estadstica, Registro Nacional de Tumores de Costa Rica.

The Cancer Transition, Mexico and Costa Rica:

breast and cervical cancer, mortality time series.

0

4

8

12

16

1955

1965

1975

1985

1995

2005


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Source: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de Mama en Mxico, 1979-2008.

FUNSALUD, Documento de trabajo. Observatorio de la Salud.

1979

1985 1995

Nuevo Len

2008

0

Oaxaca

5

10

15

20

25

1979 1985 1995

2008

The cancer transition within Mexico:



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Adults

Breast

Cervix Prostate

Testis

HL

N HL

Leukaemia

All cancers

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

Children

LOW

INCOME

HIGH

INCOME

Survival

inequalityg

ap

LOW

INCOME

HIGH

INCOME

100%

The opportunity to survive (M/I)

should not be defined by income.

Yet it is.


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Stigma:

Juanita

Cancer, and

especially

reproductive

cancers, adds

a layer of

discrimination

onto gender,

ethnicity, andpoverty.

The most insidious example of


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The most insidious example of

injustice is access to pain controlNon-methadone, Morphine

Equivalent opioid consumptionper death from HIV or cancer in

pain by income level

Russia: 937 mg; ALL Developed

countries 57,041

Ch ll d di th


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minimalists:

myths about cancer

M1. Unnecessary NECESSARY

M2. Unaffordable: .for the poorM3. Impossible

M4: Inappropriate: either/or

Challenging cancer implies taking

resources away from other diseases of

the poor


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`5/80 Cancer Disequilibrium

Almost 80% of the DALYs (disability-adjustedlife-years) lost worldwide to cancer are in LMICs,yet these countries have only a very small share of

global resources for cancer ~ 5% or less.

Africa

1% of global spending on health64% of new cancer cases

15% of the global population.

I ti i CCC


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Investing in CCC:

We cannot afford not toHealth is an investment, not a cost

World Economic Forum: chronic disease is 1

of the 3 leading global economic risksEconomic value of lost DALYs: $921 million

VSL losses: $2.5 billion

Total economic cost of cancer, 2010

2-4% global GDP


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80% of total

75% ofbreast

95% of cervical

Avoidable cancer deaths:

1/3 to 1/2 or 2.4-3.7 million

Income Region% of all cancer deaths

considered avoidableBreast

Low income 52% 79%

Lower middle

income44% 73%

Upper middle

income33% 56%

High income 21% 40%

LMICs: Avoidable

deaths

I ti i CCC


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Investing in CCC:

we cannot afford not to

Assuming that between 50% of

deaths are avoidable

Total annual cost: $310 billionInvesting in CCC yields an annual

return on prevention and treatment of

between 1.5:1 to 3.7:1.

Economic cost of inaction, 2009

$US 2010 billion130-850


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Second-line TB Drugs

(Farmer, 2009)% Decline in price 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Reduced drug and vaccine prices

HPV vaccine in LMICs: Before 2011: from $US 30 to $US 100 per dose

PAHO Revolving Fund: decreased from US$ 32 per dose in January

2010 to US$ 14 per dose in April 2011.

GAVI: June 2011 Merck offers vaccine at US$ 5 per dose for low

income countries.

Hep B vaccine: decline from a 1982 launch price of over $100 to$0.20 a dose has enabled developing countries to dramatically increase

vaccination rates with support from GAVI



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minimalists:

myths about cancer

M1. Unnecessary

M2. Unaffordable:M3. Impossible POSSIBLE


Challenging cancer implies taking

resources away from other diseases of

the poor

Champions


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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

Champions from LMICs: Mxico


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Champions from LMICs: Mxico

Successes treating other diseases:


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Successes treating other diseases:MDR-TB treatment

Source: Paul Farmer., 2009

cured

83%

abandon

therapy

2%

failed

therapy

8%

died

8%

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-

Outcomes in MDR-TB patients in Lima,

Peru receiving at least 4 months of therapy

WHO 1997, Multidrug-resistant

tuberculosis is too expensive to treat in

poor countries; it detracts attention and

resources from treating drug-susceptible

disease.

Drug % Decline inprice 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Reduced prices of

second-line TB drugs

S i t ti l


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Mexico: cervical cancer.

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2006)

0

4

8

12

16

1955

1965

1975

1985

1995

2005

Success in treating several cancers.

Financing innovations:


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Financing innovations:

DomesticIntegrate CCC into national insurance programs to

express previously suppressed demand, beginning

with cancers of women and children:

Mexico

Colombia

Dominican Republic

Peru

China

India

Rwanda

Taiwan

Innovations in Financing:


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Innovations in Financing:

Global

Integrated, innovative financingmechanisms that have gone to scale -

Global Fund and GAVI - can be leveragedRMNCH platforms provide models forbroad-based international partnership and

commitment-building for cancer and NCD.Recent, diagonal partnership initiatives arepromising -pink ribbon red ribbon



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minimalists:

Myths about cancer& NCD

M1. Unnecessary NECESSARY

M2.Unaffordable AFFORDABLE

M2. Impossible POSSIBLE


Challenging cancer implies takingresources away from other diseases of

the poor

Women and mothers in LMICs


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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 30years

= 430, 210 deaths

The Diagonal Approach to


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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 provide

opportunities to tackle disease-specific priorities

while addressing systemic gaps.

Optimize available resources so that the whole is

more 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?

Shared risk factors

Success and life cycle

Common need for strong healthsystems platforms

Efficiency

Economic developmentSocial justice

Di l St t i


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Diagonal Strategies:

Positive Externalities

Promoting prevention and healthy lifestyles:

Reduce risk for cancer and other diseases

Reducing stigma for womens cancers:Contributes to reducing gender discrimination.

Pain control and palliation

Reducing barriers to access is essential forcancer, for other diseases, and for surgery.


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Delivery: Harness platforms byintegrating cancer prevention,

screening and survivorshipsupport into MCH, SRH,

HIV/AIDS, social welfare andanti-poverty programs.

A Diagonal Strategy:


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Cases:

Juanita

Mexico

Mexico Seguro Popular Insurance


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g p

a diagonal strategy that includes financial

protection for catastrophic illness

Accelerated universal vertical coverage by disease

with a specified package of interventions

2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers

2007: Breast cancer

2011: Testicular cancer and NHL

Seguro Popular and cancer:


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Seguro Popular and cancer:

Evidence of impact

Since the incorporation of childhoodcancers into the Seguro Popular

30-month survival: 30% to almost 70%adherence to treatment: 70% to 95%.

Access to medicinesan anecdote

Breast cancer adherence to treatment:2005: 200/600

2010: 10/900

H i l d i l fi i l i i


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Beneficiaries: Population covered

Benefit

s:coveredinterventions

Horizontal and vertical financial protection strategies:Seguro Popular for Breast Cancer, Mexico

Catastrophic Illness

ACCELERATED VERTICAL COVERAGE: Ex: breast cancer,

Package ofessential personal

services

Community Health Services - NUTRITION

Poor Rich

M i f f t


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Mexico: summary of facts

Since 2006, breast cancer is the second leading cause ofdeath among women aged 30 to 54 years of age and the

principal cause of death due to tumors.

Seguro Popular: since 2007 all women diagnosed with

breast cancer have very complete access to treatmentwith financial protection

Only 5-10% of cases in Mexico aredetected in Stage 1 or in situ

i i


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Early Detection = survival

Stage at diagnosisSurvival rates,

US ACS

0 - 1 98%

2 - 3 84%

4 27%

Fuente: American Cancer Society. Breast Cancer Facts & Figures, 2007-2008. Atlanta, GA. : American Cancer Society, Inc.,

y Secretara de Salud. Programa de Accin: Cncer de mama. Mxico, D.F.

Mexico: 70% in late stages

IMSS M i 40 50% f


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IMSS Mxico: 40-50% of cases are

detected in stages III-IV. 85+ in II+

10%

30%

50%

1992 2002 2006

Stage I Stage II Stage III & IV

Stage at diagnosis by level of municipal


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g g y p

marginalization, Mexico, IMSS 2006(Mxico, IMSS 2006)

Source: Authors estimation based on IMSS data, 2006.

N=221(3.8%)

N=1737(30%)

N=2877(49.8%)

N=946(16.4%)

% diagnosed

in Stage 4

Late detection by state

0%

10%

20%

30%

40%

50%

Poor (High) Middle Low Very low

Stage 1 Stage 2

Stage 3 Stage 4

< low

> mid

> high

Wh ?


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Why?

Social and health systems

barriers to early detectionand

non-price barriers totreatment

Vignette: a series of Missed Opportunities:


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g ppJuanita

(patient journey analysis)42; left breast substantially larger than right; arrived at Morelos

Womens Hospital bc she could not move her swollen arm; father of

children abandoned household at diagnosis

History 1:

- 5 children aged 7-18; breast fed all

- Cartilla de la mujer: regular PAP and clinic visits

- Has Oportunidadesattends regular community health platicas

History 2:

Felt a breast lump 4 years priorfear kept her from saying anything

Lump grewlast year asked doctor-pasante at local clinic and given anti-b

w/out bc

Is entitled to Seguro Popular and free care

Cannot travel to Mexico City so seeking care locally and paying out of pocket

J it


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br

Juanita:Advanced metastatic breast

cancer is the result of a series ofmissed opportunities


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Barrier 1: financing

Barrier 2: myth and machismo

Barrier 3: Inequity in addition to lack


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0%

10%

20%

30%

+ Poorest

Q1 Q2 Q 3 Q 4Least poor

QV

16%

21% 22%24%

28%

Fuente: ENSANUT, 2006

q y

of overall access and utilization

Only 1 in 5women 40-69

report a

preventivehealth visit

including

mamography2006

B i 4 P lit i


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Barrier 4: Poor quality services

women diagnosed with bc reported problems withproviders when seeking diagnosis.

In routine, annual repro health/OBGYN visit/ PAP

screening, there was no BCE

Physician insisted woman was overreacting and sent herhome with no diagnosis

Health professionals and first-level care providers

report lack of sensitivity of health personnel relating to

the requests of women regarding breast health

Results from a national qualitative studynigenda et al, 2009

a series of missed opportunities


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a series of missed opportunities

Nurse and midwife

Works on MCH, SRH and HIV/AIDS

locally

Has participated in global advocacy andtraining conferences

Undertakes research and field surveys

.has never considered including NCD or

cancerbcthere is no treatment

available or it is not a problem

Policy maker in MOHoffice down the

hall from women and cancer Manages the cash-transfer, family

planning program

Information on NCD and cancers are not a

topic that is covered in the discussions

bc it is not a problem and there are no

materials

Breast cancer advocate, runs an

international NGO. Concerned about funding for

treatment but does not participate

in debate about health care reform

Patients are surviving to suffer

other diseases (diabetes?), but her

group cannot offer assistance

they have no linkages to other

groups

Does not participate in advocacy

about women and health more

broadly, yet one of the mainbarriers to early detection of her

patients is machismo and gender

discrimination

Programs to reduce


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Programs to reduce

barriers

Core project components


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Core project components1) Expand potential for early detection

Harness anti-poverty and MCH Oportunidades programTraining of health promoters

Improved referral system

Training of primary care-level physicians and nurses

2) Expand potential for care and treatment in secondary level

hospitalsSupervision and capacity building from tertiary to secondary

district hospitals

Centers for chemotherapy and survivorshipsecondary and

primary levelAcreditation of secondary centers so SPSS can finance

3) Increase data-for-decision-making, evaluation and monitoring

Improved or new registries

Evaluation and monitoring

P ti i ti i tit ti


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Participating institutions:

Seguro Popular and MOH MexicoMinistry of Health of Jalisco, Morelos, Nuevo Leon, Puebla,

Sinaloa.

National Cancer Institute of Mexico

National Institute of Public Health

Cncer de mama: Tmatelo a pecho

Mexican Health Foundation

The Global Task Force on Expanded Cancer Care and Control inDeveloping Countries through the Secretariat based at the

Harvard Global Equity Initiative and Seattle Cancer Care Alliance


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g pminimalists:

Myths about breast cancer,cancer& NCD

M1. Unnecessary NECESSARYM2. Impossible POSSIBLE

M3.Unaffordable AFFORDABLE

M4. Inappropriate : APPROPRIATE


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Be anoptimist

optimalist

Expanding access to cancer care and control in

Breast Cancer in LMICs: Meeting the Challenge of Closing the Cancer Divide.”

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Transcript of Breast Cancer in LMICs: Meeting the Challenge of Closing the Cancer Divide.”