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CC i ?i ?CancerCancer-- Did you Know?Did you Know?
Disproving the MythsDisproving the MythsDisproving the MythsDisproving the Myths
About Cancer inAbout Cancer in
WORLDWORLD
CANCERCANCER
ResourceResource--constrained Settingsconstrained Settings
CANCERCANCER
DAYDAY
SeminarSeminar
HarvardHarvard SchoolSchool ofof PublicPublic HealthHealth
FebruaryFebruary 1st, 20131st, 2013
SeminarSeminar
Felicia Marie Knaul, PhDFelicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access toHarvard Global Equity Initiative, Global Task Force on Expanded Access to
Cancer Care and Control in LMICsCancer Care and Control in LMICsCancer Care and Control in LMICsCancer Care and Control in LMICs
Tómatelo a Pecho A:C. MéxicoTómatelo a Pecho A:C. México
Mexican Health FoundationMexican Health Foundation
Union for International Cancer ControlUnion for International Cancer Control
Thank youThank you
GlobalGlobal TaskTask ForceForce onon ExpandedExpanded
AccessAccess toto CancerCancer Care andCare and
Control inControl in DevelopingDeveloping CountriesCountriesControl inControl in DevelopingDeveloping CountriesCountries
l b l h lth= global health + cancer care
GTF.CCC
Members
Applies a diagonalApplies a diagonal
approach to manageapproach to manageapproach to manageapproach to manage
‘‘chronicitychronicity’ and avoid’ and avoidchronicitychronicity and avoidand avoid
the false dilemmasthe false dilemmas
between disease silosbetween disease silos
CD/NCDCD/NCD th tth t--CD/NCDCD/NCD-- thatthat
continue to plaguecontinue to plaguecontinue to plaguecontinue to plague
global healthglobal healthgg
Closing the Cancer Divide:
An Equity Imperative
Expanding access to cancer care and control in LMICs:
I: Should be doneM1. Unnecessary
II: Could be done
M2. Unaffordable
M3 Impossible
III: Can be done
M3. Impossible
M4: Inappropriatepp p
The Cancer Transition
i h id i l i l i i
The Cancer Transition
Mirrors the epidemiological transition
LMICs increasingly face both infectionLMICs increasingly face both infection-
associated cancers, and all other cancers.
Cancers increasingly only of the poor, are
not the only cancers affecting the poor.not the only cancers affecting the poor.
Did you know?????Did you know?????
LMICs account for
>90% of cer ical For children & adolescents>90% of cervical
cancer deaths and
#2 f d h i l h i
For children & adolescents
5-14 cancer is:
>60% of breast
cancer deaths. Both
#2 cause of death in wealthy countries
#3 in upper middle-income
#4 in lower middle-income
are leading killers –
especially of young
#4 in lower middle income
and # 8 in low-income countries
especially of young
women.
Closing the Cancer Divide
C i di f b h i h d b
is an Equity Imperative
Cancer is a disease of both rich and poor but
the poor suffer even more:the poor suffer even more:
1. Exposure to risk factors1. Exposure to risk factors
2. Preventable cancers (infection)
3. Treatable cancer death and disability
acets
4. Stigma and discrimination
5 Avoidable pain and suffering
Fa
5. Avoidable pain and suffering
The Opportunity to Survive Should Not,
b I D fi d b I
100%
but Is Defined by Income
AdultsChildren
ine
Leukaemia
Surviv
equality
All cancers
val
ygap
LOW
INCOME
HIGH
INCOME
LOW
INCOME
HIGH
INCOME
In Canada, almost 90% of children with
leukemia survive
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
leukemia survive.
In the poorest countries only 10%.
The most insidious injustice is lack
of access to pain controlof access to pain control
Non-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
Challenge and disprove theChallenge and disprove the
myths about cancer
M1 Unnecessary NECESSARYNECESSARYM1. Unnecessary NECESSARYNECESSARY
M2. Unaffordable: ….for the poorUnaffordable: ….for the poorpp
M3. Inappropriate: either/or
Ch ll i i li kiChallenging cancer implies taking resources
away from other ‘diseases of the poor’
M4: Impossible
Investing In CCC:
We Cannot Afford Not To
Inaction reduces efficacy of health and social investments
Total economic cost of cancer, 2010: 2-4% of global GDPg
Tobacco is a huge economic risk: 3.6% lower GDP
1/3-1/2 of cancer deaths are “avoidable”:
2 4 3 7 million deaths✓ 2.4-3.7 million deaths,
of which 80% are in LIMCs
✓
Prevention and treatment offers potentialeve o d e e o e s po e
world savings of $ US 130-940 billion
The costs to close the cancer divide
b l th fmay be less than many fear:
All b 3 f 29 LMIC i i h dAll but 3 of 29 LMIC priority cancer chemo and
hormonal agents are off-patent
Pain medication is cheap
P i d H B d HPV iPrices drop: HepB and HPV vaccines
Delivery and financing innovations arey g
underutilized and undeveloped: purchasing is
fragmented and procurement is unstablefragmented and procurement is unstable
Global Paediatric Financing EntityGlobal Paediatric Financing Entity
Challenge and disprove theChallenge and disprove the
myths about cancer
M1 Unnecessary NECESSARYNECESSARYM1. Unnecessary NECESSARYNECESSARY
M2. Unaffordable: AFFORDABLEAFFORDABLE
M3. ImpossibleM3. Impossible
M4 I i t ith /M4 I i t ith /M4. Inappropriate: either/orM4. Inappropriate: either/or
Challenging cancer implies taking resourcesg g p g
away from other ‘diseases of the poor’
Women and mothers in LMICs
f i k th h th lif lface many risks through the life cycle
Women 15-59, annual deathsWomen 15 59, annual deaths
Diabetes
Breast
cancer
Cervical
cancer
Mortality
in
childbirth- 35%
in 30
years
120,889166,577 142,744342,900
430 210 d h
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
= 430, 210 deaths
Harvard, Breast Cancer in DevelopingHarvard, Breast Cancer in Developing Countries, Nov 4, `09Countries, Nov 4, `09
Champions
Harvard, Breast Cancer in DevelopingHarvard, Breast Cancer in Developing Countries, Nov 4, 09Countries, Nov 4, 09
Nobel Amartya Sen,
Cancer survivor diagnosed in India
Drew G. Faust
President of Harvard University Cancer survivor diagnosed in India
50 years ago
President of Harvard University
22+ year BC survivor
Young champions, from LMICsg p ,
Abish Romeo,
México
Breast cancer, 23Breast cancer, 23
Beneficiary of
Seguro PopularSeguro Popular
PIH Rural Rwanda: 0 oncologists
Burkitt´s
lymphoma
Embryonal
RhabdomyosarcomaRhabdomyosarcoma
Source: Paul Farmer., 2009
The Diagonal Approach to
Health System Strengthening
Rather than focusing on disease-specific vertical
programs or only on horizontal systemprograms or only on horizontal system
constraints, harness synergies that provide
t iti t t kl di ifi i itiopportunities to tackle disease-specific priorities
while addressing systemic gaps.
Optimize available resources so that the whole is
more than the sum of the partsmore than the sum of the parts.
Bridge the divide as patients suffer diseases over aBridge the divide as patients suffer diseases over a
lifetime, most of it chronic.
Domestic, Diagonal
financing innovations
Integrate CCC into national insurance
programs to express previously suppressedprograms to express previously suppressed
demand, beginning with cancers of women
and children:
Mexico Colombia DominicanMexico, Colombia, Dominican
Republic, Peru
China, India, Taiwan
R d KRwanda, Kenya
México Seguro Popular:
Cancer and the Fund for Protection fromCancer and the Fund for Protection from
Catastrophic Illness
Accelerated, universal, vertical coverage by disease
with an effective package of interventionsp g
2004: HIV/AIDS
i l2005: cervical cancer
2006: ALL in children2006: ALL in children
2007: All pediatric cancers; Breast cancer
2011: Testicular and Prostate cancer and NHL
2012 C l t l2012: Colorectal cancer
México Seguro Popular and
cancer: Evidence of impact
Access to medicines
Since the incorporation of childhood cancers
into the Seguro Popularinto the Seguro Popular
Adherence to treatment: 70% to 95%
Breast cancer adherence to treatment:
2005: 200/6002005: 200/600
2010: 10/900
Delivery failure: México Breast Cancer
•# 2 killer of
% diagnosed in Stage 4 by state
# 2 killer of
women 30-54
•Only 5 10% of•Only 5-10% of
cases in Mexico
d d iare detected in
Stage 1 or in situ
•Poor
municipalites: Poor/Marginalizedmunicipalites:
50% Stage 4; 5x
rich
oo / a g a ed
rich
Juanita:Jua ta:
Advanced metastatic breast
f i fcancer, the result of a series of
missed opportunitiesssed oppo tu t es
Solution:
‘Diagonalizing’ Delivery
Harness platforms by integrating breast and
cervical cancer prevention, screening andcervical cancer prevention, screening and
survivorship care into MCH, SRH, HIV/AIDS,
social welfare and anti poverty programssocial welfare and anti-poverty programs.
Examples: Harnessing the primary level of care
• Integration of breast
and cervical cancer
awareness and screening
into the national anti-
poverty program
Oportunidades Results: 000´s promoters, nurses, doctors
Where are the opportunities?Where are the opportunities?
LMIC h b h h l lif i• LMICs: not months but rather whole lifetimes to
be gained
• Recognize cancer in LMICs as an integral
component of our common search for globalcomponent of our common search for global
health solutions:
investment in learning, research,
knowledge-sharing and translation andknowledge sharing and translation, and
ultimately in human beings
From anecdoteFrom anecdote …
t id… to evidence
January, 2008June, 2007
Cancer- Did you know? Disproving the myths about cancer in resource-constrained settings
BeBe ananBeBe anan
optimistoptimistoptimistoptimist
optimalistoptimalistoptimalistoptimalist
Expanding access to cancer care and control inExpanding access to cancer care and control in
LMICs: Should, Could, and Can be done

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Cancer- Did you know? Disproving the myths about cancer in resource-constrained settings

  • 1. CC i ?i ?CancerCancer-- Did you Know?Did you Know? Disproving the MythsDisproving the MythsDisproving the MythsDisproving the Myths About Cancer inAbout Cancer in WORLDWORLD CANCERCANCER ResourceResource--constrained Settingsconstrained Settings CANCERCANCER DAYDAY SeminarSeminar HarvardHarvard SchoolSchool ofof PublicPublic HealthHealth FebruaryFebruary 1st, 20131st, 2013 SeminarSeminar Felicia Marie Knaul, PhDFelicia Marie Knaul, PhD Harvard Global Equity Initiative, Global Task Force on Expanded Access toHarvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICsCancer Care and Control in LMICsCancer Care and Control in LMICsCancer Care and Control in LMICs Tómatelo a Pecho A:C. MéxicoTómatelo a Pecho A:C. México Mexican Health FoundationMexican Health Foundation Union for International Cancer ControlUnion for International Cancer Control
  • 3. GlobalGlobal TaskTask ForceForce onon ExpandedExpanded AccessAccess toto CancerCancer Care andCare and Control inControl in DevelopingDeveloping CountriesCountriesControl inControl in DevelopingDeveloping CountriesCountries l b l h lth= global health + cancer care
  • 5. Applies a diagonalApplies a diagonal approach to manageapproach to manageapproach to manageapproach to manage ‘‘chronicitychronicity’ and avoid’ and avoidchronicitychronicity and avoidand avoid the false dilemmasthe false dilemmas between disease silosbetween disease silos CD/NCDCD/NCD th tth t--CD/NCDCD/NCD-- thatthat continue to plaguecontinue to plaguecontinue to plaguecontinue to plague global healthglobal healthgg
  • 6. Closing the Cancer Divide: An Equity Imperative Expanding access to cancer care and control in LMICs: I: Should be doneM1. Unnecessary II: Could be done M2. Unaffordable M3 Impossible III: Can be done M3. Impossible M4: Inappropriatepp p
  • 7. The Cancer Transition i h id i l i l i i The Cancer Transition Mirrors the epidemiological transition LMICs increasingly face both infectionLMICs increasingly face both infection- associated cancers, and all other cancers. Cancers increasingly only of the poor, are not the only cancers affecting the poor.not the only cancers affecting the poor.
  • 8. Did you know?????Did you know????? LMICs account for >90% of cer ical For children & adolescents>90% of cervical cancer deaths and #2 f d h i l h i For children & adolescents 5-14 cancer is: >60% of breast cancer deaths. Both #2 cause of death in wealthy countries #3 in upper middle-income #4 in lower middle-income are leading killers – especially of young #4 in lower middle income and # 8 in low-income countries especially of young women.
  • 9. Closing the Cancer Divide C i di f b h i h d b is an Equity Imperative Cancer is a disease of both rich and poor but the poor suffer even more:the poor suffer even more: 1. Exposure to risk factors1. Exposure to risk factors 2. Preventable cancers (infection) 3. Treatable cancer death and disability acets 4. Stigma and discrimination 5 Avoidable pain and suffering Fa 5. Avoidable pain and suffering
  • 10. The Opportunity to Survive Should Not, b I D fi d b I 100% but Is Defined by Income AdultsChildren ine Leukaemia Surviv equality All cancers val ygap LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME In Canada, almost 90% of children with leukemia survive Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010. leukemia survive. In the poorest countries only 10%.
  • 11. The most insidious injustice is lack of access to pain controlof access to pain control Non-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
  • 12. Challenge and disprove theChallenge and disprove the myths about cancer M1 Unnecessary NECESSARYNECESSARYM1. Unnecessary NECESSARYNECESSARY M2. Unaffordable: ….for the poorUnaffordable: ….for the poorpp M3. Inappropriate: either/or Ch ll i i li kiChallenging cancer implies taking resources away from other ‘diseases of the poor’ M4: Impossible
  • 13. Investing In CCC: We Cannot Afford Not To Inaction reduces efficacy of health and social investments Total economic cost of cancer, 2010: 2-4% of global GDPg Tobacco is a huge economic risk: 3.6% lower GDP 1/3-1/2 of cancer deaths are “avoidable”: 2 4 3 7 million deaths✓ 2.4-3.7 million deaths, of which 80% are in LIMCs ✓ Prevention and treatment offers potentialeve o d e e o e s po e world savings of $ US 130-940 billion
  • 14. The costs to close the cancer divide b l th fmay be less than many fear: All b 3 f 29 LMIC i i h dAll but 3 of 29 LMIC priority cancer chemo and hormonal agents are off-patent Pain medication is cheap P i d H B d HPV iPrices drop: HepB and HPV vaccines Delivery and financing innovations arey g underutilized and undeveloped: purchasing is fragmented and procurement is unstablefragmented and procurement is unstable Global Paediatric Financing EntityGlobal Paediatric Financing Entity
  • 15. Challenge and disprove theChallenge and disprove the myths about cancer M1 Unnecessary NECESSARYNECESSARYM1. Unnecessary NECESSARYNECESSARY M2. Unaffordable: AFFORDABLEAFFORDABLE M3. ImpossibleM3. Impossible M4 I i t ith /M4 I i t ith /M4. Inappropriate: either/orM4. Inappropriate: either/or Challenging cancer implies taking resourcesg g p g away from other ‘diseases of the poor’
  • 16. Women and mothers in LMICs f i k th h th lif lface many risks through the life cycle Women 15-59, annual deathsWomen 15 59, annual deaths Diabetes Breast cancer Cervical cancer Mortality in childbirth- 35% in 30 years 120,889166,577 142,744342,900 430 210 d h Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011. = 430, 210 deaths
  • 17. Harvard, Breast Cancer in DevelopingHarvard, Breast Cancer in Developing Countries, Nov 4, `09Countries, Nov 4, `09 Champions Harvard, Breast Cancer in DevelopingHarvard, Breast Cancer in Developing Countries, Nov 4, 09Countries, Nov 4, 09 Nobel Amartya Sen, Cancer survivor diagnosed in India Drew G. Faust President of Harvard University Cancer survivor diagnosed in India 50 years ago President of Harvard University 22+ year BC survivor
  • 18. Young champions, from LMICsg p , Abish Romeo, México Breast cancer, 23Breast cancer, 23 Beneficiary of Seguro PopularSeguro Popular
  • 19. PIH Rural Rwanda: 0 oncologists Burkitt´s lymphoma Embryonal RhabdomyosarcomaRhabdomyosarcoma Source: Paul Farmer., 2009
  • 20. The Diagonal Approach to Health System Strengthening Rather than focusing on disease-specific vertical programs or only on horizontal systemprograms or only on horizontal system constraints, harness synergies that provide t iti t t kl di ifi i itiopportunities to tackle disease-specific priorities while addressing systemic gaps. Optimize available resources so that the whole is more than the sum of the partsmore than the sum of the parts. Bridge the divide as patients suffer diseases over aBridge the divide as patients suffer diseases over a lifetime, most of it chronic.
  • 21. Domestic, Diagonal financing innovations Integrate CCC into national insurance programs to express previously suppressedprograms to express previously suppressed demand, beginning with cancers of women and children: Mexico Colombia DominicanMexico, Colombia, Dominican Republic, Peru China, India, Taiwan R d KRwanda, Kenya
  • 22. México Seguro Popular: Cancer and the Fund for Protection fromCancer and the Fund for Protection from Catastrophic Illness Accelerated, universal, vertical coverage by disease with an effective package of interventionsp g 2004: HIV/AIDS i l2005: cervical cancer 2006: ALL in children2006: ALL in children 2007: All pediatric cancers; Breast cancer 2011: Testicular and Prostate cancer and NHL 2012 C l t l2012: Colorectal cancer
  • 23. México Seguro Popular and cancer: Evidence of impact Access to medicines Since the incorporation of childhood cancers into the Seguro Popularinto the Seguro Popular Adherence to treatment: 70% to 95% Breast cancer adherence to treatment: 2005: 200/6002005: 200/600 2010: 10/900
  • 24. Delivery failure: México Breast Cancer •# 2 killer of % diagnosed in Stage 4 by state # 2 killer of women 30-54 •Only 5 10% of•Only 5-10% of cases in Mexico d d iare detected in Stage 1 or in situ •Poor municipalites: Poor/Marginalizedmunicipalites: 50% Stage 4; 5x rich oo / a g a ed rich
  • 25. Juanita:Jua ta: Advanced metastatic breast f i fcancer, the result of a series of missed opportunitiesssed oppo tu t es
  • 26. Solution: ‘Diagonalizing’ Delivery Harness platforms by integrating breast and cervical cancer prevention, screening andcervical cancer prevention, screening and survivorship care into MCH, SRH, HIV/AIDS, social welfare and anti poverty programssocial welfare and anti-poverty programs. Examples: Harnessing the primary level of care • Integration of breast and cervical cancer awareness and screening into the national anti- poverty program Oportunidades Results: 000´s promoters, nurses, doctors
  • 27. Where are the opportunities?Where are the opportunities? LMIC h b h h l lif i• LMICs: not months but rather whole lifetimes to be gained • Recognize cancer in LMICs as an integral component of our common search for globalcomponent of our common search for global health solutions: investment in learning, research, knowledge-sharing and translation andknowledge sharing and translation, and ultimately in human beings
  • 28. From anecdoteFrom anecdote … t id… to evidence
  • 31. BeBe ananBeBe anan optimistoptimistoptimistoptimist optimalistoptimalistoptimalistoptimalist Expanding access to cancer care and control inExpanding access to cancer care and control in LMICs: Should, Could, and Can be done