Reunión anual de la American Association for Cancer Research, 9 de abril de 2013

3. January,
2008
June,
2007

4. Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities

6. = global health + cancer care

8. Challenge and disprove the
myths about cancer
Expanding access to cancer care and control in
low and middle income countries:
I: Should be done
II: Could be done
III: Can be done
M1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate

9. 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 disability
4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide:
An Equity Imperative
Facets

10. Adults
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Survival
inequalitygap
LOW
INCOME
HIGH
INCOME
100%
Facet 3: The Opportunity to Survive
Should Not, but Is Defined by Income
In Canada, almost 90% of children with
leukemia survive.
In the poorest countries only 10%.

11. Cancer – especially in
women and children - adds a
layer of discrimination onto
ethnicity, poverty, and
gender.

12. Facet 5: The most insidious injustice
is lack of 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

13. Investing In CCC:
We Cannot Afford Not To
! Tobacco is a huge economic risk: 3.6% lower GDP
! Total economic cost of cancer, 2010: 2-4% of global GDP
! Inaction reduces efficacy of health and social investments
Prevention and treatment offers potential
world savings of $ US 130-940 billion
1/3-1/2 of cancer deaths are “avoidable”:
2.4-3.7 million deaths,
of which 80% are in LIMCs
✓

14. ! Mirrors the epidemiological transition
! LMICs increasingly face both infection-
associated cancers, and all other cancers.
The Cancer Transition
! Cancers increasingly only of the poor, are
not the only cancers affecting the poor.

15. #2 cause of death in wealthy countries
#3 in upper middle-income
#4 in lower middle-income
and # 8 in low-income countries
More than 85% of pediatric cancer cases and 95% of
deaths occur in developing countries.
For children & adolescents
5-14 cancer is

16. Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.
The cancer transition in LMICs:
breast and cervical cancer
53%
20%19%
-31%
0%
LMIC’s High
income
% Change in # of deaths
1980-2010LMICs account for
>90% of cervical
cancer deaths and
>60% of breast
cancer deaths.
Both diseases are
leading killers –
especially of young
women.

17. Cancer transition in Mexico:
Breast and Cervical mortality
México
0
4
8
12
161955
1960
1970
1980
1990
2000
2010
Mortality
rate
adjusted
by
age
Oaxaca
(Poorest)
Nuevo León
(Wealthiest)
Source:
Knaul
et
al.,
2008.
Reproduc?ve
Health
MaCers,
and
updated
by
Knaul,
Arreola-­‐Ornelas
and
Méndez.
0
10
20
30
1980
1990
2000
2010
0
10
20
30
1980
1990
2000
2010

18. Trends in the difference between mortality rate
from cervical and breast cancer Mexico, by level
of state marginality, (1979 -2010)
-­‐10
-­‐5
0
5
10
15
1979
1980
1985
1990
1995
2000
2005
2010
Difference
in
mortality
rate
(Per
100,000
women
age-­‐adjusted)
Very
Poor Poor
Average Wealthy
Very
Wealthy

19. 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

20. The Diagonal Approach to
Health System Strengthening
! Rather than focusing on either disease-specific
vertical or horizontal-systemic programs, harness
synergies that provide opportunities to tackle disease-
specific priorities while addressing systemic gaps and
optimize available resources
! Diagonal strategies:  X = > Σ parts
! Bridge disease divides: patients suffer over a lifetime, most
of it chronic.
! Generate positive externalities

21. Diagonal Strategies:
Positive Externalities
! Promoting prevention and healthy lifestyles:
! Reduce risk for cancer and many other diseases
! Reducing stigma around women’s cancers:
! Contributes to reducing gender discrimination
! Pain control and palliation
! Reducing barriers to access is essential for cancer as
well as for for other diseases and for surgery.

22. ‘Diagonalizing’ Financing:
Integrate cancer care and control into
national insurance and social security
programs to express previously suppressed
demand beginning with cancers of women
and children:
! Mexico, Colombia, Dom Rep, Peru
! China, India, Thailand
! Rwanda, Ghana, South Africa

23. México

24. Mexico: Seguro Popular
Horizontal
Coverage:
>
54.6
million
Beneficiaries
Ver?cal
Coverage
Diseases
and
Interven?ons:
Expanded
Benefit
Package

25. Seguro Popular:
Cancer and the Fund for Protection from
Catastrophic Illness
! Accelerated, universal, vertical coverage by disease
with an effective package of interventions
! 2004: HIV/AIDS
! 2005: cervical cancer
! 2006: ALL in children
! 2007: All pediatric cancers; Breast cancer
! 2011: Testicular and Prostate cancer and NHL
! 2012: Ovarian (colorectal) cancer

26. Seguro Popular and cancer:
Evidence of impact
! Since the incorporation of childhood cancers
into the Seguro Popular
! Adherence to treatment: 70% to 95%
! Breast cancer adherence to treatment:
! 2005: 200/600
! 2010: 10/900
¡

27. % diagnosed in Stage 4 by state
• # 2 killer of women 30-54
• Only 5-10% detected in Stage 0-1
• Poor municipalites: 50% Stage 4; 5x rich
Delivery failure: Breast Cancer
Juanita
Poor/Marginalized

28. Effective financial coverage of
breast cancer in Mexico
– Primary prevention
– Secondary prevention (early detection)
– Diagnosis
– Treatment
– Survivorship care
– Palliative care
Large and exemplary investment in cancer treatment for
women, yet a low survival rate.
Opportunities to diagonalize delivery

29. Harness platforms by integrating breast and
cervical cancer prevention, screening and
survivorship care into MCH, SRH, HIV/AIDS,
social welfare and anti-poverty programs.
Solution:
‘Diagonalizing’ Delivery

30. Including breast cancer awareness for
early detection in Oportunidades
• “Guía de orientación y
capacitación a titulares
beneficiarios del programa
Oportunidades” includes
information on breast cancer
as of 2009/10
• 1.5 million copies to
promoters
• Reaches 5.8 million families =
more than 90% of poor
households

31. ‘Diagonalizing’ Delivery
Results: 000´s promoters, nurses, doctors
Harnessing the primary level of care

32. Where are the opportunities?
• LMICs: the potential to reduce DALYs lost is huge
• Focus on prevention but do not stop there!
– No prevent/treat dichotomization
• Do not take prices as fixed or given – price permeability
• Innovate in implementation, delivery and financing
– Evaluate, replicate and scale up
– Leapfrog and give forward
• Harness global and national health system platforms
• Harness cancer to strengthen health and social systems
• Recognize LMICs as part of a global solution:
 investment in learning, research and human beings

33. Expanding access to cancer care and control in
LMICs: Should, Could, and Can be done