Asia's Quiet War on Lung Cancer
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This document discusses the issue of lung cancer in Asia. It notes that lung cancer is primarily caused by smoking, and Asia accounts for over 60% of global lung cancer cases due to its high smoking rates, particularly in China, India, Indonesia, and South Korea. However, the document also discusses the rise of non-smoking related lung cancer in Asia due to factors like air pollution, second-hand smoke, and exposure to asbestos, industrial pollution, and cooking oil particles. Countries like China and Taiwan are seeing increasing rates of adenocarcinoma lung cancer in non-smokers due to air quality issues.
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Asia's Quiet War on Lung Cancer
- 1. eden strategy institute H E A L T H C A R E Asia’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
- 2. 14 million people around the world are diagnosed with cancer each year Source: Cancer Research UK 2014 eden strategy institute | 2
- 3. 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)
- 4. 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
- 5. 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
- 6. 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
- 7. 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
- 8. 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
- 9. 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
- 10. 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
- 11. 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
- 12. 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
- 13. 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
- 14. 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)
- 15. 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
- 16. 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
- 17. 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
- 18. 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
- 19. 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
- 20. 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
- 21. 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
- 22. 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
- 23. 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
- 24. 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
- 25. 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
- 26. 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
- 27. 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
- 28. 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
- 29. • Eden’s Healthcare PracYce. Eden Strategy Ins]tute approaches the global issues of disease, poverty, illiteracy, and exploita]on head-‐on, by formula]ng strategies, models, processes, products, and designs that help our clients create, realize, and sustain quantum profit in addressing these issues. Our experience spans the en]re healthcare system, from R&D at medical technology firms, pharmaceu]cal companies, and biotechnology ins]tu]ons, to commercializa]on, manufacturing, downstream distribu]on, hospital installa]on and management. We have an extensive network of contacts with the en]re healthcare ecosystem across Asia-‐Pacific. • Sustainability in healthcare. Eden brings sustainability to the Healthcare sector by suppor]ng governments with policy and infrastructure development, helping research ins]tu]ons go-‐to-‐market while protec]ng and managing their innova]on pipelines, planning the market entry of medtech firms, hospitals, and pharma companies, suppor]ng healthcare educa]on to raise pa]ent awareness, facilita]ng the flow of medical tourists, assis]ng in API manufacturing and vaccine distribu]on, assessing treatment efficacy, and working with health insurers and reimbursement systems to improve treatment quality while reducing costs. • Our philosophy. We believe in the power of ideas to posi]vely shape our world, one client at a ]me. Our focus is unparalleled in bringing to bear our en]re senior management team, as well as the world’s foremost experts, on our clients’ most pressing sustainability issues. In turn, we elect to only collaborate with clients who are seriously commised to crea]ng value together. Asia’s Leader in Social InnovaYon ConsulYng eden strategy institute
- 30. eden strategy institute Contacts: Calvin Chu Yee Ming, Partner Amanda Tan, Strategy Analyst Eden Strategy Ins]tute T: +65 9751 5817 E: query@edenstrategyins]tute.com www.edenstrategyins]tute.com Thank you