Closing the Cancer Care Gap
Cancer has taken centre stage this month with the celebration of World Cancer Day on February 4th and the headline news that King Charles is currently being treated for cancer.
One in two people will develop cancer in their lifetime and cancer is the second leading cause of death worldwide. Each of us knows someone who is living with cancer or has sadly died of cancer. The fact that King Charles’ cancer diagnosis and subsequent treatment was within days is not lost on many living in the UK where there are long waiting times to access NHS diagnostic and treatment services for cancer and other health conditions.
This year’s World Cancer Day theme “Close the Care Gap” is apt as there continues to be huge disparities in access to cancer prevention and treatment services. Globally, low-and-middle-income countries (LMIC) shoulder most of the cancer burden, with a sharp rise in early-onset cancer cases among young populations. The majority of cancers in LMICs are diagnosed at advanced stages which significantly affects an individual’s prognosis and the cost of care remains one of the main barriers to treatment. A 2023 article analysing the cancer treatment gap in Lower- to Middle-Income Countries found that in low-income countries, the cost of 58% of essential cancer medications is borne by the patient. This falls to 32% for low-middle-income countries and just 1.8% for upper-middle-income countries. It is unsurprising then that in 2020, out of nearly 10 million cancer-related deaths worldwide, an estimated 70% were in low-and-middle-income countries yet these countries receive only 5% of global cancer spending.
I have seen the disparities in cancer care first hand in my global health work. A decade ago, I was living in Haiti, managing the country’s only free cancer service. Haitians travelled from all over the country to central Haiti to receive free cancer care at Hôpital Universitaire de Mirebalais. The dedicated Oncology team of Haitian doctors, nurses and social workers provided high quality care to patients who gave biopsy samples to find out if they had cancer, they sensitively informed patients of their cancer diagnosis when their biopsy results came back, they held patients’ hands through the gruelling months of chemotherapy and prescribed anti-nausea medication to combat the gruesome side effects of their treatments. Haiti has no radiotherapy centres so the cancer service forged a partnership with a medical institution in neighbouring Dominican Republic which allowed many Haitian patients to receive free radiotherapy treatment. The team’s brilliant social worker -one of the kindest and most empathetic people I’ve ever met- held consultations with patients and their families to ensure their psycho-social needs were not forgotten. Some of the most humbling moments of my career involved supporting the nurses in the chemotherapy room with patients undergoing their treatment. In 2013, diagnostics in Haiti was limited so we sent off patients’ biopsy samples to Brigham and Women’s Hospital in Boston for testing before waiting up to a month, sometimes more to receive results. Thankfully, a pathology laboratory has now been built on the hospital site and Haitian technicians are trained to process biopsy samples, which has greatly reduced waiting time for results and initiation of treatment.
In my little island of Montserrat, only basic sonograms and X-rays are currently offered. A new hospital is currently being built which will provide more advanced diagnostic services including a CT scanner and a 3D mammography unit. The Pink Ribbon Charity provides funds for women to access mammography services in neighbouring Antigua, however persons must travel to the United Kingdom or other Caribbean islands for further investigation and treatment. The Cancer Centre Eastern Caribbean in Antigua opened in 2015 to provide chemotherapy and radiation services to cancer patients, however it closed in 2023. There are plans underway for the reopening of the centre in 2024.
On a work visit to Jordan a few years ago, I visited the King Hussein Cancer Centre (KHCC) and was extremely impressed with the facilities and services available. Established in 2001, the centre provides “the most advanced cancer care to both paediatric and adult patients from Jordan, the region and across the world. With over 300 Oncologists and consultants and 1100 Oncology nurses, the Centre is ranked as the top cancer centre among developing countries, and the 6th top ranked centre internationally for treating cancer”. According to KHCC 2022 annual report, the institution provided care to 27,000 patients with 6,800 new patients from Jordan and other Arab countries. KHCC has the largest bone marrow transplant programme in the Middle East and conducted 250 bone marrow transplants with success rates exceeding 85%, which is on par with international rates. Additionally, 33 advanced cancer surgeries were performed utilizing a surgical robot that is the first of its kind in Jordan.
Through the King Hussein Cancer Foundation (KHCF), more than 28,000 women received mammograms for early detection of breast cancer. Patients also received extensive psychosocial support and KHCC boasts a Healing Garden, serving as a calm and peaceful space for patients and their families. KHCF’s Cancer Care Insurance programme expanded by more than 30,000 new subscribers, bringing the total number of subscribers to over 200,000 individuals and corporate employees. Jordanians even if they have no health insurance are still able to access cancer treatment at KHCC free of charge. In 2022, 789 patients began treatment and received financial support for their treatment, accommodation and transportation costs.
Africa’s most populous country Nigeria has a population of around 213 million people yet it has only eight certified radiotherapy centres. The National Health Insurance Scheme has limited coverage for cancer and with the recent exit of pharmaceutical companies from the country, there is growing concern around the two-to-three-fold increase in prices of chemotherapy drugs which the average Nigerian cannot afford. According to the Global Cancer Observatory, there were 79,542 cancer deaths in Nigeria in 2022. The Government recently announced plans to build six new cancer centres across the six geopolitical zones in the country. In 2021, the Federal Ministry of Health established the Cancer Health Fund to provide funding and health care services to cancer patients. Patients apply to the fund and can access drugs, radiotherapy and chemotherapy at six pilot hospitals across the country as part of the Cancer Access Partnership. Partners include the American Cancer Society, ROCHE, PFIZER, MYLAN, Clinton Health Access Initiative among others.
Non-Communicable Diseases including cancer is on the rise globally and especially so in LMICs. 74% of all deaths globally are due to Noncommunicable diseases. Cancer, cardiovascular diseases, respiratory diseases and diabetes account for over 80% of all premature NCD deaths. Of the 7 million cancer deaths worldwide, 5 million are in LMICs.
How can we have greater equity and close the care gap to decrease the high cancer mortality rates in LMICs? I offer some suggestions for LMIC Governments and global funders to consider.
Firstly, national Governments and the global community must recognise cancer as a high priority public health issue. Infectious Diseases continue to get the lion’s share of global health funding, however with NCDs causing more than 75% of deaths, funders must now interrogate their funding priorities. In order for us to achieve Universal Health Coverage and meet SDG Target 3.4- to reduce by one third premature mortality from non-communicable diseases through prevention and treatment- we need greater financial investment for cancer, increased global partnerships to address the cancer burden in LMICs and expansion of cancer care across LMICs.
Secondly, each country should establish a national cancer control programme. Cancer prevention, early detection, diagnosis, treatment and palliation will require a multi-sectoral, multidisciplinary approach so a dedicated programme within the health system is a necessity. The International Atomic Energy Agency (IAEA) in collaboration with WHO supports IAEA Member States to establish national cancer control programmes and they provide technical advisory services, resource mobilization, education and training of personnel. LMICs should also strongly consider establishing national cancer registries to be able to conduct cancer surveillance, plan cancer services and identify where further progress is needed in order to improve the lives of people living with cancer.
Thirdly, LMICs must invest in cancer centres with diagnostic, treatment, palliation and psycho-social facilities available to meet its population’s needs. The King Hussein Cancer Centre in Jordan is an excellent example to other LMICs of how cancer care must be prioritised as a health issue. Having a dedicated cancer centre may sound like an extreme proposition for every country, however with 1 in 2 people being diagnosed with cancer in their lifetime and 70% of cancer deaths occurring in LMICs, the demand for these specialist services will only increase over time. Regional cancer centres – such as The Butaro Cancer Center of Excellence in Rwanda which serves East Africa- can also be another solution to address the growing and underserved need for cancer treatment in a particular region.
Fourthly, LMICs should initiate innovative partnerships with pharmaceutical companies, the private sector, higher education institutions and others to accelerate cancer care provision and facilitate cutting edge cancer research. In both Jordan and Haiti, the hospitals established partnerships with High Income Country (HIC) institutions to foster knowledge transfer, share resources and expertise. According to their website, KHCC enjoys strong partnerships with the world leaders in cancer care including the University of Texas MD Anderson Cancer Centre, St. Jude Children's Research Hospital, and the American University of Beirut Medical Centre.
In Haiti, a partnership with Boston based Dana Farber Cancer Institute and Brigham and Women’s Hospital led to the donation of a chemotherapy mixing unit and two US trained Oncology nurse specialists spending three-month placements in Haiti working alongside Haitian nurses sharing best practices in clinical care. Together, the American and Haitian nurses amended clinical protocols based on the day-to-day realities in Haiti. The Haitian Oncology Clinical Director held weekly calls with leading US based Oncologists to discuss challenging cancer cases and develop personalised treatment plans for patients. Similarly, LMICs can take advantage of telemedicine and video assisted consultations to bring in additional regional or international expertise as they train their national workforce to provide specialised cancer care.
Lastly, LMICs should ensure that cancer research forms part of their cancer care package. LMICs have long been under-represented in global clinical trials, however access to cancer clinical trials can facilitate access to cancer medicines that might otherwise be unaffordable while also fostering global diversification of the clinical research landscape.
Cancer care poses unique challenges- from infrastructure, diagnostics and treatment access to a trained healthcare workforce to meet countries need. In LMICs, the challenges are even greater with limited resources and competing health priorities. As a global community, we must continue to ensure equity is at the heart of our work. This will need to translate into financial investment to LMIC health systems to improve access to the latest cancer innovations to “Close the Care gap” and reduce cancer related morbidity and mortality.