Ian Magrath December 2010

World Development Indicators 2005 World 1 billion 2.7 billion)

The incidence of cancer is lower in countries at a lower level of economic development, but they account for more than half of global cancer and a higher fraction of patients die 70% of global deaths from cancer occur in developing countries

Population in millions, diseases in thousandsWHO Statistics, % of cancer deaths occur in LMIC

WHO Statistics, 2010 NCDs affect older people, so less impact

World Health Report 2006

$3039$5274$2489$12 World Development Indicators 2005

Actual deaths Deaths per 100,000 Tuberculosis587,00081 Malaria900, AIDS2,400, Cancer506,11170 These diseases interact, increasing further the burden of disease Cancer is rapidly increasing, but is neglected, compared to infectious diseases

 Lifestyles differences (urban –rural, rich poor) often vary dramatically – particularly in developing countries, creating unique opportunities for epidemiological studies  Regionally prevalent subtypes are often well defined and homogeneous – (BL, NK/T)  Familial studies aided by larger sib-ships (consanguinity very high in some world regions)  Impact of environmental factors can be studied with respect to ◦ Lymphoid neoplasia overall ◦ Impact on different lineages (B;T;NK) ◦ Impact on disease categories (DLBCL, FL, MC, BL) ◦ Impact on disease subtypes (GCB, ABL, 1;14, 11;14, 14;18)  Differences are not static: vertical and horizontal

billion; 2.7 billion) Data from UNDP Grey: no data or NPLNational Poverty Line

No data 30, , , , , ,000 <1000 Data from IMF

MalesINCIDENCEMORTALITYCrudeASRCrudeASR N. America W.Europe Middle Africa South Central Asia Globocan 2002

2002 Per 100,000 per annumThousands per annum

The global cancer burden will increasingly shift to less economically developed countries

Incidence per 100,000 per annum Demographic changes only – i.e. aging of populations

Thousands per Annum Influence of aging and increases in population size

 Cancer causes more deaths globally than AIDS, malaria and TB combined  In 2002, >50% of the 11 million estimated patients with cancer and 70% of cancer deaths were in developing countries, which have perhaps 5-10% of global resources  Developing countries will account for an ever increasing fraction of the global cancer burden: NOW IS THE TIME FOR ACTION  The WHA has approved a resolution (May 2005) recommending that countries develop and implement cancer control plans

Developing Countries have a small proportion of global human and financial capital: most people in the world must pay out-of-pocket for cancer treatment

Mean aggregated data , WHO

World Health Report 2006

$3039$5274$2489$12 World Development Indicators 2005

Per Capita Countries <$100 Countries <$500 Countries >$1000 Total Health Expenditure Government Expenditure Data from WHO World Health Statistics countries, 2004, International dollars 1 21 less than $ >$2000

Private Expenditure Countries >90% Countries >50% Countries <10% Private prepaid plans Out-of-pocket Data from WHO World Health Statistics countries, countries <1% 1 43 countries >99%

Do visas kill? Health effects of African health professional emigration By Michael Clemens 53 sending countries, 9 receiving countries

Do visas kill? Health effects of African health professional emigration By Michael Clemens 53 sending countries, 9 receiving countries

Number of registries does not accurately reflect population coverage (e.g., African registries cover approx 7 million of the 888 million people Fraction of World Population 14% 9% 5% 60% 11% 1%

 In Dec 2004, there were approximately 2500 radiotherapy centers and 3700 machines for cancer therapy in the developing world (enough for 1.85 million patients per year compared to 3 million who need it.  Maldistribution worsens the situation: many countries have one machine for millions of patients (1 per 250,000 in high income countries). Over 20 countries – mostly African - have none (IAEA).  Many existing machines are idle for lack of maintenance, expired sources or lack of radiotherapists or physicists  Old cobalt sources require longer radiation times

 Governments generally able to obtain generic essential drugs at reasonable prices  Taxes and duties add substantially to price  Procurement systems often sporadic, such that needed drugs not always available  Drugs may be available in the private sector at 4-6 times the price  Drug costs alone may be months to many years of a family’s income Treatment of ALL in India: $3000-$4000; BL in Africa: $

 Poverty and ignorance delay seeking help  Existing primary (and secondary) care suboptimal: lack of emphasis and knowledge leads to misdiagnosis and misinformation; traditional medicine prevalent  Few specialized centers: long journeys to large cities  Result: late diagnosis; advanced disease; limited options – even palliative care is rarely available

 Inadequate numbers of cancer specialists - too many patients; too few staff  Poorly trained staff deliver sub-optimal care and and provide sub- optimal education and training  Limitations in material resources (drugs, equipment) and/or ability to pay  Poor follow up results in limited evidence of what works and what doesn’t Reception area, Cancer Institute (CIA), Chennai, India

Less Limited Resources Fewer Patients with More Limited Disease and Fewer Potential Patients Prevention Public Education Screening GREATER CAPACITY Lower Mortality Rate Less need and greater capacity for terminal care IMPROVED ACCESS

Reduction of the morbidity and mortality associated with cancer Based on the best available evidence for primary prevention, early detection, diagnosis and treatment, palliative care

 Halving smoking rates would avoid million deaths by 2025 but in the poorest countries, tobacco epidemic in early stages  Modification of lifestyle important but difficult; chewing, wading in water, diet  In developing countries, infection control is important to cancer control: schistosomiasis treatment, HBV and now HPV vaccines  Exposure to workplace and environmental chemicals higher because of lax regulations or enforcement

 Approaches in high income countries may not be feasible or cost effective in developing countries - cytopathology, mammography, PSA, colonoscopy Crude Incidence NigeriaUSA Breast (F) Cervix Uteri (F) Prostate (M) Colon (M) GNI per cap (2004) $430$41,440

 Patients present with advanced disease  No insurance; cost of treatment may be prohibitive  Too few specialist facilities; too few specialists  Nurses have a more limited role; less infrastructure; medical staff correspondingly larger role  Patients often present at cancer centers having had some, poorly documented treatment (radical mastectomy, drugs)  Specialist education often lacking; diagnosis and staging inadequate; treatment suboptimal

 Therapy, including supportive care may be based on realities (available resources) rather than “accepted” treatment approaches  Accepted treatment approaches generally derived from entirely different circumstances (high income nations); not always feasible or even desirable  Abandonment of treatment frequent – no time for staff to speak to patients, limited education or understanding on part of patients  Outcome often unknown due to poor follow up – value not perceived, therefore minimal effort; few support staff, limited patient comprehension

 Cancer services are limited and already overwhelmed in developing countries in spite of relatively low cancer burden  The cancer burden will increase markedly in the next decades (150m )  Building human capital is a priority, but obstacles include pool of teachers, losses of personnel to better circumstances (internal or external)  Material shortages – facilities, equipment, drugs etc. – and poorly structured health services compound the problem  Poverty, illiteracy, stigmata, traditional healers create additional obstacles to care