Women’s Empowerment Cancer Advocacy Network (WE CAN) Conference Global Efforts to Address the Rising Cancer Burden Dar es Salaam, Tanzania, September 2014 Julie R. Gralow, M.D. Jill Bennett Endowed Professor of Breast Cancer Director, Breast Medical Oncology Professor, Global Health University of Washington School of Medicine Fred Hutchinson Cancer Research Center Seattle Cancer Care Alliance

MYTH Cancer is a disease of developed countries FACT Low and middle-income countries now bear a majority share of the burden of cancer

Globocan 2008 Cancer Incidence and Deaths Less Developed versus More Developed Countries Cancer Incidence Cancer Deaths Less Developed More Developed Less Developed 4.8 million; 64% 2.7 million; 37% 7.1 million; 56% 5.6 million; 44%

Percent of Worldwide Cancers Diagnosed in Developing Countries 1970 – 15%1970 – 15% 2008 – 56%2008 – 56% 2030 – 70%2030 – 70% Ferlay J, et al. GLOBOCAN Lyon: International Agency for Research on Cancer, 2010Ferlay J, et al. GLOBOCAN Lyon: International Agency for Research on Cancer, 2010 Beaulieu N, et al. Breakaway: the global burden of cancer—challenges and opportunities. A report from the Economist Intelligence Unit, 2009.Beaulieu N, et al. Breakaway: the global burden of cancer—challenges and opportunities. A report from the Economist Intelligence Unit, 2009.

Most Common Cancer Site in Females Globally Source: GLOBOCAN 2008

Source: Knaul, Arreola, Mendez. estimates based on IHME, The Cancer Transition in Low and Middle Income Countries (LMICs): Breast and Cervical Cancer 53% 20% 19% -31% 0% LMIC’s High income % Change in # of deaths LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers – especially of young women.

Cancer Estimates for Africa Ferlay et. al :2008: –681,000 diagnosed –512,400 deaths 2030 (projected):2030 (projected): –1.28 million diagnosed –970,000 deaths

Cancer Care and Control: A Call to Action Farmer P et al, Lancet, August 2010

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries Task Force report available as free pdf download: Force report available as free pdf download:

Global Task Force Report: Core Elements of a Cancer Care and Control Strategy Many cancers are preventable through infection control and lifestyle modificationsMany cancers are preventable through infection control and lifestyle modifications Accurate cancer diagnosis is critical to determining an appropriate and successful treatment planAccurate cancer diagnosis is critical to determining an appropriate and successful treatment plan Many cancers are highly treatable with affordable therapies that result in the addition of many years of lifeMany cancers are highly treatable with affordable therapies that result in the addition of many years of life –Denial of therapy for diseases that are highly curable with affordable drugs is unacceptable Palliation of pain and suffering from cancer is a basic human rightPalliation of pain and suffering from cancer is a basic human right Reliable data is needed to understand the magnitude of the cancer burden and the potential impact of interventionsReliable data is needed to understand the magnitude of the cancer burden and the potential impact of interventions

A Global Call to Action UN High-level Meeting on Prevention & Control of Non-Communicable Diseases (NCDs) September 19-20, 2011 Millennium Development Goals expire 2015Millennium Development Goals expire 2015 NCDs – cancer, cardiac, respiratory, diabetes – a major challenge to health and development in 21st centuryNCDs – cancer, cardiac, respiratory, diabetes – a major challenge to health and development in 21st century NCDs a priority for UNNCDs a priority for UN Goal of 25% reduction in preventable deaths due to NCDs by 2025Goal of 25% reduction in preventable deaths due to NCDs by 2025

WHO Global Monitoring Framework for NCDs Provides a clear vision for action by 2025Provides a clear vision for action by 2025 UN Member States formally adopted the global monitoring framework as part of a comprehensive "Omnibus" Resolution at the 66th World Health Assembly in May 2013UN Member States formally adopted the global monitoring framework as part of a comprehensive "Omnibus" Resolution at the 66th World Health Assembly in May 2013 –9 global targets –25 indicators Primary Target:

Global NCD Targets for 2025

WHO Global Monitoring Framework for NCDs: Selected Cancer-related Metrics 80% availability of affordable basic technologies & essential medicines required to treat major NCDs80% availability of affordable basic technologies & essential medicines required to treat major NCDs Access to palliative care assessed by morphine equivalent consumption of strong opioid analgesics per death from cancerAccess to palliative care assessed by morphine equivalent consumption of strong opioid analgesics per death from cancer Availability, if cost ‐ effective and affordable, of vaccines against human papillomavirus (HPV)Availability, if cost ‐ effective and affordable, of vaccines against human papillomavirus (HPV) Vaccination coverage against HBV monitored by number of 3rd doses of Hep ‐ B vaccine administeredVaccination coverage against HBV monitored by number of 3rd doses of Hep ‐ B vaccine administered Proportion of women between screened for cervical cancer at least onceProportion of women between screened for cervical cancer at least once

Global Alliance for Vaccines and Immunization (GAVI) and HPV Vaccine Pricing Effective May 2013, lowest income countries have access to HPV vaccines for US $4.50 per doseEffective May 2013, lowest income countries have access to HPV vaccines for US $4.50 per dose –Same vaccines costs > $100 in developed countries –Previous lowest public sector price $13 per dose GAVI working mostly in Africa, preparing for introducing the HPV vaccine through national roll out or pilot projectsGAVI working mostly in Africa, preparing for introducing the HPV vaccine through national roll out or pilot projects –Anticipated that > 30 million girls will be immunized by 2020

UN High-level Meeting - Comprehensive Review and Assessment of the Progress Achieved in the Prevention and Control of Non-Communicable Diseases (NCDs) July 10-11, 2014 WHO report: NCDs country profiles 2014WHO report: NCDs country profiles 2014http://

US NCI Center for Global Health Established November, Goals:Goals: –Advance global cancer research, build expertise and leverage resources across nations to address challenges of cancer and reduce cancer deaths worldwide –Advance global cancer research, build expertise and leverage resources across nations to address challenges of cancer and reduce cancer deaths worldwide

American Society of Clinical Oncology (ASCO) International Portfolio of education and research opportunities to accelerate collaboration between members, organizations, and countriesPortfolio of education and research opportunities to accelerate collaboration between members, organizations, and countries –Multidisciplinary Cancer Management Courses –International Clinical Trials Workshops –Palliative Care Courses –Oncology for the Non-Oncologist Course –International Development and Education Awards (IDEA) –International Innovation Grants

2007 Institute of Medicine Report Cancer Control Opportunities in Low- and Middle-Income Countries Sloan FA, et al, National Academies Press, 2007 Patient advocacy has a key role to play in bringing the public’s concerns about cancer to decision makersPatient advocacy has a key role to play in bringing the public’s concerns about cancer to decision makers Summary recommendations: AdvocacySummary recommendations: Advocacy –Provide active support and assistance of cancer advocacy in low- and middle-resource countries –Suggested activities: »Set up advocacy networks within countries, regions, internationally »Identify successful approaches to cancer advocacy and replicate/adapt for use in other settings »Provide hands-on training and technical assistance

Promotion of public advocacy for breast and cervical cancer Women’s Empowerment Cancer Advocacy Network (WE CAN) Goals: To combat breast and cervical cancer by building and supporting advocacy groups with skills to address:To combat breast and cervical cancer by building and supporting advocacy groups with skills to address: –inadequacy in information –inequity in treatment and care –injustice in breast nd cervical cancer early detection, screening, treatment, and prevention

WE CAN Eastern Europe/Central Asia Breast and Cervical Cancer Advocacy Conferences Vilnius, Lithuania 2003 Kiev, Ukraine 2005 Minsk, Belarus 2007 Bishkek, Kyrgyzstan 2009 Vilnius, Lithuania 2011 Tbilisi, Georgia 2013

WE CAN East Africa Breast and Cervical Cancer Advocacy Conferences Kampala, Uganda September 2013 Dar es Salaam, Tanzania October 2014

The Power of Social Media: Connecting Across Continents #WECAN14 Twitter chat tonight 6-7 pm with breast cancer patient advocates in North America!#WECAN14 Twitter chat tonight 6-7 pm with breast cancer patient advocates in North America!

MYTH It’s too expensive and there are too many obstacles to prevent or treat cancer in developing countries FACT Much can be done to prevent, treat and palliate cancer even in resource-constrained settings

The time has come to challenge and disprove the assumption that cancer cannot be prevented, treated, or palliated in developing countries