Breast Cancer: Global Disparities

Closing the Gap: Addressing Disparities in Breast Cancer Lincoln Medical and Mental Health Center, NY June 7, 2012

Felicia Marie Knaul, PhD

Closing the Cancer Divide:

A Blueprint to Expand Access in LMICs Challenge and disprove the myths about cancer
M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate

Much
Should Could, and Can ...

.be done

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

= global health + cancer care

From anecdote
to evidence

January, 2008 June, 2007

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

From anecdote

to evidence

Expanding access to cancer care and control in LMICs: A) Should be done:

Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

Breast cancer: myths and realities

It is a disease of
developed countries
The majority of cases and deaths occur in the developing world A large proportion of cases and deaths perhaps the majority happens in women <54
More deaths and DALYs lost due to breast cancer in all developing regions except the most poor

It is a disease of
older women

It is of lower
priority than cervical cancer

The cancer transition in LMICs: breast and cervical cancer

LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers especially of young women.
% Change in # of deaths 1980-2010
53%

19%

20%

0%

LMICs

High income
-31%

Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

Among women aged 15-59 Breast cancer is #1 cause of death in wealthy countries #2 in middle-income countries # 5 in low-income countries

The Cancer Divide: An Equity Imperative

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. Death and disability from treatable cancer 4. Stigma and discrimination 5. Avoidable pain and suffering

Facets

The Opportunity to Survive (M/I) Should Not Be Defined by Income

100%

Children

Adults Survival inequality gap

Leukaemia

All cancers LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10%.

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

Survivorship care is nonexistent.

The most insidious injustice: 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

Expanding access to cancer care and control in LMICs: A) Should be done:

Myth 1. Unnecessary

Myth 2. Inappropriate B) Could be done:

Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

Women and mothers in LMICs face many risks through the life cycle

Women 15-59, annual deaths

- 35% in 30 years
Mortality in childbirth Breast cancer Cervical cancer Diabetes

342,900

166,577

142,744

120,889

= 430, 210 deaths

Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

The Diagonal Approach to Health System Strengthening

Rather than focusing on disease-specific vertical programs or only on horizontal system constraints, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps.
Optimize available resources so that the whole is more than the sum of the parts. Bridge the divide as patients suffer diseases over a lifetime, most of it chronic.

A Diagonal Strategy:
Delivery: Harness platforms by integrating breast and cervical cancer prevention, screening and survivorship care into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programs.

Positive Externalities
Promoting prevention and healthy lifestyles: Reduce risk for cancer and many other diseases Reducing stigma around womens cancers: Contributes to reducing gender discrimination

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate A) Could be done: Myth 3. Unaffordable C) Can be done
Myth 4: Impossible

`5/80 cancer disequilibrium (Frenk/Lancet 2010)

Almost 80% of the DALYs (disability-adjusted life-years) lost worldwide to cancer are in LMICs, yet these countries have only a very small share of global resources for cancer ~ 5% or less.

Investing In CCC: We Cannot Afford Not To

Health is an investment, not a cost Tobacco is a huge economic risk: 3.6% lower GDP Total economic cost of cancer, 2010: 2-4% of global GDP Prevention and treatment offers potential world savings of $ US 131-850 billion mostly due to productivity gains and reducing suffering

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths Of which 80% are in LIMCs

The costs to close the cancer divide may be less than many fear:
All but 3 of 29 LMIC priority cancer chemo and hormonal agents are off-patent: many < $100 / course

Prices drop: HPV 2011 from $US 100

/dose to:
GAVI $5 and PAHO $14

Pain medication is cheap

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate A) Could be done: affordable C) Can be done Myth 4: Impossible

Champions
Drew G. Faust
President of Harvard University And 22+ year BC survivor
Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Initial views on MDR-TB treatment, c. 1996-97

In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries. WHO 1996
MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease. WHO 1997
Outcomes in MDR-TB patients in Lima, Peru receiving at least 4 months of therapy
Failed therapy 8% Died 8%

Abandon therapy 2%

Cured 83%

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Source: Paul Farmer., 2009

PIH Rural Rwanda: 0 oncologist

Burkitts lymphoma

Embryonal Rhabdomyosarcoma

Source: Paul Farmer., 2009

Success in treating several cancers.

Mexico: cervical cancer.

16
12

0 1965 1975 1985 1995

1955

2005

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2006)

Mexico: summary of facts

Since 2006, breast cancer is the second leading cause of death among women aged 30 to 54 years of age and the principal cause of death due to tumors. Seguro Popular: since 2007 all women diagnosed with breast cancer have very complete access to treatment with financial protection

Mexican Champion: Abish Romeo treatment through Seguro Popular

Only 5-10% of cases in Mexico are detected in Stage 1 or in situ

- 50% of women from poor municipalites are diagnosed in stage 4 compared to 10-15% of women from wealthy areas

Education to reduce barriers: promoters, nurses, doctors

Challenge: from survival to survivorship

Challenge and disprove the minimalists: Myths about breast cancer, cancer& NCD
M1. Unnecessary: M2. Inappropriate: M3.Unaffordable: M4. Impossible: NECESSARY APPROPRIATE AFFORDABLE POSSIBLE

Be an optimist optimalist

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