Disclaimer: The views expressed in this paper/presentation are the views of the

author and do not necessarily reflect the views or policies of the Asian Development
Bank (ADB), or its Board of Governors, or the governments they represent. ADB does
not guarantee the accuracy of the data included in this paper and accepts no
responsibility for any consequence of their use. Terminology used may not
necessarily be consistent with ADB official terms.

Cancer Control in Low and MiddleIncome Countries:

Key messages
Hellen Gelband *, Rengaswamy Sankaranarayanan *, Cindy L. Gauvreau *, Susan Horton
*, Benjamin O. Anderson, Freddie Bray, James Cleary, Anna J. Dare, Lynette Denny, Mary
K. Gospodarowicz, Sumit Gupta, Scott C. Howard, David A. Jaffray, Felicia Knaul , Linda
Rabeneck, Preetha Rajaraman, Terrence Sullivan, Edward L. Trimble, Prabhat Jha *
for the DCP3 Cancer Authors Group
* Editorial Team

DCP3 Cancer Authors

Issac Adewole, Hemantha Amarasinghe, Benjamin O.

Anderson, Federico G. Antillon, Samira Asma, Rifat Atun,
Rajendra A. Badwe, Freddie Bray, Frank J. Chaloupka, Ann
Chao, Chien-Jen Chen, Wendong Chen, James Cleary, Anna J.
Dare, Anil DCruz, Lynette Denny, Craig Earle, Silvia
Franceschi, Cindy L. Gauvreau, Hellen Gelband, Ophira M.
Ginsburg, Mary K. Gospodarowicz, Thomas Gross, Prakash C.
Gupta, Sumit Gupta, Andrew Hall, Mhamed Harif, Rolando
Herrero, Susan Horton, Scott C. Howard, Stephen P. Hunger,
Andre Ilbawi, Trijn Israels, David A. Jaffray, Prabhat Jha,
Newell Johnson, Jamal Khader, Jane Kim, Felicia Knaul, Carol
Levin, Joseph Lipscomb, W. Thomas London, Mary
MacLennan, Katherine A. McGlynn, Monika L. Metzger, Raul
Murillo, Sherif Omar, Krishna Palipudi, C.S. Pramesh, You-Lin
Qiao, Linda Rabeneck, Preetha Rajaraman, Kunnambath
Ramadas, Chintanie Ramasundarahettige, Timothy Rebbeck,
Carlos Rodriguez-Galindo, Rengaswamy Sankaranarayanan, ,
Isabelle Soerjomataram, Lisa Stevens, Sujha Subramanian,
Richard Sullivan, Terrence Sullivan, David Thomas, Edward L.
Trimble, Joann Trypuc, Judith Wagner, Christopher P. Wild,
Pooja Yerramilli, Cheng-Har Yip, Ayda Yurekli, Witold
Zatonski, Ann G. Zauber, Fang-hui Zhao

Conclusions

Cancers in LMICs set to grow as % of global total and as % of

all deaths

In high-income countries 2/3 of cancer patients survive,

in LMIC only 1/3 do
An essential package of cost-effective prevention AND
treatment would cost ~ $1.7, $1.7 and $5.7 extra per capita
in low-income countries, lower-middle income countries,
and upper middle-income countries, respectively
Total cost of about ~$20 billion/year or ~3% of public spending on
health in LMICs (but more in poorest countries)
Tripling tobacco excise tax would cut smoking prevalence by a 1/3
and raise extra $100 billion

Global support to lower costs for inputs; expand technical

assistance; and research

DCP3: Audience and methods

Audience:
DCP1- 1993: World Bank (WDR 1993)
DCP2- 2006: Global communities of practice
DCP3- 2015-17: Ministries of health/finance;
communities of practice, and aid agencies
Methods: 2.5 year project
~75 Authors, 4 editors, 19 countries, 18 chapters
3 review meetings, IOM independent review
Support: Gates Foundation, NCI, IARC and CIHR
April Lancet launch (NCI+IARC), plus online chapters,
book to follow

Framework to design
essential cancer package
Disease Burden

CostEffectiveness

Feasibility of
Scale-up

Essential cancer
package

Probability of dying from cancer

<70 years, 2011, World
Male
All cancer
Tobacco-attributable
Infection-attributable
Other cancers

8.0
3.0
1.9
3.3

Female
6.0
1.1
1.5
3.6

Cancer deaths and change in death

rates <70 years, 2000 and 2010, LMICs

All cancer
Tobacco-attributable
Infection-attributable
Other cancers

Deaths in
2010
(millions)
3.2
0.8
0.7
1.8

Change between
2000-10
-9% (13% in HIC)
-9%
-15%
-8%

Age-standardised death rate (per

100,000)

Age-standardized cancer death rates, ages

30-69 Years, by education level, India
120

107 107
93

100

Men
80

Women

64

60

46

43

40
20
0
Illiterate

Primary
Educational level

Above secondary
Dikshit and others 2012

Resource-appropriate
interventions (from BHGI)

Cost-effectiveness of selected cancer

control interventions
* Treat breast cancer LICs
* Screen and treat breast cancer LICs
Screen and treat breast cancer MICs
HPV vaccination @$240+/girl
Treat CRC LICs
Treat breast cancer MICs
HPV vaccination @$50/girl MICs
Tobacco comprehensive measures LICs
** Hepatitis B vaccination LICs
Auto-disable syringe (prevent Hep B, C)
Tobacco taxes LICs
Cervical cancer screen VIA COST SAVING
HPV vacc @$15/girl LICs COST SAVING
1

10
Cost per DALY averted US $2012

100

1000

Range

Various sources

10000

DCP3 essential cancer package and

(WHO Best Buys)
Comprehensive tobacco control measures
Hepatitis B vaccination
Screen for cervical cancer and treat precancerous
lesions and treat early-stage cervical cancer
HPV vaccination
Opportunistic screen & treat early-stage breast
cancer
Treat selected pediatric cancers
Palliative care/pain control for all cancers

Cervical cancer: reduce deaths by 80%

with screening and vaccination

Source: Sankaranarayanan 2012

Quality matters: referral for childhood

cancers in Honduras and Colombia

165

Effective interventions at a range of prices:

childhood ALL treatment

HIC = >90% survival for >100,000$

100%

50% survival for >50$

Survival 50%

0%

0 100 1,000

10,000

100,000

Cost Per Child, $

Approximate marginal per capita costs (in 2013 US$) of

essential cancer intervention package
0.05

Lower middleincome
0.07

Upper middleincome
1.06

0.08
0.26

0.04
0.29

0.04
0.87

0.23
0.43

0.23
0.43

0.40
1.29

0.03

0.03

0.09

0.05

0.06

0.06

1.13

1.15

3.81

0.57

0.58

1.91

1.70

1.73

5.72

Intervention

Low-income

Comprehensive tobacco control

HBV vaccination
Screen and treat precancerous and
early-stage cervical cancer
HPV vaccination
Promote early diagnosis and treat
early stage breast cancer
Treat selected childhood cancers
Palliative care and pain control
Subtotal
Cancer system strengthening
50% of subtotal)
TOTAL COSTS

Resource requirements for essential or

augmented package for LMICs
World Bank
Economic Category

Low-income
Lower middleincome
Upper middleincome
Low- and middleincome*

Pop in
billions,
2013

0.8

Required
amount
for cancer
in 2013
US$
(billions)

Cancer
package as %
of total
public
spending on
health in
2013

1.4

13.0%

2.4

4.4

4.9%

2.3

13.8

2.6%

5.5

19.6

3.1%

Annual cost of package in US $bn

Total cost - $19.6bn
1.4
4.4

13.8

Low income countries

Upper-middle income countries

Lower-middle income countries

Domestic finance is key

Essential cancer package:
Covers about 5.8 billion people, address 3.2
million cancer deaths <70 years
Costs as % of public spending: <3% in
upper MICs; 5% in lower MICs, but 14% in
low-income countries (3% in all LMICs)
Growing per capita income will make more
money available
Some funding possible from tobacco taxes

How can the essential package be

afforded?
Non-communicable diseases will primarily
be covered from domestic resources
However international community can help
by
Participating in networks to improve quality
Helping create/shape markets (e.g. Gavi in
building market/driving down price for HPV
vaccine)
Providing technical assistance

International support
Currently only 1% of $30 billion in global
developmental assistance for NCDs including
cancers
Three major priorities:
Lower costs of key inputs
Large scale purchasing, global negotiated prices

Technical assistance
Formalize communities of practice (radiotherapy
or childhood cancer working groups)

Research

Research
Currently $6 billion at NCI/CRC UK alone
Four major priorities:
Burden
Expand and improve registries, representative
cause of death data (Indian Million Death Study)

Implementation science
Epidemiology and biology
Economics (costing)

UK male cancer mortality trends at

ages 35-69, 1950-2007: selected sites
Main causes of trends
in recent decades
35-year risk (%)

Lung: cigarettes
Colorectal: treatment
Stomach: Unknown

Source: Peto, 2012

UK female cancer mortality trends at

ages 35-69, 1950-2007: selected sites
Main causes of trends in
recent decades
35-year risk (%)

Breast: treatment
Lung: cigarettes

Colorectal: treatment
Uterus: screening
Stomach: Unknown
Source: Peto, 2012

Reasons for optimism?

1. Tobacco control (esp. higher taxes)
possible even with industry opposition
(FCTC)
2. GAVI and vaccine expansion
3. Affordability: $20 billion affordable except
in poorest countries
4. Various pathways for universal health
coverage
5. Experience from HIV/TB/malaria/vaccines
to bend the cost curve

21st century
hazards of
cigarette
smoking in 6
distinct
populations

Jha and Peto, NEJM 2014

CHINA: Proportion of deaths among

middle-aged males from smoking
1990s
2010

12%
20%
(25% urban, 15% rural)

1998 Hong Kong +

2030s China

33%
33%

+ Hong Kong male smokers started smoking seriously 20 years before

Li, Peto et al, 1998, Lam et al, 2001, Peto 2001

INDIA: Years of life lost

among 30 year old smokers*
(MDS results)

Men who smoke bidis

6 years

Women who smoke bidis

8 years

Men who smoke cigarettes

10 years

* At current risks of death versus non-smokers, adjusted for age, alcohol use and education
(note that currently, few females smoke cigarettes)

Jha et al, NEJM, Feb 2009

INDIA, MEN: RR (smoker: nonsmoker),

specific causes, ages 30-69, 2001-03 vs
2010-11

US: Years gained from quitting smoking

by age
55-64

45-54

35-44

25-34

10

Jha et al, NEJM, Jan 24, 2013

Cigarette prices tripled, consumption halved,

tax revenue doubled: FRANCE

UK & France, lung cancer mortality trends (35-44) to

1997, but not beyond

Male

Male

Source: Peto, 2012

Conclusions

Cancers in LMICs set to grow as % of global total and as % of

all deaths

In high-income countries 2/3 of cancer patients survive,

in LMIC only 1/3 do
An essential package of cost-effective prevention AND
treatment would cost ~ $1.7, $1.7 and $5.7 extra per capita
in low-income countries, lower-middle income countries,
and upper middle-income countries, respectively
Total cost of about ~$20 billion/year or ~3% of public spending on
health in LMICs (but more in poorest countries)
Tripling tobacco excise tax would cut smoking prevalence by a 1/3
and raise extra $100 billion

Global support to lower costs for inputs; expand technical

assistance; and research

FEMALES: Survival probabilities

between ages 25 and 80 years among current and
never-smokers in the US

HR adjusted for age,

education, alcohol,
adiposity (BMI),
scaled to 2004
national rates, but
comparable results
if only actual cohort
used

Jha et al, NEJM, Jan 24, 2013

$5.72

Cost in US $

5
4
3
2

$1.67

$1.72

1
0
Low income countries

Lower-middle income
countries

Upper-middle income
countries

Tobacco control

Hep B vaccine

Cervical cancer*

HPV vaccine

Breast cancer*

Pediatric cancers**

Palliative care

Strengthen system

* Screen and treat precancerous lesions (cervical)

and early-stage (cervical and breast) ** Treat