Breast Cancer in LMICs: Meeting the Challenge Felicia Marie Knaul

October 13, 2011

The 2011 Breast Cancer Global Congress A partnership of the US Department of State and the Avon Foundation for Women

From anecdote
to evidence

January, 2008 June, 2007

Harvard School of Public Health

Con jf en harvard

Global Task Force on Expanded Access to Cancer Care and Control

From anecdote

to evidence

Challenge and disprove the myths about cancer

M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate Expanding access to cancer care and control in LMICs: Should, Could, and Can be done

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 1980-2010

80%

% Change in incidence and mortality

60% 53% 47%

BC cases BC deaths CC cases

40%

24%

19%

20%
CC deaths

0%

-40%

-31%

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

High income

The cancer transition in LMICs: breast and cervical cancer 1980-2010

LMICs as % of global incidence and mortality
90%

87% 79%

88% 82% 63% 49% Breast Cervical

60%

59% 52%

30%

0%

1980

2010

1980

2010

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

The Cancer Transition, Mexico and Costa Rica: breast and cervical cancer, mortality time series.
16

12

1955

1965

1975

1985

1995

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (19551978), and Ministry of Health in Mexico (1979-2006)

Costa Rica 1995 - 2005

2005

Breast cancer
Source: Instituto Nacional de Estadstica y Censos, Ministerio de Salud, Unidad de Estadstica, Registro Nacional de Tumores de Costa Rica.

Cervical cancer

1995

2000

2005

The cancer transition within Mexico: breast and cervical cancer 1979-2008
25

Oaxaca

Nuevo Len

20

15

10

2008

1979

1985

1995

1979

1985

1995

Source: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de Mama en Mxico, 1979-2008. FUNSALUD, Documento de trabajo. Observatorio de la Salud.

2008

The opportunity to survive (M/I) should not be defined by income.

Yet it is.
100%

Children

Adults

Survival inequality gap

Leukaemia
Cervix

Prostate
HL N HL

All cancers

Breast Testis

LOW INCOME

HIGH INCOME

LOW INCOME

HIGH INCOME

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

The Cancer Divide: disparities in outcomes

between poor and rich directly related to inequities in access and differences in underlying socioeconomic and health conditions.

The divide is the result of concentrating risk factors, preventable disease, suffering, impoverishment from ill health and death among poor populations.
fueled by progress in cutting-edge science and medicine in high-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:
Exposure to risk factors Cancers of infectious origin Death from treatable cancer Stigma and discrimination Avoidable pain and suffering Impoverishment

Challenge and disprove the minimalists: myths about cancer

M1. Unnecessary NECESSARY M2. Unaffordable: .for the poor M3. Impossible M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor

`5/80 Cancer Disequilibrium

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.

Africa
1% of global spending on health 64% of new cancer cases 15% of the global population.

Investing in CCC: We cannot afford not to

Health is an investment, not a cost World Economic Forum: chronic disease is 1 of the 3 leading global economic risks Economic value of lost DALYs: $921 million VSL losses: $2.5 billion

Total economic cost of cancer, 2010 2-4% global GDP

Avoidable cancer deaths: 1/3 to 1/2 or 2.4-3.7 million

Income Region Low income Lower middle income Upper middle income High income % of all cancer deaths considered avoidable Breast

52%

79%

44%
33% 21%

73%
56% 40%

LMICs:

80% of total 75+% of breast 95% of cervical

Avoidable deaths

Investing in CCC: we cannot afford not to

Assuming that between 50% of deaths are avoidable Total annual cost: $310 billion Investing in CCC yields an annual return on prevention and treatment of between 1.5:1 to 3.7:1. Economic cost of inaction, 2009 $US 2010 billion130-850

Reduced drug and vaccine prices

Second-line TB Drugs (Farmer, 2009)
Amikacin

% Decline in price 1997-9

90%

Ethionamide
Capreomycin Ofloxacin

84%
97% 98%

Hep B vaccine: decline from a 1982 launch price of over $100

to $0.20 a dose has enabled developing countries to dramatically increase vaccination rates with support from GAVI

HPV vaccine in LMICs:

Before 2011: from $US 30 to $US 100 per dose PAHO Revolving Fund: decreased from US$ 32 per dose in January 2010 to US$ 14 per dose in April 2011. GAVI: June 2011 Merck offers vaccine at US$ 5 per dose for low income countries.

Challenge and disprove the minimalists: myths about cancer

M1. Unnecessary M2. Unaffordable: M3. Impossible POSSIBLE M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor

Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Drew G Faust President of Harvard University, Breast Cancer survivor, 20+ yrs

Nobel Laureate Amartya Sen, Cancer survivor, diagnosed in India 50 years ago

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 died 8% 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, DFCI, BWH Rural Rwanda, Burkitts lymphoma

0 oncologists

Regimen of vincristine, cyclophosphamide, intrathecal methotrexate

Central Haiti
Status post-CHOP in Central Haiti: Still in remission three years later

Source: Paul Farmer., 2009

Mortality from breast and cervical cancer in Mexico,1955-2008: less death from cervical
16

Age-adjusted rate per 100,000 women

12

1995

Source: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de mama en Mxico, 1979-2007.
FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretara de Salud de Mxico.

2005

1955

1965

1975

1985

There are many opportunities and alternatives for action

~ Lethality (mortality/incidence)
60

Mxico
48% 40 40%

Breast

38% Inequality gap in survival 24%

20

~ Lethality Low income: 48% Lower middle income: 40% Upper middle income: 38% High income: 24%

Low income countries

Lower middle Upper middle High income income income countries

Source: Author estimates based on IARC, Globocan 2010

Challenge and disprove the minimalists: Myths about cancer& NCD

M1. Unnecessary NECESSARY M2.Unaffordable AFFORDABLE M2. Impossible POSSIBLE M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor

Women and mothers are at risk for many reasons (15-59)

Mortality of mothers in childbirth (-35% 19802008)

Breast and cervical cancer

LMICs

342,900

166,577 +142,744 =309,321

~40% occur in pre-menopausal women (<55)

Low-income countries High-income countries

33%
34.2%

Age of Diagnosis

65%
66.6%

15-39

40-54

20%
Age of Death

>55

54%

Source: Author estimates based on IARC, Globocan, 2008 and 2010.

Cases:
Juanita Mexico

The diagonal approach to health system strengthening

Rather than focusing on disease-specific vertical programs or only horizontally on 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 divides as patients suffer diseases over a lifetime, most of it chronic.

Diagonal Strategies
1. Harness platforms: Integrate prevention, screening and survivorship into MCH, SRH, HIV/AIDs, social welfare/anti-poverty programs. 2. Delivery: Catalyze, employ and deploy community health workers and expert patients. Harness ICT. 3. Financing: Social protection strategies that include horizontal and vertical coverage. 4. Stewardship: Improve regulatory frameworks to remove non-price barriers to pain control.

Mexico Seguro Popular Insurance a diagonal strategy that includes financial protection for catastrophic illness
Accelerated universal vertical coverage by disease with a specified package of interventions

2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers

2007: Breast cancer

2011: Testicular cancer and NHL

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

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

Stage at diagnosis by level of municipal marginalization, Mexico, IMSS 2006

(Mxico, IMSS 2006)
50% 40%

30%

Late detection by state

% diagnosed in Stage 4
< low

20%

10%

0%

Poor (High) N=221 (3.8%)

Middle N=1737 (30%)

Low N=2877 (49.8%)

Very low N=946 (16.4%)

> mid > high

Stage 1 Stage 3

Stage 2 Stage 4

Source: Authors estimation based on IMSS data, 2006.

Why? Social and health systems barriers to early detection and non-price barriers to treatment

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

Mexico: Harnessing the primary level of care for improving BC detection and care

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

Be an optimist optimalist. Economics of hope.

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

Breast Cancer in LMICs: Meeting the Challenge Felicia Marie Knaul

October 13, 2011

The 2011 Breast Cancer Global Congress A partnership of the US Department of State and the Avon Foundation for Women