Cancer in Developing Countries: Facing the Challenge
Cancer as Part of the Global Health Agenda
Over the past decade, health care priorities focused on the challenges posed by HIV/AIDS, malaria, and tuberculosis. As a result, cancer and other chronic diseases were marginalized on the global health agenda. While progress has been made in combating infectious diseases, the global burden of diseases has dramatically changed. Today, non-communicable diseases (NCDs), such as cardiovascular disease and cancer, are the major causes of death globally and kill more than twice as many people as HIV/AIDS, tuberculosis, malaria and all other infectious diseases combined.
Among these global killers, cancer deaths are increasing faster than deaths from other leading causes of mortality, particularly in low and middle income countries. The changing life style and continued growth and ageing of the world population will considerably aggravate the burden of cancer. Achieving the MDGs already presents a significant challenge for many countries, which is now exacerbated by the need to raise sufficient funds to develop the capacity to treat the large numbers of cancer patients that will be diagnosed in the coming years. If cancer is not given a higher priority through focused global efforts, health-care systems in less developed countries will face even more challenges as the number of cancer cases increase.
During the Cancer as part of the Global Health Agenda session of the Scientific Forum, panellists discussed the way forward to tackle this global issue. They considered the questions whether there is hope that cancer can be prioritized to improve resources and awareness, as well as suggesting how the international community can address this looming pandemic:
WHO´s Role in Setting Agenda for Non-Communicable Diseases and Cancer
Over the past decade, international development assistance focused considerable attention on controlling communicable diseases such as HIV/AIDS. According to the WHO, low and middle income countries (LMIC) that are already challenged by infectious diseases are confronting additional burdens caused by non-communicable diseases including cancer. Over 7 million deaths worldwide are caused annually alone through cancer.
The currently allocated official development aid however, has not yet established specified budget lines recognizable as support for NCD control in LMIC. WHO, alarmed by the epidemiological transition towards NCDs, began in 2000 to develop an overarching framework, endorsed by several World Health Assembly (WHA) resolutions, granting the WHO the mandate to develop the necessary strategies and tools to effectively prevent and control NCDs. Cancer shares with other NCDs behavioral risk factors such as tobacco, overweight and alcohol use, all of them addressed by key WHA resolutions including the Framework Convention on Tobacco Control (2003), the strategies against unhealthy diet (2004) and harmful use of alcohol (2010). The 2005 WHA resolution on cancer control provides direction for a comprehensive set of cancer-specific interventions from prevention to palliative care. A road map to implement these NCD and cancer-specific strategies along the lines of clearly defined objectives was established in 2008 with the WHA endorsement of the WHO NCD action plan. It sets the agenda for international partners to invest in NCD control and to collaborate with the WHO in assisting in NCD control among its Member States.
It is in this overall context that IAEA has set up a specific cancer program focusing on capacity building in radiotherapy, which is one of the key elements of cancer control and is imbedded in a national cancer planning process. There is increasing awareness among LMIC that the control of NCDs, including cancer, should be given priority. The WHO Country Cooperative Strategy, which defines how WHO and its partners provide assistance to national health planning, is the necessary framework through which development aid providers and stakeholders will align their activities in response to the challenge of the NCDs, in which cancer control will play an integral part.
Union for International Cancer Control (UICC): Role of NGOs in Global Fight Against Cancer and World Cancer Declaration (WCD) as a Tool for Improving Global Cancer
Cancer is not only a problem of developing countries; rather, it is a global issue. Cancer is neither on the global health agenda, nor one of the Millennium Development Goals. Cancer is both a health care issue together and a development issue. Without involving health systems, economical components and political will anything will happen. Although many declarations were signed and meetings held, only a few implementation actions have occurred, in isolation, with limited coordination, and mainly through the effort of individuals. Thus, there is a need for coordinated action. Supported by all its member organizations and endorsed by the new NCD Alliance, the UICC´s priority is to put cancer on the global agenda by including cancer and NCDs among the Millennium Development Goals. In addition to the NDC summit in New York in September 2011, a three-day event should be held with all stakeholders, both non-governmental and governmental bodies, to pursue the goal of producing a substantive set of consensus recommendations.
"Institut National du Cancer (INCa)", France: An Integrated Approach to Cancer Control
Tremendous added value can be derived from working together, as well as in creating a continuum from research to care, in building synergies, partnerships, sharing knowledge and experience. In Europe, there are still large discrepancies in cancer incidence and mortality between states, and also large discrepancies in health systems. The European Parliament and the European Council launched the European Partnership for Action against Cancer. INCa is now sharing experience and building partnerships with all stakeholders, academics, private sector, and non-governmental organizations. Coordination in this environment is still needed and will bring knowledge and improvements. INCa is considering IAEA´s PACT programme as an excellent framework to support cancer control initiatives and is capable of addressing the national demands for education, training and safety issues. There is a clear need for more experienced radiation therapists, physicists, oncologists, specialised surgeons, pathologists, specialised nurses, social workers, and palliative care. Some countries will be facing an explosion of cancer incidence and we all should help each other to avoid similar problems that high-income countries faced in previous years, especially on safety issues with chemotherapy and radiation therapy.
Lance Armstrong Foundation: Make Cancer Survivorship a Global Theme
Cancer is progressively becoming a problem of developing countries. The economic losses from cancer exceed the damages resulting from all other single-disease causes and represents an enormous strain on productive populations. The Lance Armstrong Foundation began by conducting research to inform its global cancer campaign and discovered that cancer was not high on national agendas, including those in the developed world. However, there is a significant range of programmes around the world that addressed prevention and diagnosis as well as education and awareness, which is an area of interest for the Lance Armstrong Foundation. One of the Foundation´s primary global priorities is to reduce cancer stigma. Projects, initiated by the Foundation in Mexico and South Africa, use many of the local organizations to work in their home countries to build replicable and sustainable models and empower the cancer survivors to take action. The projects aim to build a mobilized and empowered grassroots base, share available resources, urge governments to take action and place cancer on the national agenda, facilitate more public-private partnerships, increase accountability and transparency, and inspire and engage survivors at the community level. The Lance Armstrong Foundation has an assertive agenda to help grassroots organizations grow and to empower survivors around the world.
American Cancer Society (ACS): The United States Food and Drug Administration and its Ability to Regulate Specific Aspects of Tobacco Products and have an Impact on the Global Regulation of Tobacco
Tobacco presents a huge economic cost, much of which is cancer-related. Cancer will kill anywhere between 30 to 50% of the people who smoke. Currently, there are approximately one billion male smokers worldwide. The ACS projects that 300 to 500 million of these smokers will die prematurely. Therefore, it is important to address tobacco through the WHO´s treaty, the Framework Convention on Tobacco, which has provided a standardised framework for countries to go about regulating tobacco in their countries. There are 171 countries that are party to the Treaty. Since 2009, the United States´ Food and Drug Administration has the authority to regulate the content, marketing and sale of tobacco products in the United States. This law also requires tobacco companies and importers to reveal all of the product ingredients and bear the health care costs. For instance, Nepal now dedicates one rupee from the sale of every cigarette to support tobacco and cancer care in that country. There are other countries approaching the tobacco industry to help pay for the health care costs caused by the use of their products.
National Cancer Institute (NCI), Egypt: Breast Cancer in Egypt - Civil Society Can Make a Difference
In Egypt, there are nearly 100 000 new cancer cases each year, and 50 000 deaths from cancer annually. Those numbers are projected to rise by 40% in the coming decade. The most prevalent forms of this disease are breast, bladder, lymphomas, liver and lung cancers. One of the important risk factors is late diagnosis due to cultural, social and financial reasons. The Egyptian civil society is very active. Some of the NGOs such as the Breast Cancer Foundation are focusing on breast cancer leading to higher awareness among women. They are also facilitating training for doctors, in particular female doctors, to adapt to the cultural expectations. The Breast Cancer Foundation began providing free surgeries, free biopsies and free mammograms. However, it is not enough to have some active NGOs to build some cancer centres and to work in tobacco control. It is also important to develop a comprehensive national cancer control plan. There will be no cure and the expenses will be huge, if prevention and early detection is not addressed at the same time. In a country where 75 to 80% of the cancer cases are advanced, it is not sensible to ignore palliative care.
"Alliance des Ligues et Associations Francophones Africaines et Méditerranéennes (ALIAM)": Challenges of Cancer Management in Africa
Millions of people will die from cancer in the coming ten years, if no concerted action is taken today to fight the disease. Most of these deaths are occurring in developing countries, which receive only 5% of the world´s financial resources to fight cancer. Up to 80% of the patients are diagnosed with cancer at a very late stage, thus severely limiting the possibility of a cure. Some medical staff and nurses cannot provide a swift cancer diagnosis. Patients travel long distances to seek treatment and bear high costs as a result. The subsidy provided by the government to help cancer patients is insufficient and some governments do not provide financial support. Without a comprehensive programme, cancer cannot be properly managed. Cancer treatment should not be separated from prevention and early detection. The prevalent challenges can be only overcome if the IAEA, WHO, United Nations and the World Bank join their efforts as they had when combatting HIV/AIDS, malaria and tuberculosis.
Cancer is not a priority on the global health agenda. Its absence results from the disease´s complexity, as well as the needed long-term commitment to national cancer control that may require up to 20 years to achieve results, thus reducing cancer control´s political palatability. Cancer is also misperceived as a disease that cannot be prevented or treated, and whose survivors cannot lead productive lives. The panel discussion recommended that the WHO should play a central role in placing cancer on the global and national health agendas. Currently, a major NCD Summit is scheduled for September 2011 during the UN General Assembly.
The participants suggested the following means to address cancer and other NCDs: Prevention should be promoted through the health system and by addressing common risk factors. In parallel, the benefits of an effective health service infrastructure for early detection, diagnosis, treatment and palliative care need to be made as widely known as possible. Here the cancer community needs to showcase the feasibility of such integrated cancer control programmes, particularly in low resource settings. For this purpose, there is a need to involve and collaborate more with NGOs such as the UICC, ACS, Lance Armstrong Foundation, ALIAM and National Cancer Institutes. National initiatives such as INCa´s effort in France to help move cancer on to the health agenda should be emulated elsewhere. The World Cancer Declaration of the UICC should be endorsed and further disseminated. All of the partners should empower survivors, reduce stigma, share resources and encourage collaboration with governments to ensure sustainability. Tobacco control should be instituted by developing national tobacco control programmes, preferably through the WHO Framework Convention on Tobacco. A number of other challenges should be addressed in developing countries, such as the lack of health care facilities, human resources, equipment, and affordable, plentiful drugs. The panellists were hopeful that the needed changes can be undertaken, given the partners´ determination to the general public´s and governments´ awareness, while joining forces with UN agencies, governmental and non-governmental organizations to place cancer on the global health agenda.
- Andreas Ullrich, Cancer Control Coordinator, World Health Organisation, Switzerland.
- Eduardo Cazap, President Elect, International Union Against Cancer, Argentina.
- Francesco Cavalli, Member of Board of the International Union Against Cancer (UICC), Switzerland.
- Fabien Calvo, Deputy Director General, "Institut National du Cancer (INCa)", France.
- Craig Nichols, Lance Armstrong Foundation, USA.
- Mark Clanton, Chief Staff Medical Officer, American Cancer Society, USA.
- Mohamad Shaalan, Chairman, Breast Cancer Foundation, Egypt.
- Paul Ndom, Chairman, "Alliance des Ligues et Associations Francophones Africaines et Méditerranéennes (ALIAM)", Cameroon.