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The Challenge of Breast
Cancer in DevelopingCountries:
Innovative Solutions forClosing the Cancer Divide
Felicia Marie KnaulOctober 5, 2011
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From anecdote
to evidence
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January, 2008
June, 2007
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br
Juanita:Advanced metastatic breastcancer is the result of a seriesof missed opportunities
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Global Task Force on Expanded
Access to Cancer Care and Control
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From anecdote
to evidence
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Challenge and disprove the
myths about cancerM1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate
Expanding access to cancer careand control in LMICs:
Should, Could, and Can be done
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The divide is the result of concentrating riskfactors, preventable disease, suffering,impoverishment from ill health and deathamong poor populations.
fueled by progress in cutting-edge science andmedicine in high-income countries.
The Cancer Divide:disparities in outcomes
between poor and rich directly related to inequitiesin access and differences in underlying socio-
economic and health conditions.
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Th i i i LMIC
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The cancer transition in LMICs:
breast and cervical cancer 1980-2010
53%47%
20%24%
19%
-31%
60%
-40%
0%
40%
80%
LMICs High income
BC cases
BC deaths
CC cases
CC deaths
% Change in incidence and mortality
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Source: Knaul et al., 2008. Reproductive Health Matters, and updated byKnaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-
1978), and Ministry of Health in Mexico (1979-2006)
1995 2000 2005
Costa Rica 1995 - 2005
Breast cancer
Cervical cancerSource: Instituto Nacional de Estadstica y Censos, Ministerio de Salud,Unidad de Estadstica, Registro Nacional de Tumores de Costa Rica.
The Cancer Transition, Mexico and Costa Rica:
breast and cervical cancer, mortality time series.
0
4
8
12
16
1955
1965
1975
1985
1995
2005
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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.
1979
1985 1995
Nuevo Len
2008
0
Oaxaca
5
10
15
20
25
1979 1985 1995
2008
The cancer transition within Mexico:
breast and cervical cancer 1979-2008
Th h f i l h ld t b id t
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The chance of survival should not be an accident
of geography or income*
However, it is.
And yetThe alternative actions are many
~Lethality(mortality
/incidence)
Source: Author estimates based on IARC, Globocan 2010
Low income
countries
Lower middleincome
Upper middleincome
High incomecountries
0
20
40
6048%
40% 38%
24%~ Lethality Low income: 48%
Lower middle income: 40%
Upper middle income: 38% High income: 24%
Breast Inequality gapin survival
Mxico
Th t iti i LMIC
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LMICs as % of global incidence and mortality
Breast
Cervical
The cancer transition in LMICs:
breast and cervical cancer 1980-2010
0%
30%
60%
90%
1980 2010 1980 2010
52%
59%
49%
63%
79%
87%82%
88%
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Breast cancer: myths and realities
It is a disease ofdeveloped countries
It is a disease ofolder women
It is of lower prioritythan crevical cancer
The majority of cases anddeaths occur in the
developing world
A large proportion of casesand deathsperhaps the
majorityhappens in
women
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Challenge and disprove the
minimalists:
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable: .for the poorM3. Impossible
M4: Inappropriate: either/or
Challenging cancer implies taking
resources away from other diseases of
the poor`
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Investing in CCC:
We cannot afford not toHealth is an investment, not a cost
World Economic Forum: chronic disease is
one of the three leading global economicrisks
Economic value of lost DALYs: $921 billion
VSL losses: $2.5 billion
Total economic cost of cancer, 2010
2-4% global GDP
A id bl d th
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80% of total
75+% ofbreast
95% of cervical
Avoidable cancer deaths:
1/3 to 1/2 or 2.4-3.7 million(Breast 60-78%; Cervical 75-87%)
Income Region
% of deaths
considered
avoidable
Breast Cervical
Low income 52% 79% 80%
Lower middle
income44% 73% 73%
Upper middle
income33% 56% 81%
High income 21% 40% 63%
LMICs: Avoidable
deaths
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Investing in CCC:
we cannot afford not to
Assuming that between 50% of deaths are
avoidable
Total annual cost: $310 billionInvesting 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
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Source: Paul Farmer, 2009
Drug% Decline in price
1997-9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Reduced prices of second-line
TB drugs
Ch ll d di h
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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
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Harvard, Breast Cancer in Developing Countries
Nov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor
Initial views on MDR TB treatment
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In developing countries, people with multidrug-resistant tuberculosis usually
die, because effective treatment is often impossible in poor countries. WHO 1996
Initial views on MDR-TB treatment,c. 1996-97
Source: Paul Farmer., 2009
cured
83%
abandon
therapy
2%
failed
therapy
8%
died
8%
Mitnick et al, Community-based therapy for multidrug-resistanttuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.
Outcomes in MDR-TB patients in Lima,
Peru receiving at least 4 months of therapy
MDR-TB is too expensive to treat in poor
countries; it detracts attention and resources from
treating drug-susceptible disease. WHO 1997
PIH DFCI BWH
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Rural Rwanda, Burkitts lymphoma
Source: Paul Farmer., 2009
Regimen ofvincristine,
cyclophosphamide,
intrathecal
methotrexate
Status post-CHOPin Central Haiti:
Still in remission
three years later
Central Haiti
0
oncolo
gists
PIH, DFCI, BWH
M t lit f b t d i l i
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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.
Mortality from breast and cervical cancer inMexico,1955-2008: less death from cervical
Age-adjusted rate per 100,000women
0
4
8
12
16
1955
1965
1975
1985
1995
2005
Ch ll d di th
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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 takingresources away from other diseases of
the poor
Women and mothers are at risk for
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LMICs
Mortality ofmothers inchildbirth
(-35% 1980-2008)
342,900
Breast andcervical cancer
166,577+142,744
=309,321
Women and mothers are at risk for
many reasons (15-59)
40% i l
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~40% occur in pre-menopausal
women (55
Age of
Diagnosis
Age ofDeath
Source: Author estimates based on IARC, Globocan, 2008 and 2010.
33%
20%54%
66.6%
34.2%65%
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Case:
Juanita
Mexico
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br
Juanita:Advanced metastatic breast
cancer is the result of a series of
missed opportunities
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Mexico: summary of facts
Since 2006, breast cancer is the second leading cause ofdeath 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 treatmentwith financial protection
Only 5-10% of cases in Mexico aredetected in Stage 1 or in situ
Stage at diagnosis by level of municipal
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Stage at diagnosis by level of municipal
marginalization, Mexico, IMSS 2006(Mxico, IMSS 2006)
Source: Authors estimation based on IMSS data, 2006.
N=221(3.8%)
N=1737(30%)
N=2877(49.8%)
N=946(16.4%)
% diagnosed
in Stage 4
Late detection by state
0%
10%
20%
30%
40%
50%
Poor (High) Middle Low Very low
Stage 1 Stage 2
Stage 3 Stage 4
< low
> mid
> high
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Why?
Social and health systemsbarriers to early detection
Th di l h
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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 systemicgaps.
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.
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Mexico: Harnessing the primary level of
care for improving BC detection and care
B
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Be an
optimistoptimalist.
Economics
of hope.Expanding access to cancer care and control in
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