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Relever les dfis du cancer du sein au
Rwanda:
Appliquer les leons mondial
Meeting the Challenges of Breast Cancer
in Rwanda:Applying Global Lessons
Felicia Marie KnaulDirector, Harvard Global Equity Initiative
Secretariat, Global Task Force on Expanded Access to Cancer Care and Control inDeveloping CountriesAssociate Professor, Harvard Medical School
Womens Cancer Summit in Rwanda
April 29, 2011
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to the Rwanda Task Force on Expanded
Access to Cancer Care and Control
Felicitations/Felicidades/
Congratulations
et
Merci/Muchas gracias/
thank you
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From evidence
to anecdote
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July, 2007
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January, 2008
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From anecdote
to evidence
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1. Evidence to anecdote to evidence
2. Cancer in LMICs: so muchmore can be done
3. Breast cancer: global health priority
4. Applying the diagonal approach towomens cancer
OUTLINE:
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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary:
Not a health priority in LMICs/not a problem
of the poorM2. Impossible:
Nothing we can do about it
M3. Unaffordable: .for the poor
M4: Inappropriate: either/or
Challenging cancer implies taking resourcesaway from other diseases of the poor`
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Cancer is a disease of rich and poor
Yet, transition is polarizing the burden so that itis increasingly the poor who suffer:
Incidence and death: preventable cancers
Death: treatable cancer
Avoidable pain and suffering particularly at end oflife
Financial impoverishment from the costs of care andeffects of the disease
The cancer divide
C i f li
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Concentration of mortality:example Cervical cancer
Children orphaned by cervicalcancer
HPV Vaccine
Source: Paul Farmer., 2009
275,000 deaths worldwide; 93% in LMCs
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LMICS: More than 85% of pediatric cancercases and 95% of deaths.
Level ofIncome
Incidence Mortality Population
Low 21% 27% 20%
Low middle 50% 55% 57%
Upper middle 15% 15% 13%
High 15% 5% 10%
Distribution of childhood cancer globallyby level of income (< 15)
For children & adolescents 5-14 cancer is#2 cause of death in wealthy countries
#3 in upper middle-income#4 in lower middle-income
and # 8 in low-income countries
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Lethality by cancer type and country income
Adults (15+)
Casefatalityapproximatedby
mortality/incidence
Breast
Cervix uteri Prostate
Testis
Hodgkin lymphoma
Non - Hodgkin lymphoma
Leukaemia
All cancers
0
0.2
0.4
0.6
0.8
1
Low income Lower middleincome
Upper middle
incomeHigh income
0
0.2
0.4
0.6
0.8
1
Low income Lower middle
income
Upper middle
income
High income
Source: Knaul, Arreola, Mendez. estimates basedon IARC, Globocan, 2010.
Children
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`5/80 cancer disequilibrium(Frenk/Lancet 2010)
Almost 80% of the DALYs (disability-adjusted life-years) lost worldwide tocancer are in LMICs, yet these countries
have only a very small share of globalresources for cancer ~ 5% or less.
Worse in certain regions:
Africa: only 02% of global cancer medicalcosts, 1% of global spending on health, 64%of new cancer cases, and 15% of the globalpopulation
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In developing countries, people withmultidrug-resistant tuberculosis usuallydie, becauseeffective treatment is oftenimpossible in poor countries.WHO 1996
MDR-TB is too expensive to treat in poorcountries; it detractsattention and resources fromtreating drug-susceptible disease.WHO 1997
Initial views on MDR-TB treatment, c. 1996-97
Source: Paul Farmer., 2009
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Outcomes in MDR-TB patients inLima, Peru receiving at least four
months of therapy
Mitnick et al, Community-based therapy for multidrug-resistanttuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.
cured83%
abandon
therapy
2%
failed
therapy
8%
died
8%
All patients initiated therapybetween Aug 96 and Feb 99
Source: Paul Farmer, 2009
Drug % Decline inprice 1997-9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Making commoncause with WHO:
Reduced prices ofsecond-line TB
drugs
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Rural Rwanda, Burkitts lymphoma
Source: Paul Farmer., 2009
Regimen ofvincristine,cyclophospha
mide,intrathecal
methotrexate
Status post-CHOPin Central Haiti:Still in remissionthree years later
Central Haiti
0o
ncolo
gists
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Africa
LMICs
Maternalmortality
APPROX: 210,000
APPROX: 360,000
Breast andcervicalcancer
67,885
75,893
=133,778
772,728
478,640
=1,251,368
People are at risk for manyreasonsvictims of success?
OUTLINE
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1. Evidence to anecdote to evidence
2. Cancer in LMICs: so much more can
be done
3.Breast cancer: global health
priority4. Applying the diagonal approach towomens cancer
OUTLINE:
Th id i f b
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The epidemic of breast cancer:Unforseen challenge in LDCs
Some 45% of the more than 1 million new casesof breast cancer diagnosed each year, and morethan 55% of breast-cancer-related deaths, occurin low- and middle-income countries.*
Such countries now face the challenge ofeffectively detecting and treating a disease thatpreviously was considered too uncommon to meritthe allocation of precious health care dollars.Source: Porter, P. (2007). "Westernizing Womens Risks? Breast
Cancer in Lower-Income Countries." New England Journal ofMedicine 358(3):4
Curado MP, Edwards B, Shin HR, et al., eds. Cancer incidence in five continents. France: InternationalAgency for Research on Cancer, 2007.
M th lit
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Myth .versus ..reality:
breast cancer in LMICs
a disease ofdevelopedcountries andwealthy women.
a disease ofolder women
less of ahealth prioritythan cervicalcancer.
More than half of casesand almost 2/3 of deathsdeaths occur in thedeveloping world.
large proportion of casesand 60% of deaths inwomen < 54.
More deaths and DALYslost to breast cancer, in alldeveloping regions otherthan SEAsia and SSAfrica.
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In developing regions, breast cancer
Most frequent cause of cancer-related death in developingand developed regions
2-3rd leading couse
268,000 of the 458,000 deaths per year are in LIMCs: 58%
Most common cancer in developed and developing regions
4.4 million women alive (diagnosed): how many indeveloping regions?
2008: 1.38 million new cases; 50% of which are fromLIMCs
10.9% of all incident cancers second to lung
(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).
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Among women 15-59
Breast cancer is globally
#1 cause of death in wealthy countries
#2 in middle-income countries and
# 5 in low-income countries
(IARC, GLOBOCAN, 2008/10) C l i li f b
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Cumulative mortality of breast cancer,(age 20-80), 2010
Mohammad H Forouzanfar; Institute for Health Metrics and Evaluation
Ch i l ti t lit f
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29
#
Change in cumulative mortality ofbreast cancer, 1990-2, (20-80)
Mohammad H Forouzanfar; Institute for Health Metrics and Evaluation
I LIMCS h hi h ti f
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In LIMCS, a much higher proportion ofdiagnosis and death is in women 55
33%67%
66%
34%
Agea
tdiagnosis
Ageatdeath
20%
Mortalit from breast and cer ical cancer
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Fuente: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 cancerin Mexico 1955-2008
2006: CS>CC.Por primera vez en ms de 5 dcadas.
Tasa por 100,000 mujeresajustado por edad
0
4
8
12
16
1955
1965
1975
1985
1995
2005
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Cervical and breast cancer mortality by state in Mexico
Fuente: 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.
0 0
5
10
15
20
25
30
Oaxaca Tabasco
5
10
15
20
25TM x 100,000 mujeres TM x 100,000 mujeres
1979
1979
1980 1985 1990 1995 2000 2005
1979
1980 1985 1990 1995 2000 2005
1979
1980 1985 1990 1995 2000 2005
0
4
8
12
16
1980 1985 1990 1995 2000 2005
crvix
mama
TM x 100,000 mujeres
0
4
8
12
16
Nuevo LenDistrito FederalTM x 100,000 mujeres
2008
2008
2008
2008
The opportunity to survive should not be an accident of
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The opportunity to survive should not be an accident ofgeography or defined by income.
Yet it is.But . there is scope for action.
~casefa
tality(inciden
ce/mortality)
Source: Author estimates based on IARC, Globocan, 2008 and 2010.Quote: HRH Princess Dina Mired
Low-income
countries
Lower middle Upper middle High-income
countries0
20
40
60Breast
48%
40% 38%
24%
OUTLINE
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1. Evidence to anecdote to evidence
2. Cancer in LMICs: so much more can
be done3. Breast cancer: global health priority
4.Applying the diagonalapproach to womens cancer
OUTLINE:
Gl b l L I t ti
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Vertical programs refer to targeted interventions, proactiveand disease-specific on a massive scale (HIV, maternal andchild health), while horizontal programs refer to more
integrated health services corresponding to functions of thehealth systems, guided by demand and shared resources.
it has been discussed at length what the mosteffective approach is to deliver health interventions:vertical programs or horizontal programs. This is a false
dilemma, because both interventions need to coexist inwhat could be called a diagonal approach
Seplveda et al., Aumento de la sobrevida enmenores de 5 aos: la estrategia diagonal
Global Lesson: IntegrationThe diagonal approach to
health system strengthening
A diagonal approach to women and
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Horizontal Coverage: BeneficiariesWOMEN
A diagonal approach to women and
health and cancer care and control
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1. Integrating breast and cervical cancer
screening into MCH, SRH2. Integrating disease prevention and
management into social welfare and anti-poverty programs
3. Catalyzing and employing community healthworkers and expert patients
4. Financial protection/insurance strategieswith horizontal and vertical coverage
5. Reducing non-price barriers to pain control6. Developing effective health services
research and monitoring
Diagonal approaches
ServiceP
latforms
HealthSystemsFunctions
Mexico: innovations in financial
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Mexico: innovations in financialprotection, early detection and delivery of
treatment for breast cancer
Problem 60-70% of cases aredetected in stage III-IV
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R l l dfi d d i
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Relever les dfis du cancer du sein au
Rwanda:
Appliquer les leons mondial
Meeting the Challenges of Breast Cancer
in Rwanda:Applying Global Lessons
Felicia Marie KnaulDirector, Harvard Global Equity Initiative
Secretariat, Global Task Force on Expanded Access to Cancer Care and Control inDeveloping CountriesAssociate Professor, Harvard Medical School
Womens Cancer Summit in Rwanda
A il 29 2011