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8/2/2019 The Challenge of Breast Cancer in Developing Countries: Innovative Solutions for Closing the Cancer Divide 051011

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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


16/44Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

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:


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


20/44Source: Knaul Arreola Mende . estimates based on IHME 2011.

LMICs as % of global incidence and mortality

Breast

Cervical

The cancer transition in LMICs:


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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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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minimalists:

myths about cancer

M1. Unnecessary

M2. Unaffordable:M3. Impossible POSSIBLE


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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minimalists:

Myths about cancer& NCD

M1. Unnecessary NECESSARY

M2.Unaffordable AFFORDABLE

M2. Impossible POSSIBLE


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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