Meeting the Challenges of Breast Cancer 290411

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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



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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


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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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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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

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Meeting the Challenges of Breast Cancer 290411