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Management & Treatment

Existing cost-effective interventions such as surgery, radiotherapy, and access to essential oncologic drugs can greatly improve cancer survival worldwide.

Cancer management starts with obtaining a valid diagnosis. However, lack of diagnostic imaging and pathologists are major barriers to receipt of high-quality oncologic care in many parts of the world. (Figure 1) Indeed, 8 million people die annually due to poor-quality care in low- and middle-income countries (LMICs), including many due to cancer.

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Figure 1. Pathologists per million population, select countries, 2011-2013. Pathologists per million population are the following: 48 in United States. 4.5 in South Africa. 2.8 in Botswana. 1.8 in Namibia. 1.4 in Kenya. 1.3 in Gabon. 1.1 in Ghana. 0.9 in Nigeria. 0.8 in Mauritania. 0.7 in Central African Republic. 0.7 in Uganda. 0.6 in Ethiopia. 0.6 in Cote d’Ivoire. 0.6 in Malawi. 0.5 in Angola. 0.5 in Tanzania. 0.5 in Rwanda. 0.4 in Burkina Faso. 0.4 in Togo. 0.4 in Zambia. 0.3 in Mozambique. 0.3 in Burundi. 0.3 in Mali. 0.2 in Democratic Republic of the Congo. 0.2 in South Sudan. 0.2 in Chad. 0.1 in Madagascar. 0.1 in Niger. 0 in Benin. 0 in Seychelles. 0 in Somalia.

Surgery is needed for 80% of early-stage cancer patients, and as a palliative measure for a substantial proportion of late-stage cancer patients. However, surgery is only delivered to one in four eligible patients globally due to infrastructure and workforce limitations, as well as lack of affordability, particularly in LMICs. Furthermore, although specialized surgery performed by an oncologic surgeon is crucial to patient outcomes, due to shortages of these specialists, cancer patients in LMICs usually receive surgery from a general surgeon. As surgery is a key contributor to improving the survival of cancer patients, the inequities in LMICs must be tackled.

The chance for a cure, the chance to live, should no longer remain an accident of geography.

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

Radiotherapy is indicated for about 60% of cancer patients to cure certain tumors, relieve symptoms (palliative treatment), shrink tumors before surgery, or kill remaining cancer cells after surgery to avoid recurrence. For example, within 5 years after a diagnosis of cervical cancer, radiotherapy prevents recurrence in 1 in 3 patients and death in 1 in 5 patients. Radiotherapy coverage is less than optimal in many LMICs, with about one-third in Africa, about two-thirds in Asia Pacific, and around 90% in Europe and Latin America. (Map 1) In Ethiopia, for example, a population of nearly 100 million is served by a single radiotherapy center. Newly implementing radiotherapy (mostly in Africa) and scaling up coverage (in South-East Asia) will require financial and human resources as well as continuous technical support.

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Radiotherapy can prevent one out of five deaths among cervical cancer patients.
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Systemic therapy has changed over time, from administration of chemotherapy to all patients to personalized approaches considering receptor status, RNA expression, underlying DNA mutations, tumor environment and immunologic responses. Meanwhile, the cost of cancer drugs continues to rise, with over US$100,000 per treatment in many high-income countries. Still there are many low-cost and effective cancer drugs for broad and equitable application in LMICs, which are on the WHO essential drug list. (Figure 2, 3)

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Figure 2. Breast cancer recurrence and mortality (%) with and without 5 initial years of tamoxifen treatment, 15 years after diagnosis. Among those without 5 years of initial tamoxifen treatment, recurrence was 46% and mortality was 33% 15 years after diagnosis. Among those with 5 years of initial tamoxifen treatment, recurrence was 33% and mortality was 24% 15 years after diagnosis.

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Figure 3. Cancer therapy included on the World Health Organization essential medicines list, and the proportion of countries including the medication on their national essential medicines list. 95% of countries include Methotrexate on their national essential medicines list. Methotrexate is used for the following cancers: Breast, bladder, leukemia, sarcoma. 89% of countries include Cyclophosphamide on their national essential medicines list. Cyclophosphamide is used for the following cancers: Breast, lymphoma. 83% of countries include Tamoxifen on their national essential medicines list. Tamoxifen is used for the following cancers: Breast. 82% of countries include Vincristine on their national essential medicines list. Vincristine is used for the following cancers: Lymphoma, acute leukemia, sarcoma. 81% of countries include Fluorouracil on their national essential medicines list. Fluorouracil is used for the following cancers: Breast, gastrointestinal. 73% of countries include Doxorubicin on their national essential medicines list. Doxorubicin is used for the following cancers: Breast, lymphoma, sarcoma, bladder. 72% of countries include Cisplatin on their national essential medicines list. Cisplatin is used for the following cancers: Lung, head and neck, ovary, osteosarcoma, cervix. 70% of countries include Bleomycin on their national essential medicines list. Bleomycin is used for the following cancers: Germ cell tumor, Hodgkin lymphoma. 65% of countries include Cytarabine on their national essential medicines list. Cytarabine is used for the following cancers: Acute leukemia. 65% of countries include Hydroxycarbamide on their national essential medicines list. Hydroxycarbamide is used for the following cancers: Chronic myeloid leukemia. 64% of countries include Mercaptopurine on their national essential medicines list. Mercaptopurine is used for the following cancers: Acute lymphocytic leukemia. 62% of countries include Calcium folinate on their national essential medicines list. Calcium folinate is used for the following cancers: Colorectum. 62% of countries include Chlorambucil on their national essential medicines list. Chlorambucil is used for the following cancers: Chronic lymphocytic leukemia. 62% of countries include Etoposide on their national essential medicines list. Etoposide is used for the following cancers: Lung, ovary, germ cell tumor.

Political will and stewardship at the national level, as well as greater awareness and engagement across stakeholders, are necessary to close the cancer divide. This also requires health system improvements critical to addressing the delays in diagnosis and the lack of access to therapy that lead to disparities in premature death and survival between countries. Evidence-based guidelines to perform phased implementation are provided by the National Cancer Control Network according to different geographic regions. (Figure 4)

Figure 4
Initiatives to improve access and quality of cancer care in low- and middle-income countries
NATIONAL CANCER CONTROL NETWORK (NCCN)
Resource stratified guidelines help to define appropriate treatment pathways based on available resources—Basic, Core, Enhanced, and NCCN Guidelines®—and deliver a tool for healthcare providers to identify treatment options that will provide the best possible outcomes given specific resource constraints.
Regional guidelines are targeted regional resources created as part of a collaborative effort to combat skyrocketing cancer rates and unique care circumstances. They represent both the optimal care that low- and mid-resource countries aspire to provide, and pragmatic approaches that provide effective treatment options for resource-constrained settings
DISEASE CONTROL PRIORITIES 3: CANCER
Disease Control Priorities provides a periodic review of the most up-to-date evidence on cost-effective interventions to address the burden of disease in low-resource settings. This textbook provides evidence for investments in cancer control, from prevention to treatment, worldwide.
LANCET JOURNAL COMMISSIONS
Responding to the Cancer Crisis: Expanding Global Access to Radiotherapy: This Commission presents research that quantifies the worldwide coverage of radiotherapy services by country, also providing evidence that investment in radiotherapy not only enables treatment of large number of cancer cases to save lives but also brings positive economic benefits.
Global Surgery: This Commission describes the role of surgical and anesthesia care in improving health and economic productivity. It presents findings on the state of surgical care in LMICs, as well as recommendations, indicators, and targets needed to achieve the vision of universal access to safe, affordable surgical and anesthesia care when needed.
THE NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE
The report “Crossing the Global Quality Chasm: Improving Health Care Worldwide” examines the global impacts of poor-quality health care and recommends measures to improve quality while expanding universal healthcare coverage, particularly in low-resource areas.
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Ferlay J, Ervik M, Lam F, et al. Global Cancer Observatory: Cancer Today. Lyon, France: IARC. Available from: https://gco.iarc.fr/today.

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Figure 1:
African Strategies for Advancing Pathology: ASAP [cited 2019 Apr 11]. Available from: URL: https://www.pathologyinafrica.org/.

Figure 2:
Davies C, Godwin J, Gray R, et al. Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials. Lancet. 2011; 378(9793):771–84.

Figure 3:
Robertson J, Barr R, Shulman LN, Forte GB, Magrini N. Essential medicines for cancer: WHO recommendations and national priorities. Bulletin of the World Health Organization. 2016;94:735–742.

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