ESMO 2013-GLOBAL CANCER PROBLEM

AMSTERDAM — A new report with contributions from more than 100 cancer specialists across the world highlights the huge differences in cancer care between countries, and proposes a new way of financing a solution to the global cancer problem — a public/private partnership.

"Radical solutions are urgently needed," concludes the State of Oncology report, presented here at the European Cancer Congress 2013.

It would take an estimated $215 billion annually to equalize cancer outcomes across all the resource settings, and there is no one source of philanthropy that could afford that sort of investment, said lead author Peter Boyle, PhD, president of the International Prevention Research Institute in Lyon, France.

"We need a new model...an effective public/private partnership, which needs to be driven by the private sector, and needs commitment from governments and nongovernment organizations," he said. It would need the commitment of the pharmaceutical industry, as well as industries involved in diagnosis, pathology, screening, and radiation, and these companies would contribute not only funds, but also equipment, training, and knowledge, he suggested.

"We have had a good response from industry," Dr. Boyle said during a press briefing. "These things don't happen overnight," he said, but he hopes that enough details will be in place to make an announcement at the World Prevention Summit in Washington, DC, in November 2014.

"Working to improve health must cease to be viewed as a competition," the report authors write. "Public and private organizations have an underlying suspicion of each other that must be overcome in the interests of improving cancer care and outcomes worldwide."

"The situation is dramatic and urgent, and it behooves all parties to put this frequently deep-rooted suspicion behind them and develop an effective collaboration to improve this key aspect of public health throughout the world," they conclude.

The report was coauthored with Richard Sullivan, MD, PhD, from the Kings Health Partners Integrated Cancer Centre in London, United Kingdom; Christopher Zielinski, MD, director of the clinical division of oncology at the Medical University of Vienna in Austria; and Otis Brawley, MD, from the American Cancer Society. However, there were more than 100 contributors to the book, each outlining the situation in a particular country, Dr. Boyle commented.

Lack of Cancer Infrastructure

The aim is to allow every patient with cancer to have the most appropriate treatment for their disease, Dr. Boyle declared.

That this is far from the case in many parts of the world is the main focus of the report, which outlines the state of oncology in more than 50 countries, including those in Africa, Australasia, China, parts of Europe (Bulgaria, Cyprus, Hungary, and Turkey), the Indian subcontinent, and Latin America.

Dr. Boyle gave several examples from Africa, where many countries do not have a single radiotherapy machine and others have only 1 machine per country, but the technology is old and there are problems with electricity supplies. There is a lack of everything — 80% of cancer in Africa is treated without any pathology or histology being available, which is like "taking a shot in the dark."

Another country that is particularly starved for cancer resources is Nepal, where figures show the lack of expert physicians — there is only 0.17 oncologist per 1 million of population, Dr. Boyle noted.

One of the consequences of a lack of cancer infrastructure is that when cancers are diagnosed, they are at such an advanced stage "that cure is impossible, and palliation is the only option," he said. But this too has problems, as the international restrictions on opium-derived drugs make it impossible in some countries to use morphine for the relief of pain in terminal cancer patients, and so these patients are treated with paracetamol (acetaminophen), "which is inappropriate," he added. The scope of this problem was outlined in a global survey presented last year at the European Society of Medical Oncology annual meeting.

"It is bad to have cancer, but it is worse to have cancer when you are poor," the report concludes.

"The gap between rich and poor, between highly educated and less educated, the north/south divide as we frequently refer to it, is already substantial, and is set to continue to grow," Dr. Boyle said.

"We are making steady progress in all aspects of oncology, and we are moving survival ahead," he commented. The report details how survival rates in many cancers, including breast, prostate, and colorectal, have vastly improved over recent decades, and also outlines progress that has been made with targeted therapies, such as imatinib (Gleevec) and related drugs in chronic myeloid leukemia and gastrointestinal stromal tumors.

"The problem is not everyone in the world has got access to that progress and can benefit from that progress," he commented.

"Many parts of the world are already unable to cope with the current situation and are totally unprepared for the future growth of the cancer problem," the report authors write.

The dominant contribution to the global cancer burden in the next 50 years will come from China, India, and Nigeria, but there will also be increasing demands from countries such as Bangladesh, Indonesia, Pakistan, and Vietnam, where rapid change is taking place, the report notes.

The cancer problem will increase not only because of population growth, but also because people are living longer and the risk for cancer increases with age, and because of the increasing adoption of Western-style lifestyles, which increases cancer risk, the authors comment.

Menu of Actions

In addition to proposing a new financial model for producing funds to tackle the problem, the report also outlines a menu of actions, to be adapted in each country to its own particular needs and means.

First of all, prevention of cancers that are preventable. The authors criticize current efforts with their silo mentality of separating cancer prevention from that of diabetes and cardiovascular disease. These common chronic conditions, and others such as osteoporosis, have many lifestyle habits in common and all of them could be tackled together in one model of disease prevention, they say. Top of the agenda should be avoiding tobacco and limiting alcohol consumption, followed by avoidance of obesity and encouragement of physical activity. Also under this action point are organized screening programs and vaccination (e.g., against hepatitis B and human papillomavirus).

Second, treatment resources should be available everywhere. This includes having appropriate imaging and radiotherapy equipment, surgery, laboratory and pathological services, as well as therapeutics. Also, the report authors note that in many countries there is still a stigma related to cancer, which needs to be eliminated so that patients seek medical attention at an earlier stage of their disease, when treatment is still possible.

Third, it is vital to have resources in place to provide curative therapy for those cancers that are curable. This is a major challenge in low-income countries, and is becoming increasingly important as more targeted drugs become available. "If these curative therapies do not become available in lower-income countries at the same time as in higher-income regions, then the gap between rich and poor will widen even further," the authors warn.

Fourth, the provision of palliative, supportive, and terminal care is an essential part of cancer care, and yet it is missing in many of the poorer regions of the world. This will require strong action, coupled with significant training programs, and the need is urgent.

The State of Oncology report was funded by the International Prevention Research Institute, and supported by an educational grant from Roche.

European Cancer Congress 2013 (ECCO-ESMO-ESTRO): Abstract 1401. Presented September 29, 2013.