While cancer is still broadly perceived as disease of high-income countries (HICs), nowadays low-middle income countries (LMICs) bear a majority share of the burden of cancer, and this trend will only be increasing over the next decade. Some figures are telling: over 70 % of all global cancer deaths occur LMICs, where cancer claims over 5,3 M lives each year. The rising proportion of cases in these countries is caused by population growth and ageing, combined with reduced mortality from infectious disease.
For many types of cancers, future changes in incidence, survival, and mortality rates will greatly depend on whether key risk factors can be controlled in LMICs, as in these countries major risk factors continue to rise and awareness of the importance of screening and early detection is low. Besides, in LMICs stigma associated with cancer and the financial barriers of poverty prevent many people from seeking preventive services or care at early stages.
While a widespread assumption is that cancer control and care is not feasible or effective in LMICs, the following evidence challenges it, and supports a global policy change:
1) much can be done without the latest and most expensive technologies to treat cancer. Indeed, for several cancers, life can be substantially extended with fairly low cost system drug treatment, mostly through prevention (tobacco for lung cancer, HPV per cervical, head and neck, anal cancer, hepatitis infection for hepatocellular cancer). Other cancers, as cervical, breast, colorectal, are potentially curable with early detection and treatment, including surgery.
2) pain control is typically low cost and easily delivered, and the barriers to delivery are mostly caused by substance controls. Better regulation for pain control could have a substantial impact at improving quality of life of oncological patients.
3) lessons from the past: think of HIV! A decade ago, vehement critics were asserting that complex care as that needed for AIDS could not be scaled up within weak health systems, such as sub-saharian Africa. However these predictions proved wrong, and represent now a fundamental precedent that we cannot ignore. The increasing burden of cancer in LMICs represents a problem of unacceptable inequality in the distribution of resources worldwide, and requires a transition from a policy focus on public health to a policy focus on global health. According to the definition proposed by Lee & Collins (2005), the transition from public health to global health issue occurs where “The determinants of health or health outcomes circumvent, undermine or are oblivious to the territorial boundaries of states and this beyond the capacity of individual countries alone to address through domestic institutions”.
The perception that cancer is a disease only of HICs is deeply entrenched in our society, but it has been proven erroneous, and needs getting rid of. Such a perception leads to an underestimation of the costs associated with premature death and disability in LMICs: according to current estimates, only around 5 % of global resources for cancer are spent in LMIC countries, while these countries get around 80 % of the disability-adjusted life years lost worldwide to cancer. This is the so-called 5/80 cancer disequilibrium and is no longer acceptable.
Farmer P, Frenk J, Kanul FM, et al. Expansion of cancer care and control in countries of low and middle income: a call to action, Lancet 2010, doi:10.1016/S0140-6736(08)61345-8.
Lee K, Collin J, eds. Global change and health. Maidenhead, Berkshire UK; McgrawHill, Open University Press 2005.