Closing cancer divided:

Expanding Access to Care & Control

International Kidney Cancer Coalition 2018 Conference
April 12, 2018: Mexico City, Mexico

Dr. Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico
 Closing cancer divides:
Affordable and achievable
health, equity & economic imperative.
.
Synergistic, diagonal strategies,
guided and inspired by patient voice
need to be
developed & implemented.
January, 2008
June, 2007
 Global Task Force on Expanded
Access to Cancer Care and Control
in Developing Countries

= global health + cancer care

 Closing the Cancer Divide:
An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary I: Should be done
M2. Unaffordable
M3. Impossible
II: Could be done
M4: Inappropriate III: Can be done
1: Innovative Delivery
2: Access: Affordable Meds, Vaccines & Tech’s
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
 Challenge and disprove the
myths about cancer

M1. Unnecessary
 The Cancer Transition
Mirrors the epidemiological transition
LMICs increasingly face both infection-
associated cancers, and all other cancers.

LMICs: majority of cancer cases and deaths.

Cancers increasingly only of the poor, are
not the only cancers affecting the poor
Source: IHME. GBD 2015.
 For kids 5-14 cancer is:

#1 cause of death in wealthy countries

#3 in upper middle-income
#6 in lower middle-income
and # 7 in low-income countries
More than 85% of pediatric cancer cases
and 90% of deaths occur in LMICs.
Source: IHME. GBD 2015.
The Cancer Divide: disparities in outcomes
between poor and rich are directly related to inequities
in access and differences in underlying socio-economic
and health conditions.

• The divide is the result of concentrating risk

factors, preventable disease, suffering,
impoverishment from ill health and death
among poor populations.

• fueled by progress in cutting-edge science and

medicine in high-income countries.
 The Cancer Divide:
Both Health & Equity Imperative
Cancer is a major health challenge for rich &
poor; yet it is the poor who increasingly suffer:
1. Exposure to risk factors
2. Preventable cancers (infection)
Facets

3. Treatable cancer death and disability

4. Stigma and discrimination
5. Avoidable pain and suffering
The most insiduous injustice: The Pain Divide
Distributed opioid morphine-equivalent mg/patient & (% of SHS palliative care need)

Poorest 50%: 1%
Wealthiest 10%: 90%
Russia:
124 mg (8%)

China:
314 mg (16%)
USA:
55,704 mg (3150%)

India:
Mexico: Nigeria: 43 mg (4%)
0.8 mg (0.2%)
562 mg (36%)
Bolivia:
74 mg (6%)

Source: Author calculations using INCB (2010-13) and GHE 2015 (www.incb.org,
http://www.who.int/healthinfo/global_burden_disease/en/) . See Data Appendix for methods.
 The Opportunity to Survive (M/I)
Should Not Be Defined by Income
Breast
100% 100%
Survival inequality gap

Children Cervix

Haití India Testis

Prostate
China
Non-hodkins

Tyroid
Canada
Leukaemia Kidney

LOW HIGH LOW HIGH

INCOME INCOME INCOME INCOME

In Canada ≅90% of kids with leukemia survive.

In the poorest countries only 10% survive.
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010. Source: IARC. Globocan, 2012
 Challenge and disprove the
myths about cancer

M1. Unnecessary

M2. Unaffordable
The costs of inaction are huge:
Invest IN action
Total economic cost of cancer:
2-4% global GDP
1/3-1/2 of cancer deaths are “avoidable”:

✖ 2.4-3.7 million deaths,

of which 80% are in LIMCs
Prevention and treatment offer
potential world savings of
$ US 130-940 billion
 Champions
- The economics of hope:
Drew G. Faust Nobel
President of Harvard U Prize-
30+ year breast cancer survivor
Recipient
Amartya
Sen,
Cancer
survivor
diagnosed in
India 65+
years ago

Harvard, Breast Cancer in

Developing Countries, Sept. 2010
The costs to close the cancer divide are and
may be less than many fear:
Almost all LMIC priority cancer chemo
and hormonal agents are off-patent
Pain medication is cheap
Prices drop: HepB and HPV vaccines
Delivery & financing innovations
aggregate purchasing to reduce price and
stabilize procurement
 Prices can drop:
through effective global action, aggregate
platforms and public- private collaboration

Cost of one dose of HPV vaccine, 2016, USD:

Private sector: $ 67.00

PAHO Strategic Fund: $ 8.50
GAVI: $ 5.00

¡US: $US150 /dose! HPV Vaccine

 Success reducing cost:
MDR-TB treatment
Initial views on MDR-TB
treatment, c. 1996-97

“MDR-TB is too expensive to treat

in poor countries; it detracts
attention and resources from
treating drug-susceptible disease.”
WHO 1997

Source: Paul Farmer., 2009

 Outcomes in MDR-TB patients Making common
in Lima, Peru receiving at least
four months of therapy
cause with WHO:
Reduced prices of
failed second-line TB drugs
therapy died
abandon 8%
8%
therapy
2% % Decline in
cured Drug
price 1997-9
83%
Amikacin 90%

Ethionamide 84%

Capreomycin 97%
All patients initiated therapy
Ofloxacin 98%
between Aug 96 and Feb 99
Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis
in Lima, Peru. NEJM 2003; 348(2): 119-28.
Source: Paul Farmer, 2009
 Challenge and disprove the
myths about cancer
M1. Unnecessary

M2. Unaffordable

M3. Inappropriate
 Closing the Cancer Divide:
A BLUEPRINT TO EXPAND ACCESS IN LMICs

Applies a diagonal
approach to avoid
the false dilemmas
between disease silos
-CD/NCD- that
continue to plague
global health
 Women and Mothers in LMICs
face many risks through the life cycle
Annual deaths: Women 15-59

35% Mortality Breast Cervical

in in 65% cancer cancer
30 childbirth:
in
years 291,000 30 195,000 131,000
years

= 326,000

Source: Estimates based on data from IHME 2016

 Worldwive wave of reforms
to achieve UHC
Universal health coverage (UHC): all people should
obtain needed health services – prevention,
promotion, treatment, rehabilitation, and palliative
care– without risking economic hardship or
impoverishment (WHO, WHR 2013).

In the challenging context of rapid and

complex epidemiological transition, and
while battling fragmented health systems
 The Diagonal Approach to
Health System Strengthening
Rather than focusing on either disease-specific vertical or
horizontal-systemic programs, harness synergies that
provide opportunities to tackle disease-specific priorities
while addressing systemic gaps and optimize available
resources

Diagonal strategies major benefits:  X = >  parts

Bridge disease divides using a life cycle response
Generate positive externalities: e.g. women’s cancer
programs fight gender discrimination; pain control 4all
 Diagonal Strategies:
Positive Externalities
Promoting prevention and healthy lifestyles:
Reduce risk for cancer and other diseases
Reducing stigma for women’s cancers:
Contributes to reducing gender discrimination.
Increasing access to pain control
Better access for all patients in need
Improves surgical platforms
 ‘Diagonalizing’ Cancer Care:
Financing, Delivery & Evidence
1. Financing: Integrate cancer care into national
social insurance and social security programs
and reforms, e.g. Mexico and China
2. Delivery: Integrate cancer prevention,
survivorship and palliative care into existing
primary care platforms, e.g. Maternal and Child
Health, HIV/AIDS, and anti-poverty programs.
 Challenge and disprove the
myths about cancer
M1. Unnecessary

M2. Unaffordable

M3. Inappropriate

M4: Impossible
 Expansion of Financial Coverage:
Seguro Popular México, 2004-2018
Affiliation:
• 2004: 6.5 m

Diseases and Interventions:

• 2017: 53.5 m

Benefits Package
Vertical Coverage
Benefit package:
• 2004: 113
• 2018: 294
• 65 in the
Catastrophic
Illness Fund Horizontal Coverage:
Beneficiaries
 Seguro Popular now includes
cancers in the national,
catastrophic illness fund
Universal coverage by disease with an
effective package of interventions
2004/6: HIV/AIDS, cervical, ALL in kids
2007: pediatric cancers; breast cancer
2011: Testicular, Prostate and NHL
2012: Ovarian and colorectal
Seguro Popular and breast cancer:
Evidence of impact
Adherence to treatment:
2005: 200/600
2010: 10/900

Human faces of impact:

Guillermina
Abish
 Breast Cancer early detection:
Delivery failure
• 2nd cause of death, women 30-54
• 5-10% of cases detected in stage 0-1
• Poor municipalities: 50% Stage 4; 5x rate for rich
Late detection by state Stage 1 Stage 2
% cases detected in 50% Stage 3 Stage 4
stage 4
40%
< Low
> Medium 30%

> High
20%

10%

0%
High Medium Low Very Low
Source: Authors’ estimates with database from IMSS, 2014
Juanita:
Advanced metastatic breast cancer
as a result of a series of missed
opportunities and barriers to access
 Diagonalizing Delivery: Training primary care
promoters, nurses and doctors in early
detection of breast cancer

Health Promoters
8 Risk Score (0-10)
Significant increase in knowledge,
7 *

6
among health promoters,
5
especially
4 in clinical breast examination
(Keating, Knaul et al 2014, The Oncologist)
3
Pre Post 3-6 month
Mexico: Cartilla Nacional de Salud de la Mujer
offered to all women 20 -59
 Conditional Cash Transfer Programs
• Virtually every country in Latin America has a program
• Cover the majority of the poor
• Largest social assistance program in the case of Brazil
(Bolsa Familia) and Mexico (Prospera)
• Transfer cash to poor households via mothers, on the
condition that those households make pre-specified
investments in health, nutrition, education etc:
– periodic checkups, growth monitoring, and vaccinations;
perinatal care and attendance by mothers at periodic health
information talks
 Diagonalizing delivery:
Inclusion of early detection of breast cancer in
the cash transfer, anti-poverty program Prospera

• Training materials for beneficiaries includes information about

early detection of breast as well as cervical cancer
• 3 million copies for promoters and trainers
• Reaches more than 90% of poor households in rural areas
 Be an
optimist Ju

optimalist

We can close global cancer divides

 Closing cancer divided:
Expanding Access to Care & Control
International Kidney Cancer Coalition 2018 Conference
April 12, 2018: Mexico City, Mexico

Dr. Felicia Marie Knaul

UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico