Tag Archives: treatment

Bold policies for progress north and south

anna portrait  picWorking in silos has long been a problem within the cancer community, as people engaged in increasingly specialised fields struggle to remain aware of the bigger picture. So it can be important, on occasion, to bring the different constituents together around a single agenda.

One might have wondered, however, whether the World Oncology Forum, which gathered almost two months ago in Lugano, Switzerland, might not have been a little over-ambitious in setting an agenda that focused on two topics that are poles apart in almost every respect, including the geographical.

The first of these, fixing the ‘broken model’ of new drug development, is a priority issue for the northern hemisphere. The second, addressing unmet need for the most rudimentary detection, treatment and palliative care, is the priority in the South. The opportunity to explore these challenges and the associated policy implications, within a single gathering, however, turned out to be remarkably constructive.

wof collage Hearing about some of the best examples of low- to middle-income countries that have taken well-planned, system-wide, sensibly financed steps to get the widest possible access to the best possible early detection, treatment and follow-up showed just how much can be achieved for cancer patients, even with modest resources, by simply getting the fundamentals right.

While hearing about the cost, both in health expenditure and overtreatment, of squeezing out additional survival benefit for patients in better resourced health systems brought home how unsustainable current approaches to developing new treatments are becoming, even for world’s wealthiest countries. The message that came out was about priorities.

  • Don’t waste resources on expensive equipment and therapies if the money can be better used getting the fundamentals right for everybody who needs them.
  • Don’t waste resources on developing new therapies unless they aim high – which means tackling resistance rather simply chasing cancer cell evolution from dependence on one mutated pathway to the next.

Bold policy initiatives that champion the public interest will be needed at international and national level to achieve what must be achieved. The task of the 35 assembled experts, leaders and innovators in their own fields, was to spell out the core elements of such initiatives.

As keynote speaker Paul Workman, chief executive of the UK Institute of Cancer Research, points out in the video below, the level of agreement among participants was remarkable, given the differences in their geographic and professional backgrounds and the strong views held by all.

The exact wording of the final policy appeal is currently being finalised. It will be published on this blog and in the March issue of Cancer World, which will carry a full report of this remarkable meeting. It will also feed into a discussion at the ‘Davos’ World Economic Forum on meeting the challenge of the global cancer epidemic, if and when the organisers confirm that the issue has made it onto the final agenda at the end of January 2015.

Slides from most of the presentations are available now on the ESO website (access requires you to register with Club ESO).

Speeding up global access to detection and care

 

Dr Rengaswamy Sankaranarayanan

Dr Rengaswamy Sankaranarayanan

Rengaswamy Sankaranarayanan, special advisor on cancer control and head of early detection and prevention at IARC (the WHO’s International Agency for Research on Cancer), Lyon, will lead the session on Access to effective and affordable treatments in middle- and low-income countries at the World Oncology Forum, Lugano, October 23–25. In this guest blogpost he talks about the policy recommendations he will be arguing for.

I’M LOOKING FORWARD to speaking at the World Oncology Forum about new healthcare financing models that are extending access to effective early diagnosis and treatment of cancer in many low- to- middle-income countries. I would like to see the Forum issue recommendations that can catalyse the pace of this transformation and deliver a very blunt message to governments and international development agencies.

Some success stories

The last few years have seen important progress in access to healthcare, particularly in middle-income countries. I would like to see this replicated in low-income countries.

Thailand, for instance, started introducing universal healthcare from 2002. Today, anyone living anywhere in Thailand, can access care seamlessly across public health services.

Initially under the Thai scheme, people were required to make a single, small copayment – 30 Baht or around $1 – the first time they see a healthcare professional for a particular complaint. That payment would cover the entire journey that follows, including diagnostic tests, treatments and follow-up. This co-payment was abolished in 2007, and universal health care became free for poor people.

Despite initial fears that the health system would collapse, it is working well. One important reason is that the government is investing a substantial amount of its GDP into healthcare. Another is that the “30-Baht” scheme mainly covers people from the very poorest rural communities – those employed by the government and the private sector have their own insurance systems.

Not only has it considerably improved access to healthcare in Thailand, it has also regulated the market, because the system will only pay for standard procedures. Since then, many other middle-income countries have implemented successful schemes to widen access to healthcare, including Turkey, India and Malaysia as well as many of the larger countries in Latin America, such as Mexico, Brazil, Colombia, Peru, Argentina and Chile.

Spreading the success: two recommendations

1. Cancer control must be a national responsibility

Countries like Thailand have shown it is possible through a variety of models to provide sustainable good-quality health services on a subsidised basis for a large proportion of people, while recovering healthcare costs from those who can afford it.

However, we also need to learn from our failures. In sub-Saharan Africa, for instance, health services have barely improved, there are no health financing systems, and access to healthcare has not improved at all.

I think one of the major reasons for this is the amount of external assistance they receive, which has blunted internal investment and internal drive and internal planning.

We need to make governments realise that healthcare is their own responsibility, and the systems and investments they have to make should be their own, and should come from their own national budgets. The way to do this is to substantially increase the GDP proportion that is contributed to healthcare from national budget.

So one message I would like to come out of the World Oncology Forum is that:
International organisations and funding agencies should insist that the countries they help must predominantly use national resources to develop and sustain their own national healthcare services.

 2. Cancer control needs a joined up approach

Another lesson we need to learn is that countries need to approach cancer control as a whole, linking prevention, early detection, treatment and palliative care. In Latin America, for instance, screening with the Pap smear was carried out for many many years, with very little impact on disease. Everyone blamed the poor cytology, but the bigger problem was that most women with the positive cytology never had a diagnosis made and never received treatment.

Governments and international agencies need to take a more comprehensive view across the entire spectrum of cancer control.

I think we have lessons to learn here from the comprehensive approach taken by the GAVI alliance, which has been very successful in terms of immunisation coverage and reducing child mortality. So another key message I would like to see coming out of the World Oncology Forum is:
We need to think in terms of a global alliance for cancer care continuum.

 Other key issues

Other key issues I will be asking the World Oncology Forum to consider include:

  • The urgent need to secure universal access to basic early diagnosis and treatment services
  • Opportunities for working within the wider efforts to tackle “non-communicable diseases”
  • Reversing the worrying trend towards adopting expensive and unnecessary imaging investigations, very expensive, very high-tech radiotherapy equipment and techniques, and expensive chemotherapy regimens and targeted drugs whose additional benefit has not been well demonstrated.

I look forward to the discussion

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Heads up: it may be best to do nothing

Simon Crompton

Simon Crompton

 

It’s always strange emerging from the single-mindedness of a conference to breathe the outside world’s unconcerned air. I doubt there was a person attending the British Medical Journal’s recent “Preventing Overdiagnosis” conference in Oxford who didn’t come away with the sense that overdiagnosis and its consequences is one of the biggest challenges facing health providers globally.

 

But beyond the concern of a handful of international experts – many of whom were gathered in Oxford – awareness and concern among the international cancer community seems low. Yes, most of us know that there are risks as well as benefits to breast cancer screening, and that PSA testing for prostate cancer can lead to unnecessary tests and treatment. But does that result in changes to practice? Does every one of us need to sit up and listen a bit more?

The papers presented at the conference certainly suggested “yes”. As keynote speaker Ilona Heath, a former President of the Royal College of General Practitioners, said: “Susan Sontag’s kingdom of the well is being absorbed into the kingdom of the sick, and clinicians and health services are busy ushering people across this important border in ever-increasing numbers. The costs, personal, social and economic, are enormous.”

The issue of overdiagnosis doesn’t just hover over breast cancer and prostate cancer.

The conference heard evidence that it is an issue in melanoma. An analysis of data by America’s National Cancer Institute, presented at the conference, showed that melanoma incidence has been increasing since 1975 while mortality has remained stable, strongly suggesting overdiagnosis.

Or take ovarian cancer. The conference heard about concerns that improved testing with blood tests and ultrasound are leading to increased detection of borderline ovarian tumours that might never present clinically in the lifetime of a woman.

Or thyroid cancer. A population-based study of thyroid cancer patients in Ontario, Canada between 2000 and 2008 shows that this relatively benign cancer is increasing at an “epidemic” rate. The increase seems to be confined to more affluent areas, and closely related to the availability of diagnostic ultrasound.

The suggestion is that, without sophisticated diagnostic techniques, large numbers of people with these diseases would have died of something else without even knowing they had cancer. They might have avoided distressing decisions, painful tests, potentially disabling treatments.

Such interpretations of data can prove controversial. Some evidence is strong, some is preliminary to say the least. But it undoubtedly opens up important questions for all those involved in the detection and treatment of cancers. It asks us to look up from a heads-down determination to track down and destroy cancer, and question whether sometimes – quite often – doing nothing is the best course.

It’s not an easy thing to do. Cancer World will be exploring the issues in its next three editions.