Understanding the Burden of Cancer in Developing Countries (Executive Summary)

Executive Summary May 2010

Understanding the Burden of Cancer in Developing Countries

In 2009, The Global Health Council undertook the Cancer Advocacy and Learning Initiative, a project to raise aware-ness about the burden of cancer in developing countries and to develop policy, advocacy and research agendas to direct the global health community’s work on this growing topic of concern. The Initiative included a critical review of the peer-reviewed literature on cancers associated with reproductive health and with infectious diseases; focus groups with CEOs, academic leaders, and program implementers; an online survey with 174 respondents; working group meetings with community partners; and a panel discussion on the burden of cancer in developing countries.

The Scenario in Developing CountriesGlobally in 2009, there were an estimated 12.9 million cases of cancer.1 Like infectious diseases and maternal, child and re-productive health issues, cancer is a growing health problem in developing countries. The global cancer burden has doubled in past 30 years; further, by 2020, the cancer burden of 2000 is expected to double again.2 Currently, more than half of the cancer burden is borne by low- or middle-income countries.3;4 In 2007, 72 percent of cancer deaths occurred in developing countries.5 By 2020, 60 percent of new cases are expected to be in the least developed countries; this differs drastically from 1970, when only 15 percent of reported new cancer cases occurred in developing countries.2;5

An estimated 4.8 million people in less developed countries died of cancer in 2008, with more than 7 million new cases re-ported.6 The leading types of cancers in less developed countries are:

Type Men Women Total

Incidence

(in 1000s)

Deaths

(in 1000s)

Incidence

(in 1000s)

Deaths

(in 1000s)

Incidence

(in 1000s)

Deaths

(in 1000s)

Lung 612 539 272 239 884 778Stomach 467 353 247 203 714 556Liver 441 403 186 178 627 581Esophageal 263 223 138 116 401 339Cervical 453 242 453 242Breast 691 269 691 269Colorectal 274 154 232 134 506 288Prostate 255 122 255 122TOTAL 2,312 1,794 2,219 1,381 4,531 3,175

In 2002, 1.9 million cases of cancer were attributable to infec-tious agents.7 Cancers due to infectious diseases account for 8-10 percent of cancers in high-income countries, but 20-26 percent of cancers in developing countries.4;8 Among the viruses and bacteria associated with cancer are:9

Human papilloma virus—cervical cancer �

Hepatitis B & C viruses—liver cancer �

H. pylori � (bacteria)—stomach cancer

Epstein-Barr virus—Burkitt’s lymphoma and nasopharyn- �geal cancer

HIV—Kaposi’s sarcoma and other lymphomas �

Herpes virus 8 & T-lymphotropic viruses—adult T-cell �leukemia and other lymphomas

In addition to infectious diseases, many reproductive health diseases are associated with cancer.10 For example, breast cancer is the most common cancer among women and second most common cancer worldwide. Breast cancer is increasing in developing countries and is more aggres-sive in those countries than it is in high-income countries. Cervical cancer is at the intersection of infectious diseases (human papilloma virus), reproductive health and cancer. It is a prevalent disease and significant challenge in developing countries. Endometrial, ovarian and prostate cancers are also problematic in many developing countries.

Cancer has been increasing in developing countries for a number of reasons. Lifestyle changes (e.g., changes in diet, weight gain and use of tobacco) have contributed to the increase.9;11 Environmental exposures, increased life ex-pectancy, population growth and emerging or problematic infectious diseases also have contributed to an increase in the number of cases. Lack of health care services, in terms of both a primary care system that includes prevention and early screening services and routine reproductive health care, have also contributed to the more severe nature of cancers detected in developing countries. In addition to ac-tual increases in cancer incidence, prevalence and deaths in developing countries, some of the increase may be an artifact of increased reporting and data collection; the pro-portion attributable to better data collection is unclear.

Some of the risk factors that contribute to the cancer burden are modifiable; others are not.11 Some factors require systemic change; others rely on individual change. Behavioral factors (e.g., unsafe sex; lack of physical activ-ity, use of tobacco or alcohol, an unhealthy diet of high fat foods and obesity) are, to a varying degree, modifiable and individual risks. Food contaminants, ultraviolet or ionizing radiation and occupational or environmental exposure may be modifiable but require a more systematic response. Fac-tors that cannot be changed are the higher risks associated with aging, ethnicity or race, heredity and gender issues.

The medical and non-medical costs (e.g., productivity) totaled US$ 286 billion in 2009. About 5 percent of cancer resources were allocated to developing countries, despite the growing cancer burden. The chronic nature of cancer requires a long-term investment of resources and a delivery system that can sustain continuity of care and provision of palliative care. Compared to infectious diseases or maternal and child health conditions often faced in developing coun-tries, cancer and chronic diseases require using different tools/equipment, training and medicines, negotiating with different actors, and partnering in different ways.

Where does cancer fit in the global health context?

From the focus groups and online survey, there is clear �consensus that cancer is a significant and growing problem in developing countries.

More than 60 percent of survey respondents noted �that the emerging cancer burden was a very impor-tant or extremely important topic in global health;

About 70 percent rated chronic diseases as very �important or extremely important.

Nearly 60 percent believed that chronic diseases �should receive the same level of attention in devel-oping countries as infectious diseases and maternal and child health issues.

Although some facilities and NGOs in developing coun- �tries address the full scope of cancer, others focus on specific types of cancers—for example, cervical can-cer services at reproductive health clinics or studies on breast cancer in certain populations.

There is debate about whether to focus messaging on �specific types of cancer or to promote health systems.

There is a need for more detailed and geographically �specific data; there are not only variations in disease burden between countries but also within countries.

Stigma, lack of funding and lack of infrastructure �are problematic—stakeholders do not often address chronic diseases.

There are tough choices to be made in terms of treat- �ment and care options, and distribution of resources, e.g., is screening without treatment an ethical course? Is palliative care all that can be offered to some people?

Meeting global cancer needs will require new sources �of funding and a greater focus of activity—from basic research to delivery of services; from coordination among stakeholders to political will within countries and communities.

Among survey respondents who work on cancer, lack �of health care infrastructure and lack of political will were the most cited barriers to providing services.

Research PrioritiesMetrics. � It is important to identify the outputs and out-comes of projects, and to examine patient impact. Early metrics of success are essential to measure not only a program’s outputs (e.g., number of cancer cases diag-nosed) but also health outcomes—does the program/diagnostic tool/medication, etc. actually improve health and reduce the disease burden? What aspects of the programs works (or do not work)?

Capacity building. � Building capacity within national insti-tutions is the best way to prevent health care workforce migration to developed countries. There is a need to train both researchers and health care workers to conduct research. There is also a need to conduct research on the most appropriate configuration of health care work-ers and their ability to reach people through programs. In addition, horizontal (cross-cutting) capacity building is essential to address fully the disease burden.

Instill a research focus. � A research ethic needs to be im-plemented within service delivery programs and interven-tions. Research needs for program and outcome assess-ment should be identified in grant proposals—currently research-related components are frequently removed.

Focus on the link with infectious diseases. � By focusing on infectious diseases, we can identify many cancers. For example, a surprising number of people in both the developed and developing world do not realize that HIV-positive people can develop certain cancers because they have HIV.

Bring in the economic issues. � Cancer is not just a health cost but an economic cost, as it strikes younger members of the workforce, who are may be forced into early retire-ment, as well as the elderly. This has an economic impact on the community.

Policy Priorities Focus on the “fixable.” � Increased funding for the cancers that a) are most problematic and b) have potential for progress. The four cancers that can be treated, even in developing countries, and are prevalent in several regions of the world are: cervical cancer, smoking-related can-cers, breast cancer, and liver cancer.

Capacity building. � Ministries of Health, Education and Finance need to be engaged in developing and supporting national plans that include: training personnel with the necessary skills to diagnose and treat cancer patients, strengthening medical institutions and diagnostic labo-ratories, addressing service delivery and access issues,

developing country-level and country-led initiatives, facili-tating the development of specialized cancer centers, and fostering sustainable programs.

Cancer surveillance. � The need for more useful data is important for the development of programs that address disease, to measure progress achieved by interventions, and to better understand both the burden of disease and needed responses. Without a standard set of metrics and methodologies, addressing the scale and scope of chronic diseases in developing countries will likely remain on the “back burner” as more pressing needs take center stage.

Focus on locally relevant approaches. � Using a combina-tion of local resources and external partnerships, pro-grams and models can draw on local interventions that address other diseases, education, behavior change, community development, and other issues. This approach can highlight best practices to develop a response that is sustainable and multisectoral, reinforcing the most prom-ising locally appropriate programs and models.

Information and awareness. � Advocacy efforts should focus on increasing awareness on a global scale by engaging donors, decision makers in the U.S. and other high-income countries, government officials and decision makers in developing countries, journalists who report on global health issues, and other stakeholders. Awareness-raising campaigns should promote key internal leaders, program implementers, patients or clients, families and others who can deliver an effective message about the importance of addressing cancer and chronic diseases in developing countries.

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