Breast Cancer: unforeseen health priority in developing countries 150311

8/2/2019 Breast Cancer: unforeseen health priority in developing countries 150311

1/48

Felicia Marie Knaul,

Harvard Global Equity Initiative, HarvardMedical School; GTF.CCC

Tomatelo a Pecho; Fundacin Mexicana parala Salud

PATH

March 15th, 2011Seattle, WA

Breast Cancer:

Unforeseen PublicHealth Priority in

Developing Countries


2/48

From evidence

to anecdote


3/48

July, 2007


4/48

January, 2008


5/48


6/48


7/48


8/48


9/48


10/48


11/48


12/48

Harvard, Breast Cancer in Developing CountriesNov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor


13/48

From anecdote

to evidence


14/48

1. Evidence to anecdote to evidence

2. Cancer in LMICs: so muchmore can be done

3. Breast cancer: global health priority

4. Applying the diagonal approach inMexico

OUTLINE:


15/48

Mandate: Design, develop andimplement global, regional andlocal strategies to improve the

financing, procurement anddelivery of cancer care,control, treatment and

palliation in a sustainablemanner applying innovativeservice delivery modelsappropriate to health systems

in the developing world.

Convened in Nov 2009By HSPH, HMS, HGEI, DFCI

27 membersrepresenting theglobal health andcancer

communities


16/48

Challenge and disprove themyths about cancer/NCD

M1. Unnecessary:

Not a health priority in LMICs/not a problemof the poor

M2. Impossible:

Nothing we can do about it

M3. Unaffordable: .for the poor

M4: Inappropriate: either/or

Challenging cancer implies taking resourcesaway from other diseases of the poor`


17/48

LMICS: More than 85% of pediatric cancercases and 95% of deaths.

Level ofIncome

Incidence Mortality Population

Low 21% 27% 20%

Low middle 50% 55% 57%

Upper middle 15% 15% 13%

High 15% 5% 10%

Distribution of childhood cancer globallyby level of income (< 15)

For children & adolescents 5-14 cancer is#2 cause of death in wealthy countries

#3 in upper middle-income#4 in lower middle-income

and # 8 in low-income countries


18/48

Lethality by cancer type and country income

Adults (15+)

Casefatalityapproximatedby

mortality/incidence

Breast

Cervix uteri Prostate

Testis

Hodgkin lymphoma

Non - Hodgkin lymphoma

Leukaemia

All cancers

0

0.2

0.4

0.6

0.8

1

Low income Lower middleincome

Upper middle

incomeHigh income

0

0.2

0.4

0.6

0.8

1

Low income Lower middle

income

Upper middle

income

High income

Source: Knaul, Arreola, Mendez. estimates basedon IARC, Globocan, 2010.

Children


19/48

Concentration of mortality:example Cervical cancer

Children orphaned by cervicalcancer

HPV Vaccine

Source: Paul Farmer., 2009

275,000 deaths worldwide; 88% in LMCs


20/48

Cancer is a disease of rich and poor

Yet, transition is polarizing the burden so that itis increasingly the poor who suffer:

Incidence and death: preventable cancers

Death: treatable cancer

Avoidable pain and suffering particularly at end oflife

Financial impoverishment from the costs of care andeffects of the disease

The cancer divide


21/48

IT CAN BE DONE: From evidence to action:Innovation Initiative Partnerships in LMICs

Treating cancer in LMICs usinginnovative delivery and financing: task sharing and shifting Infrastructure shifting Application of technology of

communication Social Protection and health insurance

Models: Low-income: Rwanda-Malawi-Haiti

Lower middle-income: Jordan

Upper middle-income: Mexico

ACCESS

QUALITY

FINANCIAL

PROTECTION


22/48

In developing countries, people withmultidrug-resistant tuberculosis usuallydie, becauseeffective treatment is oftenimpossible in poor countries.WHO 1996

MDR-TB is too expensive to treat in poorcountries; it detractsattention and resources fromtreating drug-susceptible disease.WHO 1997

Initial views on MDR-TB treatment, c. 1996-97



23/48

Outcomes in MDR-TB patients inLima, Peru receiving at least four

months of therapy

Mitnick et al, Community-based therapy for multidrug-resistanttuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

cured83%

abandon

therapy

2%

failed

therapy

8%

died

8%

All patients initiated therapybetween Aug 96 and Feb 99

Source: Paul Farmer, 2009

Drug % Decline inprice 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Making commoncause with WHO:

Reduced prices ofsecond-line TB

drugs


24/48

Rural Rwanda, Burkitts lymphoma


Regimen ofvincristine,

cyclophosphamide,

intrathecalmethotrexate

Status post-CHOPin Central Haiti:Still in remissionthree years later

Central Haiti

0o

ncolo

gists

OUTLINE


25/48


2. Cancer in LMICs: so much more can

be done

3.Breast cancer: global health

priority4. Applying the diagonal approach inMexico

OUTLINE:

M th lit


26/48

Myth .versus ..reality:

breast cancer in LMICs

a disease ofdevelopedcountries andwealthy women.

a disease ofolder women

less of ahealth prioritythan cervicalcancer.

More than half of casesand almost 2/3 of deathsdeaths occur in thedeveloping world.

large proportion of casesand 60% of deaths inwomen < 54.

More deaths and DALYslost to breast cancer, in alldeveloping regions otherthan SEAsia and SSAfrica.


27/48

In developing regions, breast cancer

Most frequent cause of cancer-related death in developingand developed regions

2-3rd leading couse

268,000 of the 458,000 deaths per year are in LIMCs: 58%

Most common cancer in developed and developing regions

4.4 million women alive (diagnosed): how many indeveloping regions?

2008: 1.38 million new cases; 50% of which are fromLIMCs

10.9% of all incident cancers second to lung

(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).

P l i k f


28/48

Africa

LMICs

Maternalmortality

APPROX: 210,000

APPROX: 360,000

Breast andcervicalcancer

67,885

75,893

=133,778

772,728

478,640

=1,251,368

People are at risk for manyreasonsvictims of success?

The opportunity to survive should not be an accident of


29/48

The opportunity to survive should not be an accident ofgeography or defined by income.

Yet it is.But . there is scope for action.

~casefa

tality(inciden

ce/mortality)

Source: Author estimates based on IARC, Globocan, 2008 and 2010.Quote: HRH Princess Dina Mired

Low-income

countries

Lower middle Upper middle High-income

countries0

20

40

60Breast

Cervix

48%

40% 38%

24%

63%

52%48%

37%

I LIMCS h hi h ti f


30/48

In LIMCS, a much higher proportion ofdiagnosis and death is in women 55

33%67%

66%

34%

Agea

tdiagnosis

Ageatdeath

20%


31/48

Mexico: key evidence

Since 2006 breast cancer is the #2 cause of deathamong women age 30 to 54 years; and the leadingtumor-related cause

In 2006, women between 30 an 65 years were morelikely to die of breast than cervical cancer. In 1980the risk of dying from cervical cancer was twice ashigh as breast cancer

Only 5-10% of cases are detected in stage 1 or in-situ, compared to approximately 60% in US.


32/48

Fuente:Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de mama en Mxico, 1979-2007.

FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretara de Salud de Mxico.

Mortality from breast and cervical cancer inMexico1955-2008: less death from cervical

2006: BC>CC.Por primera vez en ms de 5 dcadas.

Rate for100,000 womenadjusted for age

0

4

8

12

16

1955

1965

1975

1985

1995

2005

Breast cancer and


33/48

Breast cancer andSeguro Popular

As of Feb 2007 all Mexicanwomen diagnosed with breast

cancer have the right to financialprotection in health for breast

cancer treatment


34/48

Early Detection = survival

Stage at diagnosisSurvival rates,

US ACS

0 - 1 98%2 - 3 84%

4 27%

Fuente: American Cancer Society. Breast Cancer Facts & Figures, 2007-2008. Atlanta, GA. : American Cancer Society, Inc.,

y Secretara de Salud. Programa de Accin: Cncer de mama. Mxico, D.F.

Mexico: 5-10% in stage 0-1;60-70% in III-IV

Stage at diagnosis by level of municipal


35/48

Stage at diagnosis by level of municipalmarginacin, Mexico, IMSS 2006

(Mxico, IMSS 2006)

N=221(3.8%)

N=1737(30%)

N=2877(49.8%)

N=946(16.4%)

Source: Authors estimation based on IMSS data, 2006.

0%

10%

20%

30%

40%

50%

Poor (High) Middle Low Very low

Stage 1

Stage 2

Stage 3

Stage 4


36/48

Why?

Health, social and health

system barriers

Barrier 1: myth stigma and


37/48

br

Barrier 1: myth, stigma andmachismo

Barrier 2: Inequity in addition to lack of


38/48

0%

10%

20%

30%

+ Poorest

Q1 Q2 Q 3 Q 4Least poor

QV

16%

21% 22%24%

28%

Fuente: ENSANUT, 2006

Barrier 2: Inequity in addition to lack ofoverall access and utilization

Only 1 in 5women 40-69

report a

preventivehealth visitincluding

mamography2006


39/48

Barrier 3: Poor quality services

women diagnosed with bc reported problems withproviders when seeking diagnosis.

In routine, annual repro health/OBGYN visit/ PAP screening,

there was no BCE Physician insisted woman was overreacting and sent her

home with no diagnosis

Health professionals and first-level care providers report lack

of sensitivity of health personnel relating to the requests of

women regarding breast healthRESULTS FROM A NATIONAL QUALITATIVE STUDY NIGENDA ET AL, 2009

Barrier 4 Lack of financial protection


40/48

Barrier 4: Lack of financial protectionfor early detection.

Fuente: Groot et al, 2006. TheBreastJournal

Since February of 2007, every Mexican womanhas the right to financial protection (full healthinsurance) for the treatment of breast cancer.Seguro Popular de Salud

Yet, early detection is only covered for those

already insured

and early detection is unaffordable:

mammography, biopsy and pathology - at themost subsidized level in a public hospital -costs more than one month of subsistenceincome.

OUTLINE


41/48


2. Cancer in LMICs: so much more can

be done3. Breast cancer: global health priority

4.Applying the diagonalapproach in Mexico

OUTLINE:

The diagonal approach to


42/48

it has been discussed at length whatthe most effective approach is to deliver

health interventions: vertical programs orhorizontal programs. This is a falsedilemma, because both interventions

need to coexist in what could be called adiagonal approach

Seplveda et al., Aumento de la sobrevida enmenores de 5 aos: la estrategia diagonal

The diagonal approach tohealth system strengthening

A diagonal approach to women and


43/48

Horizontal Coverage: BeneficiariesWOMEN

A diagonal approach to women and

health and cancer care and control


44/48

1. Integrating breast and cervical cancer

screening into MCH, SRH2. Integrating disease prevention and

management into social welfare and anti-poverty programs

3. Catalyzing and employing community healthworkers and expert patients

4. Financial protection/insurance strategieswith horizontal and vertical coverage

5. Reducing non-price barriers to pain control6. Developing effective health services

research and monitoring

Diagonal approaches

ServiceP

latforms

HealthSy

stemsFunctions

Vignette: a series of Missed


45/48

Vignette: a series of MissedOpportunities: Juanita

left breast substantially larger than right;arrived at Morelos Womens Hospital bcshe could not move her swollen arm; fatherof children abandoned household at

diagnosis History Part 1:

- Age 42; 5 children aged 7-18; breast fed all

- Cartilla de la mujer: regular PAP and clinic visits

- Has Oportunidades attends regular community health platicas

History Part 2:

Felt a breast lump 4 years prior fear kept her from saying anything

Lump grew last year doctor at local clinic gave anti-b w/out BCE

Is entitled to Seguro Popular and free care

Cannot travel to Mexico City; seeking care locally; paying out of poc

M i H i th i l l f


46/48

Mexico: Harnessing the primary level ofcare for improving BC detection and care


47/48


48/48

Felicia Marie Knaul,

Harvard Global Equity Initiative, HarvardMedical School; GTF.CCCTomatelo a Pecho; Fundacin Mexicana para

PATH

March 15th, 2011Seattle, WA

Breast Cancer:

Unforeseen PublicHealth Priority inDeveloping Countries

Documents

Breast Cancer: unforeseen health priority in developing countries 150311