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Cancer Control in Low and Middle-‐Income Countries: Key messages
Hellen Gelband *, Rengaswamy Sankaranarayanan *, Cindy L. Gauvreau *, Susan Horton *, Benjamin O. Anderson, Freddie Bray, James Cleary, Anna J. Dare, LyneJe Denny, Mary K. Gospodarowicz, Sumit Gupta, ScoJ C. Howard, David A. Jaffray, Felicia Knaul , Linda Rabeneck, Preetha Rajaraman, Terrence Sullivan, Edward L. Trimble, Prabhat Jha *
for the DCP3 Cancer Authors Group
* Editorial Team
DCP3 Cancer Authors Issac Adewole, Hemantha Amarasinghe, Benjamin O. Anderson, Federico G. AnTllon, Samira Asma, Rifat Atun, Rajendra A. Badwe, Freddie Bray, Frank J. Chaloupka, Ann Chao, Chien-‐Jen Chen, Wendong Chen, James Cleary, Anna J. Dare, Anil D’Cruz, LyneJe Denny, Craig Earle, Silvia Franceschi, Cindy L. Gauvreau, Hellen Gelband, Ophira M. Ginsburg, Mary K. Gospodarowicz, Thomas Gross, Prakash C. Gupta, Sumit Gupta, Andrew Hall, Mhamed Harif, Rolando Herrero, Susan Horton, ScoJ C. Howard, Stephen P. Hunger, Andre Ilbawi, Trijn Israels, David A. Jaffray, Prabhat Jha, Newell Johnson, Jamal Khader, Jane Kim, Felicia Knaul, Carol Levin, Joseph Lipscomb, W. Thomas London, Mary MacLennan, Katherine A. McGlynn, Monika L. Metzger, Raul Murillo, Sherif Omar, Krishna Palipudi, C.S. Pramesh, You-‐Lin Qiao, Linda Rabeneck, Preetha Rajaraman, Kunnambath Ramadas, Chintanie RamasundaraheZge, Timothy Rebbeck, Carlos Rodriguez-‐Galindo, Rengaswamy Sankaranarayanan, , Isabelle Soerjomataram, Lisa Stevens, Sujha Subramanian, Richard Sullivan, Terrence Sullivan, David Thomas, Edward L. Trimble, Joann Trypuc, Judith Wagner, Christopher P. Wild, Pooja Yerramilli, Cheng-‐Har Yip, Ayda Yurekli, Witold Zatonski, Ann G. Zauber, Fang-‐hui Zhao
Conclusions • Cancers in LMICs set to grow as % of global total and as % of
all deaths – Cancer death rates <70 fell 9% in last decade in LMICs (less than in high income countries)
• An ‘essenTal package’ of cost-‐effecTve cancer intervenTons would cost ~ $1.5, $1.6 and $5.1 extra per capita in low-‐income countries, lower-‐middle income countries, and upper middle-‐income countries, respecTvely – Total cost of about $18 billion/year or < 3% of public spending on health in LMICs (but more in poorest countries)
– Tripling tobacco excise tax would cut smoking prevalence by a 1/3 and raise extra $100 billion
• Global support to lower costs for inputs; expand technical assistance; and research
DCP3: Audience and methods Audience: • DCP1-‐ 1993: World Bank (WDR 1993) • DCP2-‐ 2006: Global communiAes of pracAce • DCP3-‐ 2015-‐17: Ministries of health/finance; communiAes of pracAce, and aid agencies
Methods: 2.5 year project • ~75 Authors, 4 editors, 19 countries, 17 chapters • 3 review meeAngs, IOM independent review • Support: Gates FoundaAon, NCI, IARC and CIHR • Feb 9th Lancet launch (NCI+IARC), plus online chapters, book to follow
Framework to design essenTal cancer package
Disease Burden
Cost- Effectiveness
Feasibility of Scale-up
Essential cancer package
Cancer type Male Female Both Lung 537 222 759 *
Other tobacco 446 195 641 *
Liver 343 125 468 +
Stomach 247 126 373 +
Breast -‐ 344 344
Colorectal 175 132 307
Cervix 225 225 +
Prostate 68 0 68
Other cancers 686 617 1,303
TOTAL 2,504 1,987 4,490
Cancer deaths before age 70 years worldwide, 2011
*Tobacco (31%) + InfecTon (24%)
Male Female
All cancer 8.0 6.0 Tobacco-‐a^ributable 3.0 1.1 InfecAon-‐a^ributable 1.9 1.5 Other cancers 3.3 3.6
Probability of dying from cancer <70 years, 2011, World
Absolute numbers of cancer incidence and mortality before age 70 Years
GLOBOCAN 2012
• In high-‐income countries, 2/3 of cancer paTents survive
• In LMICs, only 1/3 do
10793
46
107
64
43
0
20
40
60
80
100
120
Illiterate Primary Above secondary
Educational level
Ag
e-s
tan
dard
ised
death
rate
(p
er
100,0
00)
Men
Women
Age-‐standardized cancer death rates, ages 30-‐69 Years, by educaTon level, India
Dikshit and others 2012
“Resource-‐appropriate” intervenTons (from BHGI)
1 10 100 1000 10000
§§ HPV vacc @$15/girl LICs COST SAVING
ǂǂ Cervical cancer screen VIA COST SAVING
¶ Tobacco taxes LICs
†† Auto-‐disable syringe (prevent Hep B, C)
** HepaAAs B vaccinaAon LICs
¶ Tobacco comprehensive measures LICs
ǁ HPV vaccinaAon @$50/girl MICs
† Treat breast cancer MICs
§ Treat CRC LICs
ǂ HPV vaccinaAon @$240+/girl
† Screen and treat breast cancer MICs
* Screen and treat breast cancer LICs
* Treat breast cancer LICs
Cost per DALY averted US $2012 Range
Cost-‐effecTveness of selected cancer control intervenTons
Various sources
Cervical cancer: reduce deaths by 80% with screening and vaccinaTon
Source: Sankaranarayanan 2012
Quality maJers
165
EffecTve intervenTons at a range of prices: childhood ALL treatment
Cost Per Child, $
Survival
0 100 1,000 10,000 100,000 0%
100%
50%
HIC = >90% survival for >100,000$ 50% survival for >50$
IntervenTon Low-‐income Lower middle-‐income
Upper middle-‐income
Comprehensive tobacco control 0.05 0.07 1.06
HBV vaccinaAon 0.08 0.04 0.04 Screen and treat cervical cancer 0.26 0.29 0.87 HPV vaccinaAon 0.23 0.23 0.40 OpportunisAc screening and treat early stage breast cancer
0.44 0.39 1.30
Treat selected paediatric cancers below age 15 years
0.03 0.03 0.09
Screen oral cancer and treat early stage disease in some countries
0.11
PalliaAve care and pain control 0.05 0.06 0.06 Subtotal 1.14 1.22 3.82 Cancer system strengthening (33% of subtotal)
0.38 0.40 1.26
TOTAL COSTS 1.52 1.62 5.08
Approximate marginal per capita costs (in 2013 US$) of essenTal cancer intervenTon package
World Bank Economic Category
Pop in millions, 2013
Required amount for cancer in 2013 US$ (billions)
Cancer package as % of total public spending on health in 2013
Low-‐income 849 1.3 12.1%
Lower middle-‐income
2561 4.2 4.7%
Upper middle-‐income
2409 12.2 2.3%
Low-‐ and middle-‐income*
5819 17.7 2.8%
Resource requirements for essenTal or augmented package for LMICs
DomesTc finance is key EssenTal cancer package: • Covers about 5.8 billion people, address 3.2 million cancer deaths <70 years
• Costs as % of public spending: 2% in upper MICs; 5% in lower MICs, but 12% in low-‐income countries (3% in all LMICs)
• Growing per capita income will make more money available
• Some funding possible from tobacco taxes
InternaTonal support Currently only 1% of $30 billion in global developmental assistance for NCDs including cancers Three major prioriTes: • Lower costs of key inputs
– Large scale purchasing, global negoAated prices • Technical assistance
– Formalize communiAes of pracAce (radiotherapy or childhood cancer working groups)
• Research
Research Currently $6 billion at NCI/CRC UK alone Four major prioriTes: • Burden
– Expand and improve registries, representaAve cause of death data (Indian Million Death Study)
• ImplementaAon science • Epidemiology and biology • Economics (cosAng)
Deaths in 2010 (millions)
Change between 2000-‐10
All cancer 3.2 -‐9% (13% in HIC) Tobacco-‐a^ributable 0.8 -‐9% InfecAon-‐a^ributable 0.7 -‐15% Other cancers 1.8 -‐8%
Cancer deaths and change in death rates <70 years, 2000 and 2010, LMICs
Can cancer death rates <70 years be reduced by 1/3 by 2030 in LMICs?
• 2000-‐2010 decline of 9% per decade • If this rate of progress conAnues, then by 2030 cancer deaths will be 17% lower vs 2010 (i.e. 0.91*0.91), and 32% lower by 2050 vs. 2010 – Cancers due to tobacco falling less fast then those due to infecAon (e.g. cervical cancer which fell 17% per decade)
• Rate of progress needed to achieve 1/3 reducAon by 2030 is 19% per decade
Main causes of trends in recent decades 35-‐year risk (%) Lung: cigareJes Colorectal: treatment Stomach: Unknown
UK male cancer mortality trends at ages 35-69, 1950-2007: selected sites
Source: Peto, 2012
UK female cancer mortality trends at ages 35-69, 1950-2007: selected sites
Main causes of trends in recent decades 35-‐year risk (%) Breast: treatment Lung: cigareJes Colorectal: treatment Uterus: screening Stomach: Unknown
Source: Peto, 2012
Reasons for opTmism? 1. Tobacco control (esp. higher taxes)
possible even with industry opposiTon (FCTC)
2. GAVI and vaccine expansion 3. Affordability: $18 billion affordable except
in poorest countries 4. Various pathways for universal health
coverage 5. Experience from HIV/TB/malaria/vaccines
to “bend the cost curve”
Conclusions • Cancers in LMICs set to grow as % of global total and as % of
all deaths – Cancer death rates <70 fell 9% in last decade in LMICs (less than in high income countries)
• An ‘essenTal package’ of cost-‐effecTve cancer intervenTons would cost ~ $1.5, $1.6 and $5.1 extra per capita in low-‐income countries, lower-‐middle income countries, and upper middle-‐income countries, respecTvely – Total cost of about $18 billion/year or < 3% of public spending on health in LMICs (but more in poorest countries)
– Tripling tobacco excise tax would cut smoking prevalence by a 1/3 and raise extra $100 billion
• Global support to lower costs for inputs; expand technical assistance; and research
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