by ecancer reporter Clare Sansom

The global burden of cancer is becoming huge; worldwide, over sixty percent of all deaths are now attributed to non-infectious diseases, with a high proportion of these being due to cancer.

However, whereas these diseases are often thought of as “diseases of affluence”, by far the largest burden falls on those in low and middle-income countries.

Only a fifth of deaths from non-communicable disease occur in the most developed countries.

Furthermore, the prospects for a newly diagnosed cancer patient vary tremendously depending on where that patient happens to live.

The marked increases both in cancer cure rates and in life expectancy of people living with cancer that have been seen in countries such as the US in recent years have not been replicated elsewhere.

One very significant difference between the developed economies and the rest of the world in cancer care is in access to oncology drugs.

The average cost of a month’s treatment with a tyrosine kinase inhibitor or a monocloncal antibody – two of the most promising classes of drugs for cancer – ranges from about $5,000 to $10,000 per month of treatment: beyond the reach of all but the best-funded health systems.

The current debate over access to oncology drugs in the UK, with the seventh largest economy in the world, is another illustration of the intractable nature of this problem.

Gilberto de Lima Lopes Jr. from Johns Hopkins Singapore International Medical Centre, Singapore, and two colleagues from Brazil have now published a review in Nature Reviews Clinical Oncology in which they discuss how emerging economies are attempting to address this problem and suggest that worldwide action is needed for lasting solutions to be found.

Taking South-East Asia as an example, Lopes and his colleagues calculated the yearly expenditure per capita on a “basket” of modern oncology drugs to be $0.49 in Thailand and only $0.04 in Indonesia, compared to $6 in Singapore; the first two countries are both ranked as middle-income by the World Bank.

Many countries are taking effective steps to improve their citizens’ access to drugs, for example by setting up universal access to healthcare (most often via insurance-based systems); investing in generic and biosimilar drugs; and expanding their involvement in clinical trials.

A number of countries, particularly middle-income ones in Asia and Latin America, have introduced near universal healthcare systems in recent decades, although they have often struggled to implement these in full.

Furthermore, most countries in the world’s poorest continent, Africa, have not yet been able to introduce universal healthcare.

Drugs are expensive largely because of the patent protection that is rightly offered to companies to recoup the enormous cost of drug discovery and development.

Once a drug is out of patent protection, competition from non-branded generic medications will generally reduce its cost, and most studies have found little difference in effectiveness between generic and branded medications; interestingly, this is not always the case with oncology drugs.

The World Trade Organisation’s Trade-Related Aspects of Intellectual Property Rights agreement (TRIPS) agreement allows countries to issue licenses permitting the production of generic drugs while patents are still in force.

This agreement has increased developing countries’ access to generic copies of small molecule drugs on patent, and to “biosimilar” copies of biopharmaceuticals such as antibodies; it also tends to increase these countries’ bargaining power in negotiations with pharmaceutical companies over the price of branded drugs.

Clinical oncologists in middle- and low-income countries have been increasing their involvement in clinical trials, partly in order to gain access to experimental drugs for their patients.

Although this offers many advantages, there are also problems with issues such as oversight and informed consent, and trial participation cannot guarantee that the drugs will be made more widely available after the trials end.

There are now an increasing number of well funded international bodies that support the efforts of governments in lower income countries to improve access to healthcare, but these are mainly focused on infectious diseases.

Negotiations by the public-private GAVI Alliance, which promotes vaccination, have been able to reduce the cost of the hepatitis B and HPV vaccines that protect against liver and cervical cancer respectively in many countries.

Despite these important developments, much remains to be done to improve cancer care in low and middle-income countries.

In conclusion, Lopes and his co-workers propose that a global fund be set up to fight cancer in these countries, along similar lines to the Global Fund to Fight AIDS, Tuberculosis and Malaria , as the best way of reducing mortality due to cancer in these countries.

The authors invite readers to post comments and suggestions on this proposal to the Cancer Control in Low and Middle Income Countries webpage .

Reference

Lopes, G.L. Jr, de Souza, J.A. and Barrios, C. (2013). Access to cancer medications in low and middle-income countries. Nature Reviews Clinical Oncology, published online ahead of print 9 April 2013. doi: 10.1038/nrclinonc.2013.55