by ecancer reporter Clare Sansom

Cancer has traditionally been associated with developed countries and “Western” lifestyles, but the burden of the disease in less developed regions of the world is large and growing.

The GLOBOCAN 2012 project from the International Agency for Research on Cancer estimated that about 57% of incident cancer cases and 65% of deaths from cancer now occur in countries in less-developed regions (LDCs).

Two comprehensive perspectives recently published in Nature Reviews Cancer suggest strategies for cancer screening and prevention and for treatment of cancer patients in resource poor environments.

The first perspective, by Aditi Shastri of the Albert Einstein College of Medicine, New York, USA and Surendra Srinivas Shastri of the Tata Memorial Centre, Mumbai, India, surveys the prevalence of preventable cancer types in less developed countries and discusses cost-effective methods for screening and prevention.

Cancers of the liver, stomach and cervix, which are associated with infectious agents, have considerably higher incidence in LDCs than in Western countries, and these countries are now seeing increasing numbers of cases of the so-called “lifestyle” cancers including breast and lung cancer.

Screening for breast cancer using mammography, and for cervical cancer using the PAP test, are impracticable in LDCs due to lack of skilled manpower and resources.

Tobacco is now heavily marketed in LDCs and the habit is common in many such countries, with the highest prevalence of 53% recorded for males in China.

Strategies to control tobacco use, particularly increasing taxes and establishing smoke-free areas – have had positive effects on smoking prevalence and cancer deaths in many developed countries.

Similar strategies are now being applied in some LDCs, including in India through (for example) the Smoke-Free Mumbai Campaign, and there is scope for these to be adopted more widely.

Physical breast examination by a trained healthcare professional is a cost-effective alternative to mammography screening for breast cancer that can be as effective in the early detection of breast cancer.

It also has the advantage of being more effective in the younger age groups, which is important in LDCs, and its use there should be considered more widely.

Several cost-effective alternatives to the Pap smear test for cervical cancer have been tested in clinical trials in LDCs, with some encouraging results.

Shastri and Shastri recommend several strategies for adoption in different settings, including a single DNA test for HPV infection and visual inspection of the cervix following application of acetic acid.

Girls should also be vaccinated against HPV-16 and HPV-18 wherever this is affordable.

Finally, hepatitis B vaccination and general precautions for prevention the transmission of blood-borne infections were recommended as strategies for controlling liver cancer.

The second perspective, by Lawrence Shulman of Dana-Farber Cancer Institute, Boston, MA, USA and colleagues in the US and Rwanda, discussed the challenges of cancer care in LDCs with particular reference to Rwanda.

The enormous advances in cancer treatment and consequent improvements in survival over the last half-century have not yet reached patients in LDCs, so these countries report survival rates that are reminiscent of those in the US 50 years ago.

Cancers are also detected later in these countries, so the chance of a cure is reduced, and many patients die with tumours still undetected.

Shulman and his co-authors argued that rolling out proven diagnostics and treatments to cancer patients worldwide would have a greater effect on cancer mortality statistics than more innovative treatments.

Cost has frequently been cited as a reason for not pursuing a more aggressive cancer treatment strategy in LDCs, but there has been little research into cost-effective cancer treatments in these countries.

Rwandan governments have invested heavily in healthcare infrastructure since the genocide of the 1990s, with some significant successes including a HPV vaccination programme that now reaches over 90% of teenage girls.

Unfortunately, however, resources for cancer care there are limited, as they are throughout sub-Saharan Africa, and incidence is under-estimated because many patients do not even seek care.

In 2012, Rwandan President Paul Kagame and former US President Bill Clinton launched a programme to increase the number of trained health workers, including oncologists and specialist nurses, in the country.

A partnership between experts in Boston, USA, the Rwandan Ministry for Health and a healthcare HGO has established the Butaro Cancer Center for Excellence (BCCOE) to bring cancer care to a rural district hospital.

Rwanda only has two oncologists, and it will not be possible to train enough to cover the whole population; consequently, care at the hospital is provided by generalist doctors with phone and email support from US-based oncologists.

Protocols have been established for the treatment of cancers that are commonly observed in the region.

Rwandan doctors who were trained during the first sessions have now taken over much of the training of their colleagues from foreign experts.

Access to both anti-neoplastic drugs and drugs for palliative care can be poor, and there is currently no radiotherapy equipment in Rwanda.

Patients requiring radiotherapy are currently sent to neighbouring countries, and there are plans to build a facility in Rwanda; the country’s experience with anti-retroviral drugs shows that problems of drug access can be solved.

Some cancer care is also now being provided in the community through Rwanda’s network of community health workers, based in villages.

These partnerships have already led to significant improvements in cancer care in Rwanda, although implementation research will be necessary to analyse the results of each part of the strategy and improve policy further.

References

1. Shastri, A. and Shastri, S.S. (2014). Cancer screening and prevention in
low-resource settings. Nature Reviews Cancer, published online ahead of print 30 October 2014. 

2. Shulman, L.N., Mpunga, T., Tapela N., Wagner, C.M., Fadelu, T. and Binagwaho, A. (2014). Bringing cancer care to the poor: experiences from Rwanda. Nature Reviews Cancer, published online ahead of print 30 October 2014.