At the press conference we presented a new initiative between WHO and ASCO to work on quality of cancer care globally. We were presenting this as a new initiative focussing on how to improve quality of care for cancer patients globally. The focus of the partnership is how can we work at the facility level and identify areas where there are current quality of care gaps as it pertains to how services are being provided, the types of treatments that are being received and the overall experience of those that are receiving cancer care in those facilities.
The uniqueness of this relationship is that we are able to take what happens at a hospital level and also translate it into a national dialogue. So what responsibilities not only does a hospital have, but policy makers, programme managers and community actors to address quality of care gaps at a facility level.
What practical steps can be taken to impact cancer patient outcomes?
We know already that there are major quality of care gaps. If we take the same patient with the same type of cancer, same stage of diagnosis, there are variations in outcomes that can be as significant as 10-20% overall survival difference. This is massive. On the order of treatment that we know, this would be considered a game changer as it pertains to new interventions in cancer therapies. So what is responsible for that gap? This is what we’re working to figure out.
There are a variety of factors, there’s not one simple reason. It could be that people are abandoning therapy, the cost of cancer is too high or they live too far away and they have to get back to their family. Those are problems that we can identify and address as a community. So what are the interventions that we, working at all levels – hospitals, civil society, national governments – can do to address some of those common reasons that explain the variations in cancer outcomes.
Treatment completion, in fact, there’s a huge amount of literature that is being developed – scientists, academicians are helping us understand how do we unpack that. It can be something as simple as housing – can we provide housing for people with cancer that have to travel to a capital? Because if they are able to be there with their families, if their families can support them during the process, then they’re more likely to stay. If they have to pay for housing out of pocket and they are unable to manage that for a prolonged period of time they have to make a difficult economic decision for that family. So there are interventions that once we are able to describe and present it then we can get the right stakeholders involved. Because the question always raises – whose responsibility is it? Of course, the immediate answer is it shouldn’t be the hospital, it shouldn’t be the providers, someone else should pay for the housing. But that has to be seen as part of the broader package of what it means to have cancer. It impacts the individual, it impacts the family, it impacts the community and there are solutions out there. So how do we present that to a way in which we describe the problem and help with the solution. The problem is we’re investing a lot of time and energy to care for people with cancer but if they don’t get the best possible outcome everyone loses.
Where could the money come from for cancer treatments?
There’s always the question; we all know that budgets are limited, many governments are going through budget crises after the pandemic, it’s a difficult challenge – where is the money going to come from? So the starting point when we work with governments is efficiencies. We know that asking for more money is not easy. We meet with them one day, the next day a different programme comes, the mental health team comes and says, ‘You need to invest more in mental health.’ Obviously very important. We’re not in a game of competitions. The assumption is that investing in medicine or investing in health is a zero sum game, it’s not. There are ways that we can justify why investments in health are necessary but we have to make that argument at every level – when we meet at a hospital level, when we meet with governments.
So how do we create efficiencies? Let’s start by looking at where’s money being spent. If we can identify where are areas that we could potentially save or de-implement programmes that aren’t having an intended impact then we can reallocate those funds to a different necessary source. Then of course there are stakeholders in a community. If we can justify something like the Ronald McDonald house, there are actors out there that want to support the goodwill that happens when someone is affected by cancer. So there are multiple sources by which we can generate the funds but we have to be able to describe the problem and this is where the relationship with ASCO is starting. How do we describe the problem so that we can present what those solutions are and the consequences, the value, of investing in that area?
So it’s multiple – how do we improve efficiency, how do we generate new sources of revenue or income and then how do we support implementation and show success so that when we look back we can present to other countries in the area, other stakeholders. This is what was done in this country, look at the impact – improved survival, overall benefit for the population, it’s the right investment to make.
What is the WHO stance on tobacco control?
Tobacco control remains one of the major focuses for WHO and, frankly, for all cancer actors. When we ask where are the primary contributors of cancer there is a current narrative that of course everyone fears that everything causes cancer but that’s not the way to present it. The responsible agents for what causes cancer, tobacco is number one and has been number one for decades. So tobacco is responsible for about 25% of all cancer deaths. 25% of all cancer deaths. This is an incredible number.
When we start to break down, then, how do we address tobacco control there are a variety of ways that we are always trying to respond and address. The challenge has been what avenues do we use. At WHO there is a Framework Convention for Tobacco Control. This is an agreement that we have with governments around the world on how we’re going to implement programmes to address the tobacco control issues – policy, regulatory issues, how do we address tobacco cessation, how do we educate populations. There are multiple potential interventions, a lot of them are tailored to the country context, but universally there are interventions that governments should take on.
This is presented in what is called the MPOWER package, the idea that we empower populations, we empower governments to take necessary steps to address the tobacco epidemic. This epidemic is impacting our lives in ways we can’t even begin to describe. So how do we, as the cancer community, then act as the greatest catalyst for taking on these policy, regulatory and behavioural changes that are necessary to address the tobacco epidemic that we have?
How do we fight against tobacco companies?
These are what we are now grouping as the commercial determinants of health. So tobacco is one of the primary ones that we focus on in these commercial determinants. There are billions of dollars being invested for people to use tobacco and how do we fight when, as you said, money isn’t growing on trees. So what we obviously have to do is start with what’s the right narrative, craft the guidance, prove the evidence and then deliver at the country level.
Tobacco control has decades of that history of building the narrative, identifying the interventions. When we do it by analysing how many of the governments have implemented the MPOWER package, some of the key interventions that we ask for them to prioritise, we do see progress over time. More and more countries are implementing the core interventions that are linked to the MPOWER package. It takes time; there are, as you said, commercial reasons why governments don’t take it on, both for internal and external influences. The value of the cancer community having the voice that we do is to draw attention that we should not be having these decisions in close quarters, we should have them in the day, in the light of day, and draw attention to the fact that these commercial determinants are harming populations on the order of magnitude of, again, hundreds of millions, a billion deaths per year. This is really catastrophic.
How are the WHO addressing lifestyle changes associated with westernisation in LMICs?
Another thing to understand is the answer to the question why are cancer cases increasing. A very common question that we have with governments, with stakeholders. One of the reasons cancer cases are increasing, in fact the primary reason, is because people are living longer. This is a success of public health. As people live longer the likelihood of developing cancer increases over time and that contributes to the overall total number of cases that are increasing in countries.
The way we try to analyse what are responsible for driving individual cancer cases is to look at the risk factors, to identify other causes of cancer that we haven’t yet been able to describe. When we look in low and middle income countries we do see what are traditionally considered high income country lifestyle choices that are influencing the cancer rates or risks in those populations. To some extent that’s very much true. But, again, the largest driver of the cancer burden currently are life expectancy changes and overall population growth.
As it pertains to what is happening with individual risk factors, you’re absolutely right. Obesity and physical activity, or physical inactivity, are priorities that we have to put onto the agenda. It should not negate from tobacco being a primary focus and tobacco use in low and middle income countries remains a major problem. But we should already anticipate how do we address these emerging risk factors – obesity, physical inactivity and also other broader environmental exposures like air pollution which is also harming many in low and middle income countries. Alcohol use is another common one. These are the four risk factors that are responsible for about 5-7% of cancer each.
In addition, what we see is improving in low and middle income countries is infectious causes of cancer. This is an area we can’t take our eye off because in high income countries we’ve enjoyed tremendous benefits, whether it’s hepatitis B vaccine, now HPV vaccine as a high priority. These are infectious related causes of cancer we can address, we can address today, address the cancer burden for decades ahead. Others come because of improved sanitation; helicobacter pylori responsible for gastric cancers is another primary cause of cancer globally. When we look in high income countries significant progress – gastric cancer coming down as a cause of death saving millions of lives.
So how do we balance all these prevention priorities? Again, work at the country level – what are the primary cancer burdens? What is increasing in your particular country? Obesity we know, you’re absolutely right. Nearly every country around the world is seeing increases in obesity rates. What is it that we do? At the WHO side we present what is called Best Buys. So these are the policy and programmatic interventions that governments can take on to address risk factors, not only in cancer but for all non-communicable diseases. We’ve presented that if we, in fact, make these investments today we can have a return on those investments of eight-fold, save millions of lives in the years ahead and avoid the population harms that you described.