Closing the cancer divide: Implementing the diagonal approach

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Published: 19 Apr 2013
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Dr Felicia Knaul - Harvard Medical School, Boston, USA

Dr Knaul, a health economist and patient, talks to ecancertv at the annual AACR congress, Washington DC, 6-10 April 2013, about the costs of the worldwide cancer burden. 

Economics can be a factor but also social factors such as over regulation of pain alleviating drugs, and up to date training in less economically developed countries.

Dr Knaul calls for improved cancer care at the most basic level in developing countries.


An editorial with some highlights of the meeting is available to read for free in ecancermedicalscience.

AACR Annual Meeting 2013

Closing the cancer divide: Implementing the diagonal approach

Dr Felicia Knaul – Harvard Medical School, Boston, USA

Felicia, you’ve been taking part in a talk here at the AACR on developing countries and the crisis that there is. I think that there are quite a few aspects to this because prevention is also treatment as well, isn’t it?


And management of cancer. So there’s a cancer divide; you’re well-known for your work at the Harvard Global Equity Initiative on working on cancer divide, this is a geographical divide. What is the big point? What’s your big worry about the differences in cancer all over the world?

Well first I think it’s something that’s little known that cancer is also a disease that strikes the poor. So today cancer is a disease of both rich and poor countries and individuals, but more and more, and unless we do something about it this will be increasingly the case. The suffering associated with cancer that is preventable is going to be exclusively of the poor and that is both in terms of risk factors, things like smoking, preventable cancers like cervical cancer, treatable cancers like breast cancer or most cancers in children and pain and palliation as well as the stigma that could be prevented with survivorship.

What is lacking, though, is motivation to take care of the poor, isn’t it? Because people think that so what? Maybe it’s just too bad but we can’t handle all this volume.

There’s that piece of it and I think we even saw some of that in the conference. What I wish is that we could tell the cancer community that where we can see huge payoffs in terms of life saved is by doing something in developing countries for the poor who suffer these diseases.

Is this altruism, though, or is there a gain for the country?

Both, and also for the world. Often I think the work that we can do, the sort of research that we can undertake around implementation could be very useful for how we treat patients in countries like the United States, Canada or in Europe. Second, we will learn things from the diversity that we have to see in order to do good science, that will benefit all. But third, and perhaps most importantly, there is no reason, at least in my mind, that we should think that the life of a poor person is worth less than the life of a wealthy person in any sense, and that’s really the equity part of this, the equity imperative of the cancer divide.

Right, you’re an expert in health systems and you’ve actually done some calculations of the financial benefits and there do appear to be real financial gains.

Absolutely. So according to our calculation, cancer costs between 2-4% of global GDP per year; something like tobacco an additional 3.6% is lost every year because of spending on tobacco and consumption of tobacco. The costs of inaction are huge because in addition to those fixed costs, shall we say, of the disease itself on the people that get the disease, all of the investments that we make in many associated areas like education are impoverished by not doing something about cancer.

So you educate someone but they die of cancer?

Exactly. Or we have a young mother who has not died in childbirth and has several young children and dies from a preventable cancer like cervical cancer. It was a failed investment all the way along because she died much earlier leaving orphan children.

So people are more productive if they don’t get cancer.

People lose those years of productivity, particularly children, and it’s that that’s the payoff, we know. So we believe, from the numbers we have calculated, that investing in prevention in certain aspects of treatment could have a payoff of between about $130-950 billion a year.

Now dying with cancer is one thing but also cancer treatment requires medication to control pain and quality of life is different. There’s a divide there as well, I understand from your research?

I believe the most insidious of the divides. So we looked at consumption of non-methadone opioids for HIV and cancer death in pain using data from UICC and the American Cancer Society among others. And it turns out that in the poorest 10% of countries in the world the consumption is very close to zero, about 54mg.

What’s the reason for this?

The reasons are basically associated with over-regulation and mis-information. These are the same drugs that are often traded illegally and so there are huge and rather archaic ways of managing that. The issue here is not price. The other is that by solving this for cancer we would solve this for so many other issues – surgical platforms as well as other diseases.

So if you can get pain management introduced, what actually do you have to do to get rid of those myths and overcome the prejudices about using good pain management?

There are several things. First we know that most physicians are not trained in pain management; there are very, very few. And that is something that requires effective training, to be able to alleviate pain with the drugs that are available. But second, these physicians need ways to be able to manage the drugs to get them to the patients, not interventions that stop them from being able to get access to the drugs. And third, we need to move this access to places where the patients are. Asking a patient who is dying in pain from cancer to travel eight or ten hours on a bus to get access to needed pain control is just not thinkable.

OK, we leapt onto pain control but treatment, of course, comes in the middle of all of this and the biggest cancer divide, or one of the really big ones, is the availability of good treatments which vary enormously depending on which part of the world you live in. What can be done about that?

First I think that we can actually leapfrog. That’s where I think that we can innovate in delivery in ways that would be helpful for a place like the United States, Canada or Europe. We can innovate in delivery in the sense that we can bring much of the care today for cancer much closer to the patient by having access to some of the novelties, like Herceptin or trastuzumab, which does not have to be delivered in a hospital and could be delivered much closer to where a patient lives.

So more rational systems of how you get your therapy, then?

And cheaper too, and closer to the patient.

So what is the message, then, for cancer clinicians coming out of your deliberations here in Washington DC?

I think the message for cancer clinicians is very clear. We, or they, do their business in order to try to save people’s lives from dying with cancer. Well they could save literally tens of thousands of lives every year by guaranteeing that in developing countries some of the most basic kinds of treatments were more available.

Really basic, in fact, you’ve got a couple of publications because Closing the Cancer Divide, that’s a book you published quite recently as a result of a lot of discussions with colleagues as well. But from your own experience, you’ve looked at breast cancer, Beauty without the Breast.


You have the experience of living in two different parts of the world, Mexico and the United States, what’s the motivation for this book and what are you saying here?

And actually also born in Canada, so in addition. So Beauty without the Breast is my story, diagnosed at age 41 with no reason to believe that I would have gotten the disease. I diagnosed with breast cancer, invasive breast cancer, in a small clinic in Cuernavaca, Morelos, Mexico. I was treated in Mexico, my treatment was designed from the Seattle Cancer Care Alliance but it was 90% applied and implemented in Mexico. I had excellent access to all the care that was required and I’m incredibly grateful for that. But this is the story of how a health economist, which is how I was trained, a health systems expert, moved through the health system as a patient. But it’s also the story of how the wife of the former Secretary of Health of Mexico, my husband Julio Frenk, who had just implemented a health insurance programme that would then cover 50 million people and offer full treatment coverage for breast cancer for other women; those women that were the other side of the street who, before that, had not had access to the same treatment I had.

So national services, the availability of comprehensive medical services, could be an important key?

Without any question, and the financing of those services. We’ve seen several countries around the world, developing countries, not only Mexico, innovate by including cancer treatment as well as prevention and palliation into national insurance programmes for the poor.

Now that’s all quite a hot issue, even right here in the United States at the moment, providing health services, how can you defend this? Is it purely altruism or do you come back again to the hard facts you’ve discovered about economic benefits too?

I would absolutely come back to that. We’ve seen young women saved and, in fact, we have a tremendous case of a young woman who has told her story, who was resident in the United States legally, forced to leave because she was diagnosed with breast cancer and denied care, went to Mexico, was cared for through the Seguro Popular and the public hospitals, and is now doing very well and a tremendous advocate globally for the need to insure women, and others, against cancer.

Of course medical care is one thing but in prevention you need national campaigns which are essentially political and out of the hands of the doctors, whether you discourage smoking or pass regulations about certain diets. How do you instigate those which, I think, you’re suggesting are at the heart of reducing the burden in many less developed countries, preventing cancer at source? How do you encourage doctors, medical professionals and lay people to get this whole thing moving?

Two answers: one, is we need to continue to speak to the policy makers, and not just health policy makers, also economic policy makers. So this is the sort of dialogue we encourage, the Ministers of Finance in the countries.

What are the key targets, do you think right now? 

In terms of the cancers?

Prevention, yes.

Prevention? Also certain population groups. Children’s cancers which are typically not about prevention, except in the case of Burkitt’s Lymphoma which is communicable of origin, infection associated cancer in that case, but all the other children’s cancers are not actually associated with an infection and they are treatable in many cases. So we can see a 90% survival rate for children with acute lymphoblastic leukaemia in Canada and 10% in the 25 poorest countries of the world.

Then in adults there are known causes?

In adults there are known causes that are associated with prevention, again many associated with infection. We need the HBV vaccine, we need the HPV vaccine, we need the tobacco, the anti-tobacco, we need the work on nutrition without any question. But that doesn’t mean not treating those cancers like breast cancer where we know that treatment can generate cure. And these are messages to share with the policy makers. There are also reasons for helping people to understand if they have cancer and undertaking awareness programmes and also prevention campaigns.

So what’s the bottom line you’d like cancer clinicians to take home from your message here in Washington DC?

The first is how much we can gain by applying all the knowledge we have in other populations, the knowledge that they have and that they’ve developed and that they know how to apply. And the second is by learning how to integrate these innovative models for delivery into health systems in developing countries, we can not only save those lives but also bring lessons back to the United States, Canada, Europe and others.

Felicia, thank you very much, good to see you.

Thank you very much for the interview and for all you’re doing for those of us who live with cancer.