The big debate: Where to spend scarce resources

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Published: 12 Dec 2016
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Dr Lawrence Shulman - University of Pennsylvania, Philadelphia, USA

Dr Shulman speaks with ecancertv at the 2016 World Cancer Congress about the conference debate session, in which he was cast in opposition to spending resources only on cancer prevention in low income countries.

In his role of providing a counterpoint, he highlights how many treatable diseases occur in children, and the likelihood of disease in later life that could not have been prevented.

His final point is the economic disparity inherent in recommeding a preventative-only regimen in low-income countries, and that unpreventable diseases need not be terminal.

Earlier this week we had a big debate on whether scarce resources in poor countries should go only to cancer prevention, things like tobacco control, and HPV vaccination or hepatitis B vaccination or control of obesity. Or should some of those resources go to the treatment of cancer patients. And I was assigned to support the point of view that we should use some of those resources to treat patients and I truly believe that. I am a strong believer in prevention, I think tobacco has so many ill effects, not only cancer-producing like lung cancer and head and neck cancer, but increasing the risk of cardiovascular disease and other complications. So I think we do need to make major efforts in that, I do think we do need to vaccinate young girls and boys for HPV vaccine and with hepatitis B vaccine; I do think we need to control the obesity epidemic.

But we can do more and, as was the case with the HIV epidemic in the early 2000s, it wasn’t an either/or thing. At that time the treatment of HIV was very expensive, we were able to drive drug prices down and we showed that we could effectively treat millions of HIV infected patients in Africa, reduce the death rate, and in fact that strengthened their efforts at prevention. We would say that treating cancer and doing prevention together is a more sound goal and path than just doing prevention.

There are a couple of things that I think are important to note. One is that children with cancer in the US, or in France would have an 80% cure rate. None of those cancers are preventable and if we don’t treat cancer patients then we are turning our backs on all the children who have potentially curable diseases and I don’t think that’s really an acceptable humanitarian approach. The other thing that I would say is that even if you consider a third of cancer is preventable, which is what the current estimate is, that means two thirds of cancer patients who don’t have preventable cancers, again, are being left out in the cold.

There is another way to look at this which is that in wealthy countries like France or the US cancer care, cancer treatment, is widely available to the entire population. We’re really only talking about the poor parts of the world. So if you say that in those parts that we’re only going to put our resources towards prevention what that means is that worldwide patients who are wealthy or live in wealthy countries will have access to cancer treatment and it’s only going to be the poor patients in places like Rwanda and other poor countries who will be denied cancer treatment. When we think about health equity which is one of the main tenets of both the UICC and ASCO this is a very inequitable situation. If you have money you have access to treatment, if you don’t have money you’re denied cancer treatment. That’s why we need to create equity, we need to fund cancer treatment for poor patients because if you just, say, use your resources for prevention it really means that you’re shutting out just the poor people of the world and they should in fact be able to have access to life-saving medications just as other people do in the world.