The global program of the American Cancer Society

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Published: 5 Jun 2019
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Dr Meg O'Brien - American Cancer Society, Atlanta, USA

Dr Meg O'Brien speaks to ecancer at the Global Health Catalyst Summit 2019 at the Dana Farber Cancer Institute in Boston, Massachusetts about the global program of the ACS (American Cancer Society).

She outlines the three focus areas of the ACS global program, some of the collaborators, and also ways which this program will be implemented.

Dr O'Brien also speaks about some of the barriers to care, for example financial problems. She draws parallels to the situation with HIV/AIDS, and how we can approach some of these problems in a similar way.

She ends with an overview on vaccinations and cervical cancer, which alongside a change in attitude, could be cured in many areas.

Our global programme has three focus areas. One of them is prevention of cancer, so we work specifically on smoking cessation and then HPV, so vaccination and screening for HPV. Then we have a second programme which is on capacity development. That team works with local cancer societies to improve the civil society support around cancer. They also work a little bit on patient support programmes such as transportation, lodging and navigation. Then the third part of our global programme is access to treatment. So there we work on access to chemotherapy, radiotherapy, surgery and pain relief with a focus on reducing the cost, improving availability and also getting services delivered in a more timely manner.

Who do you work with?

The American Cancer Society has a memorandum of understanding with ministries of health in sub-Saharan Africa. Then in several of the countries we have staff who actually sit in the Ministry of Health and work on cancer programmes for that government.

Cancer care in Africa is severely under resources, how do we change this?

It is. This is the early days. What we’re seeing is there is very little treatment now but the treatment is expanding pretty rapidly. Most governments in sub-Saharan Africa are investing quite a lot of money to expand cancer treatment services. So we have new cancer centres opening in several countries, we’re also starting just in the last five years to see the introduction of fellowship training. So now we can train oncologists in Africa instead of sending them abroad. We have nurse oncology training programmes coming on board; we have a lot of new radiotherapy resources that are coming online. So I’m very hopeful because I’ve seen a tremendous expansion in cancer services just over the last five and ten years.

I think that’s what’s happened is that as cancer cases have grown the governments and the health systems in these countries are responding but the institutions around them are still trying to develop that response. So there’s not a lot of funding available; a lot of the major funders in the global health community have yet to take on cancer. So that means that most of the financing for cancer treatment comes directly from patients. In countries that don’t have health insurance programmes it means patients have to bear the full cost of treatment which, as you know, can be quite expensive. That’s part of why it’s been slow to develop but it is moving and there’s a lot involved. We often talk about the leaky pipeline to cancer treatment and by that we mean that there are a lot of barriers along the way. So from the time that a patient first develops symptoms of cancer they’re going to have to find a way to get in to see a physician. That step alone many patients will fall out because they live far from a health facility or their health facility isn’t well resourced. But once they get there then they’ll usually need some kind of workup, usually imaging, and that can be costly. So they have to find funds for that and then once they get that done there’s usually pathology required. So there are all these steps before they even get to a cancer centre.

So do you have to be well-off to get treatment for cancer in Africa?

Either well-off or very lucky. Some patients get through it because there are programmes but the reality is that for people who don’t have resources it can be extremely challenging to get to cancer treatment, it’s true. People who have resources oftentimes are able to go abroad or they’re able to access services in their country. But we do have a lot of challenges right now in terms of both financing and then getting patients through a rather complex system.

The end result is that at the cancer centres, even if we have treatment available, by the time patients can get to those cancer centres if they’re coming from far out in the country they’re so advanced at that point that the treatment that we give them isn’t going to be very effective. So we’re constantly challenged to try to expand our cancer treatment so that we can start getting patients in earlier and then we’ll really have a chance to treat them.

This is very similar to what we saw in HIV about 15-20 years ago which is that before we had treatment for HIV we had the same thing. We had very few patients able to access it and patients having to spend a lot of money to get to treatment. By the time they got to us in HIV we often weren’t able to do much for them. What we found back then was that by expanding services, by having more HIV treatment and once we started being able to get the prices down patients were able to get more treatment and then we started getting patients that we could actually treat and save. So there’s a lot of similarities.

What would you expect to see in the next 5-10 years?

A few of the developments that I think are going to be the most exciting for us are, one, I think we’re going to see a continued expansion of training programmes in the region. So once African countries can start training their own oncologists and their own oncology nurses and pharmacists, they will be much better able to get a handle on the problem. So that’s going to be really important.

The second thing is that I think we will see prices come down. We’ve already seen some movement in the prices for chemotherapy and radiotherapy in several countries. As the volumes increase and we can start taking targeted steps to change the market so that people get more affordable treatment that will be really important. We’re also starting to see the expansion of health insurance coverage for cancer and in the places where that has happened, such as Kenya, we’ve seen a huge expansion in the number of people getting treatment and able to complete treatment quickly. So those are three factors that are going to be really important.

Another one is if we can start to get more financing for cancer treatment from global health funders, like the global fund and others, that will also be a breakthrough that will help us to really expand services quickly and get more patients on to treatment.

How can we improve vaccine access in Africa?

The HPV vaccine is a very important development for preventing cancer. Cervical cancer is the number one cancer in Africa, it is entirely preventable through vaccination and that vaccine is relatively affordable. So in terms of long-term solutions this is the centre of any solution that we come up with. In the short term there are challenges around availability of the HPV vaccine, so there are not enough doses right now to supply everyone. This is one of the challenges that we have which is that when we negotiate for lower prices for some parts of the world when there is a shortage then companies are not incentivised to sell in those parts of the world where profits are smaller. So there is going to be in the near term some challenges around availability of vaccine but at the same time if we can get vaccination built into national strategies once we solve some of that supply side then we can start focussing on the demand side and getting girls vaccinated.

Is there any other international help and funding for these vaccines? Is there any pushback?

I can tell you that Gavi is very much behind the HPV vaccination programmes so there’s a lot of support coming from Gavi to expand access to those vaccines. I expect we would see that from other international actors as well. It’s a really good solution and it’s a really good buy for cancer prevention.

In terms of the pushback that we see in the US, I don’t think it’s necessarily a given that we would see that in other countries and we haven’t seen it in sub-Saharan Africa. A lot of that is political and the challenge for us is just to get people accurate information and then to roll these vaccines out in a way that makes sense in the cultural context that it’s delivered in. Too, people in the US aren’t used to seeing a lot of cervical cancer because we’ve had strong screening programmes whereas in sub-Saharan Africa people are aware that cervical cancer is the number one cancer so it is something that people have a lot more awareness about than we do in the US.

Do you also work in Asia or South America?

The American Cancer Society has some projects in Latin America, mostly around our prevention programmes, but when it comes to cancer treatment our focus is sub-Saharan Africa.