Cancer care in low and middle income countries

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Published: 18 Jun 2019
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Dr Gouri Shankar Bhattacharyya - FORTIS Hospital, Kolkata, India

Dr Gouri Bhattacharyya talks to ecancer at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting about some of the primary issues concerning the lack of cancer care in low and middle income countries.

He describes issues with resources, literacy, infrastructure, and political barriers to cancer access in these countries.

The point that is important when we talk about low and middle income countries compared to these so-called developed countries is of two issues. The majority of cancer patients today are in the lower and middle income countries; the majority of deaths are also in the low and middle income countries. But when we are looking at the resource distribution, 90% of resource is in that area where there is only 30% of patients and lower than 20% death rates. If you’re looking in terms of research publications then again it’s from that particular area. So the biggest disparity is that we don’t have data coming in because we don’t have proper cancer registries. So one of the major needs in low and middle income countries is to have a good cancer registry, a developed registry.

The second issue is that I have a strong feeling that people are not literate enough. I’m not talking educated or having a degree, I’m talking in terms of health literacy. There is not enough health literacy or advocacy leading to health literacy so awareness is lacking. Since awareness is lacking there’s a lot of fear and since there’s a lot of fear there is nothing like screening that is possible. The second part of it is that if you’re looking at the healthcare structures in the LMICs, the LMICs basically do not have funding that comes from the government or from the insurance. The majority of them are out of pocket expenditures. So if I look at it carefully, out of every ten patients who go in for cancer treatment there’s a chance of four of them going into a pecuniary hardship and you might learn of at least three of them going into bankruptcy. So that needs to be taken care of very carefully.

The other major issue that is coming up with the low and middle income countries when we’re looking at is that we are not adapting the methods of treatment and guidelines in the right framework into a developing country. So we need to see that we understand the issues that are important. For example, in the developed countries infection as a cause of cancer accounts for less than 10% but infection as a cause of cancer accounts for almost 30% of all cancers that we see in developing LMICs. Things like hepatoma that’s related to viruses, hepatitis C and hepatitis B; cervical cancer which is related to basically an HPV virus or nasopharyngeal carcinoma related to EBV virus or stomach cancer related to Helicobacter pylori. So when these are related there are methods of prevention are there which can be had. Now, this is another aspect that we are not paying too much attention on.

So we need to keep in mind that the diseases are different, the disease methodology is different so approaches have to be different. The other thing is that we have to learn that when we talk of LMICs and healthcare services that it’s just not strengthening the governmental methodology but also to strengthen the non-governmental agency. To give an idea of how cancer care is done in LMICs, 30% of patients actually go to a structured institute where cancer care is done in these countries, 70% don’t reach these centres. So when we make a guideline, we make a system, it is to this 70% that we have to cater for.

Then comes up a major issue and that issue is palliative and supportive care in developing countries. We very often talk about it but we don’t pay too much attention to it. For example, again, in developing countries or LMICs we have 75% patients who come with advanced cancers. These patients are actually not going to get cured. I know that there have been breakthrough methods in our treatment methodologies that they will go into cutting edge research with immunotherapies and liquid biopsies to diagnose and targeted therapies. But effectively in countries where they are affordable also they are actually applicable and have fruitful results in about 15%. In a developing country, LMIC, this doesn’t even happen because the affordability is not even there for those 15%. So we’ve got to think of good palliative care and early integration of palliative care and treatment. So we need good guidelines for good supportive and palliative care in this.

Until the time we are reaching out and getting these things organised the best method of approaching anything in an LMIC is to look at prevention. This prevention of cancer has to be something that is inbuilt with ongoing programmes. These ongoing programmes are something which are there only within the health structure. So if we can integrate them it becomes important. Like we have the sustainable goals for healthcare which the WHO has laid down, if we can get into these chronic disorder groups and in these disorder groups we can start integrating concepts of methodology proven to cancer. For example, if you start thinking about HPV vaccination, HCV treatments and early detection, HPV vaccination they all get integrated with getting treated with basic disorders or childhood immunisation schedules.

The other is trying to change lifestyles because unfortunately the LMICs are also at what is called a phase of transition. They are moving away from infectious disease to communicable disease but in the process they have both diseases running in society. So there’s a zone of transition. They are moving away from societies of have-nots to a society earning so they are picking up side effects and bad habits which can lead to disease from the advanced countries. So they have dual burdens. So until the time we have to learn until we get good methodology, the finance has come up and we have cost-effective treatments coming up and cost-effectiveness ratios done, we’ll have to think of how do we handle the issue of this preventive care within our means. For example, taking care of our diets, taking care of exercises, taking care of the vaccines that can be provided and trying to lead a healthy lifestyle.

So for right now let’s do something is have a health policy but let’s not play health politics. By that I mean you can’t have fly-by-night people coming to LMICs and saying, ‘We will take care of your burden.’ You have to have health governance and it has to be a global governance, that’s got to be important.