By Lars Holmberg*, Senior Professor, Uppsala University and King’s College London,
Uppsala Health Summit Program Committee Chair
CARE FOR CANCER
A year ago, in May 2017, the World Health Assembly adopted the historic ‘Cancer Resolution’. It is an acknowledgement of the fact that although prevention, notably life-style prevention, continues to be important to decrease the incidence of cancer, it is not enough to substantially reduce the burden of the disease.
Development, not only of healthcare systems, but also of education, economies, infrastructures, etc. have all contributed to a general improvement in life expectancy. Cancer is increasingly seen as a disease that we can survive and recover from if society can provide early access to diagnosis and treatments. Compared to previous global policy documents addressing the growing cancer burden, the WHA resolution underlines the need for access to diagnoses and treatments.
A global outlook on cancer epidemiology
Global cancer incidence is steadily increasing and estimated to reach around 23 million new cases in 2030, an increase of 66 % compared to 2012. The rate of increase is larger in low- and middle-income countries mainly due to three factors: a population increase especially in older age groups, a faster decline in mortality from other diseases and an increasing exposure to tobacco in some populations.
A common estimate is that 30 % of cancer deaths could be prevented by lifestyle-related measures: addressing smoking, unhealthy diets and sedentary lifestyles, and by offering vaccination for hepatitis and HPV-infections. There are however still significant gaps in our knowledge about effective strategies to change individual lifestyle habits on a larger scale. Another threat is that we hitherto have seen a pattern where smoking tends to increase under a transition from low to medium income level and only thereafter decline. In that perspective, very large populations are now at risk of being more exposed to smoking.
Cancer mortality is also increasing. The mortality increase is disproportionate between high- and low-income countries, and the risk a cancer will be lethal is much higher in low- and middle-income countries. This is not only due to a higher incidence of cancers with a bad prognosis such as liver and oesophageal cancer in these regions, but also to low access to care. In 2015, less than 30 % of low-income countries reported to the WHO that treatment services were generally available, compared to 90 % in high-income countries. The cancer panorama is also changing in low- and middle-income countries from mainly infectious-related cancers to cancers associated with a westernized lifestyle. Simultaneously, as a consequence of improved diagnosis and treatment, we experience increasing prevalence of cancer in most countries, except in some poor regions, with an overrepresentation of African countries.
Children – encouraging results, but a slow development
In high-income countries, over 80 % of children with cancer now survive a cancer diagnosis. However, over 80 % of the world’s children live in low- or middle-income countries where outcomes are considerably worse. In low-income countries, education of parents in child health and better care pathways could lead to more effective treatment for large paediatric cancer diagnoses where today readily affordable treatments exist.
Despite the promising results from childhood cancer care in rich countries, we still see few resources devoted to research and development for this group. Childhood cancer is a rare disease, representing only 2 percent of all cases and thus the commercial potential for investments in the field is limited. The development of new treatments for children has predominantly to rely on academic research with less financial resources. Another obstacle is that the transition of knowledge from adult cancer to children is far too slow.
Advancements in diagnostics and therapies
An example of the changing biomedical innovation ecosystem is the promising developments in precision medicine. Sequencing technology has opened up for more precise diagnostics, allowing for early detection, even before symptoms appear. Early access to treatment is critical for a positive outcome. The development of rapid gene sequencing, may therefore be one of the technologies that can revolutionize cancer care, also by designing individual therapies to treat individual patients and their individual tumour.
Increasingly, cancers are classified according to which genes are going wrong. Great hopes are placed on the development of immune therapies and cell therapies. The results have also been remarkable for some conditions. In 2017, the FDA for the first time approved a new treatment based on a specific genetic indicator, instead of where in the body the tumour was found, or the tumour type (1). That same year, the FDA also approved the first two cell therapies, designed to treat advanced lymphomas in adults and acute lymphoblastic leukaemia in children (2. But while remarkable advancements have been reported, there is simultaneously a disappointment with many therapies, that have not shown more than marginal effects. An evaluation of EMA oncology approvals made during the period 2009–2013, showed that the majority of the cancer drugs approved had led to marginal gains in survival or quality of life.(Davis, C.; Gurpinar, E.; Pinto, A., BMJ 2017;359:j4530)
The informed patient
Another rapidly growing global trend is patients’ access to and empowerment by information. Healthcare systems are not yet fully adopted to meet the well-informed patient and family, nor to use the information and knowledge that patients and their kin can contribute with.
The informed patient is not ubiquitous, though. Health literacy and other socioeconomic, as well as cultural, factors influence how patients perceive their role, need and will to have insights and influence the treatment. Does the informed patient have better access to available treatments?
A widening gap
The globally increasing burden of disease imposes large demands on resources for prevention and treatment on already strained health economies. The suggested World Bank Disease Control Priorities in Developing Countries (DCP3 2016) essential package of cost-effective and feasible interventions would, if fully implemented, cost 13 % of total public spending on health in low-income countries but would require an even smaller proportion of the budget in high- and middle-income countries.
The increased prevalence of cancer imposes large demands on resources for rehabilitation, management of side-effects, and treatment of recurrences. However, these resources are even more scarce than resources for primary treatment. WHO reported in 2015 that globally only 14 % of all patients needing palliative care got it.
Costs for new therapies have risen to levels that many healthcare providers, even in high-income settings, find prohibitive. It is a seeming paradox that improved survival in cancer leads to new problems, paralleled by the rapid pace of innovations in cancer management, creates a widening gap between what potentially can be done for the individual patient and what is affordable. The increasing gap between possibility and feasibility makes already difficult prioritizations even harder.
A constant flow of new innovations raises questions as to who gets access to the new diagnostic and treatments and at what pace. It has been argued that our infrastructures for making innovations available are not adapted to the new biomedical innovation ecosystem we live in, not even in high-income countries. The value of medical advancements is lost if patients cannot access these therapies.
Differences in access and outcomes after cancer treatment appear on all levels: global, regional and national. There is strong evidence that socioeconomic group and gender strongly influences outcome following a cancer diagnosis.
While on one hand, we see a strong trend of well-informed patients, empowered by information on their diagnosis, and eager to be part of a true dialogue and to participate in decision-making about interventions, large groups still lack fundamental health literacy.
The development of genetic tools, and the surge of data available to support healthcare decision-making, could presumably urge on equal access to the best possible treatment in a given socioeconomic context. But there are many challenges to overcome, as to who shall own and have access to which data; which patient groups or which cancer diagnoses to prioritize in building biobanks and developing biomarkers, just to mention a few.
In the light of patients’ growing awareness about the increasing gap between possibilities and affordability, the healthcare system must also be prepared to explain and rationally motivate priorities. Serious healthcare providers who provide evidence-based services should not leave the field open to unreliable actors.
National cancer plans
The WHA resolution urges member states to develop, implement and finance national cancer plans. These have long been strongly endorsed internationally as central to comprehensive cancer control, from primary prevention to palliative care. 87 % of WHO member states reported in 2015 that they had policy, strategy or action plans for cancer, and 68 % reported
that these were operational. However, to achieve an effective management of national cancer issues, the strategy needs to be politically well supported, adequately funded and based on an understanding of current needs and shortfalls, and on reliable estimates of future challenges. One example from high-income settings such as the Scandinavian countries and the UK showing the importance of data, is that reliable data substantiating over-long waiting times for cancer care and socioeconomic differences in outcome after treatment led to strengthening of cancer plans.
Uppsala Health Summit 2018 – Care for Cancer!
When Uppsala Health Summit convenes in 2018, our goal is to launch open and frank dialogues on how we can nurture and take advantage of the latest opportunities created by re search and innovation, paving the way for even more patients to benefit from these advances, and for a more equitable access to the best possible diagnosis, treatment and care.
In eight different workshops, we will focus on particular challenges in driving cancer care forward. The workshops will focus on issues that are common to any kind of cancer diagnosis, and conclusions will benefit the general settings for cancer care globally.
It is our belief that the conclusions from Uppsala Health Summit can provide valuable input for the national cancer plans called for in the WHA resolution from 2017 and will inspire further collaborations. It would be a great loss if we close the widening gap between medical possibilities and feasible care plans by slowing down the pace of innovations coming from academia or industry.
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