PATH

Breast Cancer: Unforeseen Public Health Priority in Developing Countries

Felicia Marie Knaul,

March 15th, 2011 Seattle, WA

Harvard Global Equity Initiative, Harvard Medical School; GTF.CCC Tomatelo a Pecho; Fundacin Mexicana para la Salud

From evidence

to anecdote

July, 2007

January, 2008

Harvard, Breast Cancer in Developing Countries Nov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor

From anecdote

to evidence

OUTLINE:
1. Evidence to anecdote to evidence

2. Cancer in LMICs: so much more can be done

3. Breast cancer: global health priority 4. Applying the diagonal approach in Mexico

 Mandate: Design, develop and implement global, regional and local strategies to improve the financing, procurement and delivery of cancer care, control, treatment and palliation in a sustainable 27 members manner applying innovative representing the global health and service delivery models appropriate to health systems cancer in the developing world. communities

Convened in Nov 2009 By HSPH, HMS, HGEI, DFCI

Challenge and disprove the myths about cancer/NCD

M1. Unnecessary: Not a health priority in LMICs/not a problem of the poor M2. Impossible: Nothing we can do about it M3. Unaffordable: .for the poor M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor`

Distribution of childhood cancer globally by level of income (< 15)

Level of Income Low Low middle Upper middle High Incidence 21% 50% 15% 15% Mortality 27% 55% 15% 5% Population 20% 57% 13% 10%

LMICS: More than 85% of pediatric cancer cases and 95% of deaths.
For children & adolescents 5-14 cancer is
#2 cause of death in wealthy countries

#3 in upper middle-income #4 in lower middle-income and # 8 in low-income countries

Lethality by cancer type and country income

Case fatality approximated by mortality/incidence
1

Children <15

Adults (15+)

0.8

0.8

0.6

0.6

0.4

0.4

0.2

0.2

0 Low income Lower middle income Upper middle income High income Low income Lower middle income Upper middle income High income

Leukaemia

Cervix uteri Breast

Prostate Hodgkin lymphoma Non - Hodgkin lymphoma

All cancers

Testis

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

Concentration of mortality: example Cervical cancer

275,000 deaths worldwide; 88% in LMCs

HPV Vaccine

Children orphaned by cervical cancer

Source: Paul Farmer., 2009

The cancer divide

Cancer is a disease of rich and poor
Yet, transition is polarizing the burden so that it is increasingly the poor who suffer:
Incidence and death: preventable cancers Death: treatable cancer Avoidable pain and suffering particularly at end of life Financial impoverishment from the costs of care and effects of the disease

IT CAN BE DONE: From evidence to action: Innovation Initiative Partnerships in LMICs

Treating cancer in LMICs using innovative delivery and financing:
task sharing and shifting Infrastructure shifting Application of technology of communication Social Protection and health insurance

Models:
ACCESS QUALITY
FINANCIAL PROTECTION

Low-income: Rwanda-Malawi-Haiti

Lower middle-income: Jordan

Upper middle-income: Mexico

Initial views on MDR-TB treatment, c. 1996-97

In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries. WHO 1996
MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease. WHO 1997

Source: Paul Farmer., 2009

Outcomes in MDR-TB patients in Lima, Peru receiving at least four months of therapy
failed therapy died 8% 8%

Making common cause with WHO:

Reduced prices of second-line TB drugs
Drug % Decline in price 1997-9

abandon therapy 2%

cured 83%

Amikacin Ethionamide Capreomycin Ofloxacin

90% 84% 97%

All patients initiated therapy between Aug 96 and Feb 99

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

98%

Source: Paul Farmer, 2009

Rural Rwanda, Burkitts lymphoma

0 oncologists

Regimen of vincristine, cyclophospha mide, intrathecal methotrexate

Central Haiti
Status post-CHOP in Central Haiti: Still in remission three years later
Source: Paul Farmer., 2009

OUTLINE:
1. Evidence to anecdote to evidence 2. Cancer in LMICs: so much more can be done

3.Breast cancer: global health priority

4. Applying the diagonal approach in Mexico

Myth .versus ..reality: breast cancer in LMICs

a disease of developed countries and wealthy women.

More than half of cases and almost 2/3 of deaths deaths occur in the developing world.

a disease of

older women less of a health priority than cervical cancer.

large proportion of cases and 60% of deaths in women < 54. More deaths and DALYs lost to breast cancer, in all developing regions other than SEAsia and SSAfrica.

In developing regions, breast cancer

Most frequent cause of cancer-related death in developing and developed regions 2-3rd leading couse 268,000 of the 458,000 deaths per year are in LIMCs: 58% Most common cancer in developed and developing regions 4.4 million women alive (diagnosed): how many in developing regions? 2008: 1.38 million new cases; 50% of which are from LIMCs 10.9% of all incident cancers second to lung
(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).

People are at risk for many reasonsvictims of success?

Maternal mortality Breast and cervical cancer

Africa

APPROX: 210,000

67,885 75,893 =133,778 772,728 478,640 =1,251,368

LMICs

APPROX: 360,000

The opportunity to survive should not be an accident of geography or defined by income. Yet it is. But . there is scope for action.
~ case fatality (incidence/mortality)
63% 60 48%
Breast

52%
48% 37%

40

40%

Cervix

38%

24% 20

Low-income countries

Lower middle

Upper middle

High-income countries

Source: Author estimates based on IARC, Globocan, 2008 and 2010. Quote: HRH Princess Dina Mired

In LIMCS, a much higher proportion of diagnosis and death is in women <55

Low income countries Age at diagnosis High-income countries

15-44

34%

66%

67%

33%

45-54 >55

Age at death

7%

56%

20%
78%

15%

Mexico: key evidence

Since 2006 breast cancer is the #2 cause of death among women age 30 to 54 years; and the leading tumor-related cause

In 2006, women between 30 an 65 years were more likely to die of breast than cervical cancer. In 1980 the risk of dying from cervical cancer was twice as high as breast cancer
Only 5-10% of cases are detected in stage 1 or insitu, compared to approximately 60% in US.

Mortality from breast and cervical cancer in Mexico1955-2008: less death from cervical
16

Rate for100,000 women adjusted for age

12

1995

2006: BC>CC.
Por primera vez en ms de 5 dcadas.
Fuente: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de mama en Mxico, 1979-2007.
FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretara de Salud de Mxico.

2005

1955

1965

1975

1985

Breast cancer and Seguro Popular

As of Feb 2007 all Mexican women diagnosed with breast cancer have the right to financial protection in health for breast cancer treatment

Early Detection = survival

Stage at diagnosis
0-1

Survival rates, US ACS

98%

2-3 4

84% 27%

Mexico: 5-10% in stage 0-1; 60-70% in III-IV

Fuente: American Cancer Society. Breast Cancer Facts & Figures, 2007-2008. Atlanta, GA. : American Cancer Society, Inc., y Secretara de Salud. Programa de Accin: Cncer de mama. Mxico, D.F.

Stage at diagnosis by level of municipal marginacin, Mexico, IMSS 2006

(Mxico, IMSS 2006)
50%

40%

Stage 1
30%

Stage 2 Stage 3

20%

Stage 4
10%

0% Poor (High) N=221 (3.8%) Middle N=1737 (30%) Low N=2877 (49.8%) Very low N=946 (16.4%)

Source: Authors estimation based on IMSS data, 2006.

Why?
Health, social and health system barriers

Barrier 1: myth, stigma and machismo

br

Barrier 2: Inequity in addition to lack of overall access and utilization

30%

28%

20%

21% 22%
16%

24%

10%

0%
+ Poorest Q1 Least poor Q2 Q3 Q4 QV
Fuente: ENSANUT, 2006

Only 1 in 5 women 40-69 report a preventive health visit including mamography 2006

Barrier 3: Poor quality services

women diagnosed with bc reported problems with providers when seeking diagnosis.
In routine, annual repro health/OBGYN visit/ PAP screening, there was no BCE Physician insisted woman was overreacting and sent her home with no diagnosis Health professionals and first-level care providers report lack of sensitivity of health personnel relating to the requests of women regarding breast health
RESULTS FROM A NATIONAL QUALITATIVE STUDY NIGENDA ET AL, 2009

Barrier 4: Lack of financial protection for early detection.

Since February of 2007, every Mexican woman has the right to financial protection (full health insurance) for the treatment of breast cancer. Seguro Popular de Salud Yet, early detection is only covered for those already insured

and early detection is unaffordable: mammography, biopsy and pathology - at the most subsidized level in a public hospital costs more than one month of subsistence income.
Fuente: Groot et al, 2006. TheBreastJournal

OUTLINE:
1. Evidence to anecdote to evidence 2. Cancer in LMICs: so much more can be done 3. Breast cancer: global health priority

4.Applying the diagonal approach in Mexico

The diagonal approach to health system strengthening

it has been discussed at length what the most effective approach is to deliver health interventions: vertical programs or horizontal programs. This is a false dilemma, because both interventions need to coexist in what could be called a diagonal approach

Seplveda et al., Aumento de la sobrevida en menores de 5 aos: la estrategia diagonal

A diagonal approach to women and health and cancer care and control

Horizontal Coverage: Beneficiaries WOMEN

Service Platforms

Diagonal approaches
1. Integrating breast and cervical cancer screening into MCH, SRH 2. Integrating disease prevention and management into social welfare and antipoverty programs 3. Catalyzing and employing community health workers and expert patients 4. Financial protection/insurance strategies with horizontal and vertical coverage 5. Reducing non-price barriers to pain control 6. Developing effective health services research and monitoring

Health Systems Functions

Vignette: a series of Missed Opportunities: Juanita

left breast substantially larger than right; arrived at Morelos Womens Hospital bc she could not move her swollen arm; father of children abandoned household at diagnosis History Part 1:
- Age 42; 5 children aged 7-18; breast fed all - Cartilla de la mujer: regular PAP and clinic visits - Has Oportunidades attends regular community health platicas

History Part 2:

Felt a breast lump 4 years prior fear kept her from saying anything Lump grew last year doctor at local clinic gave anti-b w/out BCE Is entitled to Seguro Popular and free care Cannot travel to Mexico City; seeking care locally; paying out of pock

Mexico: Harnessing the primary level of care for improving BC detection and care

PATH

Breast Cancer: Unforeseen Public Health Priority in Developing Countries

Felicia Marie Knaul,

March 15th, 2011 Seattle, WA

Harvard Global Equity Initiative, Harvard Medical School; GTF.CCC Tomatelo a Pecho; Fundacin Mexicana para la Salud