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7/31/2019 Final Lincoln BC Global Disparities 060612
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Breast Cancer:Global DisparitiesClosing the Gap: Addressing Disparities in Breast Cancer
Lincoln Medical and Mental Health Center, NYJune 7, 2012
Felicia Marie Knaul, PhD
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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs
M1. Unnecessary
M2. Unaffordable
M3. ImpossibleM4: Inappropriate
Much
Should
Could, and
Can ...
Challenge and disprove the
myths about cancer
.be done
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Global Task Force on Expanded
Access to Cancer Care and
Control in Developing Countries
= global health + cancer care
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From anecdote
to evidence
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January, 2008
June, 2007
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br
Juanita:Advanced metastatic breast
cancer is the result of a series of
missed opportunities
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From anecdote
to evidence
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A) Should be done:
B) Could be done:
C) Can be done
Myth 1. Unnecessary
Myth 2. Inappropriate
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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Breast cancer:
myths and realities
It is a disease ofdeveloped
countries
It is a disease ofolder women
It is of lowerpriority than
cervical cancer
The majority of cases
and deaths occur in the
developing world
A large proportion ofcases and deaths
perhaps the majority
happens in women
7/31/2019 Final Lincoln BC Global Disparities 060612
13/37Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.
The cancer transition in LMICs:
breastand cervicalcancer
53%
20%19%
-31%
0%
LMICs High
income
% Change in # of deaths1980-2010LMICs account for
>90% of cervical
cancer deaths and
>60% of breast
cancer deaths.
Both diseases are
leading killers
especially of young
women.
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#1 cause of death in wealthy countries
#2 in middle-income countries
# 5 in low-income countries
Among women aged 15-59
Breast cancer is
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Cancer is a disease of both rich and poor;
yet it is increasingly the poor who suffer:
1. Exposure to risk factors
2. Preventable cancers (infection)
3. Death and disability fromtreatable cancer
4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide:
An Equity Imperative
Fac
ets
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Adults
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Sur
vival
inequa
lity
gap
LOW
INCOME
HIGH
INCOME
100%
The Opportunity to Survive (M/I)
Should Not Be Defined by Income
In Canada, almost 90% of children with
leukemia survive.
In the poorest countries only 10%.
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Stigma:
Cancerespecially in
women and children - adds a
layer of discrimination ontoethnicity, poverty, and
gender.
Survivorship
care is non-existent.
i i i i j i
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The most insidious injustice:
lack of access to pain controlNon-methadone, Morphine Equivalent opioid
consumption per death from HIV or cancer in pain:
Poorest 10%: 54 mg per death
Richest 10%: 97,400 mg per death
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A) Should be done:
B) Could be done:
C) Can be done
Myth 1. Unnecessary
Myth 2. Inappropriate
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
W d h i LMIC
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Women and mothers in LMICs
face many risks through the life cycle
Women 15-59, annual deaths
Diabetes
120,889
Breast
cancer
166,577
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
Cervical
cancer
142,744
Mortality
in
childbirth
342,900
- 35%in 30
years
= 430, 210 deaths
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The Diagonal Approach to
Health System Strengthening
Rather than focusing on disease-specific vertical
programs or only on horizontal system
constraints, harness synergies that provideopportunities to tackle disease-specific priorities
while addressing systemic gaps.
Optimize available resources so that the whole ismore than the sum of the parts.
Bridge the divide as patients suffer diseases over a
lifetime, most of it chronic.
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Delivery: Harness platforms by integrating breast andcervical cancer prevention, screening and survivorship
care into MCH, SRH, HIV/AIDS, social welfare and
anti-poverty programs.
A Diagonal Strategy:
Positive Externalities
Promoting prevention and healthy lifestyles:
Reduce risk for cancer and many other diseases
Reducing stigma around womens cancers:
Contributes to reducing gender discrimination
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A) Should be done:
necessary and appropriate
A) Could be done:
C) Can be done
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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`5/80 cancer disequilibrium
(Frenk/Lancet 2010)
Almost 80% of the DALYs
(disability-adjusted life-years) lostworldwide to cancer are in LMICs,
yet these countries have only a very
small share of global resources for
cancer ~ 5% or less.
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Investing In CCC:
We Cannot Afford Not To
Health is an investment, not a cost
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% of global GDPPrevention and treatment offers potential world savings of
$ US 131-850 billion mostly due to productivity gains and
reducing suffering
1/3-1/2 of cancer deaths are avoidable:
2.4-3.7 million deaths
Of which 80% are in LIMCs
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The costs to close the cancer divide
may be less than many fear:All but 3 of 29 LMIC priority cancer
chemo and hormonal agents are off-patent:
many < $100 / course
Prices drop: HPV 2011 from $US 100
/dose to:GAVI $5 and PAHO $14
Pain medication is cheap
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A) Should be done:
necessary and appropriateA) Could be done:
affordableC) Can be done
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
Ch i
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Harvard Breast Cancer in Develo in Countries Nov 4 `09
Champions
Drew G. Faust
President of
Harvard University
And
22+ year BC
survivor
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In developing countries, people with multidrug-resistant tuberculosis usuallydie, because effective treatment is often impossible in poor countries. WHO 1996
Initial views on MDR-TB
treatment, c. 1996-97
Source: Paul Farmer., 2009Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis
in Lima, Peru. NEJM 2003; 348(2): 119-28.
Outcomes in MDR-TB patients in Lima,
Peru receiving at least 4 months of therapy
MDR-TB is too expensive to treat in poor
countries; it detracts attention and resources from
treating drug-susceptible disease. WHO 1997
Cured
83%
Abandon
therapy 2%
Failed
therapy
8%
Died
8%
PIH R l R d 0 l i t
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PIH Rural Rwanda: 0 oncologist
Source: Paul Farmer., 2009
Burkitts
lymphoma
EmbryonalRhabdomyosarcoma
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Mexico: cervical cancer.
Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2006)
0
4
8
12
16
19551965
1975
1985
1995 2005
Success in treating several cancers.
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Mexico: summary of facts
Since 2006, breast cancer is the second leading
cause of death among women aged 30 to 54
years of age and the principal cause of death
due to tumors.
Seguro Popular: since 2007 all women
diagnosed with breast cancer have verycomplete access to treatment with financial
protection
Mexican Champion: Abish Romeo
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Mexican Champion: Abish Romeo
treatment through Seguro Popular
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Only 5-10% of cases in Mexico are
detected in Stage 1 or in situ
- 50% of women from poor
municipalites are diagnosed in stage 4
compared to 10-15% of women fromwealthy areas
Education to reduce barriers:
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Education to reduce barriers:
promoters, nurses, doctors
Challenge: from survival to survivorship
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Challenge and disprove the
minimalists:
Myths about breast cancer,cancer& NCD
M1. Unnecessary: NECESSARY
M2. Inappropriate: APPROPRIATE
M3.Unaffordable: AFFORDABLEM4. Impossible: POSSIBLE
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Be anoptimist
optimalist
Expanding access to cancer care and control in
LMIC Sh ld C ld d C b d