Cancer is no longer a first world problem

The major causes of morbidity and mortality in lower and middle income countries are infectious diseases. Accordingly, philanthropists, NGOs, nations, and intergovernmental organizations have designed global health and development programs to aid populations in need. In this battle between microbe and man, these programs have established a set of tools and strategies to reduce the burden of diseases like HIV, TB and parasitic diseases. While those programs have reduced deaths attributed to infectious disease and increased longevity, they have also unveiled the sizeable presence of cancers in these same populations. In 2008, 50 percent of global cancer deaths were in Asia and, according to the National Cancer Institute, 70 percent of cancer cases will be in developing countries by 2030.[1] Further, the types of cancers in these populations differ in each region and economic status. These projections indicate that cancer is not just a disease of the developed world and give weight to the need for a global oncology campaign to block the rising tide of morbidity and mortality.

Now, global health leaders and organizations are realizing that cancer is a disease that can be fought on a population level using the same methods used to face infectious diseases. Global oncology is an emerging field of global health that aims to reduce the international burden of cancer, promote research on cancers that are more prevalent abroad, and improve the capacity of foreign health systems to provide adequate care. Since global oncology is early in its early days, now is the perfect opportunity to learn from previous global health efforts and to recognize which aspects of cancer care require specialized attention and innovation.

I met with Ami Bhatt, MD, PhD, and Franklin Huang, MD, PhD, Senior Hematology and Oncology Fellows at Dana-Farber Cancer Institute, to gain more insight into the field and learn about the Global Oncology Initiative (GO!). GO!, an organization Drs. Bhatt and Huang cofounded last year, aims to establish relevant partnerships and projects while sponsoring talks on cancer care and delivery in resource-limited settings.  From our discussion, I learned that global oncology has the potential to change our research priorities, identify persistent holes in healthcare systems worldwide, and emphasize the importance of health equality in the effort to fully recognize and address the immense burden of cancers on individuals and populations.

Not so rare cancers

There are many other cancers that are rare in Western nations but impact thousands abroad. For example, Kaposi’s sarcoma (KS) is considered a rare cancer in the United States. In fact, the first hint that an HIV/AIDS epidemic was emerging in the United States was a rise in the number of gay men with KS that is usually found in older or immunosuppressed (ie. HIV infected) people. Now that HIV/AIDS is a global epidemic, the global burden of KS has also risen. Still, there are less than 2000 cases of KS per year in the United States while there were 34,000 new cases of KS in Africa in 2008. Other examples of cancers that are rare in the West but have significant impact elsewhere include advanced cervical cancer, liver cancers, and stomach cancers, and many of these cancers are associated with a viral or bacterial infection.

To take advantage of the success of previous public health campaigns, the global oncology field must measure the true burden of cancer by broadening screening and data-collection efforts. Only 11 percent of the African population and 8 percent of the Asian population is covered by cancer registries, the primary database on which cancer burden estimates are based. Dr. Bhatt explains, “Collecting these data is very limited in places where cancer screening is different. If you’re not doing routine mammograms, your breast cancer rates are going to be lower, presumably, and the cases that come to clinical attention are going to be late stage.” Without proper identification of patients, these patients suffer from a lack of treatment and the global health community suffers from ignorance of their need. Country-wide or regional epidemiological studies are necessary to direct resources to areas most in need of aid. Identifying populations impacted by cancers with low incidence in the West, and even cancers that are generally rare in the world, would also provide a greater pool of patients to enroll in clinical trials to test emerging treatments.

Molecular studies should be coupled with population-wide studies to identify cases that have different disease progression or response to treatment. “We are limited in our understanding of whether or not the knowledge that we gained from studying western samples applies to those in the developing world,” noted Dr. Bhatt. Cervical cancer, for instance, is associated with human papillomavirus (HPV) infection. Since HPV has different subtypes and these subtypes have a varying geographic distribution, the cervical cancers due to the HPV will differ across regions. This variability impacts the usefulness of a HPV vaccine like Gardasil, which is known to be effective in the North America and Australia but has unknown efficacy in Africa. Variability like this may exist for other cancers and must be accounted for when initiating international cancer care programs.

A global standard of care

Addressing the global cancer burden is obviously a weighty task. While most global health campaigns have focused efforts on a single infectious disease, global oncology will have to improve the treatment of multiple diseases with varying causes and malignancies. Although this makes cancer care more complex, it does not make the task impossible. The reason is that although cancers differ, there is a shared infrastructure. “[To improve global oncology] you need to push forward pathology, surgery, radiology and care-provider services to get you to a place where you can take care of many different types of cancer,” says Dr. Huang. Building this infrastructure includes acquiring MRI services, establishing a shared knowledge program between hospital staff, and providing medicines and staff to palliate pain and nausea.

Most importantly, building the infrastructure to deliver cancer care requires a universal standard of care. Many cancer patients in the US benefit from personalized care, but the costs of such treatment are not feasible in resource-limited settings. Instead, the global oncology field should focus its efforts to design a standardized care and treatment regimen for each disease. This is useful when drug supply and trained health workers are limited because it identifies the minimum resources needed to set up global health programs, guide budgets, and, most importantly, treat each patient. The tuberculosis (TB) community standardized tuberculosis treatment with Directly Observed Therapy-Short Course (DOTS), which established a protocol for administering specific TB drugs that included provision and observation by a community health worker. The level of detail that went into designing DOTS gave leverage to the TB community and affected nations to demand reduced prices for desired drugs and helped organizations around the world design sustained and effective TB treatment programs.

Again, TB is a single disease and cancer is multiple diseases. But this does not diminish the need or capacity to improve cancer care globally. “[Global oncology] is about curing cancers that are curable where cures exist, that can be administered safely and tolerably, and palliating patients with diseases that cannot be cured,” says Dr. Bhatt. Therefore, the tools and knowledge that have led to high cure rates and better care for ailing patients the US can set the standard for cancer care and improve health outcomes abroad.

Moving forward while bringing up the rear

Global health is where capacity building and scientific innovation go hand in hand. The lessons learned from the global fight against HIV, tuberculosis, and other infectious diseases include methods to improve community awareness and knowledge of the disease, to deliver complex care, to direct research efforts to previously understudied aspects of the biology of disease, and to implement clinical trials to test new therapies in resource-limited settings. These will now be the objectives for global oncology. “We want push the entire field of oncology forward, which means identifying new therapies and generating more effective and safe opportunities for treatment. But [we must] also push up the rear: that is improving access and making sure the therapies that we know that do work that are fairly safe and effective are being administered,” says Dr. Bhatt. This concerted effort will significantly reduce the disproportionate burden of cancer deaths in middle- and low-income countries as well as improve our understanding of the disease for the benefit of us all.

Since entering the field of global health, I have learned that although the fight against infectious diseases and cancers may involve different adversaries, the strategies to combat them are the same. In my previous article, I mentioned how HIV continues to spread in the United States and that the lessons learned from capacity building and innovation abroad could benefit us here. In the case of global oncology, it seems apparent that the gains made in the US to prevent cancers and reduce cancer deaths must be translated abroad. Dr. Huang states, “It is a step-wise process. We need to train, develop capacity, and build local resources in order to do these things in any meaningful substantive ways. And these are the partnerships that will build collaborations to help identify patients, identify samples, and develop scientific capacity in these kinds of settings.” This lesson was hard fought when combating HIV, TB, and other infectious disease. This lesson will ensure success in the global war against cancer.