What’s it really like in [insert country]?
February 4th is World Cancer Day, a UICC-led initiative promoting awareness about how everyone and anyone can do their part to reduce the global burden of cancer. I want to emphasize the word “global” in that sentence, because in my experience, nearly everyone in the U.S. – including many of my colleagues in the medical profession – is focused primarily on cancer-related challenges that directly affect patients here.
Even the Cancer Moonshot initiative, a worthy endeavor that is technically global in scope, will truly only impact the U.S. That’s because there is an enormous gap between U.S. patients and those in the rest of the world, another gap between developed and developing countries, and then a third gap between rich and poor inside developing countries. Even if a cure for cancer were found tomorrow as a result of this Moonshot, it wouldn’t affect the vast majority of the world’s cancer patients.
The burden of cancer is greatest in low- and middle-income countries (LMICs). In 2012, 57% of new cancer cases and 65% of cancer deaths occurred there, and the average patient in a developing country is roughly twice as likely to die from their cancer than a patient in the U.S. That increased risk is primarily from lack of screening, lack of access to treatment, and treatment methods that are decades behind those used in the U.S. One jarring statistic to illustrate the delta: 58% of breast cancer patients in Mexico present with advanced-stage cancer, versus just 12% of breast cancer patients in the U.S.
The U.S. already provides the most advanced cancer care in the world. We have a responsibility to now help the rest of the world catch up.
There are some simple steps we can take to help measurably improve survival rates for underserved cancer patients worldwide. Here at GCI, we work directly with cancer doctors in LMICs to propagate simple interventions that are common in the U.S. and have been proven to accelerate diagnosis, access, and treatment. Some examples are:
- Global Tumor Boards, which help physicians and oncologists in developing countries connect directly to U.S. physicians by videoconference to discuss challenging cancer cases and ask advice.
- Patient Navigation Programs, intended to help ensure cancer patients have rapid access to treatment. Patient Navigators help patients find physicians, deal with insurance companies, book treatment appointments, and follow up to make sure patients get to appointments. This low-cost intervention is making a big impact: In a Mexico City pilot, the program reduced the median time from diagnosis to referral to a cancer center from two months to 11 days, boosting patient outcomes and survival rates.
- Cancer Databases, to track and understand socio-demographics, treatment choices, and outcomes in patients in developing countries, to bring attention to long-standing cancer control problems (such as the larger proportions of young women with breast cancer in LMICs, like Mexico).
Do we need to find a cure for cancer? Yes, of course. But in the meantime, the U.S. has a wealth of medical knowledge that can and should be shared with the rest of the world to make an impact today. On World Cancer Day, let’s think not just about how to reduce cancers in the U.S., but globally. The rest of the world needs a Cancer Moonshot too.
Latin America is home to 60 million indigenous people. There are over 400 different indigenous groups across the region, which together represent approximately 10% of the total population of Latin America. Despite the fact that they make up a large proportion of the region’s population, indigenous peoples are marginalized, mostly poor, and largely underserved. They experience immense health disparities, and in our Lancet Oncology commission on cancer control in Latin America, we specifically discuss cancer risks, care, and outcomes in this vulnerable population.
Although there is no universal definition for indigeneity, there is a general consensus in Latin America that “indigenous” applies to descendants of the people who lived on the continent prior to European arrival. Though indigenous groups are culturally diverse, they share many common experiences – such as colonization, forced migration, marginalization, and suppression of their languages and cultures – that have resulted in similar poor socioeconomic conditions and health inequalities today.
Despite the fact that indigenous people make up 10% of the Latin American population, there is limited epidemiological data on their health conditions and outcomes, especially when it comes to cancer. In fact, there are no national cancer registries that account for ethnicity and indigeneity in the region. However, some smaller studies have shown that indigenous populations in Latin America – like those in Australia, New Zealand, Canada, and the U.S. – have more adverse cancer presentations and outcomes than their non-indigenous counterparts.
Research has shown that indigenous people are at greater risk for certain cancers and toxic exposures, including:
- Cervical cancer: There is a higher burden of cervical cancer among indigenous and rural women. This is most likely due to limited access to HPV vaccination, Pap testing, and early treatment, all of which prevent advanced cervical cancer.
- Hepatocellular carcinoma: Indigenous people have higher rates of hepatocellular carcinoma, which can be attributed to the high prevalence of viral hepatitis, alcohol use, and carcinogenic environmental exposures.
- Gastric cancer: Risk factors for gastric cancer among indigenous people include tobacco and alcohol use, higher intake of harmful food preservatives due to lack of refrigeration, and untreated H. pylori infection.
- Indoor smoke exposure: Many indigenous populations suffer from overexposure to harmful smoke pollution because they use biomass fuel for heating and cooking. Many combustion byproducts are carcinogenic.
- Environmental carcinogens: Indigenous people often live on environmentally contaminated or degraded land and are exposed to toxins such as mercury, DDT, arsenic, and petroleum.
Barriers to Care
Indigenous populations have relatively poor health outcomes, due not only to their greater risk for certain diseases, but also the many barriers they face when trying to access health care. They often reside in remote or rural communities without access to health clinics or proper cancer screening. When health services are available, they are often of poor quality and patients must undergo long waiting times for screening, follow-up care, and treatment.
Even when an indigenous patient is able to access a health care facility, cultural differences can adversely affect the patient’s interactions with modern health services. Many times, doctors are unaware of or insensitive to cultural differences, or they do not have the time to give proper explanations of the disease or next steps in care. Negative experiences can not only affect the management of the patient’s current disease, but can negatively affect health-seeking behavior in the future.
Lack of Research
We actually know very little about health and cancer among indigenous populations. Only 10% of medical publications from the Latin American region address indigenous health. An even smaller percentage of this research pertains specifically to cancer among indigenous peoples, despite the fact that they bear a disproportionately large burden of disease. We need well-coordinated research efforts to better understand risk factors, lifestyle factors, social determinants of health, environmental exposures, health-seeking behaviors, and access to oncologic services for indigenous people in Latin America. It is not until we have a comprehensive view of the problem that we can design sustainable interventions to improve outcomes.
There are some potential solutions we suggest to begin addressing the burden of cancer among indigenous populations:
- Cancer registries: What first need to establish cancer registries that specifically include ethnic data at the national, regional, and institutional levels in Latin America. This step is necessary to collect important data on indigenous health and cancer outcomes.
- Cancer prevention programs: Many of the cancers that disproportionately affect indigenous populations are preventable. We therefore recommend the expansion of cancer prevention programs, such as public education campaigns, the formation of advocacy groups, expanded HPV and viral hepatitis vaccination, cervical cancer screening, and public programs to control smoking and harmful environmental exposures.
- Provider education: To improve provider and patient relationships, we suggest providing education to health care providers on cultural sensitivity and health needs specific to indigenous populations. Additionally, hospitals in areas that service indigenous people could provide interpreting services and increase training of female health workers, since studies have shown that indigenous women strongly prefer female providers.
With more robust epidemiological data and a deeper understanding of the cancer burden among indigenous peoples, we can then work to reduce health disparities and improve outcomes of this vulnerable and underserved patient population.