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For World Cancer Day, Let’s Set Our Sights Beyond U.S. Borders

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.

 

Dr. Eduardo Paulino Discusses His Global Cancer Fellowship

Dr. Eduardo Paulino from Rio de Janeiro, Brazil, served as a 2016 GCI Global Fellow from June to December. Throughout his Fellowship, Eduardo participated in all of the projects we do here at GCI, from leading research publications on cancer control in Brazil to helping design projects that will help patients in his home country and beyond. Eduardo has been a fantastic and energetic addition to our GCI team, and in the last few days of his Fellowship, I was able to speak with him about the projects he has been working on with GCI, his time in Boston, and his goals upon returning to Brazil.


 

1. Could you tell us a little bit about your background, your work as an oncologist, and what you do in Rio? 

I’m a medical oncologist, dedicated specifically to treating gynecologic tumors. I work in the department of Gynecology Oncology at the National Cancer Institute (Hospital do Cancer II) in Rio de Janeiro, Brazil, which is a public cancer institute. Most of my patients are under-resourced and have some serious obstacles when they try to access high-quality cancer care. In my hospital, we are able to provide public care for all women with the best evidence-based practices, which is a very rewarding environment to work in.

 

2. Do you like Boston? How has your experience been in our city?

Boston is an amazing city, and it has been a great host. I have had no problems at all (if you don’t count apartment hunting…) Wherever you are, you always have access to markets, drugstores, gyms, grocery stores, etc.  The city is also very welcoming to foreign students and tourists, with so many schools, hospitals, and things to do. All of the Bostonians that I have met are very friendly and helpful.

 

3. What has been your favorite experience in your fellowship so far?

My favorite experience in my fellowship has been the opportunity to share my ideas and have them taken into account. The interaction with my mentors was very fruitful, and I believe that both sides benefited from collaborating together. It is great to work with so many different people and to meaningful contribute to projects that will change the landscape of cancer care for patients in my country.

 

4. What kinds of projects are you working on here with Dr. Goss and GCI? What projects or ideas are you most excited about sharing with your colleagues and starting at your hospital when you get back to Rio de Janeiro?

My projects with Dr. Goss and GCI are based on the barriers that patients in low- and middle-income countries (LMICs) face when trying to access quality cancer care. We believe that the first step is to find these obstacles and create plans to overcome them, in order to better serve cancer patients in under-resourced countries. GCI’s patient navigation programs and prospective databases are the most exciting projects that I would like to implement in my hospital. GCI already has a global database for young women with breast cancer, but since I specialize in gynecologic oncology, I helped to design a cervical cancer database, so we can begin to learn more about the treatment choices and outcomes for women in Brazil and elsewhere who are suffering from this disease. It will be very exciting to implement this database with my own patients and contribute to a global body of data that will help us help women around the world.

 

5. What do you think will be your biggest take-away or lesson-learned from your time here at GCI?

Multidisciplinary work! Here, I really got to experience how important it is to engage in multidisciplinary teamwork–taking into account everyone’s opinions, respecting everyone’s experience, and maximizing our impact with the best approach. This pattern of working with multidisciplinary teams is one of GCI’s key goals, and it is used in patient care, as well as any kind of research project the group performs. By engaging the right people and various experts in the field, we are able to make the best decisions possible for our patients.

 

6. What advice would you give to young oncologists, doctors, or students who are thinking about getting into public health or cancer research?

That is possible to make a difference! Public health, especially in LMICs, is challenging. When you hit your first obstacle, don’t give up because there will be many more ahead. With continuous effort, you do have the ability and power to change patient care (whether that is by treating individual patients, improving screening practices, connecting a patient to other services, providing palliative care, or even finding a cure). Believe in yourself!

 

End-of-Life Care in Latin America

Extended use of aromatase inhibitors for breast cancer therapy is both beneficial and accessible

On June 5, 2016, Dr. Goss gave a plenary lecture at the ASCO Annual Meeting on a groundbreaking clinical trial he has been leading for some time. The trial found that extending the use of aromatase inhibitors for breast cancer therapy can reduce the risk of breast cancer recurrence and decrease the chance of a new cancer forming in the other, healthy breast.

 

The ASCO selection committee chooses its plenary lectures based on their direct clinical application. From a review of 5,400 abstracts they select four most likely to change clinical practice. The trial under Dr. Goss’ leadership, called MA.17R, was selected as the number one trial for presentation at the world meeting, and the results were published in the prestigious New England Journal of Medicine.

 

In recent years, Dr. Goss has shifted his research priorities from discovering new breast cancer clinical therapies in the developed world to helping underserved patients in low- and middle-income countries (LMICs) across the globe.

 

Dr. Goss emphasizes that, unlike many cancer therapies, aromatase inhibitors are widely accessible – most are off-patent and, therefore, relatively inexpensive. “New targeted therapies, immunotherapies, and advanced genetic testing are scientifically exciting, but prohibitively expensive for most of the world’s population. Most money for cancer control is spent in high-income countries. Since 86% of funds spent on cancer control globally are spent on only 6% of the world’s population, people in LMICs do not benefit from these scientific advances. Patients from these populations would benefit more from enhanced access to simple, ‘bread-and-butter’ medicine,” Dr. Goss says.

 

Several years ago, after the global success of his original MA.17 trial, Dr. Goss traveled extensively around the world presenting results from the trial. Somewhat to his surprise, young doctors in LMICs approached him by the dozen asking to train with him, publish with him, and learn from him. They wanted to improve the state of clinical care and research in their countries, but they were always met with resistance by shortage of funds or lack of opportunity.

 

Dr. Goss realized that the true solution to global cancer control is not necessarily to cure cancer – which is undoubtedly important – but to help patients from underserved populations to access resources that have existed for many decades in the developed world. His chief mission is to improve the survival and quality of life of underserved cancer patients worldwide and thus he has founded the Global Cancer Institute.

 

So although the presentation of the MA.17R trial was a departure from his current daily focus, Dr. Goss recognizes that all patients with breast cancer – regardless of socioeconomic background – stand a chance to benefit from the results of his latest scientific research.

5 Ways Patient Navigators Are Helping Women in Uruguay

Earlier this month, we launched our newest Patient Navigation Program in Montevideo, Uruguay. At Jardines del Hipodromo, a community health center in Uruguay’s capital city, two patient navigators are helping women with abnormal Pap tests receive the follow-up care they need.

 

Pap tests are an important step in the early detection of cervical abnormalities and critical for the prevention of cervical cancer. Cervical cancer is one of the most common cancers affecting women in Uruguay and other low- and middle-income countries, and despite a comprehensive national prevention plan, the disease continues to impact the most vulnerable women in Uruguayan society – women in the public sector, young and single mothers, and those with lower educational levels and socioeconomic status.

 

In order to detect and prevent the progression of cervical cancer, Pap tests are recommended for every women between 21 and 69 years of age. However, the proportion of women who receive a Pap test in Uruguay is low, and among those who do receive a Pap test, few know the results of their test or move on to receive the recommended follow-up care. The important thing to know about cervical cancer is that it is preventable – through screening, early detection, and timely follow-up, no woman should have to suffer from it. Yet women in Uruguay and other low- and middle-income countries are still presenting with cervical cancer at advanced stages and, as a result, are dying from a preventable disease.

 

Patient navigation is one important and cost-effective way to enhance access to health care for underserved and vulnerable patients who suffer from – or are at great risk from suffering from – cancer. Patient navigators are specialized health care workers that operate at the intersection of social work, community outreach, and patient support, and they are important liaisons between patients and their health care teams. In Uruguay, our patient navigators are there to help women understand their Pap test results, know what they should do next, access existing health resources, and overcome barriers to receive the follow-up care they need. In this way, navigators are supporting women as they “navigate” the health system to access life-saving screening and treatment, thereby improving patient outcomes and cancer mortality.

 

Here are five important ways in which patient navigators are helping women in Uruguay:

 

1. Delivering test results: In a fragmented health system, sometimes just knowing your test results can be half of the battle for women receiving recommended Pap tests at their local health center. In Uruguay, there is a very important national plan to prevent cervical cancer, and the national program reads Pap tests from around the country to determine whether they are normal or not. Unfortunately, those results are not delivered back to the health center where the Pap test was performed. Even though women are supposed to receive a call from the national program with their results, the health center has no way of knowing which patients need follow-up care or if the women in their clinic are even receiving these calls. As part of the new Patient Navigation Program, navigators will personally call every women in the health center with an abnormal Pap result in the past two years to deliver the results.

 

2. Coordinating next steps: So your results have come back abnormal…now what? Once a woman learns of her Pap result from the navigator, the navigator will tell her what the recommended follow-up care is. The woman might need to come back for a repeat Pap, she may need a different test, or sometimes she will have to go to a specialty health care center for follow-up. The navigator will know this information and know how to help the woman get to where she needs to be – either by scheduling the follow-up appointment, informing her about clinic hours and days of services, or connecting her with a gynecologist to learn more about her options.

 

3. Overcoming barriers to care: Oftentimes, it isn’t enough to simply have a follow-up appointment scheduled. Patients are often faced with barriers that prevent them from showing up to their appointment or continuing to attend important follow-up appointments in the future. Work, family obligations, and childcare are some of the most common barriers that patients – especially women – face when trying to find time to go to the doctor. Other barriers may include lack of proper health insurance paperwork, difficulty reading or writing, language barriers, or lack of transportation to the clinic. The navigator is equipped to help with each of these issues – either by helping directly with the filing of paperwork for health insurance or patient registration, or connecting the patient to community resources for help with childcare or transportation. Sometimes something as simple as being able to purchase a discounted bus pass can help a women attend a lifesaving follow-up appointment.

 

4. Educating and empowering: In addition to all of the “logistical” barriers a patient could face, there are educational and psychological barriers that keep patients from attending appointments and making the most of their time with their doctor. Navigators also work to help patients understand what an abnormal Pap test means, as well as the importance of Pap tests, follow-up appointments, and both initiating and completing medical treatment. In this way, navigators can help empower patients to take an active role in seeking out healthcare, so women can continue positive health-seeking behaviors in this and other aspects of their health. By educating women about the importance of taking control of your health, the navigator can have a “ripple effect” in the community that isn’t limited just to the prevention of cervical cancer, but extends to other aspects of personal and family health.

 

5. Providing emotional support: Finally, a navigator provides emotional support throughout a woman’s journey to seek out her follow-up care. The anxiety that comes with an abnormal test result can be a barrier in and of itself, and many women feel shame or fear, which prevents them from addressing the issue early. They also worry about the impact on their families and jobs, and a navigator is there to connect women to support groups or simply provide emotional support by listening to and empathizing with them. Having an advocate dissipates some of the anxiety associated with coming to the health center to see a doctor, perform another test, or start treatment for a disease, and as a woman is shuttled around from doctor to doctor within a fragmented health system, a navigator can be a friendly face or an extra lifeline in a time of need.

 

In these ways, patient navigators facilitate access to timely and quality care and help create a more positive healthcare experience, which lead to better health outcomes and greater patient empowerment. Our patient navigators are working to change the way follow-up care is provided to women in Montevideo, and their work will undoubtedly have a positive impact on the health center, the community, and the health system.

Why Do LMICs Need National Cancer Control Plans?

When most people think of health in low- and middle-income countries (LMICs), they think of infectious disease. Infectious disease has, after all, been the most pressing health concern for the less developed regions of the world, and it oftentimes commands the attention of both media and global health philanthropy worldwide. However, what most people don’t realize is that non-communicable diseases, such as cancer, are overtaking infectious disease as the leading healthcare threat in these LMICs. And when the health system needs to divide its attention between what we are now calling the “double burden” of communicable and non-communicable diseases, it can get overwhelmed.

 

It is easy for public health officials to wave off the more gradual growth of non-communicable diseases in these countries, especially when patients are suffering from acute infectious illnesses that seem to demand more immediate attention. But as cancer incidence in LMICs rises due, among other factors, to aging, Western lifestyles, cancer-causing infections, and carcinogenic environmental factors, governments and health ministries cannot stand idly by. The burden of cancer in LMICs is now greater than that in more developed countries, as more and more patients are dying of advanced stage disease.

 

It is time to take action in LMICs to prevent, detect, and treat cancer as early and effectively as possible, and this is accomplished through national cancer control plans (NCCPs). 

 

According to the World Health Organization, an NCCP is defined as “a public health program designed to reduce cancer incidence and mortality and to improve the quality of life of cancer patients, through the systematic and equitable implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment and palliation, making the best use of available resources.” That’s a hefty definition, but essentially NCCPs lower the number of new cancer cases a country sees each year and improve the quality of care cancer patients receive by following a comprehensive national plan.

 

National cancer control plans are so important for countries that need to address the growing global cancer burden. Establishing an effective NCCP integrates existing health systems in a country and coordinates efforts to address the complexities of cancer care and treatment. However, many LMICs do not have one of these plans and are even struggling to adopt one in the face of competing health priorities, inadequate resources, and lack of expertise.

 

Latin America is one example of a region that exhibits a great need for national cancer control plans, but countries throughout the region are struggling to design and implement them. One big hurdle they face? Lack of adequate cancer registries.

 

Cancer registries are a fundamental requirement for the successful implementation of NCCPs. Why? Because you need to know the problem before you can implement a plan to fix that problem. Cancer registries collect highly valuable epidemiologic data on the state of cancer in a country – which cancers are most common, which areas have the highest cancer burden, who is most affected by cancer, etc. The data collected in cancer registries is essential for health officials to know the who, what, when, where, and why of their national cancer control plans. Armed with the knowledge of the local needs and current deficiencies in cancer care, a country can develop an evidence-based and forward-looking NCCP.

 

Fortunately, the percentage of Latin American and Caribbean countries that reported having a population-based cancer registry increased from 21% to 67% between 2011 and 2014. However, there is still a long way to go, as the proportion of the population that is actually covered by these registries is still quite low compared to developed countries. As the quality and quantity of data collected in Latin America grows, health authorities can begin to establish specific public health strategies to address the growing burden of cancer throughout the region.

 

Peru is a great example of a country in Latin America that has created, adopted, and implemented a national cancer control plan, which they have named “Plan Esperanza.” Plan Esperanza was created by a multidisciplinary team, including policy makers, that brought together different constituents to put forth comprehensive cancer control policies. The plan now impressively includes ten neoplastic diseases. Since the adoption of their NCCP, the following amazing things have happened in Peru:

  • The proportion of patients included in the universal healthcare system increased from 17% to 64%
  • The proportion of patients who paid out-of-pocket expenses for cancer treatment decreased from 59% to 7%
  • 16 million people have received preventive interventions, such as educational sessions and counselling
  • 2.5 million people have been screened for cervical, breast, gastric, colon, or prostate cancer – or a combination of these diseases

 

National cancer control plans like Peru’s are so important that coordinated international efforts – spearheaded by big organizations like the WHO – have been cropping up over the past few years. For example, the WHO endorsed the Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020, which aims to achieve a 25% reduction in premature mortality from NCDs by 2025. WHO and PAHO (the Pan American Health Organization) launched the Women’s Cancer Initiative to bring together partners to set up action plans for the prevention and control of cervical and breast cancer in Latin America. Finally, the International Cancer Control Planning Partnership (ICCPP) was launched due to the combined forces of the Center for Global Health and the National Institutes of Health in the United States, the Latin America and Caribbean Society of Medical Oncology, PAHO, and the Union for International Cancer Control. The goal of the ICCPP is to implement and assess national cancer control plans with a worldwide framework and international support.

 

Undoubtedly, there is an urgent need to plan, develop, and better implement national cancer strategies, as low- and middle-income countries continue to bear more and more of the global cancer burden. What other countries or international organizations have been particularly successful at designing and implementing NCCPs? What more is needed from the international community to make these important goals a reality? Join the conversation and comment below!

 


Information in this post is summarized from our Lancet Oncology Commissions on Planning Cancer Control in Latin America and the Caribbean and Progress and remaining challenges for cancer control in Latin America and the Caribbean.