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Felicia Marie Knaul,
Harvard Global Equity Initiative, HarvardMedical School; GTF.CCC
Tomatelo a Pecho; Fundacin Mexicana parala Salud
PATH
March 15th, 2011Seattle, WA
Breast Cancer:
Unforeseen PublicHealth Priority in
Developing Countries
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From evidence
to anecdote
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July, 2007
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January, 2008
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Harvard, Breast Cancer in Developing CountriesNov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor
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From anecdote
to evidence
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1. Evidence to anecdote to evidence
2. Cancer in LMICs: so muchmore can be done
3. Breast cancer: global health priority
4. Applying the diagonal approach inMexico
OUTLINE:
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Mandate: Design, develop andimplement global, regional andlocal strategies to improve the
financing, procurement anddelivery of cancer care,control, treatment and
palliation in a sustainablemanner applying innovativeservice delivery modelsappropriate to health systems
in the developing world.
Convened in Nov 2009By HSPH, HMS, HGEI, DFCI
27 membersrepresenting theglobal health andcancer
communities
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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary:
Not a health priority in LMICs/not a problemof the poor
M2. Impossible:
Nothing we can do about it
M3. Unaffordable: .for the poor
M4: Inappropriate: either/or
Challenging cancer implies taking resourcesaway from other diseases of the poor`
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LMICS: More than 85% of pediatric cancercases and 95% of deaths.
Level ofIncome
Incidence Mortality Population
Low 21% 27% 20%
Low middle 50% 55% 57%
Upper middle 15% 15% 13%
High 15% 5% 10%
Distribution of childhood cancer globallyby level of income (< 15)
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
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Lethality by cancer type and country income
Adults (15+)
Casefatalityapproximatedby
mortality/incidence
Breast
Cervix uteri Prostate
Testis
Hodgkin lymphoma
Non - Hodgkin lymphoma
Leukaemia
All cancers
0
0.2
0.4
0.6
0.8
1
Low income Lower middleincome
Upper middle
incomeHigh income
0
0.2
0.4
0.6
0.8
1
Low income Lower middle
income
Upper middle
income
High income
Source: Knaul, Arreola, Mendez. estimates basedon IARC, Globocan, 2010.
Children
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Concentration of mortality:example Cervical cancer
Children orphaned by cervicalcancer
HPV Vaccine
Source: Paul Farmer., 2009
275,000 deaths worldwide; 88% in LMCs
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Cancer is a disease of rich and poor
Yet, transition is polarizing the burden so that itis increasingly the poor who suffer:
Incidence and death: preventable cancers
Death: treatable cancer
Avoidable pain and suffering particularly at end oflife
Financial impoverishment from the costs of care andeffects of the disease
The cancer divide
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IT CAN BE DONE: From evidence to action:Innovation Initiative Partnerships in LMICs
Treating cancer in LMICs usinginnovative delivery and financing: task sharing and shifting Infrastructure shifting Application of technology of
communication Social Protection and health insurance
Models: Low-income: Rwanda-Malawi-Haiti
Lower middle-income: Jordan
Upper middle-income: Mexico
ACCESS
QUALITY
FINANCIAL
PROTECTION
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In developing countries, people withmultidrug-resistant tuberculosis usuallydie, becauseeffective treatment is oftenimpossible in poor countries.WHO 1996
MDR-TB is too expensive to treat in poorcountries; it detractsattention and resources fromtreating drug-susceptible disease.WHO 1997
Initial views on MDR-TB treatment, c. 1996-97
Source: Paul Farmer., 2009
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Outcomes in MDR-TB patients inLima, Peru receiving at least four
months of therapy
Mitnick et al, Community-based therapy for multidrug-resistanttuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.
cured83%
abandon
therapy
2%
failed
therapy
8%
died
8%
All patients initiated therapybetween Aug 96 and Feb 99
Source: Paul Farmer, 2009
Drug % Decline inprice 1997-9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Making commoncause with WHO:
Reduced prices ofsecond-line TB
drugs
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Rural Rwanda, Burkitts lymphoma
Source: Paul Farmer., 2009
Regimen ofvincristine,
cyclophosphamide,
intrathecalmethotrexate
Status post-CHOPin Central Haiti:Still in remissionthree years later
Central Haiti
0o
ncolo
gists
OUTLINE
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1. Evidence to anecdote to evidence
2. Cancer in LMICs: so much more can
be done
3.Breast cancer: global health
priority4. Applying the diagonal approach inMexico
OUTLINE:
M th lit
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Myth .versus ..reality:
breast cancer in LMICs
a disease ofdevelopedcountries andwealthy women.
a disease ofolder women
less of ahealth prioritythan cervicalcancer.
More than half of casesand almost 2/3 of deathsdeaths occur in thedeveloping world.
large proportion of casesand 60% of deaths inwomen < 54.
More deaths and DALYslost to breast cancer, in alldeveloping regions otherthan SEAsia and SSAfrica.
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In developing regions, breast cancer
Most frequent cause of cancer-related death in developingand 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 indeveloping regions?
2008: 1.38 million new cases; 50% of which are fromLIMCs
10.9% of all incident cancers second to lung
(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).
P l i k f
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Africa
LMICs
Maternalmortality
APPROX: 210,000
APPROX: 360,000
Breast andcervicalcancer
67,885
75,893
=133,778
772,728
478,640
=1,251,368
People are at risk for manyreasonsvictims of success?
The opportunity to survive should not be an accident of
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The opportunity to survive should not be an accident ofgeography or defined by income.
Yet it is.But . there is scope for action.
~casefa
tality(inciden
ce/mortality)
Source: Author estimates based on IARC, Globocan, 2008 and 2010.Quote: HRH Princess Dina Mired
Low-income
countries
Lower middle Upper middle High-income
countries0
20
40
60Breast
Cervix
48%
40% 38%
24%
63%
52%48%
37%
I LIMCS h hi h ti f
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In LIMCS, a much higher proportion ofdiagnosis and death is in women 55
33%67%
66%
34%
Agea
tdiagnosis
Ageatdeath
20%
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Mexico: key evidence
Since 2006 breast cancer is the #2 cause of deathamong women age 30 to 54 years; and the leadingtumor-related cause
In 2006, women between 30 an 65 years were morelikely to die of breast than cervical cancer. In 1980the risk of dying from cervical cancer was twice ashigh as breast cancer
Only 5-10% of cases are detected in stage 1 or in-situ, compared to approximately 60% in US.
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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.
Mortality from breast and cervical cancer inMexico1955-2008: less death from cervical
2006: BC>CC.Por primera vez en ms de 5 dcadas.
Rate for100,000 womenadjusted for age
0
4
8
12
16
1955
1965
1975
1985
1995
2005
Breast cancer and
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Breast cancer andSeguro Popular
As of Feb 2007 all Mexicanwomen diagnosed with breast
cancer have the right to financialprotection in health for breast
cancer treatment
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Early Detection = survival
Stage at diagnosisSurvival rates,
US ACS
0 - 1 98%2 - 3 84%
4 27%
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.
Mexico: 5-10% in stage 0-1;60-70% in III-IV
Stage at diagnosis by level of municipal
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Stage at diagnosis by level of municipalmarginacin, Mexico, IMSS 2006
(Mxico, IMSS 2006)
N=221(3.8%)
N=1737(30%)
N=2877(49.8%)
N=946(16.4%)
Source: Authors estimation based on IMSS data, 2006.
0%
10%
20%
30%
40%
50%
Poor (High) Middle Low Very low
Stage 1
Stage 2
Stage 3
Stage 4
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Why?
Health, social and health
system barriers
Barrier 1: myth stigma and
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br
Barrier 1: myth, stigma andmachismo
Barrier 2: Inequity in addition to lack of
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0%
10%
20%
30%
+ Poorest
Q1 Q2 Q 3 Q 4Least poor
QV
16%
21% 22%24%
28%
Fuente: ENSANUT, 2006
Barrier 2: Inequity in addition to lack ofoverall access and utilization
Only 1 in 5women 40-69
report a
preventivehealth visitincluding
mamography2006
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Barrier 3: Poor quality services
women diagnosed with bc reported problems withproviders 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 healthRESULTS FROM A NATIONAL QUALITATIVE STUDY NIGENDA ET AL, 2009
Barrier 4 Lack of financial protection
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Barrier 4: Lack of financial protectionfor early detection.
Fuente: Groot et al, 2006. TheBreastJournal
Since February of 2007, every Mexican womanhas the right to financial protection (full healthinsurance) 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 themost subsidized level in a public hospital -costs more than one month of subsistenceincome.
OUTLINE
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1. Evidence to anecdote to evidence
2. Cancer in LMICs: so much more can
be done3. Breast cancer: global health priority
4.Applying the diagonalapproach in Mexico
OUTLINE:
The diagonal approach to
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it has been discussed at length whatthe most effective approach is to deliver
health interventions: vertical programs orhorizontal programs. This is a falsedilemma, because both interventions
need to coexist in what could be called adiagonal approach
Seplveda et al., Aumento de la sobrevida enmenores de 5 aos: la estrategia diagonal
The diagonal approach tohealth system strengthening
A diagonal approach to women and
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Horizontal Coverage: BeneficiariesWOMEN
A diagonal approach to women and
health and cancer care and control
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1. Integrating breast and cervical cancer
screening into MCH, SRH2. Integrating disease prevention and
management into social welfare and anti-poverty programs
3. Catalyzing and employing community healthworkers and expert patients
4. Financial protection/insurance strategieswith horizontal and vertical coverage
5. Reducing non-price barriers to pain control6. Developing effective health services
research and monitoring
Diagonal approaches
ServiceP
latforms
HealthSy
stemsFunctions
Vignette: a series of Missed
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Vignette: a series of MissedOpportunities: Juanita
left breast substantially larger than right;arrived at Morelos Womens Hospital bcshe could not move her swollen arm; fatherof 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 poc
M i H i th i l l f
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Mexico: Harnessing the primary level ofcare for improving BC detection and care
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Felicia Marie Knaul,
Harvard Global Equity Initiative, HarvardMedical School; GTF.CCCTomatelo a Pecho; Fundacin Mexicana para
PATH
March 15th, 2011Seattle, WA
Breast Cancer:
Unforeseen PublicHealth Priority inDeveloping Countries