The ASCO Educational Book is a collection of articles written by ASCO Annual Meeting speakers and oncology experts. Published annually, each volume highlights the most compelling research and developments across many different fields of cancer care.
In collaboration with Cancer.Net, authors of the ASCO Educational Book have tailored their articles for patients and their loved ones so that they may be similarly informed of the latest science in oncology to improve their care and outcomes.
Sana Al Sukhun, MD, MSc, is president of the Jordanian Oncology Society. Gilberto Lopes, MD, MBA, FAMS, is a medical oncologist and the medical director for International Programs at the Sylvester Comprehensive Cancer Center. Mary Gospodarowicz, MD, FRCPC, FRCR(Hon), is the medical director at Princess Margaret Cancer Centre. Ophira Ginsburg, MD, MSc, FRCPC, is a medical oncologist at the University of Toronto Women's College Research Institute. Peter Paul Yu, MD, FACP, FASCO, is physician-in-chief of Hartford HealthCare.
Cancer is one of the main causes of sickness and death in the world. In some countries, the number of people who die from cancer is high but starting to go down. The United States and other countries such as France, Japan, and Australia are considered to be high-income countries. These countries have developed economies and broad access to resources. In other countries, the number of people who die from cancer is rising. This rise is mostly seen in low- and middle-income countries (LMICs) that have limited resources available to treat cancer. In fact, 60% of the world’s new cases of cancer are diagnosed in LMICs.
How does preventing and treating cancer vary between high-income countries and LMICs?
Deaths from cancer have started to decline in high-income countries. These countries have resources for wide-scale cancer prevention programs and modern treatment facilities. Prevention efforts include access to cancer screening programs and public health campaigns. These programs create awareness of cancer risk factors that people can change, including smoking, sun exposure, and obesity. High-income countries also have large cancer centers and hospitals, state-of-the-art research facilities, and access to cancer drugs.
LMIC is a way to describe a country that has a gross national income of less than $12,235 per person per year. Sometimes “LMIC” is used the same way as the phrase “developing country.” Governments in LMICs must make difficult decisions about where to use money given their much more limited resources.
The rates of cancer diagnoses and deaths are rising in LMICs. For instance, 11% of the world’s population lives in Sub-Saharan Africa, yet countries in this region carry 25% of the “global burden of disease.” Global burden of disease is a measurement that combines years of life lost due to early death and years spent in poor health. Countries in this part of Africa make up only 1% of global health spending. In contrast, the Americas make up 14% of the world population. They carry 10% of the global burden of disease and account for more than 50% of global health spending.
In Africa, 29 of 52 countries have no radiation therapy centers. Radiation therapy is the most common way cancer is treated. These 29 countries are home to about 198 million people. By comparison, the United States has over 2,000 radiation therapy centers for its 320 million citizens.
Overall, high-income regions spend 5 to 10 times more on health care per person than LMICs. As a result, less than 50% of people diagnosed with cancer in high-income countries die from their disease. But 66% of people with cancer in LMICs die from their disease.
Other challenges to controlling cancer in LMICs include:
Cost of and access to cancer drugs
Small numbers of cancer specialists and other oncology professionals
Patients with more advanced disease at the time of diagnosis
Cancer not seen as a priority public health issue
How can LMICs improve cancer treatment and prevention with such limited resources?
There are many governments and international organizations working together to improve access to cancer prevention and treatment worldwide. But ,money by itself will not improve cancer care. There also needs to be easier access to surgery, radiation therapy, imaging, and pathology. The organization and structure of how cancer care is delivered also needs to improve.
Resource-stratified guidelines can help control cancer in LMICs. Resource-stratified guidelines identify the treatment options that will provide the best possible outcomes for patients in areas with limited health resources. These guidelines also recommend ways for LMICs to improve cancer care and advise doctors on how to provide the best care possible with limited resources.
What are some examples of resource-stratified guidelines?
Many organizations have built resource-stratified guidelines on a leveled system. For example, the Breast Health Global Initiative (BHGI) has recommendations on breast cancer treatment based on a 4-level system. The recommendations below show how to ensure that people with breast cancer who live in areas with limited resources get the best possible care.
BHGI’s leveled system looks like this:
Basic level: Core services that are necessary (e.g., mastectomy).
Limited level: Services that will improve health outcomes at a low cost and with limited facility needs (e.g., tamoxifen as adjuvant therapy).
Enhanced level: Services that are optional but further improve outcomes and increase the number and quality of treatment options for patients (e.g., aromatase inhibitors).
Maximum level: Services that might be used in high-income countries or are recommended in cancer guidelines that do not account for resource constraints. These services cost more and are usually not within reach for places with limited resources.
Other organizations with resource-stratified guidelines include:
There is much to be done to help LMICs improve access to cancer treatment and prevention. Improving outcomes does not always mean using the most recently approved drugs or procedures, but the most valuable tool for the option. Resource-stratified guidelines are a start to helping patient receive better access and treatment in LMICs.