Cancer in My Community is a Cancer.Net Blog series that shows the global impact of cancer and how people work to care for those with cancer in their region. José Enrique Gonzales Nogales, MD, is a clinical oncologist who has been working at 4 different public hospitals in Bolivia since 2018. He completed his internal medicine specialty in Bolivia and clinical oncology specialty at Instituto Nacional de Cancerología in Mexico. In 2017, Dr. Gonzales Nogales received ASCO’s International Development and Education Award (IDEA). In 2021, he became part of ASCO’s Latin America Regional Council. You can follow Dr. Gonzales Nogales on Twitter or on his Facebook page, which is dedicated to raising cancer awareness in Bolivia.
Why I care for people with cancer
During my first internship in oncology, it struck me that more doctors are needed who can deal with the many issues that come with a cancer diagnosis, whether that means curing the cancer or helping someone with cancer cope with an advanced stage of the disease. Thanks to my training in oncology abroad, which I paid for with my own resources, I am able to go beyond the diagnosis of a person with cancer. It is satisfying to me to monitor the evolution of my patients, many of whom at first have poor functional status and emotional well-being and then start to get better as their treatment progresses. I also get satisfaction when I see them experience physical rehabilitation, mental rehabilitation, and reintegration into their work or family activities. All of this is very encouraging considering the severity of a cancer diagnosis. Yet even despite all efforts, sometimes I have patients whose disease progresses. When this happens, I am able to help them through palliative care and offer them a better quality of life.
On the academic and research side, oncology is also a great opportunity to have a big worldwide impact. In Bolivia, it brings me great joy to know that the personalized medicine we use is used the same way in other countries, too.
What cancer is like in Bolivia
In Bolivia, people with cancer can be stigmatized, similar to the experiences of people with the human immunodeficiency virus (HIV). A cancer diagnosis has a wide impact on the person’s financial security due to the cost of treatment, and people with cancer may be abandoned by their relatives. This is frequently seen in women with cervical cancer who are left by their partners.
The population of Bolivia is about 11 and a half million people. There is no cancer registry in Bolivia, but there are nearly 16,000 new cancer cases in my country each year, according to the World Health Organization. The most common types of cancer in Bolivia are cervical cancer, prostate cancer, breast cancer, and uterine cancer. The most common type of cancer for males in Bolivia is prostate cancer. Meanwhile, there are high rates of cervical cancer among females with cancer in Bolivia, followed by breast cancer. While there are well-established cervical cancer screening methods in Bolivia, including vaccination against human papillomavirus (HPV), cervical cancer is still a leading cause of cancer death in Bolivia.
How people with cancer receive care in Bolivia
In Bolivia, there are 3 types of cancer care: social security, public care, and private care. A person’s socioeconomic status often determines the type of care they receive. People with a low socioeconomic status, for example, attend public hospitals that are funded by the state. However, while the state covers some types of cancers, the coverage of cancer treatment by the government is irregular, in part due to political conflicts. Many times, people with cancer who attend public hospitals will end or abandon their treatment, often because the cost of care not covered by the government is too much.
Coverage through social security and workers' insurance offers cancer care for people with limited resources who are seeking to complete their treatments. For example, if a person with cancer has insurance through Cajas Nacional de Salud, which is a social security entity, their treatment is covered in full, including their palliative care.
Meanwhile, private cancer care is available for people with cancer who do not have insurance or who do have insurance but need more timely treatment. If a person with cancer in Bolivia chooses private treatment, they will pay for the full cost of their care. In an interview with María Juana Centellas Arías, MD, a clinical oncologist from La Paz, Bolivia, with more than 20 years of experience who was one of the first professional oncologists in the country, she tells us that the treatment done through private care is completed in most cases. However, Dr. Centellas also tells us that one of the weaknesses of private practice is not having enough trained paramedical and nursing staff available, which can force the oncologist to prescribe, supervise, and even prepare their patient's treatment.
The types of treatment available to a person with cancer also vary based on where they receive their care. Social security, for example, provides coverage for standard chemotherapy treatment. Meanwhile, in public hospitals, it is difficult to access chemotherapy due to its high costs, and even more difficult to access targeted therapy treatments. Private cancer care, where the costs of treatment are paid in full by the person with cancer, is the only type of care in which international standard treatments, such as targeted therapy, could be successfully offered and completed.
The challenges of treating people with cancer in Bolivia
To treat people with cancer in Bolivia, doctors use medications that can be found in the local market, including targeted therapy. However, if the drug is not available locally, it is difficult for a person with cancer to access the treatment regardless of the economic resources available to them, as importing the medication can take a long time and delay the start of treatment. In Bolivia, there is also not an easy way to find the mutations of different tumors through tumor marker testing. There is no national or private center that offers this service, and depending on the resources of the person with cancer, the samples would have to be sent abroad to obtain a result.
Regardless of a person with cancer’s socioeconomic status or the type of care they receive, the majority of people with cancer are diagnosed with advanced stages of the disease. In my personal experience, people often wait months to go to the doctor, opting instead for unconventional or “natural” treatments. Then, when they eventually decide to get specialized cancer care, their cancer has often already worsened, and they may face longer waiting list times.
Where people with cancer can find local resources and support in Bolivia
In Bolivia, there are several foundations that aim to help people with cancer. La Fundación Boliviana Contra el Cáncer, which is a nonprofit institution created in the city of La Paz, Bolivia, works to promote and maintain centers for the prevention, detection, orientation, and early diagnosis of cancer. Another foundation is the Fundación Nacional de Ayuda Contra el Cáncer (FUNACC), which for 15 years has been assisting with the care of and providing financial resources for people with cancer without discriminating based on their age or social status. La Asociación de Familiares y Amigos de Niños con Cáncer (AFANIC) is a non-governmental organization at the Pediatric Oncology Service of the Oncological Hospital of Santa Cruz de la Sierra, Bolivia, that helps meet the needs of children with cancer.
Cancer in adults is not covered by the Ministry of Health in Bolivia, though there are some exceptions for coverage, such as cervical cancer. However, finding out how to receive this coverage is difficult, and there is a constant protest from people with cancer and non-governmental organizations to improve governmental support for people with cancer.
Overall, although there is an awareness of the growing demand for the care of people with cancer, the current support by foundations, non-governmental organizations, and the national government is limited. This often forces people with cancer to cover their own costs for treatment or to obtain medical attention through health insurance provided by jobs.
The author has no relationships to disclose.