Cancer care--the relation between resources and outcome.

Cancer is an increasing health problem worldwide. By early in the next decade it will be the number one cause of death worldwide. This is despite the fact that our treatments for most types of cancers are improving. In the West a major reason for the increasing number of deaths is an aging population. The increase in the number of cases in older patients overcomes the impact of better treatments. In developing countries the major causes of increasing burden from cancer appear to be cigarette smoking and poor control of certain infectious diseases (e.g. hepatitis B). One impact of this increase in cancer as a health care problem is that cancer is a major component of increasing health care costs. There is a striking difference in the amount of money per capita spent on health care from country to country. This is true even in the industrial countries of Europe and North America. The United States spends the most per capita on health care delivery and spends approximately twice as much as some countries in Europe and the British Isles. Unfortunately this does not seem to relate to an improvement in treatment outcome. In fact, the United States seems to lag behind a number of European countries in certain measurements of health outcomes [1]. This probably relates to better access to health care in Europe with all citizens being able to access primary care and to have treatments for a serious disease such as cancer. Thus, simply spending more money does not guarantee a higher quality of care. In the developing world, however, health care resources can be the limiting factor in treatment quality. For example, Peter Isaacson informed me that Zambia had its first full-time histopathologist in the 1990’s. The treatment of cancer for patients in that country before that time would have been problematic to say the least. At the present time Zimbabwe has almost no organized health care and hardly any resources devoted to care. When an epidemic such as cholera is unable to be controlled, it is unlikely that many patients are able to receive modern care for cancer in Zimbabwe at the present time. In many other countries limited resources are a major factor impairing the availability of quality health care. In this issue of Leukemia and Lymphoma, Stefan and Stones address the issue of the ability to deliver high quality cancer care to children with Hodgkin lymphoma in a developing country [2]. The conclusion that one might draw from this manuscript is that it is possible to deliver high quality care in a resource poor setting under certain circumstances. Several factors seem to be important. The first is well-trained and committed physicians. I know from my own experiences in Africa that many such physicians exist—not just in South Africa—working under conditions that would discourage most physicians from Europe and America. However, they deliver excellent care. The second factor that seems to be important is the judicious but appropriate use of diagnostic and staging resources. For example, PET scans for every patient will not usually be possible in this setting, but clinical exams and other images will usually obtain enough information to make good treatment recommendations. Finally, there need to be effective drugs available at modest cost—e.g. ABVD in Hodgkin lymphoma. Routine images in remission are of questionable value in either the developed or the developing world [3,4].