Cancer Control Opportunities in Low- and Middle-income Countries
Authors: E. Huerta, N. Grey
Journal: CA A Cancer Journal for Clinicians (2007)

In January, the American Cancer Society (ACS) reported the second consecutive annual decline in US cancer deaths since recordkeeping began in 1930.1 Three thousand fewer Americans died from cancer in 2004 than in 2003. This recent announcement, in addition to the decline in US cancer mortality rates that has been observed over the past 15 years, provides further evidence of the slow but steady progress being made in the war against cancer. There is, however, another rarely reported side to this story: the numbers of death from cancer in many low- and middle-income countries have been rising rapidly. This increase in cancer cases and deaths in low- and middle-income countries is part of a pronounced shift in the global disease burden. Over the next 10 years, deaths from infectious or communicable diseases are expected to decline by 3%, while those from chronic or noncommunicable diseases will increase by 17%.2 By 2030, there are projected to be 50 million deaths from noncommunicable diseases—more than 3 times the 15.5 million deaths projected for communicable, maternal, perinatal, and nutritional conditions.3 In all regions of the world, with the exception of Africa, the number of deaths from noncommunicable diseases will be significantly higher than those for communicable diseases. And while the death toll alone is staggering, the morbidity and economic impact on those affected, their caregivers, and society at large is also profound. According to the World Health Organization(WHO), people in low- and middle-income countries tend to develop chronic diseases "at younger ages, suffer longer—often with preventable complications—and die sooner than those in high income countries."2 Despite the dramatic increase in chronic disease mortality and morbidity in low- and middle-income countries, public awareness of the problem is low. Moreover, recognition of the problem among policy makers, the press, and even the public health community has been muted. The agenda for the G8 Group of industrialized nations emphasizes infectious diseases, but does not address chronic disease.4 The UN Millennium Development Goals single out HIV/AIDS and malaria, but only broadly reference "other diseases," and the Millennium Goals 2006 Report focuses exclusively on HIV/AIDS and tuberculosis. Infectious diseases remain a threat to the health and well-being of millions of individuals throughout the world, and their control should be a top priority, but we must also begin to elevate awareness and support for controlling chronic diseases. Robert Beaglehole, former Director of WHO's Chronic Disease Program, and Derek Yach, Director of Global Health at the Rockefeller Foundation, paint a distressing picture of the current situation: "The growing global burden of noncommunicable diseases in poor countries and poor populations has been neglected by policy makers, major multilateral and bilateral aid donors, and academics. Despite strong evidence for the magnitude of this burden, the preventability of its causes, and the threat it poses to already strained health care systems, national and global actions have been inadequate."5 Cancer comprises a major part of this chronic disease burden. Today, cancer—grouping all types of the disease—is the second leading cause of death worldwide, accounting for 7.6 million (13%) of the world's 58 million total deaths in 2005. Already, more than 70% of cancer deaths occur in low- and middle-income countries, and this proportion will likely grow as deaths from cancer continue to rise. Worldwide, an estimated 9 million people are projected to die from cancer in 2015, and 11.4 million in 2030.6 Growing and aging populations are a primary driver of the increase in cancer cases and deaths in low- and middle-income countries, but there are many opportunities to reduce this burden by applying known cancer prevention and control interventions. Infections, such as human papillomavirus (HPV), Helicobacter pylori, and hepatitis B and C, continue to account for 7% of cancers in economically developed countries and 17% of all cancers worldwide. Cancers caused by infections have a disproportionate impact on low- and middle-income countries, where they are responsible for 26% of all cases.7,8 Rapid economic development and aggressive marketing practices have led to changes in lifestyle behaviors in many parts of the world, including large increases in use of manufactured cigarettes; diets with excess calories from fat, sugar, and processed foods; and sedentary lifestyles. Together, these changes have produced a tremendous increase in the prevalence of overweight and obesity, which is associated with cancers of the colon, breast (in postmenopausal women), uterus, esophagus, and kidney, among others. Of course, tobacco consumption remains the single greatest preventable cause of cancer and many other chronic diseases. Without major intervention, an estimated 1 billion people will die of tobacco-related diseases in the 21st century.9 Recent reductions in incidence and mortality rates for some cancer types largely attributable to infectious risk factors are being offset by increases in rates of cancers related to tobacco, dietary, and activity patterns prevalent in higher income countries. Without substantial public health intervention, it seems likely that incidence and mortality rates for the latter group of cancers will continue to increase, and the associated burden of suffering and death will be amplified by the demographic changes we have already noted. • Developing or updating cancer control plans in each country every 3 to 5 years. • Ratifying the Framework Convention on Tobacco Control in each country. • Incorporating hepatitis B vaccination into childhood immunization programs and expanding efforts to reduce aflatoxin exposure where needed. • Actively planning for the implementation of the HPV vaccine and considering new screening approaches for cervical cancer. • Developing resource-level-appropriate guidelines for the clinical and public health management of major cancers. • Creating government-supported cancer centers of excellence; improving cancer centers through twinning arrangements; and expanding treatment and psychosocial services for children with highly curable cancers. • Removing barriers to essential pain control medications and the provision of palliative care. • Enhancing cancer surveillance and monitoring. • Increasing involvement in these efforts by international organizations, bilateral aid agencies, advocacy organizations, national institutions, and the academic community. The ACS has supported global cancer control efforts for over 50 years and is expanding its international work in response to the growing burden of cancer in low- and middle-income countries. The nonprofit sector already plays a vital role in reducing suffering and death from cancer and in the future must continue to work with the private and public sectors in assuming even greater responsibility for addressing the global burden of cancer. The ACS provided funding for the IOM study and fully endorses the report's recommendations. We believe it is critically important that the broader global health community join with the global cancer community to take the steps laid out by the IOM study, while there is still time to stem this growing pandemic.