Promoting evidence-informed cancer treatment policy making in sub-Saharan Africa
Authors: Justice Nonvignon
Journal: The Lancet Global Health (2021)

The burden of cancers is growing globally, with WHO estimates showing that cancer remains a leading cause of death among people younger than 70 years in 112 of 183 countries.1WHOGlobal health estimates 2020: deaths by cause, age, sex, by country and by region.https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-deathDate: 2020Date accessed: July 1, 2021Google Scholar, 2Sung H Ferlay J Siegel RL et al.Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin. 2021; 71: 209-249Crossref PubMed Scopus (5875) Google Scholar Low-income and middle-income countries (LMICs), in particular, are seeing increasing new cases and deaths associated with cancers. Among children and adults, lymphomas constitute a major burden in terms of new cases and deaths, contributing to the growing burden of non-communicable diseases in LMICs.3Dawson CP Aryeetey GC Agyemang SA Mensah K Addo R Nonvignon J Costs, burden and quality of life associated with informal caregiving for children with lymphoma attending tertiary hospital in Ghana.Int J Care Coord. 2020; 23: 165-172Crossref Scopus (2) Google Scholar Policy making in the health sector of many LMICs is evolving, with increasing attention to evidence-informed decisions, and many countries seeking to institutionalise the health sector priority setting, including health technology assessments and stand-alone economic evaluations or investment cases.4Hollingworth SA Ruiz F Gad M Chalkidou K Health technology assessment capacity at national level in sub-Saharan Africa: an initial survey of stakeholders.F1000Research. 2020; 9: 364Crossref PubMed Scopus (3) Google Scholar, 5Mueller D Addressing the challenges of implementing a health technology assessment policy framework in South Africa.Int J Technol Assess Health Care. 2020; 36: 453-458Crossref Scopus (3) Google Scholar, 6Govender M Letshokgohla ME Basu D Health technology assessment: a new initiative in South Africa.S Afr Med J. 2010; 100: 334Crossref PubMed Google Scholar In The Lancet Global Health, the work by Matthew S Painschab and colleagues assessing and documenting the cost-effectiveness of alternative diffuse large B-cell lymphoma (DLBCL) treatments is therefore welcome and contributes to the scarce literature on the cost-effectiveness of treatments for adult cancers in sub-Saharan Africa.7Painschab MS Kohler R Kimani S et al.Comparison of best supportive care, CHOP, or R-CHOP for treatment of diffuse large B-cell lymphoma in Malawi: a cost-effectiveness analysis.Lancet Glob Health. 2021; (published online July 22.)https://doi.org/10.1016/S2214-109X(21)00261-8Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar The authors used clinical data from a prospective observational cohort in Malawi of patients treated with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone; a common standard care for DLBCL in sub-Saharan Africa) and clinical trial data from patients treated with R-CHOP (CHOP plus rituximab; an uncommon treatment in sub-Saharan Africa but common in high-income countries) to calculate costs per disability-adjusted life-year (DALY) averted for the treatment of patients with DLBCL with best supportive care, CHOP, or R-CHOP. Painschab and colleagues found that CHOP clearly averted more DALYs at lower costs than R-CHOP (incremental cost-effectiveness ratio of US$193 per DALY averted for CHOP vs $1148 per DALY averted for R-CHOP). This finding is useful for policy making in sub-Saharan Africa in that, though the authors were short of clearly indicating this, the results showed that a more modern and often more expensive treatment type is not necessarily the best choice, and policy makers in sub-Saharan Africa could achieve similar (or even better) health outcomes with efficient use of existing resources to offer the available treatment type for DLBCL. Simply put, with efficient allocation of resources and guided by appropriate priority-setting mechanisms, decision makers in LMICs could improve health outcomes, even with the scarce resources at their disposal. Additionally, Painschab and colleagues found that the total costs of the treatments would account for between 0·6% and 1·2% of the annual health budget of Malawi. However, for a poor country that could only afford to allocate approximately US$170 million for the 2017–18 year, how feasible would this finding be? Clearly, any such recommendation would require some understanding of the political economy of health financing in Malawi to contextualise. The findings of the study should be interpreted with caution. Although the authors used appropriate methods to estimate costs, effects, and budget impacts, the acknowledged limitations make generalising the findings to other settings tricky. Particularly, data for the study were derived from one tertiary hospital in Malawi, which—as other sub-Saharan African countries—does not have a robust cancer registry. Again, the use of estimates from international sources for the budget impact analysis means that those estimates come with some degree of imprecision. Consequently, other studies in other sub-Saharan African contexts would be helpful in validating the findings of Painschab and colleagues and addressing key questions relating to whether CHOP and R-CHOP would be cost-effective in other settings. A key recommendation that the authors made was that similar studies are required to promote continued cancer treatment investments and prioritisation. Arguably, economic evaluation studies provide policy makers with the evidence required to support their resource allocation decisions. That notwithstanding, does the promotion of evidence-based decisions rely on researchers and analysts or with other stakeholders? Within the context of LMICs, where the evidence–policy link is not as strong, there is a clear role for other stakeholders to help bridge the gap and promote the best alternatives to policy makers, and civil society organisations lately have stepped up to that role in many LMICs. Researchers and analysts present the alternative scenarios, with their costs and consequences, and clear interpretations of the implications of each alternative to decision makers and policy makers, who make the final decision. Thus, there is need for a partnership between researchers, policy makers, and other stakeholders to promote research uptake, to ensure that research questions are linked to policy questions, and to facilitate evidence-informed policy making. Although estimates of the cost-effectiveness of alternative health interventions are useful for the health sector priority setting in LMICs, findings and recommendations from such analyses need to be contextualised, while also taking advantage of existing research uptake mechanisms in-country to facilitate evidence use. I declare no competing interests. Comparison of best supportive care, CHOP, or R-CHOP for treatment of diffuse large B-cell lymphoma in Malawi: a cost-effectiveness analysisWe estimated CHOP to be cost-effective for DLBCL treatment in Malawi, and that the addition of rituximab might be cost-effective. Despite upfront costs, DLBCL treatment is probably a prudent investment relative to other accepted health interventions in sub-Saharan Africa. Full-Text PDF Open Access