Lifting the veil on cancer treatment
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2019)

Cancer is one of the toughest global health issues to tackle. Its burden is large and rising, with 9·6 million deaths in 2017 according to the Global Burden of Diseases—an increase of 25% over a decade. The complexity and diversity of the disease in terms of aetiology, symptomatology, and prognoses make it a challenge for health systems lacking the capacity for screening, diagnosis, therapy, and palliation. In many low-income and middle-income countries (LMICs), where the brunt of the disease burden is being borne, cancer services are not being prioritised and although a large proportion of cancers, 30–50%, is thought to be preventable, comprehensive cancer prevention strategies are not the norm. Yet we know a lot about cancer prevention. The main focus of global efforts against cancer has been to raise awareness of well known risk factors such as tobacco use or lack of physical activity, increase immunisation to prevent liver and cervical cancer, and improve screening for early detection. In countries with data, knowledge of risk factor distribution can reach a remarkable level of granularity. In our February issue, Wanqin Chen and colleagues presented a systematic analysis of the cancer burden attributable to 23 modifiable risk factors for all Chinese provinces, showing that 45·2% of cancer deaths could be prevented through locally-tailored primary prevention measures. When disaggregated at that level, the results of the risk factor analysis, which highlight the variations by sex, age, and province, are a very useful input for regional prevention strategies, and a way to address inequalities in exposure to those risks. Indeed inequalities have been a constant feature of cancer mortality and morbidity. Cervical cancer for example has seen great reduction in incidence, but progress has been limited to countries with the economic means to purchase the human papillomavirus vaccine, put in place effective screening to detect pre-cancerous lesions, and treat invasive cancer adequately. Unfortunately, as Felicia Marie Knaul and colleagues reflect in a Comment in this issue, in spite of progress, “cervical cancer is not a disease of the past—it is a disease of the poor” and it is imperative to examine how this disparate distribution impacts the level of priority it receives both on the research and global health policy agendas. In many regards, treatment is where these inequalities are most clearly expressed. Treatment choices for cancer usually include surgery, chemotherapy, and radiotherapy, all demanding options in terms of skilled human resources, high-tech therapeutic equipment, and expenditures. For most patients living with cancer in LMICs, access to these remains a utopia. Pharmacological treatment is a particularly difficult issue as access to cancer medicines has been heavily impacted by increasing expenditure driven by high prices. In December 2018, in response to resolution WHA70.12 on Cancer prevention and control in the context of an integrated approach, WHO quietly released a Technical Report on pricing of cancer medicines, which was discussed at the 144th Executive Board meeting last month. The report is a detailed, solution-driven examination of the pricing of cancer medicines and how it impacts availability and affordability. Among other things, the accent is put on R&D and how costs relate to pricing and innovation. The main findings are ultimately unsurprising, but they hint at the frustration felt by many around the status quo on medicine pricing. The report bluntly calls on the high variability and lack of transparency of R&D cost estimates and suggests that “the costs of R&D and production may bear little or no relationship to how pharmaceutical companies set prices of cancer medicines”, commercial goals and profit-maximising taking precedence over other considerations. Worryingly, the analysis mentions the frequent inability of pricing regulations, where they exist, to control the price of cancer medicines, particularly for newer drugs. The report also describes an imperfectly competitive and increasingly concentrated cancer medicine market, where research waste and redundancy are rampant and price competition does not systematically lead to lower prices. Beyond just the notion of financial access to treatment, drug pricing is also a key input into the economic case for investing in cancer control which, with the right set of interventions, can be cost-effective. Making the case will require lifting the veil on cancer medicines pricing practices so that beyond prevention measures, an adequate, safe, and most of all affordable array of treatment options can be offered to the vast majority of patients currently left out by their economic circumstances. Cervical cancer: lessons learned from neglected tropical diseasesDespite improvements in reducing the incidence of cervical cancer and its associated mortality, and global optimism for the prospects of its eradication,1 cervical cancer is not a disease of the past—it is a disease of the poor. Every 2 minutes a woman is lost to cervical cancer. Most of these women live in low-income areas. Full-Text PDF Open Access