Of cancer control and access to treatment!  

It is my view, as we mark this 2018, World Cancer Day, that ‘The first step in addressing cancer’s global impact will be to recognize that the disease affects people living in all countries, under all economic conditions.’  This statement is a global reality, and must be addressed by all and efforts should be put in place to work towards realising “a world where cancer is prevented or cured and every survivor is healthy.” (ASCO’s vision)!  “Cancer’s death toll is high worldwide, but the burden is tilted more toward these countries that lack resources and infrastructure, which include a shortage of health care professionals trained in research, a lack of funding, and a lack of mechanisms for conducting research.” 

Globally, more people die of cancer than of tuberculosis, malaria, and HIV/AIDS combined. This burden is not shouldered solely by high-income countries (HICs) like the United States—60% of the world’s total new cancer cases are diagnosed in low- and middle-income countries (LMICs). The truth remains that: “The basic way of preventing cancer and treating it has not reached 90% of the world’s population.”

The quest for worldwide health equity is driven by scientific discoveries from every corner of the globe, and Sub-Saharan Africa should not be excluded. Global Oncology’ requires a paradigm shift, from a model of taking knowledge generated in a ‘developed’ location and disseminating it to a ‘less developed’ location, to a multipolar model where solutions are being generated and shared across multiple settings.” The focus should be on an approach to continuously improve the quality and quantity of both cancer research and cancer care in different parts of the world, without excluding any region! 

While confronting cancer’s global impact presents an ambitious road ahead for oncology professionals from LMICs and HICs alike, experts have emphasized the importance of working together everywhere and anywhere that there is a patient with cancer. Nigerian professionals should aim to be part of the voice of global oncology, to attract, review, participate in Oncology Studies and publish work relating not only to differences in cancer biology resulting from risk factors, pathogenesis and pharmacology, but also disparities arising from social, cultural, economic and political resource-constraining issues, bench marking the findings on resource-stratified guidelines.”

One approach to combating cancer health disparities in LMICs is through investing in research efforts focused in these countries. Supporting research in all practices settings, will enable health care professionals to conduct research projects relevant to their settings and patient populations. Prof. Olufunmilayo I. Olopade, MD, FACP, FASCO, is a breast cancer researcher known globally for her work on genetics, particularly the BRCA1 and BRCA2 genes, and research to close the knowledge gap leading to disparities in cancer outcomes in the United States and abroad. She opines at ASCO 2017 Meeting; “We have to be in this together, as we don’t know where the cures are going to come from. The looming global epidemic of cancer means that all of us in oncology have to come together to make sure anyone and everyone has a chance to survive cancer.”

She notes that while the majority of patients with cancer live in low-resource settings, cancer treatments are developed for use mostly in high-resource settings, and that patients should not die prematurely from cancer because they do not have access to affordable, lifesaving treatment. “The disparities in low- and middle-resource countries aren’t there because people don’t show up,” said Dr. Olopade. “It’s because the systems fail them. And the systems of these countries are failing because everyone thinks that people who live in LMICs only get infectious diseases. People in these countries are getting cancer, and there aren’t many people or resources on the ground to treat them.” While most new cancer cases are diagnosed in LMICs, and the overall burden of all disease is greatest in LMICs, these countries receive a disproportionately low amount of funding for health (In Nigeria the health budget is only 3.9% of the total National budget far less than the 15% allocation agreed upon by Nigeria and other African Countries during the 2001 Abuja Declaration). The World Health Organization (WHO) reports that sub-Saharan Africa—with 11% of the world’s population and 25% of the global burden of disease—accounts for less than 1% of the world’s financial resources for health. In contrast, the Americas, with 14% of the world’s population and 10% of the global burden of disease, account for more than 50% of the global health expenditure.

“We really have to accept the responsibility that health is a human right,” said Dr. Olopade. “And as a society of oncology, we cannot look for the most expensive way to treat cancer when the basic way of preventing cancer and treating it has not reached 90% of the world’s population.” There are very few resources dedicated to global oncology in LMIC countries to facilitate harnessing Local Content data, assessing what is going well, what is missing, how they can improve the level of care, and how they can adapt clinical and translational research to their own environment.

So we need to build Capacity, one step at a time. Studying Current curriculum in practice in LMIC, shows that the education of primary care physicians and nurses on cancer screenings during their medical training is minimal. Thus to make a significant and sustainable impact, we need to improve their training, as these professionals are the front line of medical care. Education of primary care physicians and nurses on cervical cancer screening, diagnosis, and treatment, Breast Cancer ‘Breast Self Examination’, ‘Clinical Breast Examination’, and Digital Rectal Examination for Prostate Cancer, in a programme that will consist of culturally adapted breast health education sessions given by medical doctors, educators, and a breast cancer survivor, and aimed to transform young girls into health promoters within their households and communities. Already in existence is the BWS CDS NYSC Cancer Prevention Advocates Program that has been in place since 2009, but over the years has suffered ‘ burning Out’ due to funding constraints to sustain ‘over heads’ that are imperative! Subsequently, it will be Important to explore the potential integration of the breast and Cervical/ Prostate health education program into the educational curriculum of Secondary schools.

Such infrastructure can be supported and fortified by creating multidisciplinary, multi-institutional and Multi-country research teams from various national and international institutions, in a strong network that will foster attraction/ push factors for absorbing research funds, attracting clinical trials, and enabling acquisition of new skills to continue developing research in patients with cancer or at risk of cancer in limited-resource settings.” This later platform has been put in place by the Association For Good Clinical Practice In Nigeria (AGCPN), through its Clinical Trial Africa Vision 2020 Initiative and African Clinical Trial Consortium Network of Researchers! (ACTC).

There thus need to acknowledge the reality of limited resources in most parts of the world and accept that: “The basic way of preventing cancer and treating it has not reached 90% of the world’s population.” LMICs have the highest rates of stomach, liver, esophageal, and cervical cancer, and have a disproportionate burden of infection-related cancers (such as Cervical, Oral, Anal, Penile, Liver, Stomach Cancers and HIV related Cancers). Although these cancer rates are also high in HICs, they are plateauing or decreasing for the most common cancers due to decreases in known risk factors, screening and early detection, and improved treatment. Effective cancer control in any setting requires a complex combination of prevention strategies, early detection, and therapeutic and supportive care. This is all made even more complex in LMICs, where limited resources require a careful allocation according to priority needs. And determining the most effective approaches in LMICs is a fertile area for innovative research.

“We really have to accept the responsibility that health is a human right,” said Dr. Olopade. Going with this opinion, The Universal Health Coverage must come into operation in Nigeria, and the NHIS must look into covering Cancer treatment. In Ghana, Cancer treatment and transportation to Access the treatment are free for all Breast Cancer Patients! Breast Cancer remains the commonest Cancer in Nigeria! 

So as we mark the 2018 World Cancer Day this week, let’s break the vicious cycle! Change the narrative with better outcomes! #WECANICAN!!! Join and support organisations like BWS, to break this vicious cycle and change the deplorable cancer narrative in Nigeria …. All hands on deck!! Breast Without Spot (BWS), is a Not-for-Profit, Non-Governmental Organisation, registered in Nigeria/UK, with the mission to reduce the burden of death due to late cancer detection/other Non-Communicable diseases through health education, screening, vaccination, training, and research on ALL cancers and non-communicable diseases. In Nigeria, illiteracy and ignorance about cancer are widespread. Often complicated by cultural practices and superstitious beliefs, many of our citizens suffer untold hardship due to ‘Late Stage Cancer’ and ‘Treatment Failure’ from ‘Out of Pocket Payment’ for cancer treatment. Nigeria has the highest Cancer death rate in Africa. One of the major drivers for the high morbidity is the unaffordable medical bills associated with late presentation. Late Presentation itself is tied to the people’s fearful perception that Cancer, especially Breast Cancer is a death sentence, due to the poor Survival Statistics. The Fear that fuels the wrong perception, can only be buried if we can change the narrative, through improving survivorship, and increase the number of people who are alive to share their stories. Thus, ensuring sustained awareness to improve on compliance with Healthy living and Screening recommendations, must mandatorily be complimented by providing an Interventional Fund to ensure those detected early are assisted to access/afford medical Management across the continuum of care.

BWS started in 2008 with focus on Breast Cancer, because Breast Cancer is the most common cancer in Nigeria, accounting for 1 out of 4 cancers, with 70% mortality rate, and only. In Nigeria, the uptake of Mammography, even among Female HealthCare Professionals, has been reported to be as low as 3-8%. This is surely deplorable, when the best practice should be 99.9%. Community engagement through awareness and sustained teaching of screening recommendations, in addition to creating sustainable means of funding cancer care, are required to ameliorate the increasing cancer burden in Nigeria, change survivorship statistics positively, and thus the narrative.
Prof. Okoye is a radiologist at the Radiation Medicine Department, University of Nigeria College of Medicine (UNCM) and University of Nigeria Teaching Hospital (UNTH), Enugu.