Concerns Mount About Providing Cancer Care in Low-Resource Areas

low-resource areas: low-resource areasWhile cancer used to be considered a problem mostly in the developed world, low-income and middle-income countries now bear the majority share of the worldwide cancer burden, said speakers at a workshop in Washington, D.C. They focused on strategies to improve statistics showing that cancer mortality is higher and outcomes tend to be worse in these low-resource global areas, as well as in low-resource areas of the U.S. Poverty; lack of education; lack of medical facilities, personnel, and equipment; and lack of patient access plague low-resource areas. The workshop, the second of two on this topic, was sponsored by the National Cancer Policy Forum (NCPF) of the National Academy of Medicine, which will issue a written report on the meeting. The Burden of Cancer “The global burden of cancer is increasing,” said Michael Barton, OAM, MBBS, MD, Foundation Professor of Radiation Oncology at the University of New South Wales, Australia. By the year 2035, there will be an estimated 24 million new cancer cases globally, with the steepest rise in low-resource areas, according to Barton, who is also Research Director of the Collaboration for Cancer Outcomes Research and Evaluation and the Ingham Institute for Applied Medical Research at Liverpool Hospital. Barton noted the worldwide need for radiotherapy services will be especially acute by 2035, with about 12 million of the 24 million new cancer patients needing radiotherapy treatment. But, he said, there is a shortage of radiotherapy treatment almost everywhere in the world but in the U.S., and “the people who are most likely to benefit are those who are least likely to get it.” Barton said there are 30 countries in Africa with no access to radiotherapy, and 120,000 new trained radiotherapists are needed globally. “This is quite a big task, and if we don't get started it won't happen,” he warned. “Radiotherapy is a missing but essential component of effective cancer control,” agreed David A. Jaffray, PhD, Professor in the Departments of Radiation Oncology, Medical Biophysics and the Institute for Biomaterials and Biomedical Engineering at the University of Toronto, Canada. Jaffray estimated that, of the 12 million new worldwide cancer patients projected to need radiotherapy in 2035, 950,000 lives could be saved if there were adequate standard radiation treatments available. “This is a massive problem,” said Jaffray, noting that the radiotherapy training issues alone are daunting. “It's likely to be 3 or 4 decades before we have enough oncologists to treat all cancer patients in the world,” said Lawrence Shulman, MD, Deputy Director for Clinical Services of the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, and Director of the university's newly formed Center for Global Cancer Medicine. Shulman noted there are many people who don't think the focus should be on treating cancer in low-resource areas, and that the focus there should be on prevention (the subject of the NCPF's first workshop on cancer in low-resource areas). But, emphasized Shulman, “What we're really talking about is withholding treatment from the world's poor,” an unethical position. Workshop planning committee co-chair Robert Carlson, MD, CEO of the National Comprehensive Cancer Network (NCCN), agreed that withholding cancer treatment from the world's poor is neither ethical nor supportable. Asked by Oncology Times if he believes there is enough attention paid to the global cancer burden to develop viable solutions, he said, “I think enough people are concerned that it's going to happen. It's worked for AIDS; it's worked for polio. I'm optimistic...I think we can do it.” But, he said, it is necessary to work closely with physicians and individual groups in countries around the world to identify specific gaps and fill their patients' needs. Carlson noted that NCCN not only translates its cancer guidelines into other languages, but also has developed a resource stratification framework so its guidelines will work in other countries, including low-resource areas. For example, he said there are low-resource areas where trastuzumab is too expensive and no HER2 testing is available, so NCCN breast cancer treatment guidelines must be adapted. Asked if he is worried about the fate of cancer care in U.S. low-resource areas if the Affordable Care Act is repealed under the incoming Trump administration, Carlson said, “We need to maintain those parts of the ACA that protect lower-income Americans. We need to retain an appropriate safety net.” He noted the ACA has expanded access to care, especially for low-income Americans, and “I would be very disappointed if we lost that access.” Carlson said he would also be disappointed if the ACA's coverage provision protecting Americans with pre-existing conditions is dropped. “The third world and its problems do not reside thousands of miles away... . The third world is right here if you're talking about cancer,” emphasized Augusto Ochoa, MD, Director of the Stanley S. Scott Cancer Center at Louisiana State University Health Sciences Center (LSUHSC), Professor of Pediatrics and holder of the Al Copeland/Cancer Crusaders Chair in Neuroendocrine Cancer at LSU. Ochoa noted Louisiana has a very high cancer mortality rate. Agreeing on the problem of cancer-care disparities in U.S. low-resource areas was Olufunmilayo I. Olapade, MD, the Walter L. Palmer Distinguished Service Professor of Medicine and Human Genetics, Dean for Global Health and Director of the Center for Clinical Cancer Genetics at the University of Chicago. “Large healthcare disparities in breast cancer have been identified in the underserved communities of South Side Chicago,” she said. “Where you live determines whether you live...it's because of the way resources are being allocated in this country.” Finding Answers to Cancer Care Among the solutions to cancer care challenges in U.S. low-resource areas presented by NCPF workshop speakers were the following. Following the destruction of Hurricane Katrina in New Orleans in 2005, Ochoa led the reconstruction of the LSUHSC Cancer Center through the development of partnerships between community oncologists, hospitals, and the LSU multidisciplinary cancer clinics. “We thought, could we address health disparities?” he noted. The partnerships turned into the launch in 2014 of the Gulf South Minority/Underserved NCORP, an NCI-funded comprehensive cancer management program. NCORP is a network of physicians, nurses, and researchers from major teaching and private medical institutions throughout Louisiana and Mississippi. It provides access to investigational therapies through clinical trials that use genomic profiling to target treatments to cancer patients' individual alterations. “If given the right opportunity, community oncologists will participate in a clinical trial,” stressed Ochoa. In Delaware, healthcare workers were alarmed by the racial disparity in colorectal cancer mortality, which was much higher in African-Americans. “We decided to create a colorectal cancer screening program,” said Stephen S. Grubbs, MD, Vice President of the newly launched Clinical Affairs Department at ASCO. What made the screening program—which had an aggressive media/advocacy campaign—especially attractive was that it reimbursed for uninsured and underinsured people, and also reimbursed for treatment for those who could not pay. “This is a momentous event in Delaware,” said Grubbs, a former community oncologist and managing partner at Medical Oncology Hematology Consultants, PA, in Newark. Grubbs, who serves on the advisory council of the Delaware Cancer Consortium, noted the program has been very successful, with a 300 percent increase in diagnosis at the localized stage. Grubbs said the program is evidence that with wise use of resources “we can make a difference.” He added, “You can actually eliminate disparities statewide.” At the Ralph Lauren Center for Cancer Care and Prevention—the only outpatient center of its kind in Harlem, N.Y.—specialists provide comprehensive care and an array of social services to low-income, predominantly African-American patients. “Patient navigation is at the heart of what we do,” said CEO Gina Villani, MD, MPH, who has served as chair of ASCO's Health Disparities Committee. Villani stressed that patient access is key: “We accept all insurance; we accept the uninsured.” The center offers appointments within 24 hours and accepts walk-ins for acute needs. “We have a lot of additional services,” said Villani. These include a food pantry, free Metro cards, legal services, financial support and counseling, and even free haircuts. In New Mexico, where there is a diverse and predominantly low-income population and just one NCI-designated cancer center, the state has established through a grant with the New Mexico Minority/Underserved NCI Community Oncology Research Program (NCORP), similar to what was done in Louisiana. The grant enhances patient and provider access to NCI-led clinical trials, said Melanie E. Royce, MD, PhD, Professor in the Department of Internal Medicine, Department of Hematology/Oncology at the University of New Mexico Comprehensive Cancer Center and Principal Investigator for NCORP. The New Mexico NCORP, in partnership with the New Mexico Cancer Care Alliance—a statewide clinical trials consortium—helps provide patient access to an expansive array of clinical trials to virtually all cancer patients in the state. “Everything is centralized,” said Royce. Because of this centralization, she said, it takes just 14 weeks to activate a clinical trial. In addition to adequate funding and reimbursement, speakers at the NCPF workshop emphasized the importance of making sure low-resource areas have the infrastructure for cancer care, including a supply of drugs that does not run out. It may be necessary to use new, low-cost technologies that might better enable screening programs in low-resource areas (in one country, a mammography machine sat on a wharf for 1.5 years because there was no technician to install it). Speakers also stressed the need for sensitivity to cultural and social issues, such as fatalistic ideas about death and cancer. And if a successful cancer care program is launched in a low-resource area, it must receive continued attention and support. “Once you've achieved what you want to achieve, sustaining it requires a lot of effort,” concluded Grubbs. Peggy Eastman is a contributing writer.

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