Cancer Control in Low to Middle Income Countries

Lingwood et al. Nature Reviews Cancer 8, 398-403 (May 2008)

Cancer control in low and middle income countries will not be effective without a multifaceted, innovative approach that includes the lay public and the medical community.

By CHUMY NWOGU, MD, PhD

Published January 5, 2017

“It is crucial for people to understand that a diagnosis of cancer is not necessarily a death sentence. To the contrary, early detection of cancer makes it possible to achieve a cure.”
Chumy Nwogu, Associate Professor
Department of Surgery

The incidence and mortality rate of cancer is increasing globally because of its marked increase in low to middle income countries (LMICs). As longevity has increased and infectious diseases are better controlled in such countries, non-communicable diseases --including cancer – have been on the rise. Insufficient infrastructure and fewer resources to tackle non-communicable diseases in LMICs are exacerbating factors.

An effective approach to cancer control in LMICs must be multifaceted, starting with education of both the lay public and the medical community. It is important for the public to understand the nature of cancer to effectively combat the stigma and negative beliefs that often contribute to very late presentation or complete avoidance of treatment. It is crucial for people to understand that a diagnosis of cancer is not necessarily a death sentence. To the contrary, early detection of cancer makes it possible to achieve a cure. This is a message that medical personnel, including nurses and primary care physicians, must carry to the community.

The most cost-effective component of cancer control is prevention, including lifestyle modifications such as proper nutrition, adequate exercise, moderation in alcohol consumption, and complete avoidance of tobacco use. The widespread use of vaccination against viruses such as hepatitis B and human papilloma virus have been demonstrated to prevent liver and cervical cancer, respectively. Screening modalities have been shown to be effective in detecting premalignant conditions such as dysplasia of the uterine cervix andcolon polyps. Treatment of these conditions in turn prevents cervical cancer and colon cancer, respectively. The challenge in LMICs is the availability of resources to embark on broad, population-based screening programs. Potentially, pap smears for cervical cancer screening can be offered at a low cost; as such, this could be a viable intervention that could be pursued in many LMICs. However, other screening mechanisms, such as colonoscopy and mammography for breast cancer screening are expensive and call for creative approaches to healthcare financing in low resource environments.

Effective cancer management also requires the ability to achieve accurate diagnoses. This typically entails specialized imaging, appropriate biopsies, and competent pathologic analysis. Ultrasonography is more readily available in lower resources settings, but this often needs to be complemented by affordable computed tomography. Actual cancer treatment is often sophisticated and cost intensive. As a potential solution, resource-stratified treatment algorithms have been proposed. These often employ a combination of surgery, chemotherapy, and radiotherapy but the complexity of these therapies can be stratified according to available expertise and resources. Radiotherapy, while versatile, is resource intensive. This is the most deficient component of cancer treatment in most LMICs. Creative financing solutions are desperately needed. Given the frequent late presentation of cancer cases in developing countries, palliative care is of utmost importance. This can be provided at a relatively low cost. Oral narcotics for pain control are relatively cheap, but often unavailable due to inadequate policy measures. Global efforts are underway to rectify this problem.

Given all the cancer control challenges in LMICs, it is crucial to explore creative solutions.The World Health Organization emphasizes that cancer control plans globally should be evidence-based, priority driven & resource-appropriate. Thus, local realities, disease patterns and available resources must be taken into consideration. Lifestyle modifications and pertinent vaccinations should be broadly embraced. Adopted screening programs must be affordable and would only be ethical where appropriate diagnostic follow-up and treatment is available. A broad partnership between governmental agencies, non-governmental organizations, medical academia and private enterprise to support cancer education, clinical care, training and research is crucial. To make all this practical, innovative health care financing models are sorely needed.

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