Childhood leukemia is curable 90 percent of the time – one of the success stories noted in the three-part PBS documentary “Cancer: The Emperor of all Maladies,” which concludes tonight. But as thoroughly as the six-hour film explores both progress and disappointments in cancer treatment, it tells only part of cancer’s story – what is happening in the United States and other developed countries. In sub-Saharan Africa and other low-income countries, a child – or an adult – with cancer is far more likely to die than live.
“One of the biggest single predictors of whether you will survive [cancer] is where you live,” said Dr. Corey Casper, head of Global Oncology at Fred Hutchinson Cancer Research Center. “And that is something we should not tolerate.”
Casper welcomed more than 200 physicians, researchers, policymakers, patient advocates, and medical and public health students from around the nation and the world Tuesday to Fred Hutch to talk about how to make cancer a priority globally, not just in wealthy countries.
The first challenge, speakers at the daylong symposium agreed, is gaining recognition that cancer is even a problem in low-income countries. Global health research and aid has traditionally focused on preventing or treating infectious diseases, advancing maternal health and improving sanitation. Although cancer has always been present, its incidence has been rising partly because progress in these others areas has allowed more people to live long enough to develop cancer.
Today, more people in low- and middle-income countries die each year from cancer than from HIV, tuberculosis and malaria combined, Corey noted, citing figures from the American Cancer Society. Cancer is a leading cause of disability and death worldwide, with about 14 million new cases and 8.2 million deaths in 2012, according to the latest estimates from the World Health Organization. More than 60 percent of new cases occurred in Africa, Asia and Central and South America, which also accounted for 70 percent of cancer deaths.
“It’s very clear that chronic diseases, including cancer, have outstripped infectious diseases as the leading causes of morbidity and mortality in many parts of the world, including low- and middle-income countries,” said Dr. Judith Wasserheit, a University of Washington professor of allergy and infectious disease and chair of its Global Health Department. “Yet research regarding cancer and care is really very limited, and not a minor piece of that is limited funding.”
Only about 1 percent of an estimated $31 billion in public and private global health spending goes to noncommunicable diseases such as cancer, said Silvana Luciani, a cancer prevention and control adviser for the Pan American Health Organization, with most going to HIV/AIDS, maternal-child health, tuberculosis and malaria.
“There’s a moral imperative” to increase funding for cancer research and aid, Luciani said, pointing out that both within and among countries, cancer disproportionately affects the poor, who tend to be diagnosed at later stages and have lower survival rates. The mortality rates for cervical cancer, for example – a preventable and treatable disease – are six to seven times higher in low-income countries than in wealthy ones.
But Dr. Howard Frumkin, dean of UW School of Public Health and an internationally recognized leader in environmental health, warned against repeating earlier mistakes that made funding for some diseases so restricted that it resulted in siloed rather than holistic health care systems.
“You can imagine the predicament of a family who has to travel by bus over difficult roads over much of the day to get to an HIV clinic, then two days later has to travel the same roads to get help for cancer,” he said. “We need to be thinking in terms of systems change and systems support. Give me a dollar to do this job and I’ll figure out how to do five jobs with that dollar.”
Cancer funding also must take into account public health education to break down taboos that keep people from seeking care; capacity building, or training physicians, nurses and community health workers; and ways to evaluate what works and what doesn’t — sentiments that were repeated throughout the day by other speakers.
“We cannot underestimate the role of patient advocacy and support groups in low- and middle-income countries,” said Pat Garcia-Gonzalez, president of the Max Foundation, a Seattle-based nonprofit organization that helps people in such countries get cancer care. “For survivors to go out in the community and tell others you can survive cancer is very important. Stigma is one of the hardest things to overcome. It takes a lot of courage for patients to do that.”
As depicted in the Ken Burns-produced cancer documentary, the same was (and in some cases, still is) true in developed countries: a cancer diagnosis was all too often a closely kept secret, in part because the prognosis seemed invariably hopeless .
Survivor stories are key because many people believe that a cancer diagnosis is an automatic death sentence and so don’t seek care, said Penny Legate, a videographer who, with Dr. Julie Gralow, director of breast medical oncology at Seattle Cancer Care Alliance, has worked with East African breast cancer survivors.
“It’s remarkable how these women’s lives are being changed just by gathering together and telling stories,” Legate said.
Among the myths the women help to dispel: that cancer is a disease of the West, that it is contagious, that screening causes infertility, that everyone with cancer dies.
Fred Hutch is one of the first comprehensive cancer centers to have a program dedicated to global oncology. Its decade-long alliance with the Uganda Cancer Institute in Kampala, Uganda, is held up by the National Cancer Institute as a model for research, training and patient care in low-income countries. The partnership takes a holistic approach to cancer care through such steps as raising awareness through community outreach, speeding diagnosis and assigning case managers to help families navigate care. The 25,000-square-foot, state-of-the-art UCI-Fred Hutch Cancer Centre, the first comprehensive cancer center jointly built by U.S. and African cancer institutions in sub-Saharan Africa, is scheduled to open in May.
“We are deeply invested in, deeply committed to global oncology at the Hutch,” said Dr. D. Gary Gilliland, Fred Hutch president and director, in welcoming researchers to Tuesday’s symposium.
Dr. Mary Gospodarowicz, immediate past president of the Union for International Cancer Control and a fellow of the Royal College of Physicians and Surgeons of Canada, closed the conference on a note of optimism, despite the challenges.
Lowering the global burden of cancer and closing the “cancer divide” between rich and poor countries is “a tough problem, a complex and wicked problem,” she said. “But I have confidence that if we all work together, we can solve it. I’m an optimist. I think all of the cancer doctors are optimists, or they should get out of the business, right? The last thing we need is pessimistic cancer doctors.”
The Global Oncology Symposium was sponsored by Fred Hutch, Seattle Children's, the University of Washington's Department of Global Health and Center for Global Studies, the Fred Hutch / University of Washington Cancer Consortium, Washington Global Health Alliance and Global Oncology.
Mary Engel is a former staff writer at Fred Hutchinson Cancer Center. Previously, she covered medicine and health policy for the Los Angeles Times, where she was part of a team that won a Pulitzer Prize for Public Service. She was also a fellow at the Knight Science Journalism Program at MIT. Follow her on Twitter @Engel140.