Recent publications remind me of the ever-present need to think about the management of cancer in broad terms as a socio-behavioral, economic, psychological, and political problem with huge personal and public ramifications. This is true in developed as well as developing countries.

One of the commonly overlooked areas of cancer survivorship is how frequently treatment for cancer is associated with economic outcomes and poverty. I am thinking not of those who were unable to afford care at all or those who, on account of poverty, do not even seek treatment because of its high cost. Rather I am thinking of the population of patients who undergo treatment but are left in dire financial straits as a consequence.

In my practice in Nigeria, it was painful to watch patients and families make tough decisions—such as spending savings intended for their children’s college education (there are no college loans), selling property or investments on which the family’s livelihood depends, or disposing of household appliances and other accouterments of a comfortable middle class life—in a chase for a cure that is often elusive because the patient presented with advanced disease. This iatrogenic poverty is devastating middle-class Africa as the incidence of cancer rises in societies that have achieved increased life expectancy and reduction in infectious disease-related morbidity and mortality yet lack health care infrastructure and sustainable health care financing for management of complex diseases.

In an article published online in the February 17, 2015, edition of the Journal of Clinical Oncology, Hershman et al¹ used a health insurance database of a relatively wealthy population, all of whom had some form of prescription coverage, to examine the association between household wealth and medication adherence. They found that financial factors, such as income and net worth, were linearly associated with adherence to and discontinuation of hormonal therapy.

In another study, the Access to Care Project administered online questionnaires to evaluate the bankruptcy concerns of patients with cancer. Some 47.7% of the 480 respondents reported they had paid more for health care during the 12 months before the interviews were conducted and 37% were seriously or very seriously concerned about bankruptcy because of medical bills. This report is consistent with the findings of Ramsey et al that bankruptcy rates were 2.7 times more likely among adults with cancer compared with general adult populations, and this is particularly worse among younger compared to older cancer patients.²

Do oncologists have a role in advocating for health care systems that do not leave cancer survivors impoverished? In the United States, oncologists at several leading cancer centers have campaigned against the high cost of new anticancer treatments, and more recently, attention has been drawn to the impact of these drugs and others on overall health care spending. In other developed countries, mechanisms have been developed for approval of individual drugs before they are available in the public health system.

The challenges of cancer care in developing countries cannot be divorced from the problems of the health care system and civil society in these countries in general. But the peculiar nature of cancer diagnosis and treatment—a short period of intensive high-cost care followed by an extended relatively lower-cost follow-up period—requires the health care system to have specific design characteristics and configurations that are different from the prevalent models in most developing countries, which are more attuned to the management of illnesses that require acute short-term moderate- to low-cost care and limited long-term follow-up requirements, like acute infections and trauma.

It appears therefore that broad health systems’ interventions that strengthen the ability of the health care system to deliver care to patients with cancer and other chronic complex diseases, rather than a disease-specific intervention, would be most beneficial to patients in developing countries. This new health care system needs to be coupled with a health care financing paradigm that is attuned to the pattern of expenditure incurred during cancer care so that it can be truly responsive to the needs of our patients and their families.

References

1. Hershman DL, Tsui J, Wright JD, et al. Household net worth, racial disparities, and hormonal therapy adherence among women with early-stage breast cancer. J Clin Oncol. 2015;33:1053-9.
2. Ramsey S, Blough D, Kirchhoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood). 2013;32:1143-52.