Few readers will remember Kenneth Feinberg. A lawyer by profession, in the wake of 9/11 and more recent tragedies such as the Boston Marathon bombing, he was responsible for answering the unanswerable question: How much is a human life worth?
Put in charge of determining the compensation for each claim paid by the September 11th Victim Compensation Fund, Mr. Feinberg drew on tort law and used a formula that added economic and noneconomic losses discounted by other collateral sources, such as insurance and charity. Although the award for noneconomic losses was the same, victims who earned more before the event were entitled to a larger compensation. This may hurt our sense of fairness and justice, but the process was consistent and transparent in its methods and rules, and therefore well suited for the real world in which disparities abound and factor into decision making. Governments and private institutions, for-profit and not, have to make similar considerations when judging how to invest scarce resources, especially in health care, often by assigning an implicit dollar value to human life. This is where the dismal science can help us advance the cause of cancer control around the world.
Reducing the global economic burden of cancer
Although the economic burden of each cancer case in the United States, the United Kingdom, and Japan ranges between $183 and $460 per patient every year, in South America, India, and China it ranges from a paltry $0.54 to $7.92 per patient. Overall, high-income regions spend five to 10 times more on cancer control on a per capita basis than low- and middle-income countries. During the 2014 World Cancer Leaders’ Summit, organized by the Union for International Cancer Control (UICC), we argued that it makes economic sense to invest in global cancer control, especially in low- and middle-income countries. In 2010, taking into consideration the direct costs related to the prevention and treatment of the disease and the economic value of lives lost and disability caused, cancer cost the world approximately $1.16 trillion. Further estimates, which add the longer-term costs to patients and their families, bring the annual global cost of cancer to $2.5 trillion.
The implementation of prevention, early detection, and treatment strategies could potentially save 2.4 million to 3.7 million lives every year—the vast majority of them in low- and middle-income countries—yielding an economic benefit in excess of $400 billion. Moreover, it has been estimated that an investment of $11.4 billion in a set of core prevention strategies in less wealthy regions of the world can lead to savings of up to $100 billion in future cancer treatment costs. The measures with the highest potential for clinical and economic influence are those geared toward tobacco control, obesity reduction, vaccines, early detection and treatment, palliative care, and health systems planning, with the creation of cancer registries.
The cost of tobacco-related cancers worldwide exceeds $200 billion per year. The average low- and middle-income country could, for a cost of approximately $0.11 per capita, implement the most active control measures: education campaigns, higher excise taxes on tobacco, smoking bans in public places, and bans on smoking advertising, promotion, and sponsorship. The World Health Organization (WHO) estimates that by increasing tobacco taxes by 50%, we could reduce the number of smokers by 49 million within the next three years and ultimately save 11 million lives, without a reduction of government revenues. By increasing tobacco excise taxes by 50% per pack, countries around the world could actually collect an extra $101 billion in revenue.
Obesity, diet, and physical activity
Obesity and other diet- and physical activity–related risk factors contribute to approximately 20% of cancer cases globally and will soon be the most common modifiable causes of the disease. The Organization for Economic Co-operation and Development predicted that the implementation of strategies to improve diets, increase physical activity, and tackle obesity in Europe would lead to gains of more than 3 million years of life free of cancer over 10 years, a benefit that could increase to 11.8 million in another decade. Drawing on data from the United Kingdom, a recent report by McKinsey & Company, a business consultant firm, showed that a series of interventions to curb overweight and obesity—including public health campaigns, portion control, and limiting media exposure and price promotions—cost society less than the economic benefits they bring.
Vaccines to prevent hepatitis B (HBV) and HPV are critical in the prevention of liver and cervical cancers, respectively. Overall, chronic infections are responsible for approximately 15% of all cancers around the world, but in some regions, such as sub-Saharan Africa, nearly one-third of all cancer cases are secondary to infections, compared to less than 3% in high-resource countries. The HPV vaccine can prevent up to 70% of cervical cancer cases, and HBV vaccines have been effective in Asian countries that implemented immunization programs in the 1980s, such as Taiwan and Singapore. The GAVI Alliance, a public–private partnership formerly known as the Global Alliance for Vaccines and Immunization, was a major player in reducing the price of HBV and HPV vaccines to $0.20 and $4.50 per dose, respectively. By providing funding and creating a working market where previously there was none, the GAVI Alliance improved access in eligible low-income countries and potentially averted hundreds of thousands of future cancer deaths.
Prevention, early detection, and treatment of common cancers would have a major economic benefit worldwide. Global investment in cervical cancer prevention could save up to 230 million years of life free of disability, with an economic value of $1 trillion in 2010. The estimated cost of new breast cancers in the same year was $26.6 billion. The treatment of late-stage breast cancer is three times more expensive than the management of early-stage disease. The estimated cost of death and disability caused by colorectal cancer was $99 billion in 2008, excluding direct treatment costs. In high-resource settings, colorectal cancer screening has been shown to be cost-effective or cost-saving.
There are nearly 300,000 new cases of oral cancer worldwide every year. Studies in India, where one-third of global cases occur, show that oral cancer screening by visual inspection is cost-effective and that early detection can reduce the associated morbidity and mortality. Visual inspection for oral cancer by trained health care workers can be carried out for less than $6 per person. The incremental cost per life-year saved was $835 for all individuals eligible for screening and $156 for individuals at high risk. All of these facts attest to the economic benefits of investing in early detection, screening, and treatment of cancer in low- and middle-income countries.
Access to radiation therapy
The Global Task Force on Radiotherapy for Cancer Control, another initiative led by the UICC, is convening radiotherapy professionals, industry partners, cancer leaders, global health experts, economists, and other stakeholders to assess and quantify the investment needed to provide equitable access to radiotherapy worldwide. Radiation therapy is one of the most important tools in the management of cancer. Used in up to 50% of all patients, radiotherapy is also one of the most cost-effective interventions in oncology. One radiation machine can treat tens of thousands of patients over a decade or more. Yet many countries still lack such facilities; 45% of the countries in Africa, with a combined 198 million people, do not have any radiation machines.
Palliative care resources
WHO defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychosocial, and spiritual problems. Palliative care can lead to more appropriate and less expensive care. As such, it is important for health care planners and financers to realize that there are economic benefits to supporting a holistic approach at the end of life when it can prevent unnecessary and costly health services, particularly hospitalization. Several studies have quantified that hospital-based palliative care visits can reduce hospital costs by up to $7,500 for patients who die during their last hospital admission.
National cancer control planning
Finally, investing in national cancer control planning is vital in order to plan and deliver cost-effective programs aimed at reducing cancer incidence and mortality, improving patients’ quality of life and well-being, and decreasing the economic effects of cancer globally. The availability of high-quality cancer surveillance data—including cancer incidence, stage at diagnosis, and mortality generated by population-based cancer registries—is essential not only to develop targeted and effective national cancer control plans, but also in evaluating their effectiveness. Less than 10% of the world’s population is covered by cancer registries, with available registries predominantly located in high- and middle-income countries. Less than 6% of the population in Asia and Central and South America, and less than 1% of the population in Africa, is covered by a registry. The costs of establishing an adequate registry in most countries is low compared to the economic burden of cancer. As an example, in the United States the annual burden of cancer exceeds $216 billion, and it costs less than $75 million (0.03%) annually to fund the Centers for Disease Control and Prevention’s (CDC) National Program of Cancer Registries.
International efforts underway
International efforts to improve on the current situation are in course. The CDC, in collaboration with the International Agency for Research on Cancer (IARC), is supporting research to pilot and to develop a standardized instrument: the International Cancer Registry Costing tool (InCanRegCosting tool). This project aims to systematically assess the cost of cancer registration in lower- and middle-income countries. Moreover, the Global Initiative for Cancer Registry Development, a multipartner initiative led by the IARC, estimates that with an investment of $15 million over five years, it can establish four regional capacity building hubs that would improve cancer data collection around the world.
It is clear that supporting the international fight against cancer makes sense not only in terms of curbing human suffering and decreasing health disparities, but also on practical and economic grounds. To achieve this, it will take a global village. It is only through engagement of all stakeholders, including governments, private companies, and nonprofits, that we will inch our way toward conquering cancer.
As oncologists, it is our duty to our patients and the societies we live in to be leaders in this process. With more than 11,000 international members, ASCO is heavily involved in global oncology and one of the most influential organizations in advancing cancer control worldwide.
Two years ago, the Society launched ASCO International, a portfolio of integrated programs to support this mission, and announced its commitment to double ASCO’s international programs. Since then, several new projects were launched and existing programs have expanded. In 2014, ASCO and its collaborating organizations hosted 55 educational events in 33 countries, reaching nearly 12,000 clinicians and affecting the care they deliver to their patients.
ASCO International focuses on three key priorities:
- Improving quality of cancer care by working with organizations and hospitals to extend oncology skills and knowledge;
- Accelerating innovation and research by deepening the skills of investigators, particularly in low- and middle-income countries; and
- Supporting professional development by mentoring future leaders in oncology and providing career development for early-career oncologists in low- and middle-income countries.
Help us further cancer care around the world. Join ASCO-led discussions on value and on global oncology, or volunteer time on one of our committees or international activities. Learn more about ASCO International and how you can help.
James Randolph Hillard, MD
Jun, 26 2015 5:27 PM
I agree with all of the points that Dr. Lopes makes in this article, but I believe that it is very important to bring attention to one point that he does not make. To quote from a WHO Press Release, from September 24, 2014 http://www.iarc.fr/en/media-centre/pr/2014/pdfs/pr227_E.pdf:
"Although stomach cancer is the third most common cause of cancer death worldwide, until now it has not been given the attention it deserves," explains Dr Rolando Herrero, Head of the Prevention and Implementation Group at IARC. "We know the main cause of the disease, which is a bacterium that can be treated with antibiotics. Screening people in high-risk groups for infection with H. pylori and treating them could play a key role in reducing the burden of stomach cancer in these populations."
In the Fall of 2014, the World Health Organization IARC released an extensive monograph on the topic of eliminating stomach cancer by eliminating H. pylori in high risk populations. I have attached the citation and link below. The entire 181 page monograph is available for free download at that link. Everyone concerned with international cancer prevention and control should study this new and important resource.
IARC Helicobacter pylori Working Group (2014). Helicobacter pylori Eradication as a Strategy
for Preventing Gastric Cancer. Lyon, France: International Agency for Research on Cancer
(IARC Working Group Reports, No. 8). Available from: http://www.iarc.fr/en/publications/pdfs-online/wrk/wrk8/index.php
Gilberto Lopes, MD, FASCO, MBA
Jul, 11 2015 11:04 AM
Thanks, James! Gastric cancer is certainly very important. We are seeing encouraging data on its prevention being developed in China, Japan and Korea among other countries and we hope to soon be able to do calculations of the cost of prevention and its economic benefits. Warm regards!